How to Treat Patients with ARFID via Telehealth

CBT-AR Stage 2

Then after stage one, we move on to stage two. The main purpose of stage two is kind of a treatment planning type of foods. Here we provide psycho-education about the five basic food groups of fruits, vegetables, protein, grains, and dairy, as well as nutrition deficiencies that are common in folks with ARFID. And then we also help them select new foods to learn about in stage three and kind of think about what exposures they really want to focus on at that time.

Stage 2: MyPlate Exercise

We have been doing exercise surrounding the USDA MyPlate which is some recommendations from the US government about types of foods that should be included in a healthy diet. Different international recommendations exist as well, but they have a lot of similarities to them. And so one of the things we found in our studies is that if you look at healthy, this is children and adolescents, they might eat a little bit of extra grains and a little bit less vegetables, maybe than they're "supposed to" based on the USDA recommendations, but overall they do pretty well getting a good variety. But if you look at folks with ARFID, usually their diets are a little bit more skewed and you can see here that they might be eating quite a bit of dairy, a lot of grains but really just hardly any fruits, vegetables, or proteins.

And so in stage two, we ask patients to actually kind of draw out what their plate would look like for a typical meal. So to say, "Hey, if you're having Mac and cheese for dinner, what would that look like?" They might say, "Well, it's half grains from the pasta and then it's half sauce from the... or rather half dairy from the cheese sauce." And so in that case, they only are really getting two food groups and we think about, "Hmm, what might be missing from that?" And they might identify, "Yeah, maybe I should work on trying to incorporate more fruits or vegetables or protein." So it's kind of a motivational type of exercise.

Stage 2 : Nutrional Deficiencies

We also talk with them about nutrition deficiencies. One of the things we found is that a number of patients have never been tested for nutrition deficiencies because there are things, again, like vitamin C deficiency that are pretty low frequency in the general population. So we will encourage that to be evaluated medically. But even if the patient has fine blood work, and you can see this a lot with other eating disorders too, they might think, "Oh, well, that means I don't have any deficiencies and I'm fine." But we'll highlight that actually if you aren't eating any foods, for example, that are rich in B12 or vitamin C or zinc, you could be at risk for developing a deficiency in the future if you don't change anything and here are some of the signs and symptoms that you might want to look out for. And hey, here's a list of foods that have this vitamin in it. Would these be things that you'd be willing to learn about or do exposures with in stage three and oftentimes people will already start to do that prep work in that session.

Stage 2: Building Blocks worksheet

And then the last part of stage two is that we provide this Building Blocks worksheet to primary food group building blocks. And this is also freely available at a link at the end of the slide deck. But basically we just have a really long list of all the different foods that would be sort of categorized in each of the five basic food groups of fruits, vegetables, proteins, dairy, et cetera. And so what we do is we have folks go through this and figure out like, are there certain foods that you're consistently eating? Like maybe they already have Apple juice every day. And then if you're not consistently eating it at least once a week or a couple of times a month, are you willing to learn about it? Is this something that you might be curious about? If not, that's okay too. You could leave some blank. But we want them to go through all of the items and to indicate are you eating this already, or if not, is this something that you might be willing to learn about by having say maybe like a smaller taste in a future session?