One of the top 3 values for everyone at CNC is our continual learning.
We want to make sure that our clients are provided with the depth of our experience and the most up-to-date resources and state-of-the-art treatment. The following blog, written by Heather Bell, MPH, RDN, is a good example of our commitment to that value. Heather writes about ARFID, a fairly new diagnosis to be identified in the DSM (Diagnostic and Statistical Manual for Mental Health). Despite its new classification as an eating disorder, this is not a new presentation for us. We have been working collaboratively with families and providers for a long time on this condition. What is new are clinicians, across disciplines, who are working to identify treatment approaches providing more consistent, reliable, and effective care. Heather has participated in 3 different professional courses, just in this past year, to learn anything new that she could add to her practice for these individuals and to share with other professionals in the field. This is how we show up for our values and our commitment to clients and colleagues. I hope you enjoy the read, Lisa Pearl.
By Heather Bell, MPH, RD, LDN
This is the first in a series of blog posts sharing some of my thoughts on the treatment of Avoidant Restrictive Food Intake Disorder. My colleagues and I recently participated in a training focused on Responsive Feeding approaches, and fresh from that wonderful experience, I have some take-aways that I want to bring back to the CNC 360 community.
What is ARFID?
Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new diagnosis. It attempts to address the experience of children and adults who under-eat or avoid eating, not because a drive for thinness, but because of other struggles with food and eating.
Some individuals diagnosed with ARFID may have strong reactions to the taste, smell, or appearance of food. Some may have had previous distressing experiences with choking or vomiting and have begun to avoid foods or eating situations that they worry might cause a similar event. And lastly, some people may struggle with a lack of appetite, or have the experience of getting full very quickly, so that they aren’t able to take in enough nutrition for their well-being.
Many people with ARFID experience multiple issues with eating that raise concerns for themselves, for family members, and for their health care providers. It’s often at this point that they are referred to a registered dietitian in order to evaluate and address the concerns.
What is Responsive Feeding?
Responsive Feeding (RF) is an approach to supporting individuals in understanding, accepting, and growing their relationship with food and eating. It focuses on helping individuals be attuned to their bodies, and based on that attunement, supports them in making choices that honor their bodies’ needs and authentic preferences. It focuses on facilitating the discovery (or re-discovery) of internal cues like hunger and fullness, curiosity, and motivation where food and eating are concerned.1 It supports both bodily autonomy and emotional autonomy.
With parents and other supportive partners, RF prioritizes the relationship between the supports and the person with ARFID. The power of attunement and responsiveness in these relationships is celebrated. When caregivers are attuned to the experience of eaters, noticing what seems to work (and not work) for the people they love, and when they respond to what they see in a way that honors those needs, RF asserts that this is the best possible foundation for eaters to grow and thrive.
What are my key kernels of wisdom from The RF Training?
- It’s important to continue to believe in and facilitate every eater’s capacity for attunement and self-regulation, even if we are being told that they struggle with this ability.
While it’s true that some individuals may have medical issues that alter their experience of hunger and fullness temporarily, or in a longer-term fashion, many others do not. Struggles with anxiety, normal developmental dynamics around autonomy, and reactions to even subtle pressure to eat can result in food refusal that has nothing to do with an inability to sense and respond to hunger and fullness. Dietitians can support people with ARFID by helping them to assess and address any medical barriers, while also helping them to understand other issues that may be interfering with or complicating their personal experience of attunement. - When we and other supports believe that eaters can’t self-regulate, we’re more likely to engage in (or recommend!) counter-productive feeding techniques that actually result in more avoidant eating behavior, undereating, slowed pace of eating, decreased BMI, and increased likelihood of eating issues later in life.
This is where attunement and responsiveness come in. Whereas one person might use the suggestion to “take a few bites past fullness” to push their comfort zone in a way that feels challenging, but do-able and helpful, another might feel overwhelmed and invalidated. Dietitians can support individuals and families in recognizing and defining for themselves what is productive and counter-productive when it comes to eating experiences. - Diet culture, which includes a focus on eating the “right” foods, as well as a focus on managing weight, absolutely complicates the pressure that families and individuals feel when dealing with atypical eating patterns.
It adds to health anxieties, worries about bad parenting or self-care, and creates an urgency to “fix the problem”—often before individuals and families truly understand how the underlying eating dynamics are playing out. Dietitians can support individuals and families by exploring beliefs about food and weight that appear to increase tension and conflict about food and eating and increase the urge to engage in counter-productive feeding practices. Dietitians can offer assessment, information, and balanced perspective as a counterpoint to cultural narratives based in anxious hypervigilance and fat phobia.
1Rowell K, Wong G, Cormack J, and Moreland H. Responsive Feeding Therapy: Values and Practice.
I look forward to sharing more insights about Responsive Feeding approaches to ARFID in my future blog posts!