When gut-brain disorders affect eating in adults
"Restrictive eating in DGBI is common beyond specialist clinics and highlights the need for integrated multidisciplinary care."
-
01/07/2026
-
by Doug Brunk
About one in three adults in the general population who have disorders of gut–brain interaction (DGBI) also show signs of avoidant/restrictive food intake disorder (ARFID), according to what researchers believe is the first survey of its kind.
“This study validates that restrictive eating in DGBI is common beyond specialist clinics and highlights the need for integrated multidisciplinary care to optimize patient outcomes,” senior author Imran Aziz, MBChB, MD, a consultant gastroenterologist at the University of Sheffield, United Kingdom, told GI & Hepatology News.
For the study, published in Gastroenterology, researchers conducted a population-based internet survey of 4,002 adults in the United Kingdom and United States in 2023. They presented the survey as a “general health” study to minimize selection bias related to GI or eating disorder symptoms and used validated instruments, including the Rome IV Diagnostic Questionnaire for DGBI and the Nine-Item ARFID Screen (NIAS), and asked questions about demographics, body mass index, non-gastrointestinal somatic symptoms, anxiety and depression, quality of life, and health care use.
The mean age of the study population was 46 years and half were female. The researchers found that 42.6% of respondents experience symptoms of DGBI. Women were more likely to be affected than men (48.3% vs 36.9%), and the median age of those with DGBI was younger at 42 years, compared with 49 years for those without symptoms. One in four respondents (24.8%) had symptoms in one region of the digestive tract, 11.7% in two regions, 4.3% in three regions, and 1.7% in all four regions.
Among individuals with DGBI, 34.6% screened positive for ARFID. This prevalence was significantly higher than in those without DGBI (19.4%), even after adjusting for age, sex, ethnicity, and mood disorders. All three ARFID symptom domains were more common in DGBI: lack of interest in eating (21.5%), sensory-based avoidance (18.1%), and fear of aversive consequences such as pain, nausea, or vomiting (9.9%).
The prevalence of ARFID symptoms increased stepwise with DGBI complexity. Only 27.7% of individuals with one affected GI region screened positive, compared with 50% of those with three regions and 61.4% of those with four. Functional dyspepsia and irritable bowel syndrome were particularly associated with ARFID symptoms, with roughly half of patients screening positive.
In other findings, individuals with DGBI plus ARFID, compared with those with DGBI alone, were significantly more likely to be underweight (7.9% vs 1.5%, respectively). They also had higher rates of anxiety (51% vs 33%), depression (49.2% vs 32%), somatic symptoms (63.7% vs 43.1%), doctor visits (14.7% vs 9.6%), and medication use (83.7% vs 72.4%).
“Clinicians should routinely screen DGBI patients for ARFID, starting with an open-ended question like ‘tell me about your relationship with food’ or a brief 24-hour dietary recall,” Dr. Aziz advised. “Validated questionnaires such as the nine-item ARFID screen can also be used. If positive or concerned, clinicians should consider multidisciplinary care involving dietitians and psychologists.”
The researchers acknowledged certain limitations of the study, including the lack of gender minority groups and the lack of access of medical records to confirm self-reported data. “Longitudinal studies are needed to determine whether DGBI causes ARFID, or vice versa,” Dr. Aziz added. “Randomized trials testing multidisciplinary interventions and cognitive behavioral therapy for co-occurring DGBI and ARFID are also essential.”
The survey was funded by Tillotts Pharma and Novonesis and supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. One of the study authors reported receiving royalties from Oxford University Press and Cambridge University Press. The remaining authors disclosed no conflicts.
Data reinforces addressing food-related fear
GI & Hepatology News invited Madison L. Simons, PsyD, a GI psychologist in the Department of Gastroenterology, Hepatology, and Nutrition at Cleveland Clinic to comment on the study.
Why is this research important?
Dr. Simons: The existing research on ARFID in GI conditions has been specific to certain tertiary care centers where typically patients with more severe GI conditions are being treated. As a population-based study, this study is different in that it provides more generalizable data about the likely prevalence of ARFID among patients with disorders of gut brain interaction. This data replicates what has been found across tertiary care centers, which is that a third of patients with DGBIs screened positive for ARFID based on a brief screening measure. Compared to other studies in GI patients, patients were more likely to screen positive for ARFID based on lack of interest in eating compared to fear of the aversive consequences of food adn eating (such as nausea, vomiting, diarrhea, etc.), which may suggest there are differences in the types of patients that seek medical care for their GI symptoms.
What are the potential clinical implications of the research?
Dr. Simons: This study provides further evidence demonstrating the impact of DGBIs on patients' relationship with food/eating. Unfortunately, this is often not a primary focus of DGBI treatment unless you are being seen in a center that is able to deliver true multidisciplinary care between medicine, psychology, and nutrition. These findings highlight it is of critical importance to be talking to patients about how their GI condition affects their relationship with food/eating and also prioritizing the expansion of the multidisciplinary home for GI care.
What additional research may be needed/what questions remain unanswered?
Dr. Simons: We would still benefit from being able to predict who is at risk of developing ARFID in the context of a digestive condition. We know that there are differences between those with and without ARFID in terms of things like BMI, healthcare utilization, presence of other somatic symptoms, etc., but we do not yet have a way of identifying who could be likely to develop ARFID once their GI symptoms begin, which may help us provide earlier intervention.
A primary research priority for ARFID is the development of effective and scalable treatments for ARFID among patients with GI conditions. This research highlights the immense number of DGBI patients who exhibit symptoms of ARFID, in comparison to the dearth of specialized providers available to treat this condition. While treatments are administered in eating disorder centers for ARFID that does not occur in the context of a GI condition, there are unique medical considerations that DGBI patients have that need to be attended to during ARFID treatment. Effective ARFID treatment is not available in many centers right now; we need a way to expand access to this treatment.
Is there anything else you'd like to say about this work?
Dr. Simons: The ongoing struggle we have around ARFID in GI is that we continue to rely on measures like the Nine-Item ARFID Screen to identify those who exhibit symptoms of ARFID. While the NIAS can tell us certain features of a patient's relationship with food, I think there are more nuances around the eating experience that are not captured, such as hypervigilance around diet or the actual foods consumed and overall dietary pattern. I am hoping in the coming years we can further refine our perspective of ARFID such that it does not over pathologize eating behaviors while also being able to accurately identify those in need of additional support.
Dr. Simons reported having no relevant disclosures.
Summary content
7 Key Takeaways
-
1
Developed a paper-based colorimetric sensor array for chemical threat detection.
-
2
Can detect 12 chemical agents, including industrial toxins.
-
3
Production cost is under 20 cents per chip.
-
4
Utilizes dye-loaded silica particles on self-adhesive paper.
-
5
Provides rapid, simultaneous identification through image analysis.
-
6
Inspired by the mammalian olfactory system for pattern recognition.
-
7
Future developments include a machine learning-enabled reader device.
The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.