February 2018 Issue

Understanding Orthorexia
By Carrie Dennett, MPH, RDN, CD
Today's Dietitian
Vol. 20, No. 2, P. 24

Learn how to distinguish choice from compulsion in the pursuit of good nutrition.

Nutrition is an important element of good health, but, when taken to extremes, the pursuit of a healthful diet can become unhealthful. Orthorexia is defined as an unhealthful obsession with eating nutritious food that can lead to diets so strict that they have health-related consequences, including malnutrition, social isolation, and severe psychological strain.1-3 The term, which comes from the Greek words for "correct appetite," originated in 1997 with Steven Bratman, MD, based on his observations in the alternative medicine community.

Where does healthful eating end and orthorexia begin? While there's a fine line between healthful eating and orthorexia, there is, in fact, a line. Orthorexia isn't an official eating disorder, but, like eating disorders, it can harm both physical and mental well-being; and, as with all eating disorders, dietitians must be able to recognize the signs—in their patients and themselves.

Orthorexia and Eating Pathology
At what point does prioritizing healthful eating turn pathological? In a 2017 editorial in Eating and Weight Disorders, Bratman noted that orthorexia has two stages. The first is simply choosing to eat a healthful diet. The second is "an intensification of that pursuit into an unhealthy obsession." He cautioned that simply adopting an alternative diet, whether based on science or pseudoscience, doesn't mean someone has orthorexia.4

Some people are prone to adopting any trendy diet that restricts certain food groups. Vegetarian, vegan, gluten-free, raw food, and Paleo diets are a few. While these diets often garner criticism due to the lack of scientific evidence supporting them or concerns that—if they become too strict—they could cause unintended weight loss and nutrient deficiencies, following one of them isn't in and of itself a sign of orthorexia.5,6 It's how individuals respond to a chosen diet that matters.

Eating doesn't become pathological until it becomes entangled with obsessive thinking, compulsive and ritualistic behavior, and self-punishment.4 Individuals with orthorexia often use a diet to achieve a feeling of perfection, purity, or superiority4 and may feel judgmental toward those who don't follow a healthful diet.7 They may spend excessive amounts of time planning and researching "pure" foods, which interferes with participation in normal social activities and interactions.5 It's one thing to generally try to eat organic or eat whole grains instead of refined grains; it's another to become so fixated on avoiding pesticides, GMOs, or white flour that a diet becomes inflexible—they refuse to go out to restaurants, unwilling to let others cook for them.

Utah-based dietitian Emily Fonnesbeck, RD, CD, CLT, says that elimination diets were the slippery slope that led to her struggle with orthorexia. "I only felt worse and worse but kept chasing this magical unicorn of the 'perfect diet.' The anxiety I felt about food was suffocating and totally overwhelmed most other parts of my life. I was afraid to eat out or travel or—the worst of it—to eat a normal meal with my family. I had to have complete control of everything I was eating."

Assessing and Diagnosing Orthorexia
One difficulty with assessing the prevalence of orthorexia in the general population or within specific populations, such as dietitians or performing artists, is that there's no consensus definition of orthorexia or validated assessment tool. There's legitimate criticism that the few tools used to assess orthorexia prevalence can't distinguish between healthful eating and pathologically healthful eating. This includes the tool most frequently used in research, the ORTO-15 questionnaire, and the Bratman Orthorexia Test (BOT), the precursor to the ORTO-15.8-11

The BOT was derived from what Bratman described as an informal orthorexia self-test in the 2001 book Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating. The BOT has never been validated (Bratman himself dismisses it in his 2017 editorial),4 yet has been used in several studies, including a 2016 study that found higher tendencies for orthorexia among students with a Hispanic/Latino background and students with BMIs in the overweight and obese ranges.12 The ORTO-15 is partly validated and has been shortened for use in some studies to 11 items (ORTO-11). Where these tools primarily fall short is in accurately assessing the psychological aspects of orthorexia.13-15

"The ORTO-15 measures interest in food and nutrition; it is not intended to diagnose orthorexia," says Jessica Setnick, MS, RD, CEDRD, author of The Eating Disorders Clinical Pocket Guide: Quick Reference for Healthcare Providers. In March, an international panel of experts will meet in Rome to propose diagnostic criteria for orthorexia for inclusion in the Diagnostic and Statistical Manual of Mental Disorders. "Part of the process is determining whether orthorexia is different enough from other current diagnoses such as anorexia nervosa and obsessive-compulsive disorder (OCD). I believe that it is," Setnick says. "I believe that all of the eating disorder diagnoses would benefit from an overhaul, where assessment relies more on the etiology of the illness than on a list of eating behaviors or weight, and I am hoping that we can lead the way with orthorexia."

Criteria endorsed by Bratman in 2016 include an obsessive focus on healthful eating that includes compulsive behavior and mental preoccupation, anxiety and distress when self-imposed dietary rules are violated, dietary restrictions that escalate over time, and one of the following6:

• malnutrition, severe weight loss, or other medical complications from the restricted diet;
• intrapersonal distress or impairment of social, academic, or work functioning that's secondary to a person's dietary beliefs or behaviors; or
• positive body image, self-worth, identity, and/or satisfaction that's excessively dependent on compliance with self-defined "healthful" eating behavior.

"I would like to see more research that validates assessment tools and uniquely distinguishes orthorexia from other [eating disorders]," says Rebecca Scritchfield, MA, RDN, HFS, author of Body Kindness: Transform Your Health From the Inside Out — And Never Say Diet Again. Until then, she says, antidiet dietitians can recognize orthorexia as a disordered eating pattern and work with clients on flexible, unrestricted eating patterns.

Where Does Orthorexia Fit?
It's unclear whether orthorexia may qualify as a unique eating disorder or whether it's a variant of—or precursor to—anorexia or OCD.1,15 What orthorexia has in common with anorexia is a sense of control and predictability—you can't control life, but you can control your food—and that obsessing about food can be a way of avoiding negative feelings. The downside is that when control cracks and a forbidden food is eaten, feelings of failure, guilt, and self-hatred often follow.

Orthorexia and anorexia have several other similarities, including preoccupation with food and eating, restrictive eating habits, eating rituals, magical beliefs about food, intense anxiety and fear regarding certain foods, and an exaggerated need for self-care and protection.1,16 Orthorexia, anorexia, and OCD all share rigid and perfectionistic personality traits, need for control, and anxiety.6

Unlike anorexia, orthorexia generally doesn't have weight loss as a goal. The focus is on the quality, not the quantity, of food.2 Someone may start with wanting to be healthier but take it to a pathological level. Orthorexia has the potential to morph into anorexia, especially if the list of foods to avoid grows too long.

Abbey Sharp, RD, a Toronto-based dietitian and blogger at www.abbeyskitchen.com, struggled with orthorexia in her late teens and early 20s. The trigger was a naturopathic doctor telling her she was allergic to sugar. She started poring over cookbooks and magazines related to clean eating, and the list of foods she allowed herself grew shorter and shorter. "At my worst, I weighed 85 pounds. I could barely function," she says, even though weight loss wasn't her goal.

In fact, orthorexia has been called a variant of "healthism," which is characterized by an enthusiastic pursuit of health information, frequent use of "natural" or "holistic" supplements and alternative medicines, repeated use of detox diets or supplement protocols, and maintenance of regular exercise and healthful eating patterns.1 It places emphasis on personal responsibility for achieving health and preventing disease.17 The current trends of life extension and biohacking are newer manifestations of healthism that could lead to orthorexia. Even though health, rather than weight loss, is the primary motivation, Bratman has noted that this is a difficult distinction, given that health ideals often are entangled with body weight and body composition.4

Who's at Risk?
Roughly 70% of published articles about orthorexia found in PubMed have been published in the last five years.3 Some of that research focuses on whether dietitians and other health professionals are more prone to developing orthorexia. Although there are reasons nutrition education may increase the risk of developing orthorexia, and individuals with orthorexic tendencies may be attracted to nutrition as a course of study and career, establishing prevalence is difficult, given the lack of a reliable assessment tool.

The prevalence of orthorexia in the general population has been estimated at 6.9%,18 although a more thorough 2017 analysis places the estimate at around 1%.8 Various studies have noted a higher prevalence of orthorexia in populations with more nutrition education, including dietitians, and among nutrition, nursing, and medical students,1,19 as well as yoga instructors, exercise students, and people who work in the performing arts.18,20,21

"It's logical that if your thoughts are preoccupied with food, you'd be drawn to school and work that centers on food," Scritchfield says.

Results of a survey of 636 dietitians recently published in the Journal of the Academy of Nutrition and Dietetics suggested that nearly one-half scored at high risk of orthorexia on the ORTO-15.22 A 2016 study using the BOT found that while 26.6% of Polish dietetics students scored as "health food fanatics," none scored high enough to be considered "orthorexic."23 A 2009 study of German nutrition students and a 2013 study of Portuguese nutrition students found higher levels of dietary restraint than in control groups of nonnutrition students but found no differences in tendency toward orthorexia.24,25

"I think that dietetic training per se doesn't necessarily cause orthorexia or other eating disorders, but if you're already susceptible, the constant nutrition information can be overwhelming and scary and can accelerate obsessions," Sharp says. "Learning about the dangers of specific diet patterns or food can create an excessive amount of food fear in students who are already struggling, so it definitely can perpetuate the issues."

Influence of Social Media
When Bratman first defined orthorexia, he observed that it was primarily found in alternative medicine subcultures. Today, with increased interest in healthful eating, driven in part by the internet and social media, the prevalence may be greater.4 Research suggests many people use social media to seek advice about food,20 and social media use has been associated with negative body image, social comparison, and disordered eating, but Instagram may be unique in its association with an increased tendency toward orthorexia.20

A 2017 study found that the healthful eating community on Instagram has a high prevalence of orthorexic symptoms, with higher Instagram use linked to increased symptoms, although the authors noted that the participant sample wasn't likely representative of the general population.20 The hashtag #food is one of the most popular on Instagram, and healthful food photos receive more likes than photos of less healthful foods.20 What should dietitians on social media be mindful of?

"I think the key is to be careful what kind of copy and hashtags you're including with those images," Sharp says. "Rather than using morally loaded terms such as 'cheat day,' 'clean eating,' 'detox,' 'guilt-free,' 'low-cal,' or 'diet,' look at celebrating food for its inherent benefits and pleasure." She suggests dietitians balance the healthful foods they post with some more indulgent foods to demonstrate that RDs can and do eat them in moderation. "For example, sharing photos of your healthy salad one day if it's truly delicious and your ice cream cone the day later. Dietitians need the public to know that we're all human and that being healthy doesn't mean eating just chicken breasts and broccoli."

Depending on how it's portrayed, the clean eating trend can lead to excessive restrictions.26 At one end of the clean eating spectrum is good nutrition and an abundance of whole or minimally processed foods; at the other is a restricted diet with strict avoidance of foods considered to be unhealthful or impure.5,15,27

"Dietitians should ask themselves, 'How am I being helpful?' with their posts. Show accessible, real-world images of food," Scritchfield says. "We have a tendency to follow what each other is doing, and we also believe that being popular on social media is the key to accelerating a stellar career in nutrition."

Setnick seconds the call for more real-world food photos. "I wish people would post more photos of their wilted tuna sandwiches and reheated leftover pizza," she says. "I follow several eating disorder dietitians who do this and it is quite a relief."

Food for Thought
As with established eating disorders, orthorexia treatment typically requires a multidisciplinary team of psychiatrists, psychologists, physicians, and dietitians.2,15 "We can reduce food fears and help clients create eating patterns that feel good, incorporating mindfulness, intuitive eating, generally balanced eating patterns, and, when appropriate, apply the necessary MNT recommendations all with a gentle, compassionate approach to changing habits," Scritchfield says, adding that this doesn't apply only to patients. "Dietitians are worthy of their own recovery from their own food and body concerns and will be better positioned to do fulfilling work and help the people they serve with a healthier and more realistic mindset around food and body image."

When Fonnesbeck's husband encouraged her to seek help, she started seeing a therapist who helped her deal with her perfectionism and anxiety. "Addressing those root causes allowed me over time to challenge my food rules and feed my body in a way that felt truly nourishing, satisfying, and energizing."

Setnick says that most patients with undiagnosed eating disorders are under the care of general clinical dietitians, so knowing how to correctly address dysfunctional eating behaviors is critical. If a dietitian doesn't pick up on a patient's anxiety about eating, or misinterprets that anxiety as enthusiasm or motivation to eat well, nutrition education can contribute to unhealthful obsessions and fears about food. She cautions that vague words such as "avoid" and "eliminate" may mean "zero tolerance" to a patient, so dietitians should give specific limits. "Orthorexia at its core is high anxiety about eating and fear of mistakes," Setnick says. "By being precise and also compassionate and by recognizing that by virtue of our role we convey authority and possibly fear even when we don't mean to, dietitians can minimize the anxiety we add to the process."

Fonnesbeck says she started her career focused on numbers, diets, and weight loss as the path toward health. "I definitely had that mindset due to my dietetics training and also my personal relationship with food and my body," she says. "It is chilling for me to realize that I was a practicing dietitian when I myself was in a very deep struggle with orthorexia. I know for a fact that I was definitely triggering, which is just unacceptable." Triggering refers to a situation, interaction, emotion, or object that sets off, in this case, disordered eating behaviors.

Sharp says when dietitians catch themselves making moral judgments on food—their own food or their patients' food—it's an opportunity to stop and evaluate the language they're using. "It may be helpful to explore why you're using the language around food that you do (ie, good food/bad food), and try to find more morally neutral ways to communicate nutrition information," Sharp says.

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and frequently speaks on nutrition-related topics. She provides nutrition counseling via the Menu for Change program in Seattle.

References
1. Brytek-Matera A, Donini LM, Krupa M, Poggiogalle E, Hay P. Orthorexia nervosa and self-attitudinal aspects of body image in female and male university students. J Eat Disord. 2015;3:2.

2. Moroze RM, Dunn TM, Craig Holland J, Yager J, Weintraub P. Microthinking about micronutrients: a case of transition from obsessions about healthy eating to near-fatal "orthorexia nervosa" and proposed diagnostic criteria. Psychosomatics. 2015;56(4):397-403.

3. Missbach B, Barthels F. Orthorexia nervosa: moving forward in the field. Eat Weight Disord. 2017;22(1):1.

4. Bratman S. Orthorexia vs. theories of healthy eating. Eat Weight Disord. 2017;22(3):381-385.

5. Nevin SM, Vartanian LR. The stigma of clean dieting and orthorexia nervosa. J Eat Disord. 2017;5:37.

6. Dunn TM, Bratman S. On orthorexia nervosa: a review of the literature and proposed diagnostic criteria. Eat Behav. 2016;21:11-17.

7. Varga M, Thege BK, Dukay-Szabó S, Túry F, van Furth EF. When eating healthy is not healthy: orthorexia nervosa and its measurement with the ORTO-15 in Hungary. BMC Psychiatry. 2014;14:59.

8. Dunn TM, Gibbs J, Whitney N, Starosta A. Prevalence of orthorexia nervosa is less than 1%: data from a US sample. Eat Weight Disord. 2017;22(1):185-192.

9. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C. Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eat Weight Disord. 2004;9(2):151-157.

10. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C. Orthorexia nervosa: validation of a diagnosis questionnaire. Eat Weight Disord. 2005;10(2):e28-e32.

11. Bratman S, Knight D. Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating. New York, NY: Broadway Books; 2001.

12. Bundros J, Clifford D, Silliman K, Neyman Morris M. Prevalence of orthorexia nervosa among college students based on Bratman's test and associated tendencies. Appetite. 2016;101:86-94.

13. Missbach B, Dunn TM, König JS. We need new tools to assess orthorexia nervosa. A commentary on "Prevalence of orthorexia nervosa among college students based on Bratman's test and associated tendencies." Appetite. 2017;108:521-524.

14. Missbach B, Hinterbuchinger B, Dreiseitl V, Zellhofer S, Kurz C, König J. When eating right, is measured wrong! A validation and critical examination of the ORTO-15 questionnaire in German. PLoS One. 2015;10(8):e0135772.

15. Koven NS, Abry AW. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatr Dis Treat. 2015;11:385-394.

16. Michalska A, Szejko N, Jakubczyk A, Wojnar M. Nonspecific eating disorders — a subjective review. Psychiatr Pol. 2016;50(3):497-507.

17. Håman L, Barker-Ruchti N, Patriksson G, Lindgren EC. Orthorexia nervosa: an integrative literature review of a lifestyle syndrome. Int J Qual Stud Health Well-being. 2015;10:26799.

18. Varga M, Dukay-Szabó S, Túry F, van Furth EF. Evidence and gaps in the literature on orthorexia nervosa. Eat Weight Disord. 2013;18(2):103-111.

19. Arslantas H, Adana F, Ogut S, Ayakdas D, Korkmaz A. Relationship between eating behaviors of nursing students and orthorexia nervosa (obsession with healthy eating): a cross-sectional study. J Psychiatr Nurs. 2017;8(3):137-144.

20. Turner PG, Lefevre CE. Instagram use is linked to increased symptoms of orthorexia nervosa. Eat Weight Disord. 2017;22(2):277-284.

21. Bo S, Zoccali R, Ponzo V, et al. University courses, eating problems and muscle dysmorphia: are there any associations? J Transl Med. 2014;12:221.

22. Tremelling K, Sandon L, Vega GL, McAdams CJ. Orthorexia nervosa and eating disorder symptoms in registered dietitian nutritionists in the United States. J Acad Nutr Diet. 2017;117(10):1612-1617.

23. Dittfeld A, Gwizdek K, Koszowska A, et al. Assessing the risk of orthorexia in dietetic and physiotherapy students using the BOT (Bratman Test for Orthorexia). Pediatr Endocrinol Diabetes Metab. 2016;22(1):6-14.

24. Korinth A, Schiess S, Westenhoefer J. Eating behaviour and eating disorders in students of nutrition sciences. Public Health Nutr. 2010;13(1):32-37.

25. Mealha V, Ferreira C, Guerra I, Ravasco P. Students of dietetics & nutrition; a high risk group for eating disorders? Nutr Hosp. 2013;28(5):1558-1566.

26. James C, Harrison A, Seixas A, Powell M, Pengpid S, Peltzer K. "Safe foods" or "fear foods": the implications of food avoidance in college students from low- and middle-income countries. Eat Weight Disord. 2017;22(3):407-419.

27. Wilson B. Why we fell for clean eating. The Guardian. August 11, 2017. https://www.theguardian.com/lifeandstyle/2017/aug/11/why-we-fell-for-clean-eating  

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