Orthorexia nervosa, as originally defined, is a condition manifested by “an unhealthy obsession with eating healthy food.” The word “orthorexia” was coined by physician Steven Bratman in the 1990s from a combination of the ancient Greek for “straight, correct, or right” and “appetite” or more literally “desire”--and so becomes what might be called “righteous eating.” Bratman chose the word as a “parallel” to anorexia nervosa and first described his clinical observations in the Yoga Journal. Subsequently, he published a book Health Food Junkies (2000). Since then, there has appeared a growing number of articles worldwide in the scientific literature from countries such as Italy, Hungary, Turkey, India, and Korea, but many of these reports are individual clinical case vignettes and not evidenced-based studies. Furthermore, some of this research is not available in English translation. The term, though, has caught on in the media and now even appears in the Oxford English Dictionary.
Most recently, Moroze and his colleagues from the University of Colorado published a discussion of the syndrome in the journal Psychosomatics (2014, online ahead of print). According to Moroze et al, this extreme condition is often associated with dietary restrictions that lead to “unbalanced and insufficient diets” significant enough to lead to weight loss and medical conditions related to malnutrition (e.g. low sodium and potassium levels, metabolic acidosis.) Those with orthorexia will spend “inordinate amounts of time” each day thinking about the ingredients in their food, and they are cautious and vigilant about their food preparation. Unlike patients with bulimia or anorexia nervosa who wish to be thin, have body image distortions, and are concerned with the quantity of food they eat, those with orthorexia are generally more preoccupied with the quality of the food they ingest.
Chaki et al, in the Journal of Human Sport and Exercise (2013), note, though, that being preoccupied with the quality may not distinguish them from those with other eating disorders. They also note “There is a very thin margin between selectivity about the type and quality of food consumed and developing a psychological obsession about the diet...” They describe how the patients they have seen in their population become extremely selective about their food purity and will avoid any foods with artificial ingredients, such as artificial colors, flavors, or preservatives, and will avoid genetically modified ingredients and those that might contain pesticide residues. They are often not concerned with their weight per se, and there seems to be no specific relationship to the condition and body mass index. The condition may evolve slowly over time and begin innocently enough as a wish to eat a healthier diet (e.g. incorporate protein shakes into their diet) or improve a medical condition. Eventually, though the obsessive preoccupations and compulsive behaviors predominate with their self-imposed regimen, and there may develop a condescending, judgmental “sense of moral superiority” toward others who are not so preoccupied with the purity of their food, according to a review of the “evidence and gaps in the literature” by Varga et al in the journal Eating and Weight Disorders (2013). Social isolation may result.
Currently, the diagnosis is made by self-report. Several questionnaires have evolved from the original questions proposed by Bratman, but these are often not particularly specific and of questionable validity. As a result, information on the actual prevalence and incidence of orthorexia are not known. Some studies have suggested the condition is more common in dietitians and students of nutrition, but methods of assessment have varied considerably. Orthorexia is not technically recognized as an official psychiatric diagnosis in the latest edition (2013) of the Diagnostic and Statistical Manual (DSM-5). It is an example of what I would call “disordered eating.” If categorized as an eating disorder, though, it would now be classified under the wastebasket category of “unspecified feeding or eating disorder.” Moroze et al have suggested the condition could be classified as a subgroup of the “avoidant/restrictive food intake disorder,” though that is a disorder typically beginning in childhood. They note that there is “precious little empirical research” for this condition and standardized, validated diagnostic criteria have not yet been established. These researchers have proposed their own diagnostic criteria for orthorexia nervosa, including the person’s obsessional food preoccupations impair either their physical health due to nutritional imbalances or impair their social, academic, or vocational functioning. They have also noted those suffering may experience guilt and worries if they “transgress” from their rules of healthy eating and consume “impure foods,” may be particularly intolerant to others who do not share their beliefs, and may spend excessive amounts of money on food they believe to be of higher quality. Moroze et al have also included the caveats that the behavior is not related to the observance of organized orthodox religious food rituals or to specialized food requirements subsequent to allergies or other medically diagnosed conditions.
Bottom line: Whether orthorexia nervosa will ever achieve the status of a psychiatric disorder remains to be determined. Remarkably, it has taken sixty years for binge-eating disorder, first described by Dr. Albert Stunkard in the 1950s, to be recognized officially as a diagnosis. Clearly, well-designed clinical studies, with more sophisticated instruments for assessment, are warranted. But clinicians should be suspicious when patients seem unduly and obsessively preoccupied with the quality of their food to the exclusion of almost everything else.
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