We thank Busse and colleagues for their interest and positivity in our research and for providing an opportunity to widen the debate. We acknowledge the value of the C-FAST framework in helping conceptualize conditioned food-related sensitivity and avoidance and congratulate them on establishing this model. Our paper focused on assessing the variation in severity of ARFID against lenient versus strict interpretations of DSM-5 criteria and was not designed to explore broader mechanistic/theoretical models or treatment approaches 1. It arose from clinical concern that ARFID criteria are vague and difficult to operationalize in physical health settings. We had similar concerns regarding limitations of current ARFID screening tools, recently highlighted by Mikhael-Moussa and colleagues 2. Our current clinical approach to managing DGBI with ARFID-like restrictions involves a gastroenterology-led biopsychosocial assessment combined with dietetic and psychological formulation 3. In mild/moderately severe cases, we utilize psychoeducation on conditioned fear responses to symptoms and food combined with graded food exposure and integrate brain gut behavioral therapies and bespoke psychotherapy 3, 4. While we do not explicitly label this as C-FAST, we agree with its principles and it provides a useful and clinically applicable framework. However, there is a key limitation. There exists a complex subgroup with severe malnutrition, as observed in our cohort 1, where C-FAST and similar behavioral strategies are insufficient. These patients present with severe ARFID-like restrictions and multiple co-existing mental disorders. In UK National Health Service settings and beyond, this produces a system-level problem. Eating disorder (ED) services often decline these referrals, as ED is not considered the primary condition. Mental health services defer, as the mental disorder is seen as secondary to physical symptoms, whilst gastroenterology teams cannot progress without specialist psychological input. This cohort are poorly suited for ED units, general psychiatry wards or gastroenterology settings. This result in patients falling between services with no clear ownership and minimal interdisciplinary care. This is not an isolated issue; gastroenterology teams from across the United Kingdom discuss cases at our MDT regularly, suggesting a widespread systemic gap, rather than a local problem. Overall, we support frameworks like C-FAST or other biopsychosocial frameworks such as the Rome MDCP 5, which can assist formulation for food-related fears and avoidance. However, these models may be insufficient for severely malnourished patients. For patients of high ARFID severity, a cultural shift is now needed towards cross-disciplinary ownership and collaborative care across gastroenterology, general psychiatry, and eating disorder services. L.D.M. drafted the manuscript. All other authors contributed equally to the review and editing process. All authors approved the final manuscript. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to Martin et al. papers. To view these articles, visit https://doi.org/10.1111/nmo.70043. Data sharing not applicable to this article.
Martin et al. (Wed,) studied this question.