Orthorexia Nervosa: A Condition in Search of a Diagnosis?

One study shows distinct similarities and differences between ON and symptoms of an eating disorder.

On the surface, orthorexia nervosa, or ON, might seem like an admirable attempt to eat only “healthy foods.” Eating healthily fits right into our national trend to favor natural foods. Steven Bratman, MD, MPH, a California physician, coined the term orthorexia nervosa (“fixation on righteous eating”) in 1996. Diagnostic criteria have been proposed, but the relationship of ON to (other) eating disorders is still not clear.

Some experts think there are similarities between the constant worry about food seen in orthorexia as in eating disorders such as BN and AN because all share common efforts around food and control. There is still controversy about this pattern of eating, and some suggest ON shares characteristics with obsessive-compulsive disorders, somatoform disorders, and even autism spectrum disorders. However, ON does not neatly fit into any diagnostic criteria.

Segura-Garcia et al. showed that 28% of patients with AN and BN showed a tendency to ON using Bratman’s measure, the ORTO-15 (Eat Weight Disord. 2015; 20:161). This increased to 53% of patients by the end of the study. That study’s findings suggest that ON symptoms may recede, develop, or even coexist with an eating disorder.

Some overlapping symptoms

Marta Plichta and Marzena Jezewska-Zychowicz of Warsaw University of Life Sciences, Warsaw, Poland, designed a study to better define ON, and to compare it with symptoms of eating disorders in a sample from the general population (Nutrients. 2020; 12:218). The final sample included 1120 male and female students 18 to 35 years of age recruited from 7 universities.  The researchers gathered information about eating habits and eating disorder symptoms, as well as sociodemographic characteristics, using the Polish version of the Eating Disorder Screen for Primary Care Professionals. Orthorexia symptoms were assessed using the ORTO-15. The final study group included 70% females and 30% males. More than 70% of participants were under 23 years of age, more than two-fifths lived in large cities, and about 73% were of normal weight.

A tendency toward ON was found in 28% of the study sample, while low-level eating disorder symptoms were found in nearly 51%. More than a third of the students had only eating disorder symptoms, while 15% showed only a tendency to have ON. Nearly two-thirds reported that they ate 4 or more meals a day, while more than half (59%) did not eat meals regularly. Eating habits were not related to gender. Nearly 70% of the participants ate meals every 3 to 4 hr; more females ate every 3 to 4 hr, compared to males, who took a 4-hr break between meals. Most (87%)  students did not skip breakfast, dinner (92.3%), or supper (87.9%). Thirteen percent of the students were on special diets.

Using the results of the ORTO-15 questionnaire and a cut-off age of 35 years, ON was identified in 28% of the study sample, consistent with earlier studies. Almost half of people with a tendency to ON also showed symptoms of an eating disorder. The authors noted that although ON may precede an ED, it may also occur during remission from an eating disorder.

The authors also pointed out that a high proportion of participants—38%– showed only eating disorder symptoms. This was higher than that found in other studies among students from 9 other countries, where the incidence of eating disorder symptoms ranged from a low of 2% to a high of 29%. Some researchers have noted that starting a new educational program, such as going to college, may increase stress, social pressure, and low self-esteem and can lead to a change in eating behaviors, particularly those behaviors designed to avoid weight gain.

Some differences emerged.

Students who showed only eating disorder symptoms were characterized by unhealthy eating behaviors, such as eating fewer than the recommended number of meals daily, eating irregularly, and having a break of more than 4 hr between meals; also, they frequently skipped dinner.  In contrast, people with ON ate 4 or more meals a day, at regular intervals, and had a 3- to 4-hr break between meals. They did not skip meals later in the day. They also ate less sugar-rich foods and refined products, and their diets contained less sugar and salt than in people who had disordered eating patterns.

The authors noted that although finding that the coexistence of a tendency toward ON and eating disorders symptoms showed no relationship with eating habits provides new information, more research is needed. Such studies, using more sensitive and validated tools, will help identify both a tendency to ON and eating disorder symptoms.

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