A BRIEF LITERATURE OVERVIEW ON ORTHOREXIA NERVOSA – ONE NEW REPRESENTATIVE IN CLUSTER OF EATING DISORDERS

Abstract

The neologism "orthorexia", first described in 1997 by Stephen Bratman in the Yoga Journal, has expanded over the years by adding the term "Nervosa", coined to indicate a potential new eating disorder - Orthorexia Nervosa (ON). In essence, ON is manifested with excessive concern for a healthy diet leading to attracting all attention to food, thus developing constant and disturbing obsessive thoughts and stereotypical behavior (fixation). People with orthorexic eating habits pay too much attention to the quality of the food consumed, in contrast to the well-studied to date Bulimia nervosa and Anorexia nervosa, where the focus is entirely on the amount of food consumed. This brief literature review attempts to clarify the existing biological and demographic aspects of ON, dietary risk factors, and other preconditions for the occurrence of this disorder. To date, there are several tools available to diagnose ON, the most widely used of which is the Ortho-15 questionnaire. Given the growing interest in healthy lifestyles, attention should be paid to the problem of orthorexic eating behavior in the public sphere, including the development of targeted activities for primary and secondary prevention.

Full text

3568 https://www.journal-imab-bg.org J of IMAB. 2021 Jan-Mar;27(1)
Review article
A BRIEF LITERATURE OVERVIEW ON
ORTHOREXIA NERVOSA – ONE NEW REPRE-
SENTATIVE IN CLUSTER OF EATING DISOR-
DERS
Yavor Chenkov 1, Darina N. Hristova2
1) Department of Hygiene and Epidemiology, Faculty of Public Health, Medi-
cal University of Varna, Bulgaria.
2) Department of Organization and Economics of Pharmacy, Faculty of Phar-
macy, Medical University of Varna, Bulgaria.
Journal of IMAB - Annual Proceeding (Scientific Papers). 2021 Jan-Mar;27(1)
Journal of IMAB
ISSN: 1312-773X
https://www.journal-imab-bg.org
ABSTRACT:
The neologism “orthorexia”, first described in 1997
by Stephen Bratman in the Yoga Journal, has expanded over
the years by adding the term “Nervosa”, coined to indicate
a potential new eating disorder - Orthorexia Nervosa (ON).
In essence, ON is manifested with excessive concern for a
healthy diet leading to attracting all attention to food, thus
developing constant and disturbing obsessive thoughts and
stereotypical behavior (fixation). People with orthorexic eat-
ing habits pay too much attention to the quality of the food
consumed, in contrast to the well-studied to date Bulimia
nervosa and Anorexia nervosa, where the focus is entirely
on the amount of food consumed. This brief literature re-
view attempts to clarify the existing biological and demo-
graphic aspects of ON, dietary risk factors, and other pre-
conditions for the occurrence of this disorder. To date, there
are several tools available to diagnose ON, the most widely
used of which is the Ortho-15 questionnaire. Given the grow-
ing interest in healthy lifestyles, attention should be paid
to the problem of orthorexic eating behavior in the public
sphere, including the development of targeted activities for
primary and secondary prevention.
Keywords: Orthorexia nervosa, eating disorder,
Ortho-15, orthorexic nutritional behavior,
INTRODUCTION
The term “Orthorexia “is a neologism, first used by
American physician Steven Bratman in an article in Yoga
Journal (1997) [1]. In Greek language the meaning is “cor-
rect appetite” - ορθο - (ortho-correct, true, right) and ορεξισ
(-orexis, appetite). Bratman attempts to explain with this
term the strange eating behavior of some of his patients,
characterized by a pathological obsession (fix idea) to
healthy eating. Bratman, together with David Knight, pub-
lished in 2000 the book Health Food Junkies, which de-
scribed and expanded this concept, adding to it the term
“nervosa” created to indicate a possible new eating disor-
der - Orthorexia nervosa (ON). [2] A team of Italian scien-
tists from La Sapienza University of Rome published in
2004 the first empirical study trying to develop a tool to
investigate and measure the incidence of this condition [3].
Orthorexia nervosa manifests itself with excessive
concern for a healthy diet, leading to the full attention to
food, thus developing persistent and disturbing obsessive
thoughts and stereotyped behavior (fixation) [4]. People
with this eating behavior pay too much attention to the
quality of food consumed, unlike the well-studied Bulimia
nervosa and Anorexia nervosa to date, where the focus is
entirely on the amount of food consumed [5]. Patients with
ON spend at least 3 hours each day analyzing their own
diet. They are engaged most of their time in the search for
food and prepare it according to the technique they con-
sider to be the healthiest; they prepare foods with the best
possible composition and are fixed in striking the right bal-
ance between nutrients and their optimal composition;
avoid eating at restaurants or bars unless they have a spe-
cial menu suitable for them; àvoid food products of for-
eign origin unless they examine the detailed qualitative
composition of the product; feel guilty and/or anxious
about eating junk food. The described habits and behaviors
clearly indicate that ON is a psychological condition that
can cause suffering and disorders in daily life leading to
the social isolation of the individual.
To date, there is no standard accepted definition of
ON, the diagnostic criteria are still debatable, and the psy-
chometric tools used reveal some methodological short-
comings [6]. However, the literature has so far managed to
elucidate 2 main characteristics present among the ON di-
agnostic criteria:
(a) an obsessive focus on nutritional practices that
are thought to promote optimal well-being through healthy
eating (with inflexible eating rules, repetitive and fixed/
constant eating practices, obsessive behavior);
(b) subsequent, clinically relevant, impairment (e.g.
medical or psychological complications, major distress,
and/or impairment in important areas of functioning) [7].
Biological and demographic aspects
Age
Currently there are mixed findings regarding the role
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J of IMAB. 2021 Jan-Mar;27(1) https://www.journal-imab-bg.org 3569
of age as a potential risk factor for the onset of ON [8], but
most studies appear to indicate younger age as riskier. The
interpretation of the age-onset of ON should be interpreted
with caution, since in most of the studies the samples col-
lected are mostly students and collegers, and more investi-
gations are needed to analyze the other age groups.
Sex/gender
With regard to gender distribution, some studies have
found that women are at higher risk of experiencing
orthorexic eating behavior [9-11], but this may be ex-
plained by the fact that most of these studies are sampled
mainly from women. In other studies the results show that
this condition is more common among men [12, 13]. In one
of the most recent published systematic reviews on the
topic, a meta-analytic summary was made concluding that
orthorexic tendencies are relatively homogeneously distrib-
uted between the two sexes, but with a slightly clearer ex-
pression among women [14].
Family environment and education
The relationship between environmental influences,
education, and the emergence of ON is also controversial.
ON may be more common among higher-income earners as
they have the greater financial capacity to purchase high-
quality ON-specific foods, as well as greater access to nu-
trition and dietary knowledge. [15].
Nutritional risk factors
It is logical to assume that certain restrictive diets
(vegetarianism, veganism) can be considered as predictors
of orthorexic behavior. Few studies have examined the link
between different diet regimens and the occurrence of
orthorexic eating behavior [16 - 19], with most reports
clearly indicating that vegetarianism and veganism are at
increased risk of ON.
Some studies have found that people with a past his-
tory of an eating disorder are more likely to develop ON
than those who have never had an eating disorder [20, 21].
From here, we can hypothesize that the ON state could fit
into one continuum as a variation of any of the other eat-
ing disorders, but it is also possible to classify it as a self-
contained nosological unit of the same cluster.
With regard to BMI, most studies do not find a clear
correlation between lower BMI and the likelihood of ON
occurrence [22, 23].
Other risk factors and prerequisites for the occur-
rence of ON
Systematic reviews of the literature indicate another
half dozen risk factors associated with the occurrence of
orthorexic eating behavior [15].
The relationship between the use of social networks
(Instagram, Facebook, etc.) and the risk of ON occurrence
has been examined [24]. According to the authors of these
studies, the risk of orthorexic behavior may be increased
through selective exposure to certain accounts and pages
by consumers. Selective monitoring of certain food ac-
counts can lead consumers to believe that extreme healthy
eating is more normative than it really is.
Other factors and prerequisites associated with an
increased risk of orthorexic eating behavior are considered,
such as: engagement with exercise; use of alcohol, tobacco
and other psychoactive substances; certain professions;
eating habits, as well as other concomitant mental and so-
matic diseases [25]. However, the available literature does
not yet have sufficient empirical power to prove that the
aspects described are sufficiently reliable causal factors re-
lated to ON. Samples of different ethnic and anthropogra-
phy backgrounds have been collected in different studies,
but it is nevertheless necessary to examine more closely
the cultural aspects of different nations and the resulting
diversity of socio-cultural patterns of behavior and life-
style, as well as the possibility of certain their manifesta-
tions to mediate the onset of ON.
Obsessive-compulsive tendencies
Given that ON is characterized by excessive food
concern and ritual preparation of meals, it is not surpris-
ing that obsessive-compulsive behavior could play a sig-
nificant role in the onset of this condition. Most studies
have found a clear link between obsessive-compulsive at-
titudes on the one hand and the risk of occurrence and a
higher incidence of ON on the other [26-31]. The obses-
sive thoughts of pollution and washing compulsions, as
well as the obsessions of food decoration (e.g. dressings )
clearly correlate with the emergence and maintenance of
orthorexic eating behavior.
Diagnosis
To date, there are several tools available for the di-
agnosis of ON, the most used of which is the Ortho-15 ques-
tionnaire created and developed as early as 2004-2005
[3,32]. The tool consists of 15 questions, and the answers
are based on a 4-point Likert scale (always, often, some-
times, never). After summing the scores, higher scores in-
dicate a more moderate orthorexic tendency, while lower
scores are an indicator of orthorexic behavior. Many adap-
tations have been made to different languages, and despite
many criticisms of the validity and reliability of the tool,
ORTO-15 is currently the most commonly used ON symp-
tom screening questionnaire [33-35].
Currently, in addition to Ortho-15, there are 5 addi-
tional questionnaires for screening and diagnosis of
Orthorexia nervosa - BOT, EHQ, DOS, BOS, TOS, but none
of them, used alone, are able to cover and categorize all
aspects of orthorexic nutrition behavior [36-38, 28]. Some
additional questionnaires, such as MMPI, can also be used
to assist with the aforementioned screening tools to estab-
lish the personality traits of individuals with orthorexic eat-
ing behavior.
Treatment
To date, studies on the effectiveness of treatment for
ON have not been identified in the literature, but some sug-
gestions for good practice have been provided. The ideal
therapeutic approach involves a multidisciplinary team of
physicians, psychotherapists and nutritionists so that a
combination of medication, cognitive-behavioral therapy
and psycho-educational programs can be delivered on an
outpatient basis. In the case of significant weight loss and

3570 https://www.journal-imab-bg.org J of IMAB. 2021 Jan-Mar;27(1)
malnutrition, the intervention of specialists with experience
in these aspects is also required.
Individuals with orthorexia may have a tendency
to reject medication, considering it to be ‘unclean’, ‘un-
natural’, substances. Therefore, psychotherapeutic interven-
tions should be individualized based on the patient’s symp-
toms, recognizing that treatment goals should focus not
only on what patients eat but also on how they buy and
prepare the food they consume. Incorporating habit-chang-
ing training can be successful in treating the obsessive as-
pects of orthorexia.
CONCLUSION
Currently ON is not yet included in the current clas-
sifications of somatic, mental, or behavioral disorders de-
1. Bratman S. Health Food Junkie:
Obsession with dietary perfection can
sometimes do more harm than good,
says one who has been there. Yoga
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place in the cluster of eating or obsessive-compulsive dis-
orders.
Due to the lack of awareness of the described ortho-
rexic nutritional behavior, it is necessary for medical staff
(especially primary care physicians and nurses) to receive
the necessary training to be able to adequately recognize
and identify it within the framework of outpatient care.
Given the growing interest in healthy lifestyles, the
issue of orthorexic eating behavior in the public space, in-
cluding the development of targeted primary and second-
ary prevention activities, must be addressed.
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Please cite this article as: Chenkov Y, Hristova DN. A brief literature overview on orthorexia nervosa – one new repre-
sentative in cluster of eating disorders. J of IMAB. 2021 Jan-Mar;27(1):3568-3571.
DOI: https://doi.org/10.5272/jimab.2021271.3568
Received: 13/12/2019; Published online: 01/02/2021