Is the Fixation on “Healthy” Unhealthy? a Study on Orthorexia Nervosa

IS THE FIXATION ON “HEALTHY” UNHEALTHY? A STUDY ON ORTHOREXIA NERVOSA.

A thesis submitted to the Kent State University Honors College in partial fulfillment of the requirements for Departmental Honors

Kelsey M. Robinson

August, 2011

TABLE OF CONTENTS

LIST OF TABLES………………………………………………………………………...v

ACKNOWLEDGMENTS………………………………………………………………..vi

CHAPTER

I. INTRODUCTION……………………………………………………...…1

Orthorexia Nervosa……………………………………………..…………3

Measurement of Orthorexia Nervosa…………………...…………..……..7

II. THE PRESENT STUDY………………………………………………...11

III. METHODS……………………………………………………………....12

Participants…………………………………………………………...…..12

Research Design……………………………………………………….....13

Measures……………………………………………………………...….13

Orthorexia Screen (Robinson, 2010)…………………………….13

Three Day Food Retrospective Recall……………………...……13

Food Evaluation Questionnaire (Knight & Boland, 1989)…..…..14

ORTO-15 (Donini et al., 2005)…………………………………..15

Questions Adapted from the Florida Obsessive Compulsive Inventory (Storch et al., 2007)…………………………………...16

Additional Post-Measure Screen…………………………...... …..16

Procedure………………………………………………………………...17

IV. RESULTS………………………………………………………………..19

iii

V. DISCUSSION……………………………………………………………22

REFERENCES…………………………………………………………………………..27

APPENDIX

A. Orthorexia Screen………………………………………………………..32

B. Three Day Food Recall…………………………………………………..33

C. Food Evaluation Questionnaire…………………………………………..34

D. ORTO-15………………………………………………………………...37

E. Adapted Florida Obsessive Compulsive Inventory……………………...39

F. Food Allergies &/or Dietary Restrictions………………………………..40

LIST OF TABLES

Table 1. Serving Size Based on USDA Guidelines………………………………………30

Table 2. Descriptive Data on Dependent Measures by Group……………………………31

ACKNOWLEDGMENTS

I would like to thank Dr. Janis Crowther for her direction, assistance, and guidance in making my Honors thesis a reality. Her support and patience throughout the process were unwavering, and I owe her my deepest gratitude. I would also like to thank

Dr. Robin Joynes, Dr. Sara Newman, and Dr. Karen Lowry Gordon for sitting on my oral defense committee – your contributions are greatly appreciated.

vi CHAPTER I

INTRODUCTION

An eating disorder is formally defined as “any disturbance in eating behavior”

(American Psychiatric Association, 2000). According to the most recent revision of the

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American

Psychiatric Association, 2000), the only eating pathologies with clearly defined diagnostic criteria are anorexia nervosa (AN) and bulimia nervosa (BN). The diagnostic criteria for anorexia nervosa include an intense fear of weight gain; having a body weight below 85% with regard to normative height and weight values per age range; three consecutive missed periods (amenorrhea); and a refusal to acknowledge the seriousness these behaviors pose on the body as well as a disturbance in self image and the experience of one‟s shape or weight. Bulimia nervosa is defined as repetitive episodes of binge eating, in which the individual feels out of control of their level of consumption, often discretely followed by extreme measures to prevent weight gain (self-induced vomiting, over-exercising, diet pills and laxatives, etc.); individuals with bulimia tend to be of average or slightly above average weight, and only receive a diagnosis of bulimia nervosa if they do not exhibit behaviors and symptoms of anorexia nervosa.

Although these eating disorders have clinically significant definitions, diagnostic criteria and subtypes, more common are individuals who fall into patterns of disordered eating that do not bear enough semblance to AN or BN to meet requirements for their diagnoses. A deviation of a disorder from AN or BN has the potential to be classed as an

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Eating Disorder Not Otherwise Specified (EDNOS). The DSM-IV-TR defines EDNOS as a “category for disorders of eating that do not meet the criteria for any specific eating disorder” (American Psychiatric Association, 2000). This diagnosis is only given when the individual does not exhibit enough symptoms to be diagnosed with AN or BN, or exhibit behaviors that are not recognized by the DSM at this time (such as binge eating disorder). However, an EDNOS may also include any problematic disordered eating that is, as of yet, indefinable on a broad scale but encompasses a disturbance in normative eating behaviors.

Currently, EDNOS is composed of six common subtypes: 1. An individual exhibits all criteria for a diagnosis of AN except amenorrhea; 2. An individual meets all criteria for a diagnosis of AN, but in spite of their substantial weight loss, the individual continues to be in a “normal” weight range; 3. An individual meets all criteria for a diagnosis of BN except that binge episodes are limited to a frequency of less than twice per week or for a duration of three months; 4. An individual maintains a normal body weight, but uses negative compensatory behaviors after consuming a relatively small amount of food; 5. An individual regularly chews up food but spits it out, never swallowing or ingesting the actual food; and 6. Binge eating disorder, which is not its own eating disorder category during the most recent publication of the DSM (American

Psychiatric Association, 2000).

In a study conducted by Dalle Grave and Calugi (2007) on the prevalence of

EDNOS within an inpatient setting, 40.3% of the 186 patients being treated for eating

disorders received a diagnosis of EDNOS. According to a separate study, EDNOS accounts for roughly three-quarters of all eating disorder diagnoses in community cases

(Machado, Machado, Goncalves, & Hoek, 2007).

Because EDNOS seems to be the starting point for subtypes of disordered eating,

EDNOS may also come to recognize a disordered eating behavior developing with changing cultures called “orthorexia nervosa.”

ORTHOREXIA NERVOSA

Orthorexia nervosa (ON) was first proposed as a disorder by Steven Bratman, a practicing physician in alternative medicine. Orthorexia nervosa refers to a fixation on eating healthy foods, often with the individual becoming fixated on “safe” foods. Eating in a healthy manner would not seem so dangerous, but

“the desire to eat healthy foods is not in itself a disorder, but the obsession for

these foods, together with the loss of moderation and balance and the withdrawal

from life caused by this food habit, can then lead to orthorexia” (Donini, Marsili,

Graziani, Imbriale, & Cannella, 2005, pg. e31).

Bratman and Knight (2000), whose book is based only on the observation of

Bratman‟s patients and his personal experience without scientific basis, have chosen to describe ON as the consequence of attempting to change one‟s diet for healthy reasons, whether that be in order to improve overall health or possibly to treat an illness.

However, the transition to eating patterns and behaviors that differ from the cultural norm may be difficult for the individual; many become disciplined, and exhibit feelings of superiority toward individuals with culturally normative eating patterns. Due to the

degree of discipline elicited, healthy eating in its extreme form may resemble other eating pathologies. An individual with ON may turn food into religion, invoking a sense of spirituality; these ideologies can be disrupted, as exhibited in other eating disorders, when an individual ingests something outside of their idealistic dietary patterns and experiences this “as a fall from grace” (Bratman & Knight, 2000, pg. 9). This worship of food causes the individual to transform his or her life, spending “a great deal of his time thinking about food, frequently dedicating his whole existence to the planning, purchase, preparation and consumption of the food that he considers healthy” (Donini et al., 2004, pg. 155).

At the time of this publication, no scholarly articles were found examining ON in the United States. Indeed, the entirety of empirical research available on the relatively new topic of ON are from other countries, particularly Italy (Donini et al., 2004, 2005).

Other articles are available in scientific databases; however, a significant number are written in languages other than English (German, Spanish, etc.).

This lack of empirical data has not prevented the media from disseminating this information to the public. Orthorexia has been covered by 20/20, ABC News, and the

Rachel Ray Show in the past. Furthermore, in a recent Belgian study, psychologists (N =

57), physicians and psychiatrists (N = 19), and other professionals, particularly nurses and social workers (N = 35), were administered an anonymous survey about prospective eating disorders (Vandereycken, 2011). Vandereycken found that only 9.9% of respondents answered that ON was “totally unknown” to them. This represented the lowest percentage among the other eating disorders presented and was indicative that

90.1% of respondents had heard of ON. Given that the scientific community has not thoroughly researched ON and the number of published articles in the literature does not correlate with the level of media popularity, “indirectly we may conclude that professionals are getting a considerable part of their „diagnostic knowledge‟ from the popular media” (Vandereycken, 2011, pg. 150). Of his respondents, 25.2% also indicated that ON was “created by popular media;” 66.7% found that ON had been “observed in

[their] own practice;” and 68.5% believed that ON is deserving of more attention

(Vandereycken, 2011).

Members of the academic and scientific communities find the topic of ON to be controversial, for a number of reasons. First, based on Bratman and Knight‟s (2000) definition, individuals with ON are interested in the “quality” of their food, while anorexics or bulimics are primarily concerned with “quantity,” and this is cited as a significant deviation between eating pathologies. However, O‟Connor et al.‟s article (as cited in Kummer, Dias, & Teixeira, 2008) “found that 54.3% [of anorexics] were avoiding red meat, and in some […] the avoidance predated the onset of anorexia,” thus suggesting that anorexics also worry about the “quality” (pg. 395). Second, healthy eating does not have to merit a medical disorder. The DSM (American Psychiatric Association,

2000) states that a psychiatric condition must cause the individual significant distress or negative consequences in one‟s life; it is easy to argue that eating in a more nutritionally sound manner is indicative of wellness and should not, in theory, cause high distress or negativity.

Orthorexia nervosa has been shown to be prevalent in the medical community.

Due to the fact that many health employees, such as medical doctors, medical students, and dieticians and dietetic students evaluate other individuals‟ unhealthy eating patterns on a daily basis and are expected to serve as examples to client populations, there stands a potential correlation between in-depth nutrition knowledge and a preoccupation with adhering to medical standards such as healthy eating. In a study conducted in Turkey, resident medical doctors (N = 318; males N = 169, females N = 149) were administered questionnaires assessing “their daily nutritional intake, their physical activities, their criteria for selection of foodstuffs, and how this food choice affects their life styles in order to determine the prevalence of highly sensitive behavior related to health and proper nutrition” (Bağci Bosi, Çamur, & Güler, 2007, pg. 662). The questionnaires included a direct translation of Donini et al.‟s (2005) ORTO-15, as well as items from

Bratman‟s (2000) Orthorexia Self-Test. Of their respondents, 45.5% scored below 40 on

Donini et al.‟s ORTO-15, indicating the potential for ON, or, at a minimum, a sensitivity toward eating behaviors. In a second study (Kinzl, Hauer, Traweger & Kiefer, 2006), female dieticians (N = 283) were administered Bratman‟s (2000) informal 10-item

Orthorexia Self-Test, with 34.9% (N = 99) exhibiting “some orthorectic behavior” and

12.8% (N = 36) exhibiting full ON.

Research has suggested a comorbidity between obsessive-compulsive disorder

(OCD) and eating disorders (ED), with these disorders exhibiting chemical and biological similarities as well as clinical (Pigott et al., 1991).

The focal and extreme preoccupation with food and body image characteristic of

patients with [AN] and [BN] resembles to some extent the repetitive and

ritualistic behavior exhibited by patients with [OCD]. […] there are biological

similarities, since serotonin dysregulation has been implicated in [OCD], [AN],

and [BN] (Pigott et al., 1991, pg. 1552).

Because ON does not have set diagnostic criteria, the level of fixation that an individual must have to adhere to this healthy diet resembles the level of preoccupation often seen in

OCD.

In a study conducted by Pigott et al. (1991), 59 OCD clinical patients (27 male, 32 female) were administered the Eating Disorder Inventory (EDI) and compared to a control population of 60 subjects (25 male, 35 female), as well as 32 female patients who met diagnostic criteria for AN or BN. Upon analyzing all data, Pigott et al. (1991) found that “patients with obsessive-compulsive disorder, in comparison to healthy subjects, display significant differences in the areas of eating and weight-related concerns” and

“scored significantly higher than the sex-matched healthy subjects” (pg. 1555). Because the EDI was not created with the intent of being used as a diagnostic tool, Pigott et al. were unable to conclude OCD patients had eating disorders “but rather, that they may share some of the self-reported dimensions of psychopathology as patients with eating disorders” (pg. 1556).

MEASUREMENT OF ORTHOREXIA NERVOSA

Thus far, ON has no scientifically workable definition by DSM standards; however, Donini et al. (2005) created a measure (ORTO-15) based on an initial informal

questionnaire submitted by Bratman in his popular book Health Food Junkies (Bratman

& Knight, 2000). Bratman‟s Orthorexia Self-Test contains ten dichotomous yes/no items, such as “Do you plan tomorrow‟s food today?” or “Have you found that as the quality of your diet increased, the quality of your life has correspondingly diminished?,” with clear explanations in the text regarding how a “yes” answer increases the likelihood of ON as a diagnosis (pg. 47-53). Using these items, Donini et al. (2005) created an expanded 15- item questionnaire which included six of Bratman‟s original 10 items, but changed from the rigid YES/NO response format to a Likert scale consisting of four levels from

“always” to “never”. The ORTO-15 offers “a notable predictive capability concerning healthy eating behavior,” but “is less efficient in discriminating […] the presence of obsessive traits” (Donini et al., 2005, pg. e32). The present study utilized the ORTO-15 as an assessment tool for confirming group assignments based on the Orthorexia Screen; to my knowledge, at the time of this publication, this study was the first to utilize the measure in the United States from the Italian translation. Bağci Bosi et al. (2007) found that:

The average score on the ORTO-15 is lower in those who do their shopping

themselves, substitute lunch or dinner with salad/fruit, care about the nutritional

quality of the foods they eat, say that eating out is healthy, look at the contents of

the food purchased, say that contents is important in product selection; and

difference between the groups in healthy nutrition is statistically significant

(p<0.05) (pg. 664).

No clear system of measurement has been identified as to what constitutes a healthy food to someone who could be diagnosed with orthorexia nervosa, or even what

“healthy eating” is. Healthy eating, while seemingly “black-and-white” when viewed from a nutritional stance, is subjective: where one person may see the reduction of 2% milk to skim milk as a profound change in their diet, another person may completely eliminate dairy in all forms and consider that a healthy choice. Due to the nature and subjectivity of the perception of healthy food habits and choices, it is important to evaluate “healthy” food on a stricter scale than personal interpretation. The question is, what will most accurately measure disordered healthy eating? What foods are permissible in an allegedly healthy diet? How extreme does one‟s diet need to be in order to be tentatively considered orthorexia?

To further measure the dietary quality and essential defining factor of ON, the

Healthy Eating Index (HEI) was administered to participants during the present study.

The HEI was developed for the U.S. Department of Agriculture (USDA) because previous dietary indexes were concerned primarily with nutrients; the HEI expands the capability of dietary indexing by observing the overall quality of one‟s diet, encompassing total fat intake, saturated fat intake, cholesterol, sodium, and variety, including the distribution of grains, vegetables, fruits, dairy, and meat. The comprehensive nature of the HEI offers a wider breadth to measure the American populace by without limitation.

The HEI asks participants to fill out a 3-day dietary intake, comprising a “24 hour recall and a 2-day food record of food consumed” (Kennedy, Ohls, Carlson, & Fleming,

1995). Food consumption was then analyzed on the above ten-component scale, based on portion size and sensible allocation of foods considered “mixed” dishes to be assigned multiple food groups.

The present study utilized the HEI in a similar manner. Participants in the present study were administered a “3 day food intake recall” which asks for the day and time, place, type and quantity of foods consumed, and whether the food consumed constituted a meal or a snack. However, a few of the components measured on the HEI seemed unnecessary to this research. Given the stance that “quality” is of significance to individuals with orthorexia, only total fat intake, saturated fat intake, and the five components of the Food Guide Pyramid were taken into consideration, with the reasoning that someone acclimated to “healthier” eating would have a diet characterized by significantly greater consumption of fruits and vegetables and significantly less fat consumption. The year Kennedy et al. (1995) published their findings also seems outdated for the current research, especially given that the United States Department of

Agriculture‟s Food Guide Pyramid has developed drastically since that point in time.

CHAPTER II

THE PRESENT STUDY

Orthorexia nervosa has been identified as a potentially problematic form of eating, and has been recognized by medical professionals within the healthcare community. However, little empirical research exists on this condition. Thus, the present study compared individuals endorsing symptoms of orthorexia nervosa with individuals who do not on several measures, including the ORTO-15 (Donini et al., 2005), Healthy

Eating Index (HEI; Kennedy et al., 1995), an adaptation of several questions from the

Florida Obsessive Compulsive Inventory (FOCI; Storch, Kaufman, Bagner, Merlo,

Shapira, Geffken, Murphy, & Goodman, 2007), and the Food Evaluation Questionnaire

(FEQ; Knight & Boland, 1989).

CHAPTER III

METHODS

Participants

Participants were undergraduate students at a large public Midwestern university enrolled in psychology courses. During the Fall 2010 semester, participants completed the Orthorexia Screen (Robinson, 2010) during a large mass screening conducted by the

Department of Psychology and were recruited on the basis of their responses to this measure; during the Spring 2011 semester, participants were individually administered the Orthorexia Screen during lab research. Participants who endorsed at least 8 of the 10 items on the Orthorexia Screen met the criteria for ON and were administered additional measures in the lab setting. Participants who answered NO to all questions were considered controls and were administered identical measures given to participants with

ON.

A total of 817 participants were administered the Orthorexia Screen; only 53

(6.5%) met criteria for ON according to this measure. A total of 29 students who met the criteria for ON participated in the study, consisting of two men (6.9%) and 27 women

(93.1%). Twenty control participants were recruited, consisting of four men (20%) and

16 women (80%).

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Research Design

The independent variable of this study was group, consisting of participants who met criteria for ON and control participants, considered to exhibit “normative” eating behaviors.

Measures

Orthorexia Screen (Robinson, 2010)

The Orthorexia Screen was created specifically for the purposes of the present study. It consists of 10 items with dichotomous YES/NO responses, and asks participants to consider their attitudes and behaviors over the previous three month period when responding. The items investigated participants’ preoccupation with food; their consideration of “healthier” food choices; their feelings of superiority in their food choices; their worry, disgust, or distress when consuming foods deemed “unhealthy” by participant definition; and whether participants’ preoccupation with food has interfered with their ability to function, enjoy life, or affected social relationships (Appendix A).

Higher scores on the Orthorexia Screen indicate endorsement of greater ON symptomatology; in the present study, participants who scored an eight or above were analyzed in the experimental group.

Three-Day Food Retrospective Recall

A food recall was used to measure participants’ intake over a three-day period, typically including the day the measures were administered to the participant. Participants were administered the measure in the lab setting with all other measures and were asked to complete it at the time of their study; this measure was not taken home. Participants

were asked to write down every food consumed over this three-day period, including where the food was consumed, what time of day it was consumed, and if the food constituted a meal or a snack (Appendix B). This information was analyzed using indices from the Healthy Eating Index (Kennedy, Ohls, Carlson, & Fleming, 1995). Participants’ diets were analyzed for total fat consumption in grams, saturated fat consumption in grams, and daily intake requirements governed by the USDA concerning grains, fruits, milk/dairy, vegetables, and meats. Each individual food consumed was researched by the principal investigator for fat content and saturated fat content per serving size, then added at the end of each recorded day. Foods were scored based on the serving size standards set forth by the USDA (Table 1). Participant scores were then averaged across the three- day time span. Fat and saturated fat were calculated in grams; grains, vegetables, fruits, dairy, and meats were averaged by number of servings.

Food Evaluation Questionnaire (Knight & Boland, 1989)

The Food Evaluation Questionnaire (FEQ) was developed by Knight for research on restrictive eating behaviors. The measure provides the participant with a randomized list of 149 foods chosen from calorie-counting books and without bias toward brand names. Participants are asked to rate the foods on a 9-point scale, with 0 being indicative of “dietary permitted” (“food that you believe need not be avoided when on a weight- reduction diet”) and 8 being considered “dietary forbidden” (“food that you believe should be avoided on a weight-reduction diet”). After completing this task, participants are asked to return to the beginning of the list and place an X next to foods they personally would not consume, or would consider “forbidden.” Following the scoring

system established in Knight and Boland’s (1989) study, the number of foods rated with an X were considered an individual’s score on the measure. The present study only analyzed items marked with an X; individual food ratings were not analyzed (Appendix

C).

ORTO-15 (Donini et al., 2005)

The ORTO-15, from Donini et al.’s (2005) English publication, was administered to participants consenting to research participation to confirm group assignments from the Orthorexia Screen and assess the severity of ON symptomatology. The ORTO-15, adapted from Steven Bratman’s original questionnaire, contains 15 questions that assess factors associated with orthorexia (Appendix D). Participants respond using a Likert scale, with response choices of “1 – Always”, “2 – Often”, “3 – Sometimes”, and “4 –

Never”. Participant responses are scored based on the number chosen, with some items reverse scored (example: A response of “4 – Never” may actually be worth one point, not four). Participant scores were then added together to create a standardized number. Lower scores on the ORTO-15 are indicative of greater susceptibility to ON and demonstrate a higher degree of symptomatology. At present, the ORTO-15 is the only definitive measure to test for ON. With respect to validity, the ORTO-15 discriminates between individuals with ON and individuals with normal eating behavior. For this sample, the internal consistency (Cronbach’s alpha) was .626.

Questions Adapted from the Florida Obsessive Compulsive Inventory

(Storch et al., 2007)

The Florida Obsessive Compulsive Inventory (FOCI) contains two elements; for the purposes of this study, the questions on Part B of the FOCI were adapted to assess participant’s fixation on food. The adapted FOCI contains five questions, based on a

Likert scale ranging from 0 to 4, with 0 being “none” and 4 being “extreme” (dependent on the question). Questions ask about the amount of time an individual spends thinking about certain thoughts or behaviors pertaining to foods an individual consumes or believes they should consume; the level of distress these thoughts and behaviors cause the individual; how difficult these thoughts and behaviors are to control; how these thoughts and behaviors cause avoidance in personal relationships, doing things and leaving their home; and how much the thoughts and behaviors interfere with school, work, or social and family life (Appendix E).

Additional Post-Measure Screen

At the completion of all measures, three additional questions accounted for any dietary restrictions explicitly prohibiting participants from consuming certain foods, thus measuring for unforeseen eating behavior circumstances. These questions assessed participants’ food allergies and whether their allergies caused participants to avoid certain foods, dietary restrictions (including those due to religious affiliation), and if the individual participant was pregnant at the time they were administered all measures. Each question was on a dichotomous YES/NO scale with room to explain the reasoning behind

YES answers (Appendix F).

Procedure

Research took place in a psychology research laboratory of the large Midwestern university. The study was carried out over the course of two semesters, and appointments were set based on participant needs during this time period.

Subjects who participated during the Fall 2010 semester initially participated in a large mass screening, as administered by the Psychology Department. Subjects answered various questionnaires submitted by researchers online for course credit. The Orthorexia

Screen was administered during this battery. Once completed, data was distributed to researchers for further analysis, and students were recruited for participation in the present study.

Students who agreed to participate were scheduled in one hour timeslots to complete the Three-Day Food Recall, Food Evaluation Questionnaire (Knight & Boland,

1989), ORTO-15 (Donini et al., 2005), adapted FOCI, and additional questions to help determine if an outside factor might contribute to a participant’s eating habits.

Participants were given informed consent forms, which briefly explained the purpose of the research and the risks involved, outlined that any participation was voluntary and anonymous, and offered contact information for follow-up. Following informed consent, participants completed these measures. Once all measures were completed, participants were given two research participation points toward their research requirements in their psychology courses.

During the Spring 2011 semester, subjects were recruited through voluntary sign- up on the Sona System website. Participants were not pre-determined for their eligibility

to participate, but chose to participate based on the basic study’s definition. Participants signed up for laboratory timeslots that were pre-arranged, and up to three students were allowed to participate at any given timeslot. All participants were given informed consent forms; once these were returned, subjects were given the Orthorexia Screen as their initial measure, followed by all other measures as detailed above for the Fall 2010 participants.

Upon conclusion, students were given two research participation points toward their research requirements in their psychology courses.

CHAPTER IV

RESULTS

Before analyzing the data, the data were examined for missing data and outliers.

During the Three-Day Food Recall, two participants who met the criteria for orthorexia did not respond; thus, they had missing data on HEI measures for meat, dairy, fruits, vegetables, grains, fat intake and saturated fat intake. The FEQ also had an outlier, though the response was within acceptable parameters.

In order to compare the two groups on responses to the Three-Day Food Recall,

FEQ, ORTO-15, and questions adapted from the FOCI, independent t-tests were run. As

Table 2 indicates, results yielded statistically significant differences on meat consumption, fat consumption, saturated fat consumption, the ORTO-15, and all indices of the adapted FOCI (Table 2).

On the Three-Day Food Recall, participants who met criteria for ON scored significantly lower on meat consumption compared to control participants, t(45) = -4.50, p = .001; lower on fats compared to control participants, t(45) = -2.60, p = .013; and lower on saturated fats compared to control participants, t(45) = -2.58, p = .013.

However, results were nonsignificant on the number of portions of grains, t(45) = -.60, p

= 0.555, vegetables, t(45) = 0.24, p = .819, fruits, t(45) = 1.25, p = .217, and dairy, t(45)

= -0.96, p = .345.

19 20

Results for the FEQ were nonsignificant, although participants who met criteria for orthorexia appeared to endorse fewer forbidden foods than control participants. Group differences were not overall statistically significant when equal variances were not assumed, t(47) = -1.47, p = .155.

Results yielded statistically significant differences on the ORTO-15, indicating that individuals with orthorexia scored significantly lower on the ORTO-15 than control participants, t(47) = -7.08, p = .001.

Results yielded significant differences on all questions included in the adapted

FOCI (Storch et al., 2007). On the question concerning how much time is occupied by fixated thoughts and behaviors, participants with ON reported spending significantly greater amounts of time than control participants, t(46) = 7.43, p = .001. When asked how much distress the thoughts and behaviors cause the individual, participants exhibiting ON reported significantly higher levels of distress than control participants, t(47) = 6.67, p = .001. On the question regarding difficulty in controlling the fixated thoughts and behaviors, participants exhibiting ON had significantly higher scores for inability to maintain control than control participants, t(47) = 6.07, p = .001. Finally, participants exhibiting ON showed significantly higher avoidance compared to control participants, t(47) = 7.23, p = .001; and participants exhibiting ON recorded that these fixations interfered significantly with school, work, or social and family life, t(47) = 6.39, p = .001.

The survey at the end of the battery of tests asked participants if they had any food allergies, any special dietary requirements (lactose intolerant, vegetarian, etc.), if the

aforementioned dietary limitations were due to religious practice, and if the participant was pregnant. Only seven of the 20 control participants recorded anything in the survey;

23 of 29 participants who screened for ON recorded answers to the questions prompted.

Control participants primarily listed dietary restrictions due to allergy (4/7); one control participant had varied eating habits due to consideration for a roommate’s eating habits; and two of the seven control participants avoided certain contents in foods (fats, sugars, etc). Of the participants who exhibited orthorexia, the majority (15/29) deliberately avoided consuming specific foods or food contents, often including sugary foods, desserts, fried food, and high fats; two participants were vegetarians; one participant was pescetarian; three individuals had food allergies (dairy, peanuts); one individual had hyperglycemia, and one individual had Crohn’s, which caused avoidance toward spicy and/or greasy foods.

CHAPTER V

DISCUSSION

The present study examined the group differences between individuals with ON and a control group on their preoccupation with food and eating habits. Results indicated that compared to control participants, individuals meeting the criteria for ON were significantly more preoccupied with and distressed by thoughts and behaviors with food; they consumed less fat, saturated fat, and meat; and they reported their thoughts and behaviors interfered more significantly with their functioning.

For the purpose of the present study, I devised a screening method for ON

(Orthorexia Screen). The Orthorexia Screen was created based on the definition of orthorexia nervosa created by Steven Bratman and expanded on by researchers. The operational definition of what I believe orthorexia nervosa to be is:

A. Excessive preoccupation with healthy food

B. Distress when faced with unhealthy food choices

C. Feelings of superiority regarding diet and food choices

D. Interference with regular functioning.

The Orthorexia Screen covered these criteria. When the Orthorexia Screen was administered and participants were assigned to groups on the basis of their responses on this measure, group differences on the ORTO-15 confirmed that the Orthorexia Screen discriminated between the two groups. Before the publication of the present study, the

22 23

ORTO-15 has been the standard for measuring orthorexia in international populations.

These results suggest that the Orthorexia Screen may be useful in identifying individuals with ON; however, additional research is needed.

Interestingly, the participants with ON characteristics in Donini et al.’s 2005 study averaged 39.4 ± 4 on the ORTO-15 – a score that is higher than the average for the control participants in this study (38.85 ± 2.6). Lower scores are indicative of ON symptomatology or susceptibility to the disorder. This may be a reflection of food norms per society, as Donini et al.’s participants were located in Italy. The Donini et al. study included using multiple threshold values of the scores to determine which cutoff may best predict an individual with ON; their study found that a threshold of 40 showed predictive validity, with 35 and 45 having also been tested. However, given the difference between averages in this study, 35 seems a more predictive threshold for American samples, and future American studies may want to examine if thresholds vary by culture.

Results for the Three-Day Food Recall did not yield statistically significant differences on the majority of food groups, disproving my initial hypothesis that individuals with orthorexia would show higher consumption of the “healthy” food categories of fruits and vegetables overall. However, this measure showed that individuals with orthorexia ate significantly less meat, less fat and less saturated fats than the control group. This measure found that there were group differences in some eating habits and behaviors. Interestingly, the former USDA Food Pyramid (USDA, 1992) recommended individuals consume 2-4 servings of fruit each day, 3-5 servings of vegetables, 6-11 servings of grains, 2-3 servings of milk/dairy, and 2-3 servings of

meat/protein. Based on group averages, individuals with ON met all Food Pyramid suggestions, while the control group went above the recommendations on milk/dairy and meat/protein consumption. The individuals who are more interested in healthy eating, particularly those who meet criteria for ON, may have more readily volunteered for the present study.

Results indicated that participants who met criteria for ON scored significantly higher on the items adapted from the FOCI, demonstrating a greater preoccupation with thoughts and behaviors associated with food. Individuals with ON differed from controls on their level of preoccupation with food and eating, particularly on the foods those individuals chose to consume in comparison to controls. However, in spite of showing significance, descriptive data for the participants who screened for ON indicated moderate levels of fixation rather than the hypothesized “severe” or “extreme”.

Results for the FEQ were nonsignificant; thus, individuals with ON did not endorse a significantly greater number of foods which were considered “forbidden”. This measure seemed least descriptive in scoring participant responses, and may not have adequately assessed the dimension the present study was interested in assessing. The

FEQ was chosen to demonstrate that individuals who meet the criteria for ON exhibit a rigid adherence to healthy foods, but fell short in conveying the desired assessment. First, an individual who is vegetarian may have indicated every meat was “forbidden,” but responded that way due to personal moral convictions rather than any dietary fixation on dieting. Second, the FEQ instructions focus on dieting, whereas participants in this study may not have been dieting. Third, there is an issue of whether certain food words were

applicable to the subject pool, or if other foods adjusted for current cultural norms and society would have produced significantly different results than Knight’s original screen.

This study showed some limitations. First, the FEQ may have needed adjustments in the foods assessed as “forbidden” or “safe”. Many participants showed confusion at certain food words, such as “haddock” or “catsup” (its spelling in the original measure), which are not words in a typical American food vocabulary. The measure is also from the late 1980s, and the consumption of certain foods has become less frequent in today’s

American society. I feel that the measure could have been adjusted to account for present cultural norms, even with minor spelling changes to “ketchup.” Secondly, the generalizability of the findings is limited based on participant sample. All participants were students at a large public university, which does not thoroughly encompass the population as a whole. Third, individual’s cultures should have been accounted for during the dietary restriction survey; three participants were foreign exchange students, and the dietary habits of their individual cultures showed a clear difference in the body of this research. However, due to the lack of prompting as to whether another culture influences the individual eating habits, this was not accounted for in any aspect. Fourth, the adaptation of the FOCI may not have been thorough enough in analyzing participant susceptibility to a preoccupation with thoughts and behaviors associated with food.

Future research may find other measures more comprehensive in determining participant levels of fixation. Fifth, all measures used in this study were self-report measures, thus leaving potential for inaccurate response recording by the participants. Finally, participants who endorsed ON symptomatology may have had a better memory for food

intake on the Three-Day Food Recall than control participants, since individuals endorsing ON demonstrate a fixation with food and may actively know what they have been consuming.

Overall, this research indicates that individuals who meet operationalized criteria for ON differ from control participants on several dimensions. Individuals with ON demonstrated a fixation with thoughts and behaviors about food; distress over these thoughts and behaviors; the consumption of less fat, which may be due to the consumption of less meat; the consumption of less saturated fat; and a significantly greater susceptibility to ON. In future research, it would be desirable to use a more extensive measure for the assessment of obsessive-compulsive disorder, as the items adapted from the FOCI may have been too brief to diagnostically say the level of OCD fixation in an individual with orthorexia is significant.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders (Revised 4th ed.). Washington, DC: Author.

Bağci Bosi, A.T., Çamur, D., & Güler, Ç. (2007). Prevalence of orthorexia nervosa in

resident medical doctors in the faculty of medicine (Ankara, Turkey). Appetite,

49, 661-666.

Bratman, S., & Knight, D. (2000). Health Food Junkies – Orthorexia Nervosa:

Overcoming the Obsession with Healthful Eating. New York: Broadway Books.

Dalle Grave, R., & Calugi, S. (2007). Eating disorder not otherwise specified in an

inpatient unit: the impact of altering the DSM-IV criteria for anorexia and bulimia

nervosa. European Eating Disorders Review: The Journal of the Eating Disorders

Association, 15(5), 340-349.

Donini, L. M., Marsili, D., Graziani, M. P., Imbriale, M., & Cannella, C. (2004).

Orthorexia nervosa: A preliminary study with a proposal for diagnosis and

an attempt to measure the dimension of the phenomenon. Eating and Weight

Disorders, 9, 151-157. 27

Donini, L.M., Marsili, D., Graziani, M.P., Imbriale, M., & Cannella, C. (2005).

Orthorexia nervosa: Validation of a diagnosis questionnaire. Eating and Weight

Disorders, 10, e28-e32.

Kennedy, E. T., Ohls, J., Carlson, S., & Fleming, K. (1995). The Healthy Eating Index:

Design and applications. Journal of the American Dietetic Association, 95, 1103-

1108.

Kinzl, J. F., Hauer, K., Traweger, C., & Kiefer, I. (2006). Orthorexia Nervosa in

Dieticians. Psychotherapy and Psychosomatics, 75, 395-396.

Knight, L. J., & Boland, F. J. (1989). Restrained Eating: An Experimental

Disentanglement of the Disinhibiting Variables of Perceived Calories and Food

Type. Journal of Abnormal Psychology, 98, 412-420.

Kummer, A., Dias, F. MV., Teixeira, A. L. (2008). Letter to the Editor: On the concept of

orthorexia nervosa. Scandinavian Journal of Medicine & Science in Sports, 18,

395-396.

Machado, P.P., Machado, B.C., Goncalves, S., & Hoek, H.W. (2007). The prevalence of

eating disorders not otherwise specified. The International Journal of Eating

Disorders, 40(3), 212-217.

Pigott, T. A., Altemus, M., Rubenstein, C. S., Hill, J. L., Bihari, K., L’Heureux, F.,…

Murphy, D. L. (1991). Symptoms of Eating Disorders in Patients with

Obsessive-Compulsive Disorder. The American Journal of Psychiatry, 148,

1552-1557.

Storch, E.A., Kaufman, D.A., Bagner, D., Merlo, L.J., Shapira, N.A., Geffken, G.R.,

Murphy, T.K., & Goodman, W.K. (2007). Florida Obsessive-Compulsive

Inventory: development, reliability and validity. Journal of Clinical Psychology,

63: 851-859.

U.S. Department of Agriculture. (1992). USDA Food Pyramid. Retrieved from

http://upload.wikimedia.org/wikipedia/commons/6/6d/USDA_Food_Pyramid.gif

U.S. Department of Agriculture. (2002). How much are you eating? Dietary Guidelines

for America. Retrieved from

http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2000/2000DGBrochur

eHowMuch.pdf.

Vandereycken, W. (2011). Media hype, diagnostic fad or genuine disorder?

Professionals’ opinions about night eating syndrome, orthorexia, muscle

dysmorphia, and emetophobia. Eating Disorders, 19(2), 145-155.

Table 1

Serving Size Based on USDA Guidelines

Grains 1 slice of bread = 1 serving ~1 c. ready-to-eat cereal = 1 serving ½ c. cooked cereal, rice, or pasta = 1 serving 1 bagel 4 ½” diameter = 4 servings 1 muffin 3 ½” diameter = 4 servings 1 pancake 4” diameter = 1 serving

Vegetables 1 c. raw leafy vegetables = 1 serving ½ c. other vegetable, cooked or raw = 1 serving 1 large baked potato = 3 servings 1 medium order French fries = 4 servings

Fruits 1 medium apple, banana, orange, or pear = 1 serving ½ c. chopped, cooked, or canned fruit = 1 serving ¾ c. fruit juice = 1 serving

Dairy 1 c. of milk or yogurt = 1 serving 1 ½ oz. natural cheese = 1 serving 2 oz. of processed cheese = 1 serving

Meat 2-3 oz. cooked lean meat, poultry, or fish = 1 serving 1 c. cooked dry beans or tofu = 1 serving 5 oz. soy burger = 1 serving 2 eggs = 1 serving 4 Tbl. Peanut butter = 1 serving 2/3 c. nuts = 1 serving 3 pieces fried chicken (7-8 oz.) = 3 servings Ham or roast beef in deli sandwich = 2 servings

30 31

Table 2

Descriptive Data on Dependent Measures by Group

ON Group Control Group

Dependent Variable M(SD) M(SD) t p

Total fat (in grams) 35.25(21.98) 51.77(21.00) (45) -2.60 .013

Saturated fat (in grams) 12.39(7.09) 18.06(7.89) (45) -2.58 .013

Grains (in servings/day) 6.16(1.82) 6.51(2.18) (45) -0.60 .555

Vegetables 2.85(2.59) 2.67(2.57) (45) .24 .809 (in servings/day)

Fruits (in servings/day) 3.05(2.54) 2.17(2.16) (45) 1.25 .217

Dairy (in servings/day) 3.61(2.50) 4.19(1.69) (45) -.96 .345

Meat (in servings/day) 2.68(2.15) 5.84(2.67) (45) -4.50 .001

FEQ 12.59(7.26) 19.50(20.12) (47) -1.47 .155

ORTO-15 31.28(4.84) 38.85(2.60) (47) -7.08 .001

FOCI 1 (time) 2.39(0.83) 0.95(0.51) (47) 7.43 .001

FOCI 2 (distress) 2.31(0.93) 0.70(0.66) (47) 6.67 .001

FOCI 3 (control) 2.31(0.81) 0.90(0.79) (47) 6.07 .001

FOCI 4 (avoidance) 1.76(0.99) 0.25(0.44) (47) 7.23 .001

FOCI 5 (interference) 1.72(1.25) 0.15(0.37) (47) 6.39 .001

Appendix A

Orthorexia Screen

Please carefully complete all questions.

Over the past 3 month(s)…

Have you felt preoccupied with food? YES NO

Have you considered your food choices “healthier” YES NO than your peers’ food choices?

Have you felt superior in your food choices? YES NO

Have you felt worried about acting on impulse, YES NO such as consuming food you consider “unhealthy”?

Have you felt disgusted with yourself when you YES NO consumed a food you consider “unhealthy”?

Have you felt distressed or nervous when consuming YES NO a food you consider “unhealthy”?

Has your preoccupation with food interfered with your YES NO ability to function on a day to day basis?

Has your preoccupation with food interfered with your YES NO ability to enjoy life?

Has your preoccupation with food affected your YES NO social relationships?

Appendix B Three Day Food Recall

Meal (M) orMeal (S) Snack

ll beverages) & food

(include a

Type & Quantity of & Type Food Consumed

Place

Day & Time & Day

Appendix C Food Evaluation Questionnaire

Rate each food on a 9-point scale, ranging from 0 (dietary permitted) to 8 (dietary forbidden). A dietary permitted food is defined as a “food that you believe need not be avoided when on a weight reduction diet. In other words, it can be considered „safe‟ for a dieter.” A dietary forbidden food is defined as a “food that you believe should be avoided on a weight reduction diet. In other words, it can be considered „forbidden‟ or „taboo‟ for a dieter.” Once you have completed rating each food, please return to the list and place an X beside each food that can be considered forbidden for you, that is, a food you try very hard to avoid eating for dietary reasons and which may cause some feelings of guilt or failure when it is consumed.

Ground beef Grapefruit Popcorn Spaghetti Bean sprouts Coffee Pork Carrots Prunes Orange juice Apple Cottage cheese Grapes Ritz crackers Turkey, white Fruit salad Ham Corn Pears Fish stick Banana Broccoli Apple juice Diet salad dressing Orange Melba toast Diet cola Cauliflower Peaches Liver, beef Asparagus Peas Cherries Skim milk Chicken broth Vegetable soup Cabbage Strawberries Rye bread Tomato Tuna Brown bread Mushrooms Plain yogurt Waxed beans Haddock Onion Blueberries Cantaloupe Salmon Chicken, white Celery Pineapple Kidney beans Lettuce Egg Mustard

Beef soup Macaroni Bacon Chicken, dark Beefsteak Pudding Gelatin dessert Catsup Angel cake Turkey, dark Cream filled donut White sugar 2% milk Chocolate ice cream Beer Potato Chocolate milk shake Apple pie Shrimp Peanut butter, regular Vanilla wafer cookie Dill pickles Saltine crackers Pizza Raisins Vanilla yogurt Cashews Cooked cereal Sandwich Honey Bran muffin Peanut butter, health Pancakes Rice food Jam Chicken soup Cream sandwich cookie Mayonnaise Chewing gum Ice cream bar, chocolate Waffles Cream of mushroom covered Butter soup Chocolate bar Pretzel sticks Margarine Raspberry sherbet Plain donut Graham crackers Italian salad dressing Hard liquor Cereal, ready to eat Walnuts Gingersnap cookie Veal Frankfurter Blue cheese salad Lobster Cream cheese dressing White bread Light beer Cream Cheddar cheese Wine Brown sugar Lamb Rolls Blueberry pie Raisin bread Process cheese Gumdrops Granola bar Sweet pickles White cake Baked beans Ginger ale Soft ice cream Fruit yogurt Almonds Potato chips Blueberry muffin Cola Hard candy

Vanilla ice cream Pastries Strawberry ice cream Jellybeans Whole milk Peanuts French salad dressing Vanilla milk shake Chocolate cake

Appendix D ORTO-15 Always Often Sometimes Never

1. When eating, do you pay attention 1 2 3 4 to the calories of the food?

2. When you go in a food shop do you 1 2 3 4 feel confused?

3. In the last 3 months, did the thought 1 2 3 4 of food worry you?

4. Are your eating choices conditioned 1 2 3 4 by your worry about your health status?

5. Is the taste of food more important 1 2 3 4 than the quality when you evaluate food?

6. Are you willing to spend more money 1 2 3 4 to have healthier food?

7. Does the thought about food worry 1 2 3 4 you for more than three hours a day?

8. Do you allow yourself any eating 1 2 3 4 transgressions?

9. Do you think your mood affects your 1 2 3 4 eating behavior?

10. Do you think that the conviction to eat 1 2 3 4 only healthy food increases self-esteem?

11. Do you think that eating healthy food 1 2 3 4 changes your life-style (frequency of eating out, friends, …)?

12. Do you think that consuming healthy 1 2 3 4 food may improve your appearance?

13. Do you feel guilty when transgressing? 1 2 3 4

14. Do you think that on the market there 1 2 3 4 is also unhealthy food?

15. At present, are you alone when having 1 2 3 4 meals?

Appendix E Adapted Florida Obsessive Compulsive Inventory

The following questions refer to repeated thoughts, images, urges or behaviors about the foods you eat or believe you should eat.

In the past month…

16. On average, 0 1 2 3 4 how much time is None Mild Moderate Severe Extreme occupied by these (less than (1 to (3 to (>8 hours) thoughts or behaviors 1 hour) 3 hours) 8 hours) each day?

17. How much distress 0 1 2 3 4 do they cause you? None Mild Moderate Severe Extreme (disabling)

18. How hard is it for 0 1 2 3 4 you to control them? Complete Much Moderate Little No control control control control control

19. How much do they 0 1 2 3 4 cause you to avoid No Occasional Moderate Frequent Extreme doing anything, going avoidance avoidance avoidance and extensive avoidance anyplace or being avoidance with anyone?

20. How much do they 0 1 2 3 4 interfere with school, None Slight Definitely Much Extreme work or your social or interference interferes interference interference family life?

Appendix F Food Allergies &/or Dietary Restrictions

21. Are you allergic to any foods or food products? Y N

21a. If yes, please explain: ______

21b. Do these allergies cause you to avoid foods for health reasons? Y N

22. Do you engage in a diet that causes you to avoid certain foods? Y N

22a. If yes, please explain: ______

22b. Is this diet related to your religious affiliation? Y N

23. Are you pregnant? Y N