When is “healthy eating” not so healthy? The line between “normal” and “pathological” eating behaviours is blurry, to say the least. For some time, researchers have been attempting to define a “new” category of eating disorders: orthorexia. This category would capture “obsessions” with “healthy eating” that are (presumably) not already captured in current diagnostic criteria for eating disorders.
If you’ve been reading my posts for a while, you might already know how I feel about the liberal sprinkling of the suffix “orexia” onto behaviours related to food, exercise and body image (see, for example, my post on “drunkorexia”). The problematics of language use and eating disorders are numerous; we tend to use diagnoses as currency in discussing eating disorders, often glossing over the intricacies of behaviours with food and exercise by lumping them into (continually shifting) diagnostic criteria.
Of course, labeling is necessary to a certain extent. Diagnoses can help individuals obtain the support and treatment they need and desire. So of course, researchers and clinicians will seek to determine labels and diagnoses that match the behaviours their participants and clients exhibit.
In this post I will discuss the concept of orthorexia as articulated by Koven & Senbonmatsu (2013), and explore its measurement, as discussed in an article by Varga et al. (2014).
ORTHOREXIA?
I will reiterate my hesitancy to take up the label “orthorexia,” as I am still somewhat unconvinced about the need for a separate category for the subset of behaviours and attitudes described in the emerging criteria for “orthorexia nervosa” (ON). However, authors who use this terminology are generally referring to:
A set of eating-related behaviors that include a fixation to eat healthy, biologically-pure foods and an inflated expectation about the personal benefits of healthy eating (Koven & Senbonmatsu, 2013, p. 214)
Curiously, I would say that many individuals in the general public share these beliefs about food. Whether they act on them is debatable, but these are the kinds of messages about food we encounter on a daily basis. Nonetheless, ON encompasses related behaviours, including avoiding food treated with pesticides, obsessions about the preparation of food, and ultimately a diminished quality of life due to the fixation on “healthy foods.”
Both articles cite Bratman & Knight (2000) in defining orthorexia as a preoccupation with and/or fixation on healthy food/health food dependency.
According to Koven & Senbonmatsu, orthorexia resembles both anorexia nervosa and obsessive compulsive disorder. The difference, they suggest, is in the goals and attitudes of patients. To differentiate from anorexia, the authors argue that in AN, patients are driven by poor body image and in ON patients are seeking to maximize health through dieting. Unlike OCD, they write, “orthorexics tend to flaunt their habits.”
Unsurprisingly, I have a few issues with this framing (to say the least). Firstly, as we’ve discussed ad naseum, “poor body image” is not the sole driver of anorexia (or other eating disorders, for that matter). No, it certainly does not help and yes, people with eating disorders can certainly have poor “body image.” However, there are people with poor body image who do not have eating disorders. I would also suggest that some people predisposed to AN are initially driven by a desire to “maximize health through dieting,” which the authors seem to suggest is a more unique feature of ON.
I also take issue with the notion that individuals who suffer from orthorexia (if we are assuming that this category is a discrete entity) “flaunt their habits.” This just seems very blamey, especially if we’re going on the premise, as these articles seem to be, that this is a mental health issue.
Carrying on, what did the researchers study, and what did they find?
NEUROPSYCHIATRIC STUDY
Koven & Senbonmatsu (2013) conducted a study with 100 young adults to determine the degree to which orthorexia predicts cognitive dysfunction above and beyond symptoms of AN and OCD. They administered a number of self-report measures, including the ORTO-15 orthorexia scale (also discussed below- this open-access article also has the questions on p. 30), the Eating Disorder Inventory (EDI-2) and the Obsessive Compulsive Inventory Revised (OCI-R) as well as a battery of neuropsychological tests.
The authors found that severity of orthorexia was related to executive functioning (e.g. working memory, self-monitoring and set-shifting, among other aspects) in that the greater the severity of the orthorexia, the less well participants performed on tests of executive functioning. There was also significant comorbidity between AN, OCD, and ON, as predicted. Further, ON predicted decline in neuropsychological functioning above and beyond AN and OCD.
As the authors note, ON symptoms interacted with executive functioning in similar ways to a combination of AN and OCD behaviours. The example they give is that rules individuals with ON have around food selection (such as purchasing only foods without additives, preparing only raw foods, and/or eating foods only in particular combinations) increase in complexity as the disorder persists, eventually leading to increased rigidity. Over time, these individuals would have trouble with “set shifting,” or the ability to problem solve and adapt to new stimuli.
While these findings are interesting, it is worth looking at the validity of the instrument used to measure “orthorexia.” Varga et al. (2014) conducted a study of the psychometric properties of the ORTHO-15 scale.
ORTHO-15 SCALE
It is worth noting that the population Varga et al. used is slightly different than the college-student population from the previous study. This study looked at the validity and reliability of the ORTHO-15 scale in an 810-person Hungarian sample. Their participants were quite diverse, particularly in BMI; this ranged from 14.88 to 56.06, with a mean of 23.30. Participants’ mean age was 32.39. All were students at Hungarian universities.
Beyond testing the validity and reliability of the Hungarian version of the ORTHO scale, the researchers sought to determine whether those who exhibited orthorexic behaviours also tended to:
- Make healthier food choices
- Refuse drugs and alcohol
- Take more nutritional supplements
- Engage in more sports activities
- Have more dietary restrictions
So, in addition to having participants fill out the ORTHO scale, they asked about these variables and had participants identify the frequency with which they ate specific foods. As they conceptualized the difference between those we might call “normal healthy eaters” as related to attitudes towards others’ (e.g. moral associations between weight and personality characteristics, perceptions about the value in preparing “healthy foods”), they asked 10 questions in addition to those laid out in the ORTHO scale.
RESULTS
Behaviourally, the researchers found that individuals who had a higher tendency toward orthorexia:
- Engaged in more sports activities
- Did not drink alcohol
- Were on special diets
- Encouraged friends and relatives to follow a similar diet
- Ate more whole grains
- Ate fewer white grains
- Ate more fruits and vegetables
- Often shopped at health food stores
- Followed a strict and fixed eating schedule
- Ate similar foods each day
- Spent a great deal of time preparing meals
In terms of attitudes, individuals who were more oriented toward orthorexic behaviours:
- Saw being overweight as indicative of weakness
- Blamed people for diseases linked to obesity
- Negatively judged those who could not follow “healthy nutrition” rules
In terms of the scale itself, the authors note that an 11 item version of the ORTHO scale made the scale more reliable. The items they excluded were linked to food quality preferences, financial decisions, transgression of food rules and beliefs about unhealthy foods. Interestingly, they compared their omissions with items omitted from a Turkish version of the scale, which omitted items surrounding caloric value, confusion related to shopping, specificity of mood and preference for eating alone.
They attribute these differences to culture, highlighting the more individualistic tendencies of the Hungarian population and the differing availability of foods.
IMPLICATIONS
So, what can we take from these results? Well, to be honest, the results aren’t terribly shocking; none of the behaviours and attitudes linked to scores on the ORTHO scale are surprising. Of course individuals with a “fixation on healthy foods” will shop in health food stores more often and eat more whole grains, fruits, and vegetables. This is good evidence for the “face validity” of the scale (i.e. that it measures what it is looking to measure).
What would be more interesting, in my opinion, would be to differentiate between these behaviours across diagnostic categories. Are these behaviours really indicative of different pathology altogether, or just other eating disorders that are already noted in the literature and in the DSM? I’m hesitant as always to simply keep making new labels for behaviours.
So where is the line between healthy eating and eating disorder? Unfortunately, that line is still blurry. Much like attempting to define “normal eating,” attempting to distinguish between “normal healthy eating” and “obsessive healthy eating” still seems a bit too subjective, in my opinion, to capture using a 15 (or 11) item scale.
References
Koven, N.S., & Senbonmatsu, R. (2013). A neuropsychological evaluation of orthorexia nervosa. Open Journal of Psychiatry, 3, 214-222 : 10.4236/ojpsych.2013.32019
Varga, M., Thege, B.K., Dukay-Szabó, S., Túry, F., & van Furth, E.F. (2014). When eating healthy is not healthy: orthorexia nervosa and its measurement with the ORTO-15 in Hungary. BMC Psychiatry, 14 (1), 59-70 PMID: 24581288
Very cool post. I agree that the lines are incredibly blurry. A thought I had: I wonder if the outcomes of engaging in orthorexic behaviors on weight loss could be a factor contributing to the development of anorexia. Perhaps strict dietary regimens result in a stabilization of body weight in some, but could lead to precipitated weight loss in others (e.g., vegan or vegetarian diets). The result of the rapid weight loss may induce physiological changes that encourage the development of even stricter restrictions in those individuals. Totally speculative.
I could definitely see that being the case. Something to look into, either in the existing literature (though I don’t know that this has been looked at specifically in terms of a discrete “orthorexia” category or in a more general “dieting” sense) or by conducting some research… maybe I should add it to my growing list of studies I want to conduct. Hah.
I agree that this topic is incredibly murky–and frustrating. As a recovered anorectic/EDNOS and now a health coach, I have to walk a really fine line between being uncompromising about my own health and taking that “health” to the extreme.
I believe that diet is hugely important in recovery–nutritional support for our neurotransmitters is key, and developing a healthy relationship with food sometimes means leaving unhealthy food-products behind–but I also know too many people who slap a label on the way they eat and become fixated on perfecting their diets.
The problem with using the word “orthorexia” is that, because it’s not a diagnosable eating disorder, people throw it around willy-nilly, and there’s no “evidence” against which to argue. So orthorexia just becomes a catch-all term for someone who cares about treating their bodies well, even when that someone isn’t fixating on restriction, “safe foods,” etc….
Certainly agree about orthorexia becoming a catch-all for all sorts of (widely varied) practices. It falls into that extraordinarily murky category with the other behaviours to which people have added “orexia” or “imia) (like “drunkorexia,” “pregorexia” or “duibulimia”). Like you say, there isn’t “evidence” per se that can prove or disprove what “counts” in these categories. I think that “healthy eating” practices are also given different meanings for those who have been diagnosed with eating disorders in the past and those who haven’t. The same “health-focused” behaviours might be considered really positive in those who are prescribed weight loss and really negative for those who have recovered from an eating disorder. I think the topic really brings up the difficulty of determining what constitutes “normal eating” and “healthy eating,” and the problem with attempts to draw lines in the sand between these different categories when each person’s experience is different.
I’m not sure I understand what this “nutritional support for our neurotransmitters is key” means, really.
I like to envision how agitated the people who label health-fooders as having “orthorexia” would get if you proposed a mental illness whose symptoms consisted of trying too obsessively to maintain health and longevity by undergoing medical screenings and taking prescription drugs.
My mother has orthorexia. Your comment is interesting because this has been the greatest challenge in getting help for her. She is obsessed with researching illnesses and natural cures (supplements, functional medicine, expensive tests, genomic testing). She is also quite intelligent and can talk circles around anyone who tries to broach the subject. She spends over $1000 a month on supplements, not to mention monthly labs (which she manipulates doctors into taking), and doctor visits (along with multiple specialists). She justifies the expense by comparing her health with the neighbors who have had health problems, almost in a mocking superior tone.
I love it when people say they don’t eat anything with chemicals. It always cracks me up.
I like showing them this: http://io9.com/what-if-natural-products-came-with-a-list-of-ingredient-1503320184
Yup! I love that graphic/set of graphics.
In my mind…. (not that this is governed by any scientific definition) I have always thought of the distinction between orthorexia and anorexia is that orthorexia is obsessive about healthy/ clean food but without the weight piece. So that an orthorexic person might be too thin, and think they are too thin and want to put the weight back on but are so afraid to break their own food rules that they can’t. Also even though the orthorexic food rules are taken too far and overtake ones life in the same way that an anorexics food rules do … orthorexia has more ‘sensical’ rules (in that there is usually a nugget of truth from which they spring… as opposed to many anorexic food rules that may or not make sense and are usually rather arbitrary. I may not be making any sense but for me that’s always been the distinction. I knew a girl who struggled with orthorexia and she didnt care about weight or weight gain but was too afraid to eat unhealthy or uncleanly…. (didnt care about carbs, calories, etc…. more the sanctity of food)
just my two cents
Like Andrea said before, I don’t think that individuals struggling with anorexia are necessarily focused on weight and body image. I know part of my struggle was the fear of being unhealthy. I had a “pure ritual” that I was afraid of steering to far from. Even during times when I wasn’t overly concerned about body image, breaking that ritual was still terrifying. I still didn’t want to consume the foods required to bring my nutrient intake to a level where my body could maintain a healthy weight. Sure, clincial definitions have somewhat of an arbitrary flair to them, but according to the DSM-V, criteria for a diagnosis of anorexia include: (a) restriction of energy intake relative to requirements, leading to significantly low body weight (b) intense fear of weight gain OR persistent behavior that interferes with weight gain (c) undue influence of body weight or shape on self- evaluation (abbreviated). So, orthorexic behaviors can certainly propel some individuals toward a diagnosis of anorexia, if we use the clinical terminology.
Saying that people with orthorexia ‘tend to flaunt their habits’ seems to suggest that their habits do not significantly interfere or impact in a negative way on their lives, which often seems to be the deal breaker as to whether something gets labelled as pathological. Or are the authors suggesting some AN style denial?
I really didn’t like the “flaunting of habits” terminology, to be honest. I think that this was meant to be a feature of orthorexia that would differentiate it from AN. I agree that this framing complicates the notion that these habits significantly negatively impact the lives of individuals; I’m not sure whether what they meant was that the flaunting was in spite of a significantly impacted quality of life (e.g. putting a glossy veneer on troublesome relationships with food) or was done while denying the seriousness of the issue. I suspect to a certain degree the denial was implied, yes. But I could be wrong!