Orthorexia Nervosa: An Obsession With Healthy Eating

Jonathan R. Scarff, MD

Despite a focus on eating, orthorexia nervosa may lead to malnourishment, loss of relationships, and poor quality of life.

irst named by Steven Bratman dietary regimen and eats anything gen saturation 98% on room air. The in 1997, orthorexia nervosa containing seafood, beef, or pork remaining physical examination re- (ON) from the Greek ortho, products, which he corrects by a day vealed no abnormalities. A complete F meaning correct, and orexi, of fasting. His wife was frustrated be- blood count, thyroid function, uri- meaning appetite, is classified as an cause he refused to go to restaurants nalysis, and urine drug screens were unspecified feeding and eating dis- and started declining offers from within normal limits. Comprehensive order in the Diagnostic and Statistical friends to eat dinner at their homes metabolic profile revealed decreased Manual of Mental Disorders 5th edition unless he could bring his prepared sodium of 130 meq/L. Electrocardio- (DSM-5).1,2 food. He describes feeling “annoyed” gram revealed bradycardia. when he sees other people eating fast An ON diagnosis is made primar- HYPOTHETICAL CASE food or meat. ily through a clinical interview. Col- Mr. P is a 30-year-old male who pre- Mr. P reported no significant med- lateral information from individuals sented to the mental health clinic ical or surgical history. His family his- familiar with the patient can be help- with his wife. The patient recounted tory was significant for in his ful. Experts have proposed and re- that he had wanted to “be healthy” mother. He used to drink alcohol so- cently revised criteria for ON (Table). since childhood and has focused on cially but ceased a few years ago due Although the ORTO-15 assessment exercise and proper , but anxi- to its carbohydrate content. He never tool may assist with diagnosis, the ety about diet and food intake have smoked or used illicit drugs. tool does not substitute for the clini- steadily increased. Two years ago, he A mental status exam revealed a cal interview. adopted a vegetarian diet by progres- thin male who appeared his stated sively eliminating several foods and age. He was cooperative, casually DISCUSSION food groups from his diet. He now dressed, and made fair eye contact. There is no reliable measure of preva- feels “proud” to eat certain organi- He spoke clearly with an anxious lence of ON, though Varga and col- cally grown fruits, vegetables, nuts, tone and appropriate rate and vol- leagues initially estimated ON to beans, and drink only fruit or veg- ume. His affect was congruent with occur in 6.9% of the general popula- etable juice. stated anxious mood. He was alert, tion, and ON may occur more fre- His wife stated that he spent be- awake, and oriented to person, place, quently in health care professionals tween 3 and 5 hours daily preparing and time. He reported no paranoia, and performance artists.3 However, food or talking to friends and family auditory or visual hallucinations, and these may be overestimates, as the as- about “correct foods to eat.” He also suicidal or homicidal ideation. sessment tool used in the study does believed that errors in dietary habits A physical exam revealed a thin not adequately separate people with caused physical or mental illnesses. male in no distress who measured healthy eating habits from those with He reported significant guilt and 5 feet 10 inches tall and weighed ON.4,5 shame whenever he “slips up” on his 145 pounds, which yielded a body Most prevalence studies were mass index of 20.8. His vitals in- conducted in Europe and Turkey, Dr. Scarff is a psychiatrist at the William Jennings Bryan Dorn VA Community-Based Outpatient cluded temperature of 98° F, blood and prevalence of ON may dif- Clinic in Spartanburg, South Carolina. pressure 115/76, pulse 74, and oxy- fer in the U.S. population. A recent

36 • FEDERAL PRACTITIONER • JUNE 2017 www.fedprac.com assessment determined a prevalence 10 of about 1%, similar to that of other Table. Proposed Diagnostic Criteria for Orthorexia Nervosa eating disorders.5 No study has re- Criterion A ported a correlation between ON Obsessive focus on healthy eating, as defined by a dietary theory or set of beliefs whose and gender, but a survey of 448 col- specific details may vary; marked by exaggerated emotional distress in relationship to food lege students in the U.S. (mean age choices perceived as unhealthy; weight loss may ensue as a result of dietary choices, but this 22 years) reported highest ON ten- is not the primary goal. As evidenced by the following: dencies in Hispanic/Latino and over- • Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive weight/obese students.6 dietary practices believed by the individual to promote optimum health; • Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal Relationship to Other Illnesses impurity and/or negative physical sensations, accompanied by anxiety and shame; There is significant debate whether • Dietary restrictions escalate over time, and may come to include elimination of entire food ON is a single syndrome, a variance groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) of other syndromes, or a behavioral 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. and culturally influenced attitude.7,8 Although ON may lead to or be co- Criterion B morbid with (AN) The compulsive behavior and mental preoccupation becomes clinically impairing by any of the or obsessive-compulsive disorder following: (OCD), subtle differences exist be- • , severe weight loss, or other medical complications from restricted diet; tween ON and these conditions. • Intrapersonal distress or impairment of social, academic, or vocational functioning secondary To meet DSM-5 diagnostic criteria to beliefs or behaviors about healthy diet; for AN, patients must weigh below • Positive , self-worth, identity and/or satisfaction excessively dependent on minimally normal weight for their compliance with self-defined healthy eating behavior. height and age, have an intense fear Additional features that may confirm a diagnosis of ON include obsessive focus on food choice, of gaining weight or becoming fat, planning, purchase, preparation, and consumption; food regarded as source of health rather and have a disturbed experience of than pleasure; distress or disgust when in proximity to prohibited foods; exaggerated faith that their weight or body shape or can- inclusion or elimination of particular kinds of food can prevent or cure disease or affect daily not recognize the severity of the low well-being; periodic shifts in dietary beliefs while other processes persist unchanged; moral weight.2 In contrast, an individual judgment of others based on dietary choices; body image distortion around sense of physical with ON may possess normal or impurity rather than weight; persistent belief that dietary practices are health-promoting de- low-normal weight. Patients with spite evidence of malnutrition. AN focus on food quantity, while patients with ON tend to focus on food quality. As summarized by Brat- insight into their illness.8,10 Similari- dromal phase of schizophrenia, and man, “People are ashamed of their ties between obsessive-compulsive the development of ON may increase anorexia, but they actively evange- personality disorder (OCPD) and ON risk for future psychotic disorders.11,12 lize their orthorexia. People with include perfectionism, rigid thinking, anorexia skip meals; people with or- excessive devotion, hypermorality, Pathophysiology thorexia do not (unless they are fast- and a preoccupation with details and The exact cause of ON is unknown, ing). Those with anorexia focus only perceived rules.11 though it is likely multifactorial. In- on avoiding foods, while those with While no studies have yet de- dividuals with ON have neurocog- orthorexia both avoid foods they scribed ON as a feature of somato- nitive deficits similar to those seen think are bad and embrace foods they form disorders, some experts have in patients with AN and OCD, in- think are super-healthy.”9 hypothesized that preoccupation cluding impairments in set-shifting Similarities between ON and OCD with illness in a patient with soma- (flexible problem solving), external include anxiety, a need to exert con- tization disorder may engender a attention, and working memory.11,13 trol, and perfectionism. However, preoccupation with food and diet as Given these cognitive deficits as well patients with OCD tend to report dis- a way to combat either real or per- as similar symptomatology, there may tress from compulsive behavior and ceived illness.11 Finally, there is a be analogous brain dysfunction in a desire to change, thus exhibiting report of ON associated with the pro- patients with ON and AN or OCD.

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Neuroimaging studies of patients ble to treatment, given their pursuit ships, and poor quality of life.11 It with AN have revealed dysregulation of and emphasis on wellness.18 Ex- is a little-understood disorder with of dopamine transmission in the re- perts recommend a multidisci- uncertain etiology, imprecise assess- ward circuitry of the ventral striatum plinary team approach that includes ment tools, and no formal diagnostic and the food regulatory mechanism physicians, psychotherapists, and criteria or classification. Orthorexic in the hypothalamus.14 dieticians.11 Treatment may be un- characteristics vary from normal to Dysmorphology of and dysfunc- dertaken in an outpatient setting, pathologic in degree, and making tion in neural circuitry, particularly but hospitalization for refeeding a diagnosis remains a clinical judg- the cortico-striato-thalamo-cortical is recommended in cases with sig- ment.22 Further research is needed pathway, have been implicated in nificant weight loss or malnourish- to develop valid diagnostic tools and OCD.15 Neuroimaging studies have ment.11 Physical examination and determining whether ON should revealed increased volume and ac- laboratory studies are warranted, be classified as a unique illness or tivation of the orbitofrontal cortex, as excessive dietary restrictions can a variation of other eating or anxi- which may be associated with ob- lead to weight loss and medical ety disorders. Further research also sessions and difficulty with extinc- complications similar to those seen may identify the etiology of ON, thus tion recall.14,15 In contrast, decreased in AN, including osteopenia, ane- enabling targeted multidisciplinary volume and activity of the thalamus mia, hyponatremia, pancytopenia, treatment.  may impair its ability to inhibit the bradycardia, and even pneumotho- orbitofrontal cortex.15,16 Decreased rax and pneumomediastinum.19-21 Author disclosures volume and activity of the cingulate There are no reported studies ex- The author reports no actual or poten- gyrus may be associated with diffi- ploring the efficacy of psychother- tial conflicts of interest with regard to culty in error monitoring and fear apy or psychotropic medications for this article. conditioning, while overactivation patients with ON. However, several of the parietal lobe and cerebellum treatments have been proposed given Disclaimer may be associated with compulsive the symptom overlap with AN. Se- The opinions expressed herein are those behaviors.15,16 rotonin reuptake inhibitors may be of the author and do not necessarily beneficial for anxiety and obsessive- reflect those of Federal Practitioner, Risk Factors compulsive traits.18 However, patients Frontline Medical Communications Factors that contribute to the de- with ON may refuse medications as Inc., the U.S. Government, or any velopment of AN and possibly ON unnatural substances.18 of its agencies. This article may dis- include development of food pref- Cognitive behavioral therapy may cuss unlabeled or investigational use erences, inherited differences in be beneficial to address perfection- of certain drugs. Please review the taste perception, food neophobia or ism and cognitive distortions, and ex- complete prescribing information for pickiness, being premorbidly over- posure and response prevention may specific drugs or drug combinations— weight or obese, parental feeding reduce obsessive-compulsive behav- including indications, contraindica- practices, and a history of parental iors.11 Relaxation therapy may reduce tions, warnings, and adverse effects—before eating disorders.14 One survey as- mealtime anxiety. Psychoeducation administering pharmacologic therapy sociated orthorexic tendencies with may correct inaccurate beliefs about to patients. perfectionism, appearance orienta- food groups, purity, and preparation, tion, overweight preoccupation, self- but it may induce emotional stress REFERENCES 11 1. Bratman S. Health food junkie. Yoga J. 1997; classified weight, and fearful and for the patient with ON. 136:42-50. dismissing attachment styles.17 Sig- 2. 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