Adults with food allergies may develop dysfunctional eating behaviors or food aversions that extend beyond necessary allergen elimination, a novel Italian study in the journal Nutrients found.

These food aversions can lead to avoidant/restrictive food intake disorder (ARFID) or food neophobia, the reluctance to try new foods, according to Laura Polloni, PhD, clinical psychologist in the Food Allergy Referral Centre at the Padua University Hospital in Padua, Italy, and colleagues.

Although previous research has focused on children, clinicians treating adults should have these disorders on their radar and be ready to recommend psychological and dietary support to adult patients, the researchers advised.

“These conditions can cause severe nutritional deficiencies and high levels of anxiety in children and adults, and patients with food allergies have been found to be at greater risk,” Polloni told Medscape Medical News.

“However, the available data are still limited and virtually nonexistent when it comes to adults, so we decided to begin our preliminary investigation with the group that has received the least attention,” she said.

Food allergy anxiety entails excessive concern about allergic reactions and potentially fatal cross-contamination of foods and can lead to restrictions disproportionate to the individual’s level of risk, significantly contributing to anxiety burden and reduced quality of life.

Polloni sees a growing number of adults with these eating problems.

Study Details

The cross-sectional preliminary study involved 79 food-avoiding adults (mean age, 33 years; 70% female), 54% of whom reported having more than three food allergies. Most had suffered these allergies since childhood (56%) or adolescence (15%), and the majority (82%) had a prescription adrenaline autoinjector and past experience of anaphylaxis (82%).

In a need-vs-care dissonance, 57% reported current or previous psychological difficulties such as anxiety, depression, and stress disorders, yet only 25% reported food allergy support. Approximately 25% reported bullying related to food avoidance, for which the same percentage required psychological support.

Polloni’s group screened these adults with several instruments to determine food anxiety and other food-related behaviors. Overall, 25% and 73% of participants scored positively for ARFID and food neophobias, respectively. Among the tools used was the Dutch Eating Behavior Questionnaire-Brief, a self-report questionnaire describing three eating styles: emotional (in response to negative emotion and distress), restrained (reducing food to control weight), and external (in response to external cues such as sight or smell).

Among specific findings:

• Current psychological problems are positively correlated with ARFID (P = .004), food neophobia (P = .006), and food allergy anxiety scores (P = .03).
• Restrained eating was positively associated with female sex (P < .001), ARFID (P = .002), and food neophobia scores (P = .028).
• Having an adrenaline autoinjector prescription was negatively associated with ARFID (P < .001) and restrained eating (P = .006).
• Previous anaphylaxis was negatively associated with ARFID (P = .020) and positively associated with external eating (P = .021).

“We didn’t expect that auto-injector prescriptions would be associated with a lower likelihood of ARFID, although these results should be interpreted with great caution, given the preliminary nature of the study and the relatively small sample size,” Polloni said, calling for longitudinal studies on larger samples to confirm these findings and better understand the precipitating genetic, environmental, psychological, and physiologic factors.

“It will also be interesting to see whether these associations are confirmed in the pediatric population.” Her group is currently conducting a parallel study in children and adolescents.

“Patients with ARFID and food neophobia are not only at risk of nutritional deficiencies but may also experience distress and social isolation,” Polloni said. “They often avoid dinners, parties, or work situations involving food for fear of judgment or embarrassment, and many feel guilty or inadequate because their behavior is mistakenly interpreted as fussiness or capriciousness. This increases psychological distress and discomfort with food, which in turn can worsen eating behaviors, creating a vicious circle.”

Patients treated at Polloni’s center responded effectively to integrated intervention with a psychologist, an allergist, and a dietitian, showing both subjective benefits and objective improvements measured by food diaries and validated screening questionnaires. “At the end of treatment, patients showed reduced anxiety around food, more functional coping strategies, greater dietary variety, and a more balanced diet,” Polloni said. “For some patients, the treatment process may take several months; in less severe cases, improvement is more rapid, but a multidisciplinary approach is essential for treating ARFID and FN [food neophobia] effectively.”

Offering a US perspective on the study but not involved in it, epidemiologist Christopher M. Warren, PhD, research assistant professor in the Department of Preventive Medicine at Northwestern University Feinberg School of Medicine in Chicago, noted that while recognition of these disorders is increasing, that does not mean they are actually on the rise.

“Further work examining more recent trends is certainly needed to assess the presence of a more recent spike in true ARFID incidence, but there is no doubt in my mind that ARFID is a clinically important phenomenon,” he told Medscape Medical News.

Warren agreed that allergic reactions and treatment may reinforce dynamics contributing to ARFID — most notably the requirement of strict avoidance plus constant readiness to act swiftly with epinephrine prophylaxis.

“Perhaps unsurprisingly, patient’s caregivers often report significant stress and challenges maintaining appropriate readiness and constantly making dynamic assessments of potential risks versus the benefits of engaging in specific daily activities, given the ubiquity and unpredictability of food being present in many social and educational settings.”

Warren commended the current study for extending the ARFID discourse to adults. “It also highlights the importance of not only asking patients about what food allergens are currently being avoided but also more comprehensively understanding patterns of dietary restriction and avoidance,” he added.

Furthermore, the authors identify potentially actionable correlates for suspected ARFID other than food allergy severity alone, including distress around eating, eating style, history of internalizing symptoms, and fear of novel foods. “Clinicians who are on the lookout for patients exhibiting these characteristics may be better able to efficiently diagnose and treat ARFID and other potentially related mental health sequelae of food allergy,” he said.

The bottom line, said Polloni, is that people with food allergies are a vulnerable group in terms of nutrition and psychological well-being, and preventing further complications by fostering a positive relationship with food should be a priority.

This study received no external funding. The authors and Warren reported having no relevant conflicts of interest.