Prevalence and clinical correlates of avoidant/restrictive food intake disorder in children and adolescents with Celiac disease: a cross-sectional study

Avoidant/Restrictive Food Intake Disorder (ARFID) may represent a clinically important problem in celiac disease (CD), where lifelong dietary restriction, ongoing gastrointestinal symptoms, and food-related anxiety may promote food avoidance beyond gluten-containing foods and contribute to maladaptive eating patterns. Although adult studies have reported high rates of ARFID symptoms in CD, pediatric data are limited. This study aimed to evaluate the prevalence and clinical correlates of ARFID in children and adolescents with CD using a multidisciplinary assessment approach involving pediatric gastroenterology and child and adolescent psychiatry specialists, including anthropometric, nutritional, bone health, psychological, and health-related quality-of-life (QoL) correlates. A cross-sectional study was conducted at a tertiary-care center involving children and adolescents aged 8–17 years with biopsy-confirmed CD (n = 101). Participants were assessed using a combination of clinical interviews and psychometric scales, including the Nine Item ARFID Screen (NIAS), the Revised Child Anxiety and Depression Scale (RCADS), and the Pediatric QoL Inventory (PedsQL). ARFID diagnosis was established through a DSM-5-guided clinical evaluation by two child and adolescent psychiatrists, and clinical and anthropometric data were collected alongside laboratory results. Multivariable regression models were used to identify factors independently associated with ARFID and clinical outcomes. The prevalence of ARFID in the cohort was 42.6%. Children with ARFID exhibited significantly lower weight and BMI z-scores (p < 0.001 and p = 0.002, respectively), a higher prevalence of osteopenia/osteoporosis (p = 0.005) and micronutrient deficiencies (p < 0.001), poorer QoL (p < 0.001), and higher anxiety and depressive symptom scores (p < 0.001 and p = 0.003, respectively). Presence of gastrointestinal symptoms and higher anxiety score were independently associated with ARFID in children and adolescents with CD. In this cohort, ARFID appeared to be a clinically relevant comorbidity in pediatric CD, with adverse physical and psychosocial correlates. Restrictive eating extending beyond gluten avoidance should be recognized during clinical assessment, particularly in children with gastrointestinal symptoms, prominent anxiety symptoms, poor weight gain, or persistent micronutrient deficiencies. Longitudinal studies are needed to clarify the clinical course of ARFID symptoms and to inform targeted multidisciplinary care in this population. Celiac disease requires lifelong treatment with a strict gluten-free diet. In some children and adolescents, eating difficulties may extend beyond avoiding gluten and develop into avoidant/restrictive food intake disorder (ARFID), an eating disorder marked by very limited eating that is not driven by body image concerns. In celiac disease, ongoing digestive symptoms, fear of symptoms after gluten exposure, and the burden of following a strict diet may increase vulnerability to this problem. This study examined how common ARFID was in young people with celiac disease and explored its clinical features. ARFID was identified in 42.6% of the study group. Children and adolescents with ARFID had lower weight, more nutritional problems, weaker bone health, more anxiety and depression symptoms, and lower quality of life than those without ARFID. Ongoing gastrointestinal symptoms and higher anxiety symptoms were the factors most strongly linked with ARFID. These findings suggest that when food restriction extends beyond medically necessary dietary rules, it may indicate a more serious eating problem with both physical and emotional effects. Care for young people with celiac disease may benefit from a multidisciplinary approach that includes pediatric gastroenterology, child and adolescent psychiatry, dietetics, and psychological support.