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Orthorexia Nervosa: When The Healthy Eating Become Dangerous

Eating healthy foods is highly recommended to maintain a healthy body, but do it excessively, it becomes dangerous. Excessive healthy eating is known as Orthorexia Nervosa. Doctors need to recognize this disease so they can diagnose and provide early treatment and refer to specialists if necessary.

Orthorexia Nervosa: When The Healthy Eating Become Dangerous
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Eating Disorder

Definition Eating Disorder is abnormal eating habits that negatively affect physical or mental health. The most common eating disorders are Anorexia Nervosa and Bulimia Nervosa. However, there is one eating disorder that is rarely recognized, namely Orthorexia Nervosa (ON). Patients with orthorexia Nervosa are obsessed with a healthy eating style, focusing on quality rather than quantity. Orthorexia has some similarities with Anorexia Nervosa (AN) and Bulimia Nervosa (BN), also with Obsessive-Compulsive Disorder (OCD). However, ON has some specific characteristics. This article aims to discuss aspects of diagnosis, similarities, and differences with the three disorders, as well as information about the management of Orthorexia Nervosa.

What are the characteristics of Orthorexia Nervosa?

Since 1997, Bratman and Knight have described the characteristics of orthorexia Nervosa as fixation or excessive obsession with how to eat healthily. Orthorexia Nervosa has not been recognized as a disease by the Diagnostic and Statistical Manual-V (DSM-V) and is still controversial.

Patients with Orthorexia Nervosa are obsessed with food quality, not quantity, and they are rarely focused on losing weight. Patients manifest this obsession by a strict restrictive diet, preparing specific foods, and eating them with certain rituals.

The focus of patients is to improve their health, not to religious beliefs or the desire to protect something. When not preparing or eating, sufferers spend much time thinking about food, searching for information, weighing or measuring, and planning the following foods that interfere with daily activities.

Diagnostic Criteria for Orthorexia Nervosa

Moroze et al. propose diagnostic criteria for Orthorexia Nervosa. The criteria proposed by Moroze et al. are as follows:

Criterion A
Obsession and preoccupation with 'healthy eating,' focus on quality and composition of food: (Two or more of the following points)
  • Consume a diet with unbalanced nutrition because of beliefs about the "purity" of food
  • Preoccupation and doubt about impure and unhealthy food, as well as the influence of the quality and composition of food on physical and emotional health
  • Avoid foods that are considered 'unhealthy,' such as fatty foods, preservatives, preservatives, animal products, or other ingredients.
  • For individuals who are not professional food workers, use much time, to read, think and prepare certain types of food based on quality and composition
  • Feelings of guilt and worry after making a 'mistake' consuming food that is considered unhealthy or 'impure.'
  • Not tolerant of other people's food beliefs
  • Spending an excessive amount of money on high-quality food or foods with a specific composition.


Criterion B
Obsessions and preoccupations disrupt a patient's daily life by one of the following:
  • Physical health disorders due to unbalanced nutritional intake,
  • Impaired social, academic, or vocational functions as a result of obsessive thoughts and behaviors towards patients' beliefs about how to eat 'healthy.'

Criterion C
The disorder is not an exacerbation of other symptoms such as obsessive-compulsive disorder, schizophrenia, or other psychotic diseases.

Criterion D
Patient behavior cannot be accounted for by observing food for orthodox religious beliefs or when concerns are caused by specific food allergies or medical conditions that require certain diets.

There is no gold standard for a formal diagnosis of this disorder. A diagnostic tool known as ORTO-15 has been developed. ORTO-15 is a questionnaire containing 15 questions about the aspects and characteristics of orthorexia Nervosa, with an assessment using a Likert scale. Questions include beliefs about the effect of healthy eating, patterns of how to consume food, how patients choose food, and how significant concerns about food can affect daily life.

Unfortunately, this tool has an inconsistent result. From several studies, Cronbach's alpha coefficients obtained have a range between 0.14 to 0.70. Another disadvantage is researchers tend to eliminate some questions to increase validity. However, research by Moller et al. showed that of all types of assessment tools, there was not enough.

Similarities between Orthorexia Nervosa and Bulimia Nervosa, Anorexia Nervosa and Obsessive-Compulsive Disorder

Orthorexia Nervosa and Anorexia are characterized by perfectionism, high anxiety, and a desire to have control and the potential for significant weight loss. Orthorexia and anorexia patients achieve the goals by strict discipline.

In both eating disorders, patients deny having a problem with daily life. Patients with orthorexia and OCD have several things in common: thoughts that are continuous, disturbing, at inappropriate times, with anxiety about 'purity' and the desire to regulate and have a way of eating with certain rituals.

Orthorexia patients do not have much in common with bulimia, only a great desire to be able to have control and preoccupation with food.

Management of Orthorexia Nervosa

The procedure for managing orthorexia Nervosa has not yet been fully developed and fully investigated due to the inconclusive diagnosis. At present, treating ON needs forming teams from various fields, including doctors, psychotherapists, and nutritionists. Teams from various disciplines can control aspects of medicine, cognitive-behavioral therapy, and psychoeducation that can be applied on an outpatient basis but with close monitoring. 

Drugs that can be used are also useful for orthorexia, anorexia, and OCD, namely selective serotonin reuptake inhibitors (SSRIs). Olanzapine can be used to reduce obsessive thoughts about food. However, patients can refuse to use drugs because of the thought of 'purity,' which is interrupted by the administration of 'unnatural' drugs. Moreover, patients are also advised to undergo educational sessions about food that are brief but intensive. Sessions should include diagnosis, course of the disease, risk factors, comorbid psychiatric illness, assessment, management, and a little about psychotherapy.

The important thing that must be remembered by health workers is to be careful when discussing food to patients to avoid triggering food disorders such as orthorexia. The most frequent patients are young people, especially teenagers. Current social media exposure is enormous, and information about health from various sources is uncertain. The influence of these patient groups often approaches authority figures in the community to seek 'permission' / approval to continue their 'lifestyle.'

Education is not only aimed at young groups, but the community must also understand to prevent the development of the disease from the beginning. Interventions must be applied if the diet program starts to threaten health, makes a person feel unhappy or depressed, and when individuals continue to talk about wanting to stop the excess diet but cannot stop.

Conclusion
Orthorexia Nervosa is an eating disorder that has not been widely recognized but is dangerous. Orthorexia is not currently included in the Diagnostic and Statistical Manual and is a contentious topic to be placed in certain categories. The doctor must be able to distinguish orthorexia from other eating disorders because orthorexia has some similarities with Anorexia and Bulimia nervosa, as well as obsessive-compulsive disorder.

Health workers and figures in the community play vital roles to treat and prevent these disorders. Intervention is carried out if the disorder is threatening health, making depression, and if the patient has the desire to stop excessive dieting but is unable to. The interventions given should be multidisciplinary by involving doctors, psychotherapists, and nutritionists. Drugs that can be useful for this disorder are selective serotonin reuptake inhibitors (SSRIs), such as olanzapine.

References
1. Costa CB, Hardan-Khalil K, Gibbs K. Orthorexia Nervosa: A Review of the Literature. Issues Ment Health Nurs [Internet]. Taylor & Francis; 2017;38(12):980–8. Available from: https://doi.org/10.1080/01612840.2017.1371816
2. Koven NS, Wabry A. The clinical basis of orthorexia nervosa: Emerging perspectives. Neuropsychiatr Dis Treat. 2015;11:385–94.
3. Nevin SM, Vartanian LR. The stigma of clean dieting and orthorexia nervosa. J Eat Disord. Journal of Eating Disorders; 2017;5(1):1–10.
4. Moroze R, Dunn T, Holland J, Yager J, Weintraub P. Microthinking about Micronutrients: A Case of Transition from Obsessions About Healthy Eating to Near-fatal “Orthorexia Nervosa” and Proposed Diagnostic Criteria. Psychosomatics [Internet]. Elsevier; 2015;56(4):397–403. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25016349
5. Moller S, Apputhurai P, Knowles SR. Confirmatory factor analyses of the ORTO 15-, 11- and 9-item scales and recommendations for suggested cut-off scores. Eat Weight Disord [Internet]. Springer International Publishing; 2018;0(0):1–8. Available from: http://dx.doi.org/10.1007/s40519-018-0515-0

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