Orthorexia: When the Pursuit of Health Becomes Harmful

In addition to the widespread prevalence of eating disorders such as anorexia and bulimia nervosa, orthorexia nervosa has emerged in recent years. According to the National Eating Disorders Association (NEDA), orthorexia is the obsessive adherence to a healthy and proper diet.  Although it's a term we've been hearing more frequently in the past three or four years, from the COVID-19 pandemic and onwards, orthorexia made its debut as early as 1997. Nevertheless, even today, after all these years, this pathological relationship with food cannot be diagnosed as an eating disorder according to the latest criteria, DSV-5.  

Orthorexia Nervosa (ON), describes an obsession with proper and high-quality nutrition that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure. Contrastingly to other eating disorders it focuses on food quality rather than food quantity. Orthorexics typically limit their food consumption according to what they believe is healthy because their primary motivation is to accomplish “optimal health” The word orthorexia derives from the Greek words “ορθός” which means proper and “όρεξη” which means appetite. So the actual meaning of orthorexia is “correct appetite”. Some researchers distinguish orthorexia into “healthy" and "nervosa”, depending on the degree of adherence or obsession of the individual. However, recent studies refuse the existence of these two types and argue that orthorexia constitutes solely a pathological condition.

Since we do not have specific criteria we cannot know exactly how many people suffer from that disorder. However, in a recent meta-analysis, it has been shown to occur with equal frequency in men and women, while being much more common in populations who exercise regularly. Actually it is really impressive that in that meta-analysis approximately 53% of the exercising individuals appeared to have symptoms of orthorexia in a population of more than 18.000 people that participated. There has been a significant increase in prevalence in recent years, particularly since the onset of the lockdown due to COVID-19. Prolonged confinement with individuals in potentially unhealthy relationships, changes in exercise habits, fear of shortages of various foods, worsening economic problems, and the overall isolation of people, are just some of the reasons that led to this exacerbation. At the same time, increased engagement with social media and heightened focus on wellness and healthy standards came during the exact same period, further complicating the situation.

Risk factors and characteristics

Despite the change in daily routine, there hasn't been any disturbance throughout the entire society, but rather in a significant portion of it. Therefore, there are some additional characteristics shared by individuals who are more likely to develop an eating disorder. These factors encompass the formation of food preferences, inherited variances in taste perception, food neophobia or selectivity, having overweight or obesity, parental feeding practices and a history of parental eating disorder. Additionally, characteristics such as perfectionism, emphasis on appearance, preoccupation with weight, self-perceived weight classification, attachment styles characterized by fear or dismissal, appearance orientation, and a history of an eating disorder have also been identified. 

And how can we identify a person that has a disorder? Well a few of the characteristics these people obtain are: the compulsive checking of ingredient lists and nutritional labels, the increase in concern about the health of ingredients, the cut out of many food groups (all sugar, all carbs, all dairy, all meat, all animal products), the increased hours spent per day thinking about what food might be served at upcoming events, the obsessive following of food and ‘healthy lifestyle’ blogs on social media, the body image concerns and the psychosocial impairments in different areas of life

It is reasonable for someone to wonder why it is bad to be fully committed to a healthy diet. Initially, in orthorexia this commitment is made to a diet that the individual has deemed healthy. Often, this means that large groups of foods such as sugary foods, processed foods, but in extreme cases even all carbohydrates have been excluded, or foods of animal origin have been eliminated completely. What is the result? Significant deficiencies arise in macro and micronutrients such as iron and proteins, but also in energy intake, resulting in unhealthy weight loss. All these deficiencies can have long-term effects on the cardiovascular, nervous, immune, digestive, and other systems of the body.

But the problems do not stop there. The biggest cost of eating disorders is psychological. The individual experiences such a strong psychological compulsion with healthy eating that when, for some reason, they cannot adhere to it, they panic. If the foods they consider healthy are not available, they may prefer not to eat at all, or even if they do eat it, the guilt afterwards is unbearable.

What about the treatment?

So far, there isn't a specific treatment tailored for orthorexia. Most healthcare professionals view it as a branch of other eating disorders like anorexia. This predisposes the formation of a comprehensive interdisciplinary team consisting of the treating physician, psychologist, dietitian, and possibly a fitness trainer.

Regardless of who the individual reaches out to first, all therapists need to understand that they cannot handle such a case on their own. The first step is to refer the case to a pathologist or cardiologist to determine whether the heart function is normal or if immediate hospitalization is needed as It is quite common in prolonged disorders for there to be abnormal heart function. 

From that point onwards, each member of the team takes on their role. The psychologist delves deeper and tries to find the causes and triggers of the disorder. On the other hand, the dietitian gradually tries to reintroduce the foods that have been excluded and to normalize them. Cognitive-Behavioral Therapy (CBT) plays a primary role in the treatment of disorders. It's applied by both psychologists and dietitians and helps in identifying the problem, removing barriers, and managing relapses through changing thoughts, emotions, and behaviors. The presence of a trainer in the team also might be crucial to set boundaries and provide guidance on the exercise. None of these specialists can be effective alone. It's essential that there is direct communication among all therapists so that the individual receives consistent recommendations and advice from everyone, with each complementing the other instead of conflicting. Finally, the individual's environment, including family and friends, plays a crucial role in treatment. The team should maintain constant communication with them as well.

Conclusions

Summing up, I would like to emphasize the need for further engagement with this new class of disorders as they affect a large portion of the population. It would be beneficial to have recommendations and diagnostic criteria for identifying this disorder as well as other subtle ones. Additionally, a piece of advice to all therapists is not to take on cases of disorders if they have not been adequately trained. Eating disorders are not simply treated with medication or recommendations. They are conditions that can become life threatening and require a specific approach to yield results. I have heard several times of individuals with disorders turning to non-specialists for help, and instead of improving, their condition worsens. It's not wrong to refuse a case if you cannot manage it properly and to refer it to someone who has the capability, because above all, we want the health of our patients.