This is the first study to estimate the prevalence and characteristics of ARFID in Chinese patients with IBD. This study identified 20.3% of patients screened by NIAS above the cutoff of 28 points, suggesting that they were at risk for ARFID. The average score of ARFID in study samples was 21.9 (interquartile range=17.0-26.0), which was higher than the study done among Chinese healthy populations[18]. This finding suggests that patients with IBD may be a population with a heightened susceptibility to ARFID, which aligns with prior research conclusions[14, 16, 24]. There exist several potential explanations for the observed phenomenon. Firstly, IBD constitutes a group of disease with a high degree of malnutrition and psychological disorders[25]. Patients often experience gastrointestinal symptoms such as abdominal pain, diarrhea, and abdominal distension, as well as decreased appetite, which can lead to reduced food consumption[24]. Secondly, many patients with IBD may struggle to discern the relationship between their diet and disease relapse, leading to a period of food neophobia and subsequent symptom exacerbation resulting from inadequate dietary choices. In the studied group, the fear subscale yielded the highest mean score among patients in both groups, suggesting that the apprehension of adverse outcomes may confer a heightened susceptibility to ARFID in patients with IBD. Thirdly, food avoidance and restrictive eating behaviors are prevalent among patients with IBD. A systematic review revealed a high prevalence of food avoidance (28%–89%), as well as restrictive dietary behavior (41%–93%)[7]. The survey findings indicate a noteworthy prevalence of self-initiated food avoidance, with up to 97.3% of patients reporting such behavior, potentially leading to reduced dietary diversity and lower quality of life related to food consumption. Patients diagnosed with IBD may experience social exclusion during mealtime interactions, leading to increased levels of psychiatric symptoms and diminished quality of life[26, 27]. Specifically, depression, anxiety, and somatosensory disorders are common, which may also contribute to the development of ARFID. Unfortunately, screening and early diagnosis of ARFID are generally insufficient in clinical practical, thus clinicians are crucial to be aware of ARFID and build systems to identify and treat it.
We further sought to examine potential disparities in dietary attitudes and behaviors among patients with IBD who have ARFID compared to those without ARFID. Our results indicate that four factors, such as having CD, being in an active disease state, holding attitudes about symptom management, and reporting a specific dietary history, were associated with a higher likelihood of ARFID among patients with IBD.
A consensus has not been reached on whether type (UC or CD) and phase (active or inactive) of IBD are independent risk factors for ARFID. However, the previous studies support that both a diagnosis of CD and perceived active disease are factors associated with restrictive behaviors[7], malnutrition[5, 28], as well as impaired food-related quality of life[29]. Indeed, the overall dietary quality of patients with CD could be worse than what was found in patients with UC, as reflected by higher intakes of sugars and SFA, higher consumption of sweets and lower consumption of fruits, vegetables, legumes, non-refined cereals and dairy products[30]. Furthermore, a previous study conducted among patients with IBD confirmed ARFID risk screen were significantly more likely to be at risk for malnutrition[14]. Our study add to the current evidence that patients with CD or active symptoms were significantly more likely to screen positive for ARFID risk.
The study also found that patients who screened positive for ARFID risk exhibited a statistically significant tendency to maintain specific dietary attitudes that diet modification can reduce IBD symptoms. While dietary modifications may prove beneficial for some patients with IBD, instances arise where food avoidance can pose a hazard to their health. Qualitative and quantitative research has demonstrated that patients' restrictive dietary behaviors are linked to their perception of how food items impact their disease progression[31-34]. Inaccurate dietary attitudes among patients with IBD may result in self-imposed restrictions on certain food groups for symptom management, ultimately leading to inadequate food diversity. In additional, since eating has also increasingly become an integral aspect of socializing and pleasure, these important psychosocial roles may be dramatically shifted on account of limited food choice and gastrointestinal discomfort that may occur at meals.
Furthermore, the findings of this study revealed that individuals who self-reported specific dietary histories were at a significantly higher risk of experiencing ARFID, with an odds ratio of 3.12 (95% confidence interval = 1.92-5.14; p< 0.001). Previous research conducted in the United States has also demonstrated a correlation between attempting exclusion diets and the development of ARFID in neurogastroenterology patients[35]. This association may be attributed to the prolonged adherence to specific dietary interventions without proper guidance from dietitians, potentially exacerbating nutrient deficiencies. The topic of diet and nutrition is of significant interest to patients with IBD. It is noteworthy that despite the availability of numerous IBD-related dietary guidelines, no specific dietary interventions, including a gluten-free diet, CD exclusion diet, specific carbohydrate diet and the low FODMAP diet, have been universally deemed appropriate for all patients with IBD[36, 37]. The selection of dietary patterns among patients with IBD is a dynamic process that evolves with the progression of the disease and associated symptoms. To address these challenges, several studies have begun to explore personalized dietary regimens that leverage individual characteristics to develop targeted nutritional advice, with the aim of promoting long-lasting and beneficial outcomes in dietary behavior[38], which may be more effective than the traditional dietary interventions.
Moreover, no between-group differences were found for dietary education. Due to all the aforementioned, dietary counseling should be considered to increase access to evidence-based information to help patients with IBD to manage their symptoms, avoid exacerbating malnutrition and explain intolerance to particular diets[39]. In our study, nearly half of patients with IBD reported to receive dietary advice, and a higher rate of ARFID was observed among patients receiving dietary guidance, although this difference was not statistically significant. This may be result from lack of evaluation in the reliability and quality of dietary information. Numerous studies have shown that excessive food avoidance was associated receiving non-evidence-based information from alternative therapists, the Internet and social media. The risk of nutritional imbalance should encourage healthcare providers to keep an eye on food intake of their patients with IBD and help conduct them through the labyrinth of ideas and perceptions to which they are being exposed. It should be noted that, at diagnosis, health care providers should focus not only on dietary avoidance, but also on a balanced diet. Food intolerance is equally common in UC and CD, which is not relevant to disease activity and location, and intolerant foods are varied, but most ‘best-evidence’ guidelines offer no recommendations for the food choice in IBD. Hence, a comprehensive nutrition assessment and education by trained dietitians as part of an IBD team is imperative.
These findings may contribute to a better understanding of prevalence and characteristics of ARFID among Chinese patients with IBD. However, there are study limitations that should be noted. Firstly, the conclusions based on cross-sectional studies were prone to cause considerable bias. And another possible limitation was that the questions asked for dietary attitudes and practices both in the present and the past, which may bring about recall bias, and as a result, the extent of the reliability of the findings may be limited. Moreover, dietary attitudes and practices were self-reported and thus could be inclined to desirability bias. Last but not least, since this survey was conducted in Nanjing and the results could be dependent on the local public health education, the conclusions were mainly applicable to the developed regions in China.