Working Toward a Better Definition of Orthorexia

A small Dutch study seeks to trace the pathways from a healthy lifestyle to an eating disorder.

According to Google Trends (a Google website), the number of searches for the term ‘How to eat healthy’ has nearly tripled over the last 16 years (Google, 2018). This search for healthier eating can also lead to problems when these ideas are taken too far. One of the possible consequences of the rise in popularity of the healthy eating trend among various populations is the risk of developing a problematic preoccupation with the perceived quality of food. Orthorexia nervosa (ON) has been suggested as the supreme manifestation of this, but more work is needed to more fully understand its definition and implications.

Dr. Emma R. Douma and her colleagues at the Athena Institute, Vrije University, Amsterdam, recently studied factors that contribute to a progression from healthy eating to unhealthy and excessive preoccupation with healthy eating, or ON (Appetite. 2021. 105008).

No clear definition exists

One important distinction said to separate ON from established eating disorders such as AN and BN is the fact that the preoccupation is not linked to the amount of food or weight loss, but rather to the perceived quality of the foods consumed. However, there is no consensus about a clear definition of ON, or even clear diagnostic criteria, according to the authors. The main characteristics of this phenomenon are: (1) spending an excessive amount of time thinking about, looking for, and preparing food; (2) feeling superior to those with different eating habits; (3) rigidly following a particular health food diet and engaging in compensatory restrictions to make up for dietary indiscretions; (4) associating self-esteem with adherence to the diet; and, finally, (5) turning ‘eating properly’ into a central focus of life.

Dr. Douma’s study collected clinician perspectives on ON. First, qualitative interviews were conducted with 10 health professionals 27 to 60 years of age, including nutritionists, a nutritionist/therapist, a psychologist, a nutritional psychologist, a pediatrician, a professor specializing in eating disorders, and a support worker with personal experience of working at an ED treatment facility. The authors then administered a questionnaire online to the 10 health professionals. Each phase of the study focused on hypothesized stages of ON evolution: in the discussion of each stage, the authors sought biological, psychological, interpersonal, and contextual factors that played a role in the patients’ lives and that might have contributed to the development of ON eating patterns.

To explore baseline risks for individuals to develop ON, the researchers asked participants to identify what characterized the patients they had encountered. In all cases, the patient was a 16- to-35-year-old woman with an intermediate or high level of education. Having an active lifestyle and an ambitious personality type were also prominent characteristics (both mentioned in six interviews). Some health professionals elaborated upon the ambitious personality type, mentioning perfectionism and giving high importance of school or work (mentioned in three and two interviews, respectively). As for body weight, the health professionals had contradicting results. Four mentioned that their patients had always had healthy weights, whereas three mentioned that their patients were all overweight. Contrasting opinions about self-confidence were observed as well: three women were said to have a high degree of self-confidence, whereas four were said to have a low level of self-confidence.

Stages leading to development of ON behaviors

There was a better consensus about the development of ON behaviors. The authors posited two broad stages leading to the development of ON-related behavior. The first was a relatively harmless choice to pursue a healthy diet, and the second was an unhealthy obsession evolving from the first seemingly healthy and harmless lifestyle choice. The authors concluded that over time ON has a developmental pathway of biological, psychological, and social dynamics. Just as in earlier studies, they had inconclusive results when they sought any association between age, sex, and educational level and ON. They also reported that a better understanding of whether the two proposed phases of ON, “healthy orthorexia” and “orthorexia nervosa,” would be beneficial for clinical and therapeutic practice.

The professionals in their study did agree that young age, female gender, and a high level of education, along with perfectionism and regular use of social media, were baseline risks for ON. Also in the current study, the health professionals reported weight loss as a symptom rather than a motivation to engage in ON-like behavior.

The authors suggested that ON has a developmental pathway, and thus does not appear suddenly. Instead, its development can be interpreted as a continuous interaction of biological, psychological, and social dynamics over time. This is useful information that describes the experiences of clinicians encountering people with ON symptoms, but it will be valuable to measure these same potential factors in those with ON symptoms themselves.

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