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Orthorexia Nervosa—It Is Time to Think About Abandoning the Concept of a Distinct Diagnosis

DOI:10.3389/fpsyt.2021.640401
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Adrian Meule at Ludwig-Maximilians-University of Munich
Adrian Meule
Ulrich Voderholzer at University Medical Center Freiburg
Ulrich Voderholzer
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Abstract

The term orthorexia nervosa (ON) refers to an obsessive focus on healthy eating (1). Proposed diagnostic criteria include a dietary theory or set of beliefs about healthy foods, exaggerated emotional distress in relationship to food choices that are perceived as unhealthy, and clinical impairment because of compulsive dietary behaviors and mental preoccupation (2). Although research on ON has been conducted for 20 years, its measurement and clinical value are still hotly debated. For example, it is not clear whether ON is actually a diagnostic entity that is distinct from established eating disorders and other mental disorders such as obsessive-compulsive disorder.
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OPINION
published: 28 January 2021
doi: 10.3389/fpsyt.2021.640401
Frontiers in Psychiatry | www.frontiersin.org 1January 2021 | Volume 12 | Article 640401
Edited by:
Katrin Giel,
Tübingen University
Hospital, Germany
Reviewed by:
Nanette Stroebele-Benschop,
University of Hohenheim, Germany
Paolo Meneguzzo,
University of Padua, Italy
*Correspondence:
Adrian Meule
ameule@med.lmu.de
Specialty section:
This article was submitted to
Psychosomatic Medicine,
a section of the journal
Frontiers in Psychiatry
Received: 11 December 2020
Accepted: 07 January 2021
Published: 28 January 2021
Citation:
Meule A and Voderholzer U (2021)
Orthorexia Nervosa—It Is Time to
Think About Abandoning the Concept
of a Distinct Diagnosis.
Front. Psychiatry 12:640401.
doi: 10.3389/fpsyt.2021.640401
Orthorexia Nervosa—It Is Time to
Think About Abandoning the
Concept of a Distinct Diagnosis
Adrian Meule 1,2
*and Ulrich Voderholzer 1,2,3
1Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich,
Germany, 2Schoen Clinic Roseneck, Prien am Chiemsee, Germany, 3Department of Psychiatry and Psychotherapy,
University Hospital of Freiburg, Freiburg, Germany
Keywords: orthorexia nervosa, anorexia nervosa, bulimia nervosa, eating disorders, obsessive-
compulsive disorder
INTRODUCTION
The term orthorexia nervosa (ON) refers to an obsessive focus on healthy eating (1). Proposed
diagnostic criteria include a dietary theory or set of beliefs about healthy foods, exaggerated
emotional distress in relationship to food choices that are perceived as unhealthy, and clinical
impairment because of compulsive dietary behaviors and mental preoccupation (2). Although
research on ON has been conducted for 20 years, its measurement and clinical value are still hotly
debated. For example, it is not clear whether ON is actually a diagnostic entity that is distinct from
established eating disorders and other mental disorders such as obsessive-compulsive disorder.
MEASUREMENT OF ON
The large majority of studies on ON have been based on a questionnaire measure called the
ORTO−15 (3) or several short versions of it [e.g., (4–6)]. However, studies have shown consistently
that this instrument has poor psychometric properties, the most prominent of which is its low
internal reliability [e.g., (7–9)]. Thus, findings based on the ORTO−15 are inconsistent and
hardly interpretable. Several other instruments have been developed [cf. (9)]. However, using
these measures has not been recommended [e.g., Bratman’s Orthorexia Test (1); cf. (8,9)] or they
have only been used in a handful of studies yet [e.g., the Eating Habits Questionnaire (10) or the
Orthorexia Nervosa Inventory (11); cf. (9,12)]. A relatively new measure with sound psychometric
properties and which is increasingly used internationally (13–16) is the Düsseldorf Orthorexia Scale
[DOS; (17)]. Therefore, we focus on studies that used the DOS in this opinion piece.
OVERLAPS AND DIFFERENCES BETWEEN ON AND EATING
DISORDERS
A key feature of ON is that food choices are based on qualitative, health-related aspects of foods.
That is, unlike in persons with anorexia nervosa, food choices are not based on quantitative, energy
density-related aspects of foods that are motivated by a drive for thinness and body dissatisfaction.
Specifically, Cena et al. (12) argue that—while established eating disorders and ON share common
characteristics such as a concern over food and eating—ON is marked by open, rationalized
rules related to eating and a focus on the quality of foods instead of fears of gaining weight
and body image disturbances. Unlike eating disorders, which are more prevalent in females than
males, conceptualizations of ON do also assume that there is no sex difference in orthorexic
symptomatology (12). However, most studies that used the DOS could not demonstrate that
Meule and Voderholzer Orthorexia Nervosa 8
orthorexic symptoms are independent from features of
disordered eating behavior. For example, positive correlations
between DOS scores and eating disorder symptoms such as
drive for thinness and body dissatisfaction have been found
in both non-clinical and clinical samples [e.g., (18–20)] and
orthorexic symptomatology tends to be higher in females than
males [e.g., (21)].
In line with these reports, we found that prevalence rates
of ON (based on DOS scores of ≥30) were high in inpatients
with anorexia nervosa (48%) and bulimia nervosa (33%) in a
recent study that tested a large sample of inpatients with mental
disorders (22). Furthermore, DOS scores significantly decreased
from admission to discharge, although orthorexic eating was not
targeted in the eating disorder-specific treatment. Finally, higher
DOS scores strongly related to higher drive for thinness and
higher body dissatisfaction in these groups (r≥0.5). Thus, our
findings speak against the notion that ON represents a distinct
diagnostic entity and suggest that it may rather be an aspect of
restrictive eating disorder symptomatology.
OVERLAPS AND DIFFERENCES BETWEEN
ON AND OBSESSIVE-COMPULSIVE
DISORDER
Cena et al. (12) not only discuss similarities and differences
between ON and eating disorders but also between ON
and obsessive-compulsive disorder. Specifically, they highlight
rigidity, perfectionism, and other obsessive-compulsive features
as common characteristics while the only difference being that
obsessive-compulsive symptoms relate to food and eating in ON.
Similarly, other authors have described the rigid beliefs about
healthy eating as a form of obsessive thoughts and the avoidance
of subjectively perceived unhealthy foods as a form of compulsive
behavior [e.g., (23)] and higher DOS scores indeed relate to
higher obsessive-compulsive symptoms [e.g., (24)].
In our study in inpatients with mental disorders (22),
however, we did not find a substantial overlap between
ON and mental disorders other than eating disorders. That
is, the prevalence of ON (based on DOS scores of ≥30)
was similar to prevalence rates reported in the general
population [0–3%; e.g., (17,20,21)] in groups of patients
with a depressive episode, recurrent depressive disorder,
phobic disorders, obsessive-compulsive disorder, trauma-related
disorders, and somatoform disorders. Unlike the changes
observed in patients with eating disorders, DOS scores did not
change from admission to discharge in these groups. Thus, this
study showed a clear distinction from other mental disorders
such as obsessive-compulsive disorder, which is in line with other
reports (25).
DISCUSSION
We conclude that—although orthorexic symptoms seem to be
distinct from mental disorders such as obsessive-compulsive
disorder—this distinction does not hold for established eating
disorder diagnoses. Although features of eating disorders such
as drive for thinness, body dissatisfaction, and sex differences
are not part of ON conceptually, the independence of orthorexic
symptomatology from these features could not be demonstrated
empirically. To put our results into perspective, however, we
also need to mention that DOS scores were unrelated to
features of disordered eating in two studies from China (15,26),
indicating that there might be cultural differences in orthorexic
symptomatology or in its measurement. Cultural differences—
between China and Western countries in particular—have been
previously noted in self-report measures of eating behavior
and their correlates with the reasons for these differences
remaining elusive (27,28). Thus, we cannot exclude that the
current evaluation about the ON construct is limited to Western
(particularly European) countries, in which the majority of
studies were conducted.
As a final remark, we argue that future research on ON
requires more sophisticated approaches than cross-sectional
questionnaire studies. For example, large interview-based studies
seem to be necessary to gain deeper insights into the ON
construct. Such studies may include applying structured clinical
interviews such as the SCID−5–RV (29) and additionally the
DOS or, preferably, a newly developed ON-specific interview.
Only when individuals show an orthorexic eating behavior (e.g.,
as indicated by DOS scores ≥30) that is accompanied by a clinical
impairment or subjective distress and at the same time do not
receive an established eating disorder diagnosis (which not only
includes anorexia nervosa and bulimia nervosa but also any of
the other eating disorder diagnoses listed in the DSM−5 or
ICD−11), then a distinct diagnosis of ON may be justified. As
results from empirical studies indicate, however, we would expect
that such cases are rarely found (or may not be found at all) in the
general population.
AUTHOR CONTRIBUTIONS
UV conceived the topic and proposition of this manuscript. AM
wrote the first draft. Both authors contributed to revision of
the manuscript.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
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author(s) and the copyright owner(s) are credited and that the original publication
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... Scientists also suggest that the American Psychological Association (APA) should modify the eating disorder not otherwise specified (EDNOS) category and define new types of eating disorders [16]. There is also disagreement among researchers as to whether ON should be considered a separate disorder, a variant of a currently recognized disorder (simply) a disturbed eating behavior or a disorder at all [17,18]. Nevertheless, the National Eating Disorders Association (NEDA) has published official information on ON, emphasizing the need for further research in this area [19]. ...
... Persons under 16 years of age were excluded from the study (n = 7) due to the insufficient impact on dietary choices [4]. The reason that we concentrated on late adolescence (16)(17)(18) year) and early adulthood (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) year) is because the risk of orthorectic disorders, as was indicated by numerous authors [4,16,30,31], most frequently occurs both in young and slightly older people. Additionally, from a psychological point of view, this period may prove crucial because young adults are becoming more independent from their parents and beginning to make their own food choices. ...
... Persons under 16 years of age were excluded from the study (n = 7) due to the insufficient impact on dietary choices [4]. The reason that we concentrated on late adolescence (16)(17)(18) year) and early adulthood (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) year) is because the risk of orthorectic disorders, as was indicated by numerous authors [4,16,30,31], most frequently occurs both in young and slightly older people. Additionally, from a psychological point of view, this period may prove crucial because young adults are becoming more independent from their parents and beginning to make their own food choices. ...
Prevalence and Characteristics of Orthorectic Disorders in Adolescence and Young People: Polish Preliminary Studies
Article
Full-text available
  • May 2021
The aim of this work was to assess orthorectic behaviors among young people and to evaluate their attitudes towards caring for their health. The study was conducted in 2019 on a group of 538 respondents aged 16–35. After analysis, 65 questionnaires were eliminated from further research, and the assessment of orthorectic disorders was performed using a method based on the modified ORTO-15 questionnaire on a group of 473 respondents. A large percentage of them exhibited an increased risk of orthorectic behaviors (32.8), which was higher among women than men (34.7% and 28.2%, respectively). People with higher risks of orthorectic disorders significantly more often reduced their consumption of foods high in fats and sugars. Attitudes of people with orthorectic disorders towards health care proved neutral, with a tendency to be positive. Nutritional behaviors observed in the studied group show some irregularities, which indicates the need for preventive and educational measures aimed at increasing awareness of the role of proper nutrition among young people. The obtained results may be the basis for further research on ON symptoms. One of the major areas of future research would be to create a reliable diagnostic tool which would allow for distinguishing between orthorexia and overdiagnosis.
... ON, often truncated to "orthorexia," appears worldwide in both scientific literature and common usage to describe an overvaluation and preoccupation with food quality and its impact on health, but never with a consistent definition or standardized diagnostic criteria. ON is not recognized in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) or International Classification of Diseases (ICD-11), and there is some debate whether ON is a distinct mental disorder at all [2][3][4][5][6]. ...
... Heinrich Heine University Düsseldorf, Düsseldorf, Germany4 University of Northern Colorado, Greeley, USA5 Ecole de Psychologues Praticiens, Lyon, France ...
A consensus document on definition and diagnostic criteria for orthorexia nervosa
Article
Full-text available
Purpose Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with “correct” eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included. Methods 47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A–Definition, Clinical Aspects, Duration; B–Consequences; C–Onset; D–Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants. Results 27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON. Conclusions This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel. Level of evidence Level V: opinions of expert committees
... Overall, the associations between OrNe and OCD are small to moderate and, moreover, insignificant when controlling for symptoms of EDs (Zickgraf et al. 2019;Bartel et al. 2020). Therefore, the placement of OrNe within the spectrum of EDs is favored in literature (Brytek-Matera et al. 2017;Meule and Voderholzer 2021). ...
... As a significant low body weight and body image disturbances are core features of AN, the lack of weight or shape concerns was suggested to crucially differentiate OrNe from AN (Cena et al. 2019). Current evidence, however, tend to contradict this conceptual assumption (Bartel et al. 2020;Meule and Voderholzer 2021). Since it does not involve body image disturbances as a formal diagnostic criterion, the avoidant/restrictive food intake disorder (ARFID) was additionally proposed as a conceptually proximate ED (Moroze et al. 2015). ...
Orthorexic Eating and Addictions: Links with Substance Use, Behavioral Addictions, and Research Gaps
Chapter
  • Oct 2022
Orthorexia nervosa is described as an obsessivefixation on healthy eating in order to maintain and optimize health. The progressive rigidity of self-impose dietary rules in orthorexia nervosa may resemble the maladaptive cycle of substance abuse. Phenomenological similarities are high time investment and cognitive and behavioral preoccupation. Nevertheless, the obvious negative health consequences of substance use disorders are contrary to the aim of orthorexic eating behavior. Moreover, Orthorexia nervosa does not allow the identification of specific foods or food groups which might serve as addictive substances. Based on current evidence, there is no link between Orthorexia nervosa and substance use or abuse. Behavioral addictions, defined as compulsive and excessive non-substance-related behaviors, have also been examined in relation to orthorexia nervosa. Addictive and compul- sive exercising was moderately and positively related to orthorexia nervosa. Evidence of a link with food addiction and internet addiction is still too sparse to allow conclusions. Filling research gaps related to addictions and orthorexia nervosa could help to better understand the etiology of orthorexia nervosa and, thus, assess its distinctiveness from established psychiatric disorders.
... Available evidence points to a complex relationship between ON and EDs, suggesting that ON may precede the onset of a full-syndrome ED, coexist with it, or represent its evolution during remission and recovery phases [11,35]. Actually, a recent opinion paper suggested that a clear distinction between ON symptoms and an established ED diagnosis is hard, especially from an empirical standpoint, even though-at a conceptual level-ED features as drive for thinness and body dissatisfaction do not belong to ON [37]. ...
... Furthermore, EDs and OCD are widely acknowledged to be frequently comorbid and to share features. Nonetheless, the opinion paper mentioned above suggested that ON symptoms are actually distinct from OCD [37]. ...
What do Italian healthcare professionals think about orthorexia nervosa? Results from a multicenter survey
Article
Full-text available
Purpose Orthorexia nervosa (ON) is an obsession for healthy and proper nutrition. Diagnostic criteria for ON are lacking and the psychopathology of ON is still a matter of debate in the clinical and scientific community. Our aim was to better understand the Italian clinical and scientific community’s opinion about ON. Methods Anonymous online survey for Italian healthcare professionals, implemented with the REDCap platform and spread through a multicenter collaboration. Information was gathered about socio-demographic, educational and occupational features, as well as about experience in the diagnosis and treatment of EDs. The main part of the survey focused on ON and its features, classification and sociocultural correlates. Results The survey was completed by 343 participants. Most responders (68.2%) considered ON as a variant of Eating Disorders (EDs), and 58.6% a possible prodromal phase or evolution of Anorexia Nervosa (AN). Most participants (68.5%) thought the next DSM should include a specific diagnostic category for ON, preferably in the EDs macro-category (82.1%). Moreover, 77.3% of responders thought that ON deserves more attention on behalf of researchers and clinicians, and that its treatment should be similar to that for EDs (60.9%). Participants thinking that ON should have its own diagnostic category in the next DSM edition had greater odds of being younger (p = 0.004) and of considering ON a prodromic phase of another ED, such as AN (p = 0.039). Discussion Our survey suggests that the scientific community still seems split between those who consider ON as a separate disorder and those who do not. More research is still needed to better understand the construct of ON and its relationship with EDs; disadvantages and advantages of giving ON its own diagnosis should be balanced. Level of evidence V (descriptive cohort study).
... In line, orthorexic eating is often accompanied by other disorders, such as eating disorders, obsessive-compulsive as well as affective psychopathology (5)(6)(7). These comorbidities substantiate the debate whether OrNe is actually a diagnostic entity that is distinct from established mental disorders (8). At present, this question cannot be readily answered. ...
Psychological Correlates of Excessive Healthy and Orthorexic Eating: Emotion Regulation, Attachment, and Anxious-Depressive-Stress Symptomatology
Article
Full-text available
  • Mar 2022
Orthorexia nervosa, the pathological obsession with eating healthy, shares risks and significant comorbidity with other mental disorders. Based on a behavioral conceptualization of the overlap, emotion regulation, attachment style, and anxious-depressive-stress symptomatology are prominent but insufficiently researched endophenotypes for orthorexia nervosa. This study aimed at identifying ways in which difficulties in emotion regulation and attachment-related anxiety and avoidance become apparent in orthorexia nervosa and healthy orthorexia. Additionally, the moderating role of anxious, depressive, and stress symptoms was explored. A convenience sample of 399 adults (266 women) completed questionnaires to measure orthorexia nervosa and healthy orthorexia, difficulties in emotion regulation, partnership-related bond, and anxious-depressive-stress symptomatology. The healthy orthorexia subscale was negatively associated with lack of emotional awareness but no other subscale of difficulties in emotion regulation or attachment-related anxiety and avoidance. Orthorexia nervosa scores were positively linked to difficulties in emotion regulation as well as attachment-related anxiety and avoidance. Multiple linear regression indicated non-acceptance of emotional responses and impulse control difficulties to be the strongest predictors for orthorexia nervosa. Both subscales also mediated the effects of attachment style on orthorexia nervosa with anxious-depressive-stress symptomatology moderating some of these effects. Individuals with higher orthorexia nervosa tendencies showed difficulties in emotion regulation, a common feature also of affective and eating disorders. Improvement in understanding the psychological features of orthorexia nervosa can enable a better differentiation from other disorders, advances in the development of treatment approaches and treatment planning, and outlines directions for future research on mechanisms.
... Als wahrscheinlichste Annahme gilt aktuell, dass es sich bei Orthorexia nervosa um eine verdeckte bzw. unterschwellige Essstörung handelt, z.B. im Genesungsprozess oder als Vorstufe gestörten Essverhaltens (Bartel, Sherry, Farthing & Stewart, 2020;Depa, Barrada & Roncero, 2019;Meule & Voderholzer, 2021;Segura-Garcia et al., 2015). Der wissenschaftliche Nachweis fehlt aktuell. ...
Exzessiv gesundes Essen und Orthorexie: Phänomene gerade unter Sporttreibenden?
Article
  • Oct 2021
Zusammenfassung: Orthorexia nervosa beschreibt ein Verhalten, bei dem Personen eine zwang-hafte Beschäftigung mit und obsessives Interesse für gesunde Ernährung zeigen. Diese Beses-senheit, nur gesunde Lebensmittel zu essen, überschneidet sich dabei zumindest teilweise mit sportsüchtigen Verhaltensweisen. Es wird angenommen, dass diesem Zusammenhang bestimm-te soziodemografische Merkmale (Alter, Geschlecht, Bildung) sowie bestimmte psychologische Merkmale (Motive, Perfektionismus, Ängstlichkeit) zugrunde liegen. Ob jedoch auch Sporttrei-bende generell gefährdeter sind, orthorektisches Verhalten zu entwickeln, ist aktuell unklar. Hauptziele dieses Artikels sind es, die Gemeinsamkeiten und Unterschiede zwischen Orthorexia nervosa und Sportsucht darzustellen, das Gefährdungspotential für orthorektische Tendenzen unter Sporttreibenden herauszuarbeiten und daraus Handlungsempfehlungen für die sportpsy-chologische Praxis abzuleiten. Journal: Bewegung & Sport (Verlag Brüder Hollinek)
... The term Orthorexia Nervosa (ON) was first coined by Bratman and Knight in the late 1990s (Bratman 1997, Bratman 2017, and is defined as an obsession with 'healthy', pure and virtuous eating choices, or the thought that eating certain foods will have harmful effects. ON is not currently recognized as an eating disorder in the DSM-5, and research suggests that ON may be a facet of eating disorders, a phenotype, an emerging other specified eating disorder associated with changing socio-cultural-political climate, or a cultural pathology (e.g., internalised healthism) (Segura-Garcia, Ramacciotti et al. 2015, Hanganu-Bresch 2020, Meule and Voderholzer 2021, White, Berry et al. 2021). The dietary restriction and health-driven aspects of ON has been argued to be distinct from ARFID (Dunn andBratman 2016, Zickgraf, Ellis et al. 2019), although more research is needed. ...
'Fear of Fat' and 'Feeling Fat' or 'Feeling De-Valued' and 'Fear of Fat-Bodied Marginalisation'? Are 'Fear of Fat' and 'Feeling Fat' Over-Simplified? A Proposed Extension to Eating Disorder Constructs.
Conference Paper
  • Jun 2021
Weight-stigma and internalised weight-stigma are risks for EDs and suicidality. Suicidal ideation in current and lifetime EDs is directly and indirectly effected by perceived-burdensomeness. Similarly, research has linked weight-based discrimination with perceived-burdensomeness and increased suicidal ideation. Weight self-stigma has been linked with weight change, indicating the negative effects of weight self-stigma, and emphasising the central role of fear of being stigmatised by others in this process. Self-discrepancy and negative self-schemas may also include fear of an imagined fat/larger self, or fear of returning to a larger/fat body weight. Considering these factors in the relationship between weight stigma, fear of fatness, and disordered eating, it may be that fear-of-fatness and perceived burdensomeness in EDs more closely align with fear of weight-based discrimination. Pervasive, systemic devaluation of individuals in fat/larger bodies may foster internalised beliefs that one is worthless or a burden on society that praises thinness, dehumanises, pathologizes, and positions larger bodies as a moral/personal failure. This may compound minority stress and weight bias internalisation for those who face intersectional oppressions and experiences of their bodies and identities as a marginalised other. Fear of additional (weight-based) marginalisation may influence ED vulnerability for certain populations, including those who may experience intersectional marginalisation, and those in larger bodies. Insecure attachment, social anxiety, and fear of negative evaluation are also highly prevalent in EDs. It may be that these factors relate to increased awareness of the threat of weight-based marginalisation and therefore, heighten ED risk. This paper will explore the literature on ‘fear of fatness’, ‘feeling fat’, and negative ‘fat talk’ in EDs as related to internalised weight stigma, marginalisation (i.e., race/ethnicity, genders, sexualities, disability), perceived burdensomeness, and fear of stigmatisation. It will argue for the consideration of ‘fear of fatness’ and ‘feeling fat’ as central to ED within a broader context of body politics, weight-based discrimination and disordered eating as a means of coping with fear of (further) social discrimination.
Negative body image components as risk factors for orthorexia nervosa: Prospective findings
Article
Emerging theoretical and empirical evidence indicates that negative body image might be implicated in the onset or maintenance of ON symptoms. However, existing research investigating associations between negative body image and ON is limited to cross-sectional designs and has failed to consider the independent role of distinct components of body image. To overcome these limitations, the present study examined the prospective associations between five components of body image (i.e., overvaluation, dissatisfaction, preoccupation, body checking, and body image avoidance) and ON symptoms in community-based adult women. Participants were assessed at baseline and at a three-month follow-up, with 558 women included in the final analyses. After adjusting for baseline ON symptoms, higher scores on each of the five body image components at baseline significantly predicted greater increases in ON symptoms in univariate analyses. However, in multivariate analyses, overvaluation with weight and shape was the only component of body image to uniquely predict ON symptoms. Findings suggest that certain components of negative body image may increase the risk for ON symptoms. Findings also lend support to recent proposals that ON may be better viewed as a variant of an existing eating disorder, given that both appear to share similar underlying risk factors.
Temperaments and orthorexia nervosa: a cross-cultural study between Germany and Lebanon
Article
Full-text available
The aim of this study was to explore the association between afective temperaments and orthorexic eating and whether temperament may explain cross-cultural diferences in this behavior while considering the two dimensions of orthorexic eating, healthy (HeOr) and nervosa (OrNe). To accomplish this, 337 and 389 individuals were recruited in Lebanon and Germany, respectively. The brief version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego explored depressive, hyperthymic, cyclothymic, anxious and irritable temperaments, and the Teruel Orthorexia scale explored orthorexic eating. HeOr appeared comparable between countries but OrNe was higher in Lebanon. In terms of afective temperaments, the higher the depressive, cyclothymic, irritable, and anxious temperaments, the higher were the levels of OrNe. Only the hyperthymic temperament scale was positively associated with HeOr. Three-step regression analysis indicated only gender as a unique predictor for HeOr. By contrast, gender, depressive, hyperthymic, and anxious temperament as well as the two-way interactions country*depressive temperament and country*hyperthymic temperament were signifcant predictors of OrNe. The positive association between OrNe and depressive temperament was only found for the German sample while the negative association between hyperthymic temperament and OrNe was somewhat stronger in the Lebanese sample. Overall, a higher healthy interest in diet was linked to the hyperthymic temperament. Findings emphasized the role of temperaments in pathological orthorexic eating in general as well as in explaining cross-cultural diferences in these behaviors. The assessment of temperaments could help to ft treatments for eating pathologies to individuals from diferent cultures, focusing interventions more on these aspects.
Orthorektisches Ernährungsverhalten – Fallbeispiele und Charakterisierung eines möglichen neuen Störungsbilde
Article
  • Mar 2022
Orthorektisches Ernährungsverhalten wird in den letzten Jahren als weitere Variante der bisher klassifizierten Essstörungen diskutiert. Doch wie äußert sich dieses Phänomen in der Praxis und inwiefern kann es tatsächlich als klinisch relevantes Störungsbild eingeordnet werden? Im Folgenden sollen anhand von Fallbeispielen verschiedene Ausprägungen der Orthorexie charakterisiert sowie der aktuelle Forschungsstand im Überblick dargestellt werden.
Evaluation of Orthorexia Nervosa and Symptomatology Associated with Eating Disorders among European University Students: A Multicentre Cross-Sectional Study
Article
Full-text available
  • Dec 2020
The objectives of the present study were to (1) evaluate prevalence of orthorexia nervosa (ON) in university students in Spain and Poland, (2) assess differences in ON and eating disorder (ED) pathology in both samples and (3) examine the relationship between ON and ED symptoms among Spanish and Polish university students. Eight hundred and sixty university students participated in the present study (M age = 21.17 ± 3.38; M BMI = 22.57 ± 3.76). The Spanish and Polish samples comprised 485 and 375 students, respectively. The Düsseldorf Orthorexia Scale and the Eating Disorder Inventory were used in the present study. ON prevalence rates of 2.3% and 2.9%, respectively, are found in the Spanish and Polish samples. Compared to Polish students, Spanish university students reported increased drive for thinness and lower body dissatisfaction, lower level of ineffectiveness and lower level of interpersonal distrust. ON was positively related to drive for thinness, bulimia, body dissatisfaction, perfectionism interoceptive awareness (in both Spanish and Polish students) and ineffectiveness (in Spanish students). Our findings suggest that ON significantly overlaps with ED symptoms, which is in line with recent studies. Longitudinal studies are needed to assess how ON develops in a sample of young adults and whether it develops in isolation of or in parallel with ED pathology.
The Polish version of the Düsseldorf Orthorexia Scale (PL-DOS) and its comparison with the English version of the DOS (E-DOS)
Article
Full-text available
Purpose Although orthorexia nervosa, the fixation on health-conscious eating behaviour, was first described in the 90 s, there is no clear understanding whether existing ON measures are appropriate for its assessment. The objectives of the present study were to: (1) examine the psychometric properties of the Polish version of the DOS (PL-DOS) and to compare the PL-DOS with the English version of the DOS (E-DOS) as well as (2) evaluate the prevalence of ON among Polish university students and compare the prevalence rates of ON among Polish and U.S. students. Methods Four-hundred and twelve students (77.2% female) with a mean age of 24.62 years (SD = 6.86) participated in the present study. All participants completed the Polish version of the Düsseldorf Orthorexia Scale (PL-DOS), the Eating Habits Questionnaire (EHQ) and the Eating Disorder Inventory (EDI). Results Reliability analysis for the PL-DOS showed strong internal consistency with a Cronbach’s alpha coefficient of 0.840 and a coefficient omega of 0.840, 95% CI [0.808, 0.866]. Significant correlation coefficients were found between the PL-DOS and all subscales of the EHQ. Confirmatory factor analysis showed that the one-factor model had poor fit. Polish students had an ON prevalence rate of 6.6%, lower than that of U.S. students (8%). Conclusions Our findings validate the use of the PL-DOS as an appropriate ON measure for a Polish population.
Orthorexic eating behavior and body dissatisfaction in a sample of young females
Article
Full-text available
PurposeTo analyze body dissatisfaction in relation to orthorexic eating behavior in a sample of young females to further investigate characteristic features of orthorexic eating behavior and its association with other eating disorders.MethodsN = 197 young females (age: M = 29.59, SD = 10.85 years) completed an online survey with the following questionnaires: the Düsseldorf Orthorexia Scale to measure orthorexic eating behavior, the Eating Disorder Inventory-2 (EDI-2), measuring psychopathological aspects of disordered eating behavior, the Dresden Body Image Questionnaire (DKB-35) to measure five components of body image, and the Body Shape Questionnaire (BSQ), measuring body dissatisfaction.ResultsIn the total sample, Pearson correlations revealed that orthorexic eating behavior was positively associated with drive for thinness and body dissatisfaction. An independent samples t-Test revealed that females with elevated levels of orthorexic eating behavior (n = 35) displayed higher levels of drive for thinness and body dissatisfaction and lower levels of self-acceptance in comparison to a randomized sample from the remaining females with low levels of orthorexic eating behavior (n = 35). According to a multiple regression analysis, drive for thinness and body dissatisfaction measured by the BSQ served as positive predictors for orthorexic eating behavior, whereas bulimia and body dissatisfaction measured by the EDI-2 served as negative predictors.Conclusions Results reveal that orthorexic eating behavior is more closely related to psychopathological aspects of other eating disorders than previously assumed. Body dissatisfaction as another major feature of orthorexia nervosa should be taken into account in future studies.Level of evidenceIII, case–control analytic study.
Orthorexic tendencies in the general population: association with demographic data, psychiatric symptoms, and utilization of mental health services
Article
Full-text available
PurposeOrthorexia nervosa (ON) is characterized by a preoccupation to eat healthily and restrictive eating habits despite negative psychosocial and physical consequences. As a relatively new construct, its prevalence and correlates in the general population and the associated utilization of mental health services are unclear.Methods Adults from the general population completed the Düsseldorf Orthorexia Scale (DOS), the Patient Health Questionnaire (PHQ), the Short Eating Disorder Examination (SEED).ResultsFive-hundred eleven (63.4% female) participants with a mean age of 43.39 (SD = 18.06) completed the questionnaires. The prevalence of ON according to the DOS was 2.3%. Considering only effects of at least intermediate size, independent samples t-tests suggested higher DOS scores for persons with bulimia nervosa (p < .001, Cohen’s d = 1.14), somatoform syndrome (p = .012, d = .60), and major depressive syndrome (compared p < .001, d = 1.78) according to PHQ as well as those who reported to always experience fear of gaining weight (p < .001, d = 1.78). The DOS score correlated moderately strong and positively with the PHQ depression (r = .37, p < .001) and stress (r = .33, p < .001) scores as well as the SEED bulimia score (r = .32, p < .001). In multivariate logistic regression analyses, only PHQ depression scores were associated with past psychotherapeutic or psychiatric treatment (OR = 1.20, p = .002) and intake of psychotropic medication in the last year (OR = 1.22, p = .013).Conclusions The prevalence of ON was low compared to international studies but is in line with other non-representative German studies. Orthorexic tendencies related to general mental distress and eating disorder symptoms but were no independent reason for seeking treatment.Level of evidenceLevel V, cross-sectional descriptive study.
Introducing ORTO-R: a revision of ORTO-15: Based on the re-assessment of original data
Article
Full-text available
Background Orthorexia nervosa has attracted significant attention in the field, however, alongside increasing knowledge, more and more gaps are being identified. One of the fundamental problems concerns measurement of orthorexia nervosa. The most commonly used self-report measure, the ORTO-15, demonstrated an unstable factorial structure across different populations. Therefore, one might question whether the knowledge obtained from past research using ORTO-15 is valid or not. The aim of the present paper is to re-analyse original data used for the validation of ORTO-15 to assess its factorial structure and propose its revision, the ORTO-R.Methods The description of the sample and procedure corresponds to the one reported in Donini et al. (Eat Weight Disord 10:28–32, 2005). N = 525 subjects were enrolled. To evaluate whether the factorial structure of ORTO-15, we used confirmatory factor analysis. The results revealed that the ORTO-15 indeed does not capture the structure of orthorexia nervosa adequately and revision is needed. The ORTO-R contains six items from ORTO-15, which were identified as the best markers of orthorexia nervosa.Discussion and conclusionIn the current paper, we present a refined measure of orthorexia nervosa—the ORTO-R. It is based on a frequently used ORTO-15, overcoming its main limitations. We strongly believe that the current work will act as a bridge, linking past with the future research, and that alongside a new measure, the field of research on orthorexia nervosa will move forward.Level of evidenceLevel V, descriptive study.
Orthorexia Nervosa Inventory (ONI): development and validation of a new measure of orthorexic symptomatology
Article
Full-text available
Purpose: To overcome the problems associated with existing measures of orthorexia, we assessed the reliability and validity of a new measure: the Orthorexia Nervosa Inventory (ONI). Method: An online survey was completed by 847 people recruited from undergraduate nutrition and psychology courses and from advertisements in Facebook and Instagram targeting both healthy eaters (with keywords such as "clean eating" and "healthy eating") and normal eaters (with keywords such as "delicious food" and "desserts"). Results: Exploratory factor analysis revealed three factors with 9 items assessing behaviors and preoccupation with healthy eating, 10 items assessing physical and psychosocial impairments, and 5 items assessing emotional distress. With this sample, all scales demonstrated good internal consistency (Cronbach's α = 0.88-0.90) and 2-week test-retest reliability (r = 0.86- 0.87). Consistent with past research, ONI scores were significantly greater among vegetarians and vegans, and among those with higher levels of disordered eating, general obsessive-compulsive tendencies, and compulsive exercise. Additionally, whereas ONI scores did not significantly differ between men and women, the scores were negatively correlated with body mass index. Conclusion: The ONI is the first orthorexia measure to include items assessing physical impairments that researchers and clinicians agree comprise a key component of the disorder. Additionally, at least for the current sample, the ONI is a reliable measure with expected correlations based on the past research. Level of evidence: Level V, descriptive cross-sectional study.
Orthorexic tendencies in inpatients with mental disorders
Article
Objective Most research on orthorexia nervosa (ON)—the tendency to only eat foods that are perceived as healthy—has been based on non-clinical samples. Thus, we examined prevalence of and changes in orthorexic tendencies in a large sample of inpatients with mental disorders. Cross-sectional and longitudinal associations with body weight and eating disorder (ED) symptoms were tested in subgroups of inpatients with anorexia nervosa (AN) and bulimia nervosa (BN). Methods Inpatients (N = 1167) receiving disorder-specific treatment for disorders classified in the ICD-10 in F3, F4, or F5 completed the Düsseldorf Orthorexia Scale (DOS) at admission and a subset (N = 647) at discharge. ED patients completed the Eating Disorder Inventory–2 and their body weight and height was measured. Results Prevalence of ON was higher in ED patients than in all other groups, in which prevalence rates were similar to findings from the general population. Across ED groups, DOS scores decreased from admission to discharge, while there was no change in the other groups. In patients with BN, higher DOS scores related to lower BMI and predicted larger decreases in body dissatisfaction. Across ED groups, higher DOS scores related to higher body dissatisfaction and drive for thinness and predicted larger decreases in drive for thinness. Conclusion Our results highlight that ON is part of the ED spectrum. Associations with core ED symptoms question the suggested exclusive health focus on eating in ON and its potential as a distinct diagnosis. Rather, ON may represent a phenomenological subtype of restrictive EDs.
Orthorexia nervosa is associated with positive body image and life satisfaction in Chinese elderly: Evidence for a positive psychology perspective
Article
Objective Obsessive attention to healthy eating might paradoxically lead to physical and psychosocial impairments, a potential eating disorder termed orthorexia nervosa (ON). An ongoing debate concerns whether ON should be categorized as an eating disorder, an obsessive–compulsive disorder, or a mental disorder at all. A missing voice in this debate is ON in the elderly, which remains unknown, despite health being a more central issue in everyday life during old age. Similarly missing is ON in East Asia, which remains largely unexplored. Method The current study investigated ON in 313 Chinese elderly (M = 67.90, SD = 7.94) using the Chinese version of the Düsseldorf Orthorexia Scale (C‐DOS). Questionnaires were used to measure traditional eating disorder symptomatology, body image (body dissatisfaction, body appreciation, and functionality appreciation), lifestyle behaviors (fruit and vegetable consumption and time spent on physical activity), and indexes of well‐being (psychological distress, food‐related quality of life, and life satisfaction). Results ON symptoms were positively related to physical activity, fruit and vegetable (F&V) consumption, body appreciation, functionality appreciation, and life satisfaction, but negatively related to body dissatisfaction. Compared with those without ON, the elderly with ON scored higher on positive psychological/lifestyle measures but lower on negative psychological measures. Discussion Contrary to the dominant characterization of ON as a variant of disordered eating, in Chinese elderly ON was associated with several positive lifestyle and psychological measures. Thus, ON in the elderly might not be viewed as a form of disordered eating but can be protective and beneficial.
The psychometric properties of Orthorexia Nervosa assessment scales: A systematic review and reliability generalization
Article
  • Jul 2020
The main objective of this systematic review was to provide a comprehensive overview of the psychometric properties of all available Orthorexia Nervosa (ON) assessment tools, in order to evaluate their scope of application for research and practice. Ten databases were searched for studies quantitatively assessing ON. The psychometric properties were evaluated according to specified quality criteria, focusing on the reliability, structural validity and construct validity of the scales. A meta-analytic approach was used to summarize eligible Cronbach's alpha coefficients between studies. Sixty-eight unique studies fulfilled the inclusion criteria for this systematic review. Ten discrete ON scales were identified. Half of the included studies exclusively utilized a version of the ORTO-15. The evaluation of all available ON measures raise issues regarding ON's dimensionality and conceptualization. Most of the identified scales require further validation. Based on the reported psychometric properties it is advised to re-evaluate existing tools and to focus on establishing consensus regarding the conceptualization of ON to establish a measure with sound psychometric properties.
Classification of Orthorexia Nervosa: Further evidence for placement within the eating disorders spectrum
Article
Purpose Orthorexia Nervosa (ON) may belong on the eating disorder (ED) or obsessive-compulsive (OC) spectrum. We sought to provide additional evidence regarding the working classification of ON as an ED. Methods 512 individuals completed a measure of ON symptoms (rBOT), ED symptoms (Eating Disorder Examination Questionnaire), OC symptoms (Obsessive-Compulsive Inventory Revised), food choice motives (Food Choice Questionnaire), and perfectionism (Multidimensional Perfectionism Scale). Results ON symptoms were more strongly linked to ED symptoms than to OC symptoms. ON symptoms were related to body weight and shape concerns, and with prioritizing weight above health with respect to food selection. Both ED and ON symptoms were moderately related to perfectionism, while OC symptoms were strongly related to perfectionism. Conclusion Our results support ON being classified on the ED spectrum; however, whether ON represents a precursor to an ED, an ED with added health concerns, or a disorder that evolves from an ED is not certain. Future longitudinal research is necessary to test these alternate possibilities.