Orthorexia. When eating right becomes subjective

Orthorexia. When ‘eating right’ becomes subjective.

Orthorexia, “an alleged syndrome characterized by a pathological fixation on healthy eatingis in the news again. This time, quitting sugar might just trigger a psychological disorder that can’t actually be diagnosed.

What is orthorexia?

That depends on who you ask.  The term itself was created over twenty years ago by Dr Steven Bratman who defined orthorexia as a fixation on eating healthy food. Over the years, however, this imprecise concept has morphed into a monster and according to those issuing the stark media warnings (overwhelmingly dietitians and nutritionists rather than qualified psychiatrists), everybody from sugar quitters to Cross Fitters, paleo dieters to vegans and low carbers to Instagramers are all potential candidates for this new psychological disorder.

A sign of the times?

In addition to media representations of orthorexia, one academic has taken a catch-all approach to defining the disorder. In 2006 Guido Nicolosi introduced the concept of the ‘orthorexic society’ based upon the idea that Westerners are preoccupied with fears about health.  This preoccupation reflects a deeper anxiety about technological innovation such as the industrialisation of the food supply and GMO food; the erosion of our culinary order and individualistic approaches to health choices.

It may also reflect growing alarm at the epidemic of diet and lifestyle diseases and the increase in food allergies, intolerances and sensitivities, particularly among the younger generation.

Symptoms seem arbitrary

Italian researchers who first tried to measure orthorexia almost 14 years ago defined the condition as “a maniacal obsession for health foods” while a 2017 paper claimed that “health food fanaticism” AKA orthorexia is more common in vegetarians than non-vegetarians.

Other academics seem to clutch at any type of behaviour. Those who eat more fruit and vegetables, less white cereals and more whole grains, perform exercise and restrict alcohol consumption evidently display orthorexia tendencies.

Some say that orthorexia is about ‘purity’ and has a spiritual component, or is linked to an obsession with micronutrients. For others, it’s about ‘fitspo’. A 2017 study found that people who use Instagram have high levels of orthorexia (49 percent of respondents to be exact) although the bulk of the study participants were recruited via the author’s Instagram account.

A 2017 study suggested that ‘clean’ eating was responsible for orthorexia. Culprits of ‘clean eating’ were defined as those who followed the low carb diet (favoured by those reversing T2D); the Paleo diet (favoured by those dealing with weight or gut problems) or those following the Super Healthy Family diet (whatever that is). More importantly, the authors noted, such diets contradict national dietary guidelines (the same dietary guidelines which are currently being scrutinized amid accusations they are not grounded in sound science).

The term ‘clean’ eating was coined by trend forecaster Gerald Celente twenty two years ago (a full 14 years prior to the birth of Instagram) and refers to consumer preferences for food free of pesticides, fungicides, drug residues, colouring, irradiation, and growth hormones or are processed and packaged.

In other words, it refers to aspects of the food supply that have been linked (by the scientific community itself) to health problems.

Beat Eating Disorders UK claims that orthorexia is an unhealthy obsession with eating “pure” food or “clean eating” however the first behavioural symptom listed on its website relates to cutting out a whole food group. There are no behavioural signs listed that related to ‘clean’ or ‘pure’ food.

America’s leading eating disorders non-profit the National Eating Disorders Association claim that signs and symptoms of orthorexia include compulsive checking of ingredients and nutrition labels, concern about the health of ingredients; cutting carbs, sugar, dairy, meat or animal products; and following health-related Instagram and Twitter feeds.

Some eating disorder experts argue that orthorexia masks an existing eating disorder or is likely a manifestation of an existing obsessive-compulsive or anxiety disorder. Others suggest it may be a societal trend.

Research has shown that the highest prevalence of orthorexia is among yoga instructors, dietitians, nutrition students and exercise science students compared to the general population.

So it’s all very confusing.

Why can’t it be diagnosed?

The short answer is that orthorexia is a hypothesis and there are no reliable or valid diagnostic tools to determine its prevalence. The Bratman Orthorexia Test (BOT) developed by (Bratman and Knight, 2000) has not been found to be statistically reliable. The ORTO-15 co-developed by Professor Lorenzo Donini, co-author of the high carbohydrate, plant-based New Modern Mediterranean Diet Pyramid (the capstone of which is bizarrely filled with a slice of cake) has been found to have several admitted flaws.

Why is this a problem?

This issue of the flawed instrument was bluntly addressed by Viennese researchers in their 2015 paper ‘When Eating Right is Measured Wrong!’. The researchers administered the ORTO-15 questionnaire to 1029 random participants aged between 19-70 years and after omitting 40 percent of the questionnaire due to problems, a full 69.1 percent of participants displayed orthorexia tendencies. This result would indicate either an epidemic of orthorexia or a major problem with the questionnaire. The authors must have concluded the latter, stating that the usage of the ORTO-15 should be “rethought from scratch”.

This conclusion appears to be an understatement.

A 2017 ORTO-15 study of American dietitians suggested that 49 percent were at risk of orthorexia; a Turkish study on orthorexia (ORTO-15) found that 43.6 percent of medical students were preoccupied with healthy food; a Hungarian study (modified ORTO-15) of 810 adult students reported that over 70 percent displayed orthorexic tendencies; while studies conducted in the United States reported that 69 percent and 82 percent of undergraduate students had orthorexic tendencies. In yet another study based upon the ORTO-15 76.6 percent of students had orthorexic tendencies with exercise science students exhibiting the behaviour more than business students.

Orthorexia is a hypothesis

These results are concerning given that much of the ‘quality’ scientific literature on orthorexia is based upon ORTO-15 results. In addition, orthorexia is at this stage a hypothesis and yet it is insincerely promoted by those who should know better, as a given.

A review of the literature reveals that academics are attempting to develop a reliable tool to determine the existence and prevalence of orthorexia.

So far, they have come up empty-handed.

Trust in science

It is important to note that this discussion article is not suggesting that extreme eating behaviour doesn’t pose health risks, isn’t a problem or that researchers should ignore the issue. It is always imperative that individuals with known or suspected eating disorders or other mental health issues receive assistance from a qualified medical or mental health professional.   However, in an era where science is under greater scrutiny than ever and revelations surrounding the reproducibility crisis, use of weak research methodology, dependence on observational studies, conflicts of interest and industry influence abound, the subjectivity and conjecture surrounding orthorexia further risks harming public trust in science.

Orthorexia is a monument to uncertainty. It has yet to be clearly defined or accurately measured, enabling commentators to present the general public with a vague, arbitrary and unfairly alarmist concept pertaining to the ‘dangerous risks’ associated with healthy eating.

And when the very notion of orthorexia has become so subjective, even among ‘experts’ we should all be concerned.

The general public, whether ‘healthy eaters’ or otherwise, deserve better.