What is orthorexia

Orthorexia is also called orthorexia nervosa, literally meaning “proper appetite”, is a pathological obsession with healthy food or proper nutrition in order to avoid ill health and disease, that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure ¹. People who suffer from this eating fixation undergo a monomania for healthy food without artificial additives and are more concerned with the quality of food than the quantity ². Although prompted by a desire to achieve optimum health, orthorexia may lead to nutritional deficiencies, medical complications, and poor quality of life ³. Bratman and Knight first proposed orthorexia nervosa in 1997 ⁴, defining it an obsession with eating healthy food to achieve, for instance, improved health. Currently, orthorexia is not recognized as a disease by the fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ⁵.

Orthorexia causes

Individuals who suffer from orthorexia nervosa are characterized by their adherence to a restrictive diet; one that strictly avoids certain foods which the individuals consider to be unhealthy, together with the practice of eating rituals (e.g. waiting unusually long periods of time between meals to allow for digestion, based on self-imposed rules regarding food type combinations, or only combining certain foods during certain times during the day) ³. Different studies have observed that the risk of orthorexia nervosa is frequently related to those who opt for a vegetarian or vegan diet ⁶. The orthorexic subjects demonstrate characteristics that reflect their specific “feelings” towards food (“dangerous” to describe a product with conservatives, “artificial” for industrially produced products and “healthy” for organic produce). They also demonstrate a strong or uncontrollable desire to eat when feeling nervous, excited, happy or guilty ⁷. It is common practice among people with orthorexia nervosa to exclusively consume foods originating from organic agriculture which is free from artificial substances, like pesticides and herbicides, thus avoiding transgenic foodstuffs. They are also typically preoccupied with the techniques and materials employed in food manufacturing ⁸. Furthermore, orthorexia nervosa may involve psychological and social disorders ⁹. At the psychological level, these individuals can suffer from feelings of frustration when they transgress or fail to comply with this type of diet ¹⁰. Orthorexic individuals are at risk of social isolation due to their belief that being alone allows them to fully control the entire process of food preparation. Such a belief, for example, may inhibit them from forming relationships with people whose habits and beliefs differ from theirs ⁹.

Orthorexia symptoms

Bratman and Knight ⁴ defined orthorexia as “a fixation on eating healthy food” in order to avoid ill health and disease. The term orthorexia nervosa describes individuals with an obsession for proper nutrition who pursue this obsession through a restrictive diet, a focus on food preparation, and ritualized patterns of eating. Orthorexic individuals are typically concerned by the quality, as opposed to the quantity, of food in one’s diet ¹¹, spending considerable time scrutinizing the source (e.g., whether vegetables have been exposed to pesticides; whether dairy products came from hormone-supplemented cows), processing (e.g., whether nutritional content was lost during cooking; whether micro-nutrients, artificial flavoring, or preservatives were added), and packaging (e.g., whether food may contain plastic-derived carcinogenic compounds; whether labels provide enough information to judge the quality of specific ingredients) of foods that are then sold in the marketplace ¹². The fixation on food quality – a combination of the nutritional value of food as well its perceived purity – is prompted by a desire to maximize one’s own physical health and well-being, rather than religious beliefs or concerns for sustainable agriculture, environmental protection, or animal welfare. Such preoccupation with health from food may elicit eating patterns that are especially complex (e.g., internalized rules governing which foods can be combined at one sitting or at certain times of day) and/or require unusually long periods of time to execute (eg, beliefs that maximal digestion of one food type occurs a certain amount of time after ingestion of another food type). Outside of meals, extra time is spent researching and cataloging food, weighing and measuring food, and planning future meals, with additional, intrusive, food-related thoughts occurring outside of these circumscribed periods ¹³. Diagnostic criteria, as suggested by Moroze et al ¹⁴, are shown below.

With regard to the consequences of this extreme style of eating, orthorexic individuals may experience nutritional deficiencies due to omission of entire food groups ¹⁵ and, although long-term empirical studies are lacking, there is anecdotal evidence that this kind of dietary extremism can lead to the same medical complications that one sees with severe anorexia: osteopenia, anemia, hyponatremia, metabolic acidosis, pancytopenia, testosterone deficiency, and bradycardia ¹⁶. Psychologically, orthorexic individuals experience intense frustration when their food-related practices are disrupted or thwarted, disgust when food purity is seemingly compromised, and guilt and self-loathing when they commit food transgressions ¹⁷, all of which is superimposed on chronic worry about imperfection and nonoptimal health. Indeed, dietary violations may prompt a desire for self-punishment, manifested by an even stricter diet, or purification via supposedly cleansing fasts ¹³. Moreover, orthorexic individuals are at risk for social isolation, as they may believe that they can only maintain healthy eating while alone and in control of one’s surroundings and may adopt a stance of moral superiority about their food habits such that they do not wish to interact with others who are unlike them ¹⁷.

Orthorexia nervosa diagnostic criteria proposed by Moroze et al ¹⁴:

Criterion A: Obsessional preoccupation with eating “healthy foods,” focusing on concerns regarding the quality and composition of meals. (Two or more of the following.):

• Consuming a nutritionally unbalanced diet owing to preoccupying beliefs about food “purity.”
• Preoccupation and worries about eating impure or unhealthy foods and of the effect of food quality and composition on physical or emotional health or both.
• Rigid avoidance of foods believed by the patient to be “unhealthy,” which may include foods containing any fat, preservatives, food additives, animal products, or other ingredients considered by the subject to be unhealthy.
• For individuals who are not food professionals, excessive amounts of time (e.g., 3 or more hours per day) spent reading about, acquiring, and preparing specific types of foods based on their perceived quality and composition.
• Guilty feelings and worries after transgressions in which “unhealthy” or “impure” foods are consumed.
• Intolerance to other’s food beliefs.
• Spending excessive amounts of money relative to one’s income on foods because of their perceived quality and composition.

Criterion B: The obsessional preoccupation becomes impairing by either of the following:

• Impairment of physical health owing to nutritional imbalances (eg., developing malnutrition because of an unbalanced diet).
• Severe distress or impairment of social, academic, or vocational functioning owing to obsessional thoughts and behaviors focusing on patient’s beliefs about “healthy” eating.

Criterion C: The disturbance is not merely an exacerbation of the symptoms of another disorder such as obsessive-compulsive disorder or of schizophrenia or another psychotic disorder.

Criterion D: The behavior is not better accounted for by the exclusive observation of organized orthodox religious food observance or when concerns with specialized food requirements are in relation to professionally diagnosed food allergies or medical conditions requiring a special diet.

Warning signs and symptoms

It is important to know the warning signs of an eating disorder. These may indicate that an eating disorder is developing or is being experienced in full. Below are lists of behavioral, physical and psychological signs or changes which often accompany an eating disorder. If you or somebody you know is experiencing several of the following symptoms, it is important to seek help immediately to determine if you/they have a problem. Early intervention is vital in promoting recovery.

It is also important to realize that these warning signs may not be as easy to detect as they sound. The person with the eating disorder often experiences shame or guilt about their behavior, and will try to hide it. Also, many people with eating disorders do not realize they have a problem, or even if they do they will not want to give up their behavior at first, because it is their mechanism for coping with an issue. Thus they will go to extraordinary lengths to hide the signs of their behavior.

Please note that any combination of these symptoms can be present in an eating disorder, because no one eating disorder is exactly the same as another. It is also possible for a person to demonstrate several of these signs and yet not have an eating disorder. It is always best to seek a professional opinion.

Behavioral warning signs

• Constant or repetitive dieting (e.g. counting calories/kilojoules, skipping meals, fasting, avoidance of certain food groups or types such as meat or dairy, replacing meals with fluids)
• Evidence of binge eating (e.g. disappearance of large amounts of food from the cupboard or fridge, lolly wrappers appearing in bin, hoarding of food in preparation for bingeing)
• Evidence of vomiting or laxative abuse (e.g. frequent trips to the bathroom during or shortly after meals)
• Excessive or compulsive exercise patterns (e.g. exercising even when injured, or in bad weather, refusal to interrupt exercise for any reason; insistence on performing a certain number of repetitions of exercises, exhibiting distress if unable to exercise)
• Making lists of ‘good’ and ‘bad’ foods
• Changes in food preferences (eg. refusing to eat certain foods, claiming to dislike foods previously enjoyed, sudden interest in ‘healthy eating’)
• Development of patterns or obsessive rituals around food preparation and eating (e.g. insisting meals must always be at a certain time; only using a certain knife; only drinking out of a certain cup)
• Avoidance of all social situations involving food
• Frequent avoidance of eating meals by giving excuses (e.g. claiming they have already eaten or have an intolerance/allergy to particular foods)
• Behaviors focused around food preparation and planning (e.g. shopping for food, planning, preparing and cooking meals for others but not consuming meals themselves; taking control of the family meals; reading cookbooks, recipes, nutritional guides)
• Strong focus on body shape and weight (e.g. interest in weight-loss websites, dieting tips in books and magazines, images of thin people)
• Development of repetitive or obsessive body checking behaviors (e.g. pinching waist or wrists, repeated weighing of self, excessive time spent looking in mirrors)
• Social withdrawal or isolation from friends, including avoidance of previously enjoyed activities
• Change in clothing style, such as wearing baggy clothes
• Deceptive behavior around food, such as secretly throwing food out, eating in secret (often only noticed due to many wrappers or food containers found in the bin) or lying about amount or type of food consumed
• Eating very slowly (e.g. eating with teaspoons, cutting food into small pieces and eating one at a time, rearranging food on plate)
• Continual denial of hunger

Physical warning signs

• Sudden or rapid weight loss
• Frequent changes in weight
• Sensitivity to the cold (feeling cold most of the time, even in warm environments)
• Loss or disturbance of menstrual periods (females)
• Signs of frequent vomiting – swollen cheeks/ jawline, calluses on knuckles, or damage to teeth
• Fainting, dizziness
• Fatigue – always feeling tired, unable to perform normal activities

Psychological warning signs

• Increased preoccupation with body shape, weight and appearance
• Intense fear of gaining weight
• Constant preoccupation with food or with activities relating to food
• Extreme body dissatisfaction/ negative body image
• Distorted body image (e.g., complaining of being/feeling/looking fat when actually a healthy weight or underweight)
• Heightened sensitivity to comments or criticism about body shape or weight, eating or exercise habits
• Heightened anxiety around meal times
• Depression or anxiety
• Moodiness or irritability
• Low self-esteem (e.g., feeling worthless, feelings of shame, guilt or self-loathing)
• Rigid ‘black and white’ thinking (viewing everything as either ‘good’ or ‘bad’)
• Feelings of life being ‘out of control’
• Feelings of being unable to control behaviors around food

Orthorexia test

To date, neither the diagnostic criteria published for orthorexia nervosa ¹⁸, nor the different studies available have given enough clarity to include this disorder in the DSM-5 ¹⁹, nor in the tenth edition of the International Classification of Diseases (ICD-10) ²⁰. Furthermore, some studies have related orthorexia nervosa with obsessive compulsive disorders (OCD) ²¹.

In their original treatise on orthorexia, Bratman and Knight1 proposed a simple 10-item dichotomous rating scale by which to assess orthorexia, but this measure has not received much traction in the literature. Instead, researchers have relied primarily on a modification of this scale called the ORTO-15 ²² and, to a lesser degree, the ORTO-11 ²³ and ORTO-11-Hu ²⁴ to measure the prevalence of orthorexia in various populations ²⁴. There is debate, however, as to the reliability and validity of these measures.

Donini et al. ²² performed a study, in which they developed and validated a questionnaire to detect the risk of suffering orthorexia nervosa: the ORTO-15 (see Table 1 below).

The ORTO-15 is a 15-item measure that assesses beliefs about the perceived effects of eating healthy food (eg, “Do you think that consuming healthy food may improve your appearance?”), attitudes governing food selection (eg, “Are your eating choices conditioned by your worry about your health status?”), habits of food consumption (eg, “At present, are you alone when having meals?”), and the extent to which food concerns influence daily life (eg, “Does the thought about food worry you for more than 3 hours a day?”) ²². Responses are scored on a 4-point scale and totaled, with scores below 40 considered indicative of orthorexia and higher scores purportedly reflecting normal eating behavior. With regard to its psychometric properties, Donini et al ²² report sensitivity, specificity, and predictive validity values for the ORTO-15 using this threshold in an Italian adult sample. However, the lack of established diagnostic criteria makes it difficult to gauge the appropriateness of any self-report measure, as epidemiological research is predicated on the existence of a gold standard approach for ascertaining true from false positives and true from false negatives. Beyond this, the ORTO-15 has been criticized for potentially problematic internal consistency. In four different samples of American undergraduate students, reported Cronbach’s alpha coefficients have ranged from an unacceptable low of 0.14 ²⁵ to respectable highs above 0.70 ²⁶. While this one instance of poor overall internal consistency may represent an isolated methodological design flaw, it is also worth noting that low internal reliability may signal an orthogonal multifactorial latent structure. Indeed, factor analytic work on the ORTO-15 has suggested both two ²⁵ and three-factor ²² solutions. However, in these studies, these factors did not collectively explain a large proportion of the variance observed across the ORTO-15 items.

Some researchers have eliminated items from the ORTO-15 in an effort to strengthen its reliability and validity. For example, when adapting the ORTO-15 for use in a Hungarian population, Varga et al ²⁴ eliminated four items from the measure to improve its consistency, resulting in the ORTO-11-Hu. Although more research is needed, the ORTO-11-Hu appears to have good internal reliability (Cronbach’s α =0.82) when used in a Hungarian population. Similarly, Arusoğlu et al39 eliminated four items from the ORTO-15 for use in a Turkish population, achieving an 11-item version with an internal validity coefficient of 0.62. Notably, the items eliminated from the ORTO-15 for the Hungarian adaptation were different from the items eliminated for the Turkish adaptation. While it is possible, as Varga et al ²⁴ suggest, that cultural differences account for contradictory internal consistency values across samples, it is also possible that the ORTO-15 is simply not a reliable measure of orthorexia.

Another serious point of concern regarding the ORTO-15 is the fact that it does not account for the obsessive–compulsive symptoms that people with orthorexia experience, such as intrusive food related thoughts, concerns with contamination and impurity, and the tendency to eat in a ritualized manner. This flaw prompted the researchers who developed the ORTO-15 to only label a study participant as orthorexic if the participant exhibited both “health fanatic behavior” (as determined by ORTO-15 score) and an “altered MMPI” ²². Participants who met this latter criterion were men who scored less than 66 and women who scored less than 65 on Scale 7 of the Minnesota Multiphasic Personality Inventory, which accounts for obsessive behavior ²². Yet in various other studies ²⁷, researchers have used the ORTO-15 as the sole measure of orthorexia, raising concerns about the accuracy of their results.

Table 1. ORTO-15 questionnaire, an instrument designed to assess orthorexia nervosa behavior

1) When eating, do you pay attention to the calories of the food?
2) When you go in a food shop do you feel confused?
3) In the last 3 months, did the thought of food worry you?
4) Are your eating choices conditioned by your worry about your health status?
5) Is the taste of food more important than the quality when you evaluate food?
6) Are you willing to spend more money to have healthier food?
7) Does the thought about food worry you for more than three hours a day?
8) Do you allow yourself any eating transgressions?
9) Do you think your mood affects your eating behavior?
10) Do you think that the conviction to eat only healthy food increases self-esteem?
11) Do you think that eating healthy food changes your life-style (frequency of eating out, friends …)?
12) Do you think that consuming healthy food may improve your appearance?
13) Do you feel guilty when transgressing?
14) Do you think that on the market there is also unhealthy food?
15) At present, are you alone when having meals?
Items	Always	Often	Sometimes	Never
2,5,8,9	4	3	2	1
3,4,6,7,10,11,12,14,15	1	2	3	4
1,13	2	4	3	1

Footnote: Responses are scored on a 4-point scale and totaled, with scores below 40 considered indicative of orthorexia and higher scores purportedly reflecting normal eating behavior.

[Source ²² ]

Orthorexia treatment

To date, there are no studies of treatment effectiveness for orthorexia, although suggestions for best practices have been offered. The ideal intervention involves a multidisciplinary team that includes physicians, psychotherapists, and dieticians ²⁸ such that a combination of medication, cognitive-behavioral therapy, and psychoeducation ²⁹ can be applied with close monitoring in outpatient settings. In cases of significant weight loss and malnourishment, an inpatient setting with physicians experienced in refeeding syndrome ³⁰ would be indicated.

With regard to psychotropic medication, serotonin reuptake inhibitors are reportedly helpful for orthorexia ²⁹, which makes sense given evidence of their efficacy for both anorexia and OCD ³¹. Others have successfully used antipsychotics such as olanzapine to decrease the obsessive nature of magical food-related thinking.5 It should be noted, however, that orthorexic individuals may be apt to reject pharmaceuticals as “non-natural” substances ²⁹. When considering psychotherapy, interventions should be individualized based on the symptoms that are prominent for a given patient ³², recognizing that treatment goals should focus not only on what patients eat but also on how they shop for, prepare, and feel about the food they consume ²⁸. Exposure and response prevention, potentially in conjunction with habit reversal training ³³, may be most successful for treating obsessive and compulsive aspects of orthorexia. Cognitive restructuring is likely to be beneficial for dichotomous thinking, overgeneralization, catastrophization, and other cognitive distortions surrounding food, eating, and health ³⁴ as well as associated problematic traits such as perfectionism. Various forms of relaxation training may assist with pre- and postprandial anxiety ³⁵ and other manifestations of health anxiety ³⁶. Moreover, behavior modification strategies may be useful to expand one’s food repertoire, increase socialization during meals, and diversify leisure activities to include nonfood themes. Lastly, psychoeducation about empirically-validated dietetic science may help disabuse orthorexic patients of false food beliefs ³⁷. However, research indicates that nutrition and health education, while obviously needing to contain objective concepts about nutrients and physiology, should also recognize the deeply emotional aspects of food beliefs and food choices so as to incorporate affective approaches to patient counseling ³⁸. Asking severely orthorexic patients to abandon false food beliefs is really a request to discard a deeply held ideology; as discussed by Lindeman et al ³⁹, ideologies, whether comprised of reality-grounded or magical beliefs, provide structure and order to one’s life, reducing anxiety by providing a means to exert control over the environment. Psychoeducation, to the extent that it challenges an entrenched belief system, should be undertaken with an appreciation of its potential for significant emotional upheaval in the patient.

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