(106) A Case of Severe Perceived Food Intolerance Requiring Feeding Over Objection

Abstract: Background

Food hypersensitivity is reported by up to 35% of individuals, though fewer than 3% of cases are due to organic causes. Perceived food intolerance (PFI) is used to describe food hypersensitivity reactions that may not correlate with objective findings. People with PFI seem to report more depression, anxiety, and somatic complaints compared with the general population (De Petrillo, 2021). PFI can be associated with disordered eating behaviors, though there is limited literature exploring this relationship. Guidelines exist for management of severe eating disorders, but it is unclear their applicability to patients with severe PFI (MARSIPAN, 2012). We describe a patient reporting food intolerance leading to complete food refusal requiring hospitalization for severe malnutrition and tube feeding over objection. Treatment protocols for management of eating disorders were successfully adapted to guide her care.

Case

Ms. N is a 24 year-old with a history of social reclusiveness, severe refractory depression, and years of reported somatic symptoms triggered by food. She was hospitalized with severe malnutrition secondary to refusal of all oral intake. Despite extensive workup, no medical diagnosis explained her somatic symptoms. She denied purging behaviors or desire to weigh less. During hospitalization, she continued to lose weight despite being on total parenteral nutrition, eventually developing liver failure. Enteral feeding via nasogastric tube was initiated over her objection. She frequently requested interruptions to feeding, citing somatic complaints. Given treatment-interfering behaviors similar to those seen in eating disorders, the consultation-liaison team, in collaboration with the eating disorders specialty team, recommended interventions drawn from treatment protocols for severe anorexia. The patient’s nutritional status improved after implementation of multi-disciplinary team meetings, protocols regarding tube feeding, constant observation, and daily weights.

Discussion

Despite clear overlap with patients with eating disorders, patients with PFI have not necessarily been conceptualized or treated similarly. Avoidant-restrictive food-intake disorder (ARFID), a relatively new DSM diagnosis describing food avoidance and aversion that may encompass some patients with PFI, also lacks well-established treatment guidelines (Guss, 2018). In this case, interventions adapted from eating disorder treatment protocols were effective in bringing about patient improvement.

Conclusion

Patients admitted to the hospital with PFI leading to severe malnutrition require multi-disciplinary collaboration. Conceptualizing PFI as an eating disorder may inform treatment. Further research into the applicability of eating disorder interventions to PFI could advance care for these patients.

References

De Petrillo, Alessandra, et al. "A systematic review of psychological, clinical and psychosocial correlates of perceived food intolerance." Journal of Psychosomatic Research 141 (2021): 110344.

MARSIPAN Working Group. (2012). Management of really sick patients with anorexia nervosa.

Guss, C.E., Richmond, T.K. & Forman, S. A survey of physician practices on the inpatient medical stabilization of patients with avoidant/restrictive food intake disorder. J Eat Disord 6, 22 (2018).