Ewelina Kośmider: Orthorexia nervosa is a relatively new disorder, please explain what it is about. Or perhaps it has existed for ages but was not diagnosed?

Prof. dr hab. Anna Brytek-Matera, Institute of Psychology, University of Wrocław: Orthorexia nervosa is not a disorder sensu stricto. So far, it has not been recognised as a separate nosological entity by either the World Health Organisation, or the American Psychiatric Association. Therefore, it does not figure in any of the currently operative disease and psychological disorder classifications.

The first work on orthorexia nervosa appeared in 1997. An American doctor, Steven Bratman, MD defined orthorexia nervosa as an excessive concentration, “fixation”, as he called it, on eating healthy food. It is worth remembering that the presented eating habits result from an excessive concern with one’s health. A person with orthorexic behaviours avoids eating foods which they see as unhealthy. Hence, the term “health” has purely subjective connotations in the case of orthorexia nervosa.

Currently, availing of the definition suggested by the international research group The Orthorexia Nervosa Task Force (ON-TF), we may assume that orthorexia nervosa relates to “an obsession with the quality of the consumed food and its influence on health”.

The classification of orthorexia nervosa is currently under debate amongst researchers and practitioners. Some treat it as a psychological disorder which should be considered as (1) a diagnostic unit separate from eating disorders and the obsessive-compulsive disorder (OCD) or (2) a spectrum of eating disorders or (3) a spectrum of OCD or (4) a separate category of eating disorders. To other researchers, orthorexia is a reflection of a healthy lifestyle. There are also some who treat it as a persisting behavioural pattern.

Despite the lack of consensus in the scientific community as to the categorisation of orthorexia nervosa, I consider it a pathological state, which I articulated in my latest book. The extreme focus on eating habits with the aim of acquiring optimal health has a negative influence on the person’s psychosocial functioning. Apart from the selective way of choosing food products on the basis of their quality, there is a number of other factors indicating an eating disorder, such as the presence of recurring, hardly controllable negative thoughts about one’s health and proper nutrition, or the occurrence of negative feelings, e.g. evoked by anxiety or guilt resulting from having eaten a “wrong”, i.e. “unhealthy” product. The person gradually removes products and meals which they find unhealthy, i.e. highly processed, non-ecological, or ones containing preservatives. They devote too much attention to both meal preparation and techniques of food processing (e.g. they avoid frying their food). Breaking their own nutrition rules heightens their negative thoughts and self-image, e.g. “I am no good because I cannot achieve my goal”. Undoubtedly, orthorexic behaviours have a detrimental effect on health, despite resulting from a healthy interest in proper nutrition. In my judgement, people who are too absorbed in nutrition models which they subjectively defined as healthy, require support and specialist help.

How is this disorder diagnosed? The diagnostic criteria remained undefined until recently, have they been ultimately determined? What are the symptoms of the disorder?

It is regrettable that in spite of the increasing amount of research on orthorexia nervosa in the last two decades we still lack a uniform definition. Establishing a universal definition of orthorexia nervosa is key for several reasons: it will enable the inclusion or exclusion of the diagnosis of orthorexia nervosa from current systems of classification of diseases and psychological disorders; it will create a possibility of differentiating abnormal, i.e. pathological eating habits from the normative ones, therefore enabling the confirmation or rejection of the initial diagnosis of orthorexia and the decision to initiate proper medication.

We still lack uniform diagnostic criteria and the so-called diagnostic “gold standard”. That is why the aforementioned multidisciplinary group of experts (ON-TF) has been working on establishing them for the last few years. In 2019, the experts pointed out three basic criteria of orthorexia: (1) the pathological absorption in the consumption of healthy food; (2) the occurrence of negative emotions and emotional states (e.g. anxiety, guilt, shame) as a result of disobeying one’s self-imposed eating principles; and (3) psychosocial impairment in important spheres of life, nutritional deficiencies, and body weight loss. Prof. Lorenzo Donini along with the researchers at the ON-TF suggested the initial diagnostic criteria in 2022. Criterion A is focused on the definition, clinical aspects, and duration of orthorexia nervosa. Criterion B regards its consequences. Criterion C involves the beginning of orthorexia, whereas criterion D concerns the criteria of its elimination. The scientists suggested 27 criteria in total, in which they included risk factors (e.g. history of eating disorders or psychological disorders), pathophysiology (e.g. nutritional deficiencies, hormonal disorders), as well as psychological and clinical consequences.  

Because of the need to establish a screening tool for orthorexia nervosa, I proposed seven screening questions (Orthorexia Nervosa Screening Questions). They concern the main qualities of orthorexia nervosa and are in line with the existing diagnostic criteria established by Prof. Thomas Dunne and Dr. Steven Bratman. I use them in therapeutic practice in order to assess the risk of orthorexia nervosa.

When does the concern about one’s health in the form of a healthy diet deteriorate into an illness?

In my opinion, in the case of nutrition habits the line between the norm and pathology—understood as a medical condition—is explicit. Focusing on only one sphere of one’s life, while neglecting others—one’s family, career, social contacts—cannot be considered healthy.

What causes this disorder?

The pathogenesis of orthorexia nervosa is not known. Currently we lack knowledge about the risk factors triggering and sustaining this disorder, since there is no longitudinal research (a type of research where the same variables are analysed multiple times at certain time intervals) whose purpose is to determine and monitor the factors related to the triggering and sustaining of orthorexia, no research conducted on representative clinical and non-clinical samples, and seldom any case studies.

However, it is worth it to mention the psychosocial model of orthorexia nervosa created by Sarah McComb and Prof. Jennifer Mills. According to this model, psychological and social factors are risk factors of orthorexia nervosa. The first group consists of: perfectionism, neuroticism, obsessive-compulsive qualities, current or past eating disorders, fear of losing control, restrictive diet, pursuit/internalisation of a slim figure ideal, and susceptibility to danger. The other group, in turn, consists of: living in a culture which stigmatises obesity, access to organic foods, higher earnings, access to research/knowledge about food, positive reinforcement of other people, and planning/preparation of healthy meals.

Can this disorder be culturally or socially conditioned?

There are research results which prove that the glorification of certain nutrition habits on social media may reinforce certain people’s beliefs that only the “clean” and “healthy” nutritional choices are socially acceptable. We also know that the daily amount of time spent on social media correlates positively with orthorexia nervosa. The results of Italian research show that the frequency of occurrence of orthorexia nervosa was markedly higher in people who spent over 60 minutes a day on social media (31%), than in people spending there less than 15 minutes a day (almost 22%). Some research results confirm the exacerbation of symptoms of orthorexia nervosa in women who follow Instagram accounts concerning healthy food, health, and physical activity, in comparison to people who appear less interested in such content. Additionally, some researchers consider the frequent use of Instagram to be a risk factor of the development of orthorexia nervosa, although there is also research showing the lack of connection between Instagram use and orthorexia nervosa.

The socio-cultural context related to the impact of social media on orthorexia nervosa has been researched for several years now, mainly through qualitative research. Nonetheless, due to the lack of consistent empirical proof, we are currently unable to assume that only socio-cultural conditioning is important in the development of orthorexia nervosa.

Is orthorexia more common in women or in men?

There is no unequivocal answer to this question. There are research results showing that the prevalence of orthorexia nervosa is similar in women and in men. Others show that orthorexia is more common in women, while some point to the opposite.

What are the consequences of the disorder? There must be some phycological, physical, and social consequences?

So far only one instance of qualitative research assessed the experiences of orthorexia from the perspective of convalescents. Orthorexia had a critical impact on their emotional and social life. It contributed to an excessive concentration on the quality of food, negative emotional states (e.g. the fear of nutritional choices), as well as social isolation and negative interpersonal relations with family, partners, and friends. The people suffered from eating disorders prior to or during orthorexia nervosa, and evinced compensational behaviours, e.g. overeating followed by purging, skipping meals. In most people, the fears concerning body mass occurred. Patients also reported physical problems, e.g. insomnia, abdominal issues, as well as psychological, e.g. low mood, increased emotional distress.

How can orthorexia be cured?

Since we lack research regarding the effectiveness of the treatment of orthorexia nervosa, it is difficult to propose proper help. There are few literary publications concerning this field. Cognitive behavioural therapy is proposed most often because of the similarities in the characteristics between orthorexia nervosa and anorexia nervosa or OCD. This form of therapy enables the patient to learn to identify and modify the negative cognitive content on the subject of food and health and regulate negative emotions which often occur as a result of a deviation from the planned diet. For instance, before starting therapy a person may be convinced that if they do not have a meal consisting exclusively of natural products, their health will deteriorate severely. Therapy helps them understand their cognitive distortions and notice their impact on their emotions and behaviour.

Researchers primarily point out the activity of multidisciplinary teams (psychotherapists, dieticians, doctors) in the treatment of orthorexia nervosa. They propose using psychoeducation on the topics of nutrition and health to minimise false convictions about them, and using cognitive restructuring (i.e. the identification and questioning of the person’s disrupted thoughts)—to minimise dichotomic thinking (also known as black-and-white thinking, e.g. “Either I eat organic products exclusively, or I eat all products”), excessive generalisation (e.g. “I did not manage to cook a proper meal today, surely I will not be able to eat healthy in the future”), and other cognitive disruptions related to food and health.

Additionally, there are other promising methods of complex treatment of orthorexia nervosa such as: dietary counselling in order to restore a healthy and balanced relationship with food; intuitive attitude towards food (i.e. eating according to the needs of one’s body, e.g. having food when one feels hunger, stopping when one feels full)—in order to overcome stiff dietary principles and employ a more careful and impartial attitude towards food; and a treatment based on mindfulness (e.g. focusing only on the act of consumption while eating)—in order to provide a healthy relationship with food and mental wellbeing.

Is it difficult to convince a person suffering from orthorexia to start treatment?

The difficulty of starting treatment results from an egosyntonic quality of orthorexia nervosa. Just as in the case of anorexia nervosa, people who suffer from orthorexia nervosa do not perceive their own symptoms as dysfunctional. They deny the existence of the disorder, which is why they have low motivation to start treatment.

People with orthorexia nervosa might be more inclined to start treatment due to their concern about health. They could be prompted to seek help in order to solve their health problems, and to improve their health and wellbeing. In other words, the difficulties resulting from nutrition habits will not be a motif for starting therapeutic work, as they are perceived by the person as normative and healthy.

Does orthorexia entail other disorders?

Orthorexia nervosa may co-occur with other disorders. Some research results show a correlation between orthorexia and the symptoms of anorexia nervosa, depressive disorder, anxiety disorder, and OCD.

Orthorexia nervosa, just as anorexia nervosa, is characterised by an excessive preoccupation with food, abiding by dietary restrictions, a high level of perfectionism, a need of having control, and a stiffness of behaviour. Drawing on a systematic literature review which showed that orthorexia nervosa is related to the qualities of anorexia nervosa, mostly in the sphere of restrictive behaviours and a motivation to control one’s body, yet is not associated with a dissatisfaction with one’s body, I believe that orthorexia nervosa may be considered a separate eating disorder.

You are a pioneer in researching this disorder, for how long have you been working on it?

Twelve years ago, I published the first scientific article on orthorexia nervosa (one of a demonstrative nature). I also cooperated with Prof. Lorenzo Donini from the Sapienza University of Rome, which resulted in the publication of the Polish adaptation of the ORTO-15 questionnaire, a testing tool for orthorexia nervosa, which was immensely popular at the time. In 2015, at the invitation of the American Psychological Association (APA), the Polish version of the ORTO-15 questionnaire was included in the APA PsycTESTS database. In the following years I continued my research, mostly regarding the analysis of psychological factors co-occurring with orthorexia nervosa, in both the clinical group (patients with eating disorders) and the general population. The culmination of my research and scientific pursuits in this fascinating field is the scientific monograph, Orthorexia Nervosa: Current Understanding and Perspectives.

What are the challenges that the researchers of orthorexia nervosa are facing?

The “nature” of orthorexia nervosa requires an explanation. As researchers and specialists working with patients, we need to find the answer to the question of the kind of “disorder” orthorexia nervosa is. Should we treat it as a separate nosological entity, a new eating disorder? Or perhaps we should see it as a “manifestation” of anorexia nervosa or as a different eating disorder? It is necessary to differentiate between orthorexic behaviours and normative, health-promoting eating behaviours. Another challenge is the creation of a universal diagnostic tool for testing orthorexia nervosa.

I believe that understanding this disorder requires a lot of research—not only for its scientific value, but most of all for its clinical value.

***********

Prof. dr hab. Anna Brytek-Matera – psychologist and cognitive-behavioural therapist, head of the Nutritional Psychology Unit, Eating Behaviour Research Lab (EAT Lab) and the postgraduate studies in Psychodietetics at the Institute of Psychology. She is a Member of the Committee on Nutrition for Adults and Older Adults of the Committee on Human Nutrition Science of the Polish Academy of Sciences.

Author of over 160 scientific papers on orthorexia nervosa, eating disorders, obesity, and abnormal eating behaviours. She is among the 2% of the world’s most cited scientists (World’s TOP 2% Scientists; the single-year impact list: 2021, 2022, 2023).

She conducted lectures at the Paul Verlaine University – Metz, University of Nantes, University of Bordeaux, University of Pavia, University of Padova, University of West London, Western Sydney University, The University of Tokyo, and Stanford University. She was a visiting professor at Western Sydney University and a visiting researcher at the University of Bordeaux. As a visiting researcher, she is currently working on a scientific project in the Department of Psychosomatic Medicine, The University of Tokyo Hospital and The University of Tokyo, Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine.

Translated by Natalia Tkaczuk (student of English Studies at the University of Wrocław) as part of the translation practice.