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Ecological Tableware


The authors published an article in April 2022, in which they systematically reviewed the English and Polish language scientific publications on ARFID and its therapy published in electronic databases (PubMed and Science Direct) over the past 10 years. From this article I have summarised the relevant parts, mostly relevant for children.ARFID is an eating disorder whose development depends on a number of factors. Like other eating disorders, it is likely to be the result of biological, health, psychological and environmental factors and their interaction. Children with ARFID are younger, more likely to be male than other eating disorders, suffer from the disorder for longer before starting treatment and are more likely to have other medical conditions.The data suggest that ARFID may be as prevalent as other eating disorders. Children with sensory processing disorder on the autism spectrum may have difficulty accessing sufficient quantity and quality of food because of the texture, taste, appearance or smell of food, which may prevent them from eating certain foods. The presence of autism can complicate the diagnosis.Fear of the consequences of eating foods that are perceived as unsafe also contributes to food restriction. ARFID can be diagnosed in normal and overweight children. Drinking high energy drinks (e.g. fruit juices) in young children and energy drinks in adolescents can lead to obesity due to their high sugar content. In these cases, diagnosis is even more difficult as one of the most important criteria, significant weight loss/stagnation, is not met. This is particularly dangerous in children.Most common consequencesDifferent vitamin and mineral deficiencies can develop depending on which elements are missing from their diet. The most common deficiencies are vitamins B1, B2, B12, C, K, and minerals such as zinc, potassium and iron. There are also many cases of lower protein, fat and carbohydrate intakes, which, because they do not correspond to the child's energy needs, can lead to fatigue.   TherapyIn young children, pickiness and neophobia (fear of new things) are often part of the normal developmental process, leading to failure to recognise the disease, chaotic treatment plans and inappropriate therapy. Our current knowledge about the therapy of ARFID is scarce. As there is still little research and observation on proven effective therapeutic methods, this also creates difficulties in developing a treatment plan. The current recommendation is that ideally a team of people from different specialties should form a team for the treatment of ARFID. 

Due to the complexity of the symptoms, it is recommended that all members of the team participate in the diagnosis, each analysing the symptoms within their own area of expertise. The next step is to develop a personalised treatment plan together. In each case, it is necessary to take into account the developmental and psychological specificities of the individual case, as well as the age and severity of the illness. An integral part of the therapy is working together with parents and carers and defining the goals of all involved.For example, a dietician working with young children must have the knowledge to avoid making mistakes about foods that the child considers safe. For children with ARFID, it is not possible in the initial phase of therapy to change the foods the child eats to other, healthier foods. For these types of patients, even if the safe foods are pre-made, unhealthy foods, they cannot be removed from their diets by offering healthier alternatives. In this case, irrespective of age, the child will prefer to choose starvation. The foods that the child perceives as safe are an important starting point for therapy, which should be accepted by the family and the immediate environment (nursery, school), as well as by the professionals who help them. These foods will be the basis for the introduction of new foods in the future, e.g. through the Food Chain method. Due to the high fear of eating new foods, such a situation requires careful preparation for these children. For quite young children, therapy involves introducing them to new foods through familiarisation with toys that look like the new food, drawing and colouring. This kind of play reduces anxiety, helps to strengthen the child and prepares him or her to eat the food later. It is important to note that children with ARFID are much more resistant to this type of therapy than selective eaters.To reduce anxiety, the initial phase of working with the Food Chain technique should be based on safe foods, with only slight modifications. If, for example, a child's diet consists of cheese toast, waffles, grilled chicken breast, vegetable soup with noodles, then these are the only foods worked with in the first stage, with minor modifications with the child's consent. An example might be: cheese toast with a very small amount of butter, grilled turkey breast, waffles made with a different kind of flour, vegetable soup with a different kind of pasta. Of course, the changes are introduced one at a time, gradually, taking into account the child's ability to adapt to the changes. These are big changes for a child with ARFID, but they are within safe food limits and reduce anxiety.Other foods can then be introduced, gradually expanding the diet to new things, depending on the child's condition, motivation and behavioural problems. In any case, new things should be introduced gradually, with the child's consent and agreement, to the extent that the child is able to cooperate. It is very helpful to have a routine to follow, as this increases the sense of security. You cannot surprise a child by hiding other ingredients in his safe food that he will notice anyway. People with ARFID expect a certain taste, smell, serving method, temperature, texture from a meal prepared by the same person. Also, they will only accept a certain type of food or brand and the slightest deviation can lead to rejection.  Therapy for the youngest children is just as difficult as for older children. When treating children between the ages of 1 and 3.5 years, it is important to take into account the child's temperament and associated hyperactivity. Calming the child during and before meals, a pleasant atmosphere at mealtimes, can help when introducing new components. Exploring inner sensations, developed to treat anxiety and gastrointestinal disorders, can provide an appropriate therapeutic framework for children whose refusal/restriction of food is a result of some unpleasant bodily sensation. In this method, the aim is to enable the child to perceive both internal and external sensations as interesting rather than fear-inducing. For this reason, the therapy focuses on exploring and experiencing the unpleasant bodily sensations, rather than interrupting them. Through play, they are taught to accept them. For this reason, therapy focuses on exploring and experiencing unpleasant physical sensations, rather than interrupting them. Through play, they are taught to accept them. An important point is that interoceptive (internal) sensations have a function, namely to send information to the brain about, among other things, hunger, fullness, fatigue, feelings. Teaching self-awareness through mapping internal states can reduce feelings of anxiety and increase acceptance of these feelings. In cases where we are dealing with hypersensitive internal and external feelings, the method can be very helpful.For patients diagnosed with ARFID, it is extremely important that we never recommend starvation as part of therapy. This method is not effective and can be dangerous in the case of ARFID.Psychotherapeutic help may be needed in addition to working with the above methods. The three-dimensional model of ARFID is also useful from a therapeutic perspective. Data show that almost half of patients seeking psychological treatment experience difficulties in more than one dimension.Individuals with sensory sensitivities often describe unsafe foods as tasting intensely bad. The traditional explanation for this is that these individuals simply have no experience with these foods and will therefore only like them after repeated tasting. Adults who consider themselves picky taste both bitter and sweet flavours significantly more intensely than those who do not consider themselves picky. For children with ARFID over the age of 10, the best documented and most effective form of therapy is cognitive behavioural therapy. Since anxiety is a problem in most cases, cognitive behavioural therapy can be a solution to working through present difficulties, especially for older children. In outpatient care, it is recommended for children over 10 years of age who are somatically stable and do not require artificial feeding. Treatment consists of 20-30 sessions, with several sessions for very low birth weight patients. Parental trust and cooperation are essential for the success of the therapy. Parental pressure to eat everything can negatively affect the child's eating behaviour.  It may contribute to the child's separation of feelings of hunger and fullness from eating, or lead to the development of poor eating habits as a result of the negative feelings experienced. The success of therapy depends largely on how long the illness has been present. Patients who have been ill for longer require longer and more intensive treatment. The main goal of treatment should be to reduce symptoms, not to eliminate the disease. The next step in therapy should always be tailored to the patient's needs (personalised), with realistic and achievable goals, and should include reducing nutritional, physical and emotional risks, while helping the patient to reduce anxiety and improve diet.

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