In the previous post I mentioned how there are issues with the validity of the standard questionnaire (the ORTO-15) to diagnose orthorexia (or health fanaticism) in those orthorexia prevalence studies. So I went through the ORTO-15 and surveyed myself, and this made me more strongly agree with those concerns of validity. Before I go through the ORTO-15, just note that I would answer no to all of Dunn & Bratman’s proposed diagnostic criteria (see previous post)
As a general note these questions are a bit ambiguous at times. Besides wondering what ‘often’ and ‘sometimes’ should be operationalised to mean, questions along the line of ‘Do you think X’ (questions 9, 10, 11, 12, 14) could be interpreted in a few ways. Just to use question 9 as an example, it could be interpreted to mean either: ‘how often do you do you think your mood affects your eating behaviour’; or ‘do you think your mood often affects your eating behaviour’. In addition, the ‘your’ in questions like question 9 could be referring to yourself or to people generally, though I suspect the former. I might be overthinking this, but I think it’s plausible that if you gave questions like question 9 to a bunch of people you would get 4 different interpretations of the question from the sample. So I’ll answer that type of question two different ways and assume ‘your’ means yourself
Lower scores are more indicative of orthorexic tendencies
1. When eating, do you pay attention to the calories of the food?
Sometimes (3). It can sometimes be a good idea to know roughly how many calories are in something and that when considering a dessert for example, 100g of cake contains a lot more calories than 100g of fruit and is proportionally less satiating. Most of what I eat doesn’t have a calorie label and that doesn’t concern me
2. When you go in a food shop do you feel confused?
Never (1). When I go into a food shop I know what I want to buy and don’t spend much time doing so (10-15 minutes for a weekly shop). I think you could be confused if you had an introductory level of nutritional knowledge that was strongly influenced by the contradictory messages in the media, and then debating between various processed foods (should I buy the low fat muffin or the gluten free brownie, etc).
3. In the last 3 months, did the thought of food worry you?
Never (4). I don’t think it should unless you had something like IBS, IBD or coeliac disease, which would be quite understandable
4. Are your eating choices conditioned by your worry about your health status?
Never (4). I would describe myself as being invested in my health status, but not worried about it. With questions like this and question 3 you can see how easy it could be for someone trying to do something about a health condition they have to be labelled as orthorexic
5. Is the taste of food more important than the quality when you evaluate food?
Sometimes-often (2.5). The food I eat is simple, but tastes nice. But I don’t regularly eat junk food even though it tastes better
6. Are you willing to spend more money to have healthier food?
Sometimes (3). Healthy food doesn’t have to be that expensive and I limit expenses by generally only purchasing fruit and vegetables at ≤ $4/kg, and meat at ≤ $10/kg. Berries might be the healthiest fruit, but at $20+/kg it’s hard to justify the need for them. That being said, meat, fruit and vegetables are definitely more expensive per calorie than things like bread, pasta or rice. Perhaps I would answer ‘often’ if I had a higher income
7. Does the thought about food worry you for more than three hours a day?
Never (4). That’s a very long time to worry about food and could be a sufficient diagnostic criterion in itself
8. Do you allow yourself any eating transgressions?
Sometimes (2). Unhealthy food doesn’t makes up a fairly small part of my diet, I eat a small amount of ice cream fairly regularly, some chocolate/etc when it’s gifted to me and eat out or buy lunch rarely (only without someone else and mainly because it’s much more expensive than making your own). But ‘eating transgressions’?! That’s pretty strong language and certainly not the kind of way I would describe eating unhealthy food. Apparently only ‘sometimes’ is pretty orthorexic though
9. Do you think your mood affects your eating behavior?
Interpretation 1: how often do you do you think your mood affects your eating behaviour. Sometimes (2). I rarely think about this probably because I don’t engage in very obvious emotional eating
Interpretation 2: do you think your mood often affects your eating behaviour. Always (4). Because mood always has some effect, just to varying degrees (note: I don’t think we have free will)
10. Do you think that the conviction to eat only healthy food increases self-esteem?
Interpretation 1: how often do you think that the conviction to eat only healthy food increases self-esteem? Sometimes (3). I very rarely think about this
Interpretation 2: do you think that the conviction to eat only healthy food often increases self-esteem? If someone resolves to eat healthfully and then successfully does so, that can increase self-esteem in a very healthy way, just like resolving to and then successfully completing any other activity (Often (2)). It won’t increase self-esteem much for me though because my eating habits are quite routine. But conviction on its own without action wouldn’t increase self-esteem for me though because I haven’t achieved/done anything (Never (4)), but may increase self-esteem in other people (Sometimes (3))
11. Do you think that eating healthy food changes your life-style (frequency of eating out, friends, …)?
Interpretation 1: how often do you think that that eating healthy food changes your life-style (frequency of eating out, friends, …)? Sometimes (3). I very rarely think about this
Interpretation 2: do you think that eating healthy food often changes your life-style (frequency of eating out, friends, …)? Sometimes (3). I’m comfortable eating pretty much whatever in the odd social situation. Paleo was a gateway for my interest in chronic disease research, the blog and the people I follow on twitter, but if I changed the way I ate, without changing what I think, then I don’t expect the other stuff would change
12. Do you think that consuming healthy food may improve your appearance?
Interpretation 1: how often do you think that consuming healthy food may improve your appearance? Sometimes (3). I don’t think about this very often
Interpretation 2: do you think that consuming healthy food may often improve your appearance? Sometimes (3). For the most part the foods I eat have a unnoticeable effect on my appearance (as something that changes slowly anyway), but could easily have subtle long term effects on aging. I find some foods (wheat, chocolate) can sometimes give me a little bit of acne
13. Do you feel guilty when transgressing?
Never (2). Again, such strong language with ‘guilty’ and ‘transgressing’. I have never felt guilty when eating unhealthy food. I have sometimes regretted those decisions, but eating unhealthy food isn’t something that’s morally wrong to feel guilty over. But apparently my response is pretty orthorexic though
14. Do you think that on the market there is also unhealthy food?
Often (2). Of course there is unhealthy food in the market, most of it isn’t healthy and that shouldn’t be a controversial statement
15. At present, are you alone when having meals?
Often (2). Simply because I’m currently living by myself
I scored 40.5 with interpretation 1 and 42.5 with interpretation 2. Most studies have used a score of less than 40 as the cut-off point that indicates orthorexic behaviours, so the ORTO-15 would suggest I have borderline orthorexia or are at risk of orthorexia, but you can judge for yourself on whether that is the case
I hope you can now see quite clearly how those prevalence studies were able to find such surprisingly high prevalence rates for orthorexia. Another issue with the ORTO-15 is that the questions and responses (‘often’ and ‘sometimes’) can be interpreted in many ways and that some questions don’t necessarily do a good job of assessing orthorexia or lack thereof in some circumstances, and these other issues may explain how associations between orthorexia and other factors has been inconsistent or absent in the literature