Saturday, April 30, 2016

Summary of the Research on Orthorexia

At the time of writing this post there are 49 papers on PubMed on orthorexia.  Needless to say, the research is in its infancy, but that doesn’t mean it isn’t a legitimate condition.  Most of the studies on orthorexia are looking at the prevalence of orthorexia in a specific population (mostly in university students, but also dieticians, people with other eating disorders, etc) and/or are looking at associations between various personality characteristics such as perfectionism with orthorexia.  There are also several pretty extreme case studies in the literature

The Othorexia Prevalence Studies

The prevalence studies used a questionnaire called the ORTO-15 (or a derivative of it) and have reported a very wide range in the prevalence of orthorexia (between 6 to 88.7%) that is generally very high (~30-80%) [1] [2].  The following table comes from [1]

Study
Prevalence rate (%)
Country
Donini et al. (2005)
6.9
Italy
Bosi et al. (2007)
45.5
Turkey
Aksoydan and Camci (2009)
56.4
Turkey
Fidan, Ertekin, Işikay, and Kirpinar (2010)
43.6
Turkey
Ramacciotti et al. (2011)
57.6
Italy
Alvarenga et al. (2012)
81.9
Brazil
Segura-García et al. (2012)
Men: 28 Women: 30
Italy
de Souza and Rodrigues (2014)
88.7
Brazil
Varga et al. (2014)
74.2
Hungry
Valera, Ruiz, Valdespino, and Visioli (2014)
86
Spain
Asil and Sürücüoğlu (2015)
41.9
Turkey
Brytek-Matera, Donini, Krupa, Poggiogalle, and Hay (2015)
Men: 43.2 Women: 68.6
Poland
Gubiec et al. (2015)
59
Poland
Jerez et al. (2015)
30.7
Chile
Missbach et al. (2015)
69.1
Austria
Stochel et al. (2015)
Study 1: 53.7 Study 2: 52.6
Poland
Segura-Garcia et al. (2015)
Clinical: 58 Control: 6
Italy

If the high and variable prevalence rates sounds weird, that’s probably because it is.  Several studies have brought up issues with the ORTO-15 including:

·         That “it is counterintuitive to believe that a phenomenon of restricted eating that is not well understood has point prevalence rates found to be as high as 88.7 %, with repeated findings of 30–80 %” [2]
·         That “in this study, it is remarkable that 80 % of the sample endorse that they do not restrict the type of food that they consume, yet the ORTO-15 identifies over 70 % of the sample suffering from ON” [2]
·         That the ORTO-15 doesn’t do well at distinguishing healthy eating from disordered eating very well [2] [3] [4]
·         Issues with the questions and scoring [3]
·         The inconsistent associations between ORTO-15 scores with age, education, BMI, smoking, alcohol, and sex [4]

Orthorexia and OCD

In contrast to the ORTO-15 (which I’ll show you in the next post), in a recent review Dunn & Bratman [1] proposed some diagnostic criteria for orthorexia

Criterion A: Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue as a result of dietary choices, but this is not the primary goal. As evidenced by the following:

1.       Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices believed by the individual to promote optimum health.
2.       Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.
3.       Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy eating.

Criterion B: The compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:

1.       Malnutrition, severe weight loss or other medical complications from restricted diet.
2.       Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviors about healthy diet.
3.       Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior.

This is very similar to some other proposed diagnostic criteria by Moroze et al [5]:


Both sets of diagnostic criteria emphasise the two factors that for something to be disordered eating (as opposed to conscientious eating) it needs to cause suffering and impair function (the two key factors that really define whether something is a mental health issue or not).  They also emphasise that orthorexia is a very similar condition to obsessive compulsive disorder.  Something that is discussed well in the following review (and something I’m planning to write about later) [4]


* Orthorexia and anorexia are distinguished by orthorexia being about food quality for health and anorexia being about food quantity for weight loss.  It’s a simple story, but what about the two other combinations: an obsession on food quality for weight loss, and on food quantity for health.  The latter two could both fall into the category of orthorexia, and I can think of some examples for each of them

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