On orthorexia, Part One: Is orthorexia an eating disorder?

In the past few days, I’ve seen several news articles about orthorexia. Aside from the personal agony it can cause, it also seems to be a current cultural obsession. Search for recipes on Pinterest, and it immediately suggests several ways to filter your search: Paleo, gluten free, clean eating, vegetarian, vegan, etc.

Many of the news articles write of orthorexia as a “newly recognized” eating disorder, even if it isn’t in the DSM (psychiatry’s Bible). Newly recognized I’ll buy. I hear a lot more about orthorexia now then when I was first diagnosed, that’s for sure. Especially with the growth of smartphones and features like Instagram, Pinterest, Tumblr, and other platforms, orthorexia has become more frequently discussed.

However, can we actually call it a new disorder? In other words, is it an eating disorder in different clothing? Or could it be more related to obsessive-compulsive disorder than eating disorders? This question will be the subject of my next three posts.

What the research literature says

Let’s start with a brief description of what orthorexia is:

Having orthorexia nervosa not only means that people are obsessed with eating “healthily”, but also that they have a specific attitude to food, they prepare their food in a certain way [1] as well as avoid consumption of some foods or all of a some group of foods since they consider them to be harmful for their health. The quality of the foods they consume is more important than personal values, interpersonal relationships, career plans, and social relationships. In fact, the desire to consume healthy foods is not a disturbing behavior in and of itself, and it is only defined as orthorexia nervosa when it causes a person to give up his or her normal lifestyle. (Brytek-Matera, 2012)

As clinical reports of orthorexia grew, researchers and clinicians struggled with whether orthorexia fell under the umbrella of eating disorders or whether it was a type of OCD about food. They’re still arguing about this.

The main debate hinges around the fact that orthorexia behaviors are generally not driven by body image concerns. If you hold that body image distortion is at the core of an eating disorder, like Christopher Fairburn and others, then it would be easy to make the argument that orthorexia shouldn’t be paired with anorexia and bulimia.

Writes Anna Brytek-Matera:

Orthorexia nervosa could not be labelled as a new eating disorder because it does not include the most characteristic symptoms of anorexia and bulimia nervosa that is immense fear of be- coming fat, extreme weight-control behaviour, as well as overevaluation of shape and weight. However, since orthorexia involves disturbance of eating habits it ought to be treated as a disorder concerning abnormal eating behaviour inseparably linked with obsessive-compulsive symptoms (on account of paying too much attention to consuming healthy food and constant thinking about the quality of food intake).

The question, then, becomes whether body image distortion or a fear of fatness are really what drives eating disorders or whether it’s something else. For many people with eating disorders in Western cultures, body image distortion does appear to play a role in eating disorders. But as Pam Keel and Kelly Klump point out in a 2003 paper, this obsession with body image in individuals with anorexia appears to be the result of our current culture rather than a central hallmark of the disorder, which they refer to as a self-starvation syndrome. So if body image isn’t at the heart of anorexia or other eating disorders, then the argument that orthorexia can’t be an eating disorder because they aren’t driven by a desire to be thin makes no sense.

Furthermore, they are also missing the fact that the motivations that people give about why they’re doing what they do exist in a cultural context. Not eating to be more holy was a common explanation in the Middle Ages, but you never see it today. And in the past few years, our cultural obsession with food has shifted somewhat to be less obsessed with losing weight for the sake of losing weight to include a much greater obsession with the quality and healthfulness of our food. So is it any surprise that people are becoming more fixated on having a perfect diet?

Commonalities with eating disorders

For starters, both disorders have to do with eating. I know, it’s a really obvious statement to make, but it’s one of the primary things that would include orthorexia as an eating disorder.

If orthorexia was, in fact, an eating disorder, then it should share certain characteristics with eating disorders. There isn’t much research on orthorexia, but studies indicate the following:

Eating disorders are also elevated in these populations, which supports the idea that orthorexia is an eating disorder. Ironically, orthorexia also leads to severe malnutrition and weight loss in some cases. As well, many eating disorders begin as a genuine effort to eat more healthfully.

A screening test for orthorexia exists, and I find it strangely shocking that no one has given a group of current eating disorder patients the orthorexia screening test and vice versa. You’d think that would be a pretty obvious place to start.

Perhaps one of clearest similarities between orthorexia and eating disorders is this explanation of orthorexia from a recent research paper:

In extreme cases, the obsessive and compulsive characteristics of ON become pathological and dominate a person’s life. The preoccupation with quality of food and eating healthy comprise the principal elements of this disorder. The pathological obsession with biologically pure food and shops which sell it leads to a special lifestyle. Stringent dietary restrictions and eating plans, combined with a personality and attitude of superiority and obsessive-phobic behavioral characteristics define the core of ON. Transgressing the dietary rules leads to intense anxiety, feelings of guilt and shame and is followed by even more stringent dietary restrictions. (Varga et al, 2014)

I didn’t really have strong orthorexic tendencies while ill, but this description strongly echoes my experiences of anorexia. Of course, this also has echoes of OCD, which I’ll cover in my next post.

References:

Aksoydan, E., & Camci, N. (2009). Prevalence of orthorexia nervosa among Turkish performance artists. Eating and Weight disorders-Studies on Anorexia, Bulimia and Obesity, 14(1), 33-37. doi:10.1007/BF03327792

Fidan, T., Ertekin, V., Işikay, S., & Kırpınar, I. (2010). Prevalence of orthorexia among medical students in Erzurum, Turkey. Comprehensive psychiatry, 51(1), 49-54. doi:10.1016/j.comppsych.2009.03.001

Kinzl, J. F., Hauer, K., Traweger, C., & Kiefer, I. (2006). Orthorexia nervosa in dieticians. Psychotherapy and psychosomatics, 75(6), 395-396. doi:10.1159/000095447

Keel, P. K., & Klump, K. L. (2003). Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychological bulletin, 129(5), 747.

Segura-García, C., Papaianni, M. C., Caglioti, F., Procopio, L., Nisticò, C. G., Bombardiere, L., … & Capranica, L. (2012). Orthorexia nervosa: a frequent eating disordered behavior in athletes. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 17(4), 226-233. doi:10.3275/8272

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. doi:10.1186/1471-244X-14-59

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12 Responses to “On orthorexia, Part One: Is orthorexia an eating disorder?”

  1. This absolutely fascinates me. I believe my daughter’s anorexia might have been defined by some as orthorexia–I am glad UCSD called it anorexia and we got working on recovery.

    • I think lots of people have that experience now (an ED that starts with a preoccupation with healthful eating).

  2. Very interesting. I never thought about the OCD link with orthorexia, but I can certainly see it now. When my daughter was in residential treatment, friends/family would say that they hoped she would learn how to eat healthy. I told them I just hoped she’d learn to eat.

  3. Orthorexia is by far the number one topic that journalists want to write about, and I am not sure what it is (aside from that exotic name) that intrigues the public so much. I am happy to put my two cents in here. Just to add, binge eating disorder, which has its own home in DSM-5 now, does not revolve around body image distortion or fear of fatness, which makes it no less of an eating disorder. There are multiple pathways into anorexia nervosa and a preoccupation/obsession with healthful eating is only one of them. I worry that giving these behaviors a less severe label will only lead to taking the symptoms less seriously and missing opportunities to intervene swiftly to avoid a precipitous decline into severe anorexia.

  4. While I definitely relate more to the description of orthorexia than I do anorexia, I have to agree with Cindy on this (I mean, how can you argue with Cindy Bulik?… 😉 ) in that it seems to be just another manifestation of anorexia. Are the motivations different? Perhaps. But then I’ve never seen any two people with anorexia agree completely about what prompted and perpetuated their own struggle, either. We’re all just so different. Orthorexia seems to be just another form of anorexia and severe restriction, as the sufferer struggles to find foods that fit into their ever-shrinking definition of ‘healthy.’ Do they intend to lose weight? Not necessarily. Are they driven by an obsession with body image? Again, probably not. But otherwise the symptoms are extremely similar and ultimately, will likely lead to death if not treated. Maybe we should spend less time over how to ‘categorize’ and ‘label’ all of these things and more time into how to actually TREAT them.

  5. While coming out of my eating disorder, I fell into orhtorexia – I believed that it was a way to maintain recovery, but now I look back and see it was just part of my ED – instead of obsessing over calories, I obsessed over whole foods. While one could argue that orthorexics might not have body image problems, I would say they do but not in terms of looking thin and being a certain size, but rather about looking/appearing/seeming to be “healthy” and most of all being obsessed with how every morsel of food is doing good for the body. An orthorexic would feel guilty eating something non-organic, for example, for the reason that they would think it’s affecting the body in adverse ways. Does that make sense?

    • That’s a very interesting way of looking at the body image issue. I like it! Thanks for sharing!

  6. Good stuff, Carrie! I would imagine that anybody with an ED who is in any way OCD could slip into Orthorexia very easily; it would almost seem to be a ‘logical’ pitfall on the road to recovery. What I find very important is to keep track of the distinction between an unhealthy obsession and the drive to improve health after years of unhealthy decisions: this is where a lot of us would need careful monitoring.

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