We as dietitians live by the motto "everything in moderation", but what happens when we have a patient who ignores this golden rule? What should we do when we have a patient who lives with an obsession of healthy food?
Stems from the Greek word ortho meaning "straight, correct, & true" and orexis meaning "appetite" There is no universally accepted definition, however the literature agrees with three distinguishing characteristics of someone with orthorexia nervosa: Firstly, a strong fixation with "healthy eating" with the rigid avoidance of foods believed to be unhealthy This involves a spectrum of diet regimes and the latest tips on how to prevent illness or disease. Secondly, excessive amounts of time spent acquiring and preparing specific types of foods based on their perceived quality and composition Food must be purchased from certain locations such health food stores and often times only wood and ceramic instruments must be used in the preparation. Thirdly, the subsequent impairment of social, academic or job-related functioning owing to obsessional thoughts and behaviours This stems from the amount of time planning meals and the skepticism of a meal prepared by someone else. Essentially the obsession results in a loss of moderation and balance causing a significant withdrawal from life In severe cases, medical complications such as electrolyte abnormalities, metabolic acidosis and weight loss may result as a result of malnutrition. First described in 1997 by Steven Bratman in his book Health Food Junkies. A rather entertaining and motivational book outlining the obsession symptoms, potential causes, and treatments from the viewpoint of a naturopathic doctor.
Clear distinction between foods that are good and bad May feel a sense of superiority and driven to share the virtues of their diet with others.
This individual that I just described, I encountered him or her on a regular basis when I worked at Whole Foods last year. The reason I chose this topic was to not only understand where many of these customers were coming from but to pick the brains of dietitians to see how they would handle similar situations.
Currently, ON is not included in the DSM-V like its counterpart’s anorexia nervosa and bulimia and so authors categorize it as "avoidant/ restrictive food intake disorder". While no studies have been completed on the differential diagnosis of ON many authors have attempted to distinguish other ED from ON. The main difference between ON and AN is the motivation behind the restriction. Unlike anorexia nervosa there is less of an obsession with weight and distorted body images. Furthermore they are more concerned with the quality of food rather than the quantity. Similarities include: rigidity, perfectionism, social isolation, guilty feelings after a transgression and the diet representing identification to the individual. These are of course textbook definitions and in actual practice there is some overlap. A few authors have pointed out that this disorder rose to "fame" right before the printing of the DSM-IV and that it is every doctor's dream to coin the next new phenomenon. Nonetheless, in a study of eating disorder professionals 68% of respondents reported that they observed ON in their own practice and 25% of respondents interpret ON as a product of the media. Does media play a role?
Emergence of a society of individuals constantly called upon to sort through expert advice in order to assess the risk and benefits of food choices
Popular books on active medicine seem to actively promote ON in their enthusiasm for sweeping dietary changes
This is something you can speak to, and use as a tool when addressing ON.
I do want to caution that the evidence in not conclusive (is insufficient), but still interesting nonetheless. The literature is composed of cross-sectional studies, case studies, an explorative study using focus groups, a theoretical study and expert opinion Only two studies were aimed at the general population, predicting the prevalence to range from 6.9% to 57.6% depending on the threshold used. The associations between gender and ON tendency are not clear ON has been reported to occur equally in males and females Some studies however found that is occurred more frequently in males The literature hypothesized that higher ON tendency seems to be related to the internalization and acceptance of the sociocultural attitude toward appearance, which is independent of gender.
Other studies aimed their efforts at "high risk groups" such as dietitians, dietetics students, medical residents, performance artists, yoga practitioners, and athletes. The prevalence of ON in dietitians and dietetic students ranged from 12.8% to 81.9% when tested in different countries across the globe. The highest prevalence of Orthorexia was found in yoga practitioners (86%), followed by performance artists (54.6%), medical residents (45.5%), and male athletes (30%). Interestingly enough, some studies found that ON was more common in people who were older and with a higher BMI.
One study found a neuropsychological overlap between OCD and ON by finding similar weaknesses in set-shifting, emotional control, self-monitoring, and working memory. One study utilizing focus groups composed of women at various life stages examined the anxiety associated with sifting through scientific information on food nutrition and the risk factors.
BOT: - created by the man that coined this term - 10 questions with dichotomous choice (YES/NO) as the number of YES answers increase so does the degree of ON, requiring only 4 points to be considered to orthorexic.
Limitations: never been validated includes items not exclusive to ON (i.e. when eating do you pay attention to the calories of food? Do you think mood affects eating behaviour?))
ORTO-15 - diagnosed ON and compiled the questionnaire with the basis of health fanatic behaviour and obsessive compulsive behaviour and phobia - a liker scale questionnaire (always to never) in an attempt to make the answers more truthful - took 6 questions from BOT however modified slightly - added 9 others - Cognitive-rational area: Is the taste of food more important than the quality when you evaluate food? Do you think that eating healthy food changes your lifestyle? - Clinical area: Does the thought about food worry you greater than 3 hours a day? - Emotional area: Are your eating choices conditioned by your worry about health status? - For each question a score of 1 was indicative of ON and a score of 4 indicated normal eating behaviour - the threshold value of 40 was considered to be more predictive
Limitations: - scoring method remains ambiguous - tool poorly distinguishes between individuals informed of healthy eating and those with a sever pathological eating disorder - the tool performs inconsistently across varied cultural and language settings
- Treating individuals with ON may be challenging as conventional medical care may be believed to be harmful However given the disorder underlies with the preoccupation of heath, they may be amenable to treatment if it promises the achievement of better health. A multi-disciplinary approach composed of physicians, psychotherapists and dietitians is necessary to address the medical, psychological and nutritional consequences of ON.
Goals: Empower your participant to be positive and capable with eating Be a catalyst for productive change in eating attitudes and behaviours.
Make building relationships your priority Food-ways are intensely personal and private Sharing intimate details of food management carries the risk of criticism and shame Be accepting and back your participants up - don't criticize or undermine them Begin by asking where your participants what help, address those concerns As these clients are very health conscious, show them you want to help them Address Encoded Messages Anxiety is a dominant relation with food Even if you bend over backwards to be positive, participants may still decode your messages as negative, prescriptive and judgemental. Ask what the client hears you say - encourage them to be frank "All food can back a nutritional contribution" --> "Eat it if you must, but it isn't very good for you". Address feelings Unexpressed feelings can act as a barrier to change They can interfere with getting on the clients wavelength Correct misinformation but don't try to fix feelings Teach food acceptance Support variety by emphasizing pleasure as a guiding principle in food selection Research shows with children and adults that acceptance of specific food items increases with repeated, neutral exposure (10-20x) Exposures include: looking at the food, touching, smelling, and handling the food, preparing it and tasting it over and over Mouthing the food increases familiarity and acceptance of taste and texture. Teach participants to inconspicuously spit unwanted tastes into a napkin Address extreme food selectivity Coach mealtime social skills to allow the individual to politely but firmly fend off unwanted food Teach socially acceptable behaviour around food It is acceptable to pick and choose from what is on the table, to decline to be served, to eat only 1 or 2 food items from a meal, or to leave unwanted food on the plate. It is not socially acceptable to draw attention to food refusal or to request food that is not on the menu. Define meals in achievable ways A meal is sitting down to eat facing each other and sharing the same food Help find solutions to address obstacles Emphasize the nutrition worth of preferred food items, and recommend adding food items one at a time. "If you make that change, will you still enjoy the meal?" Help clients to understand the biological regulation of food intake and the importance of nutritional balance Use health-promoting terminology cautiously, as it may sustain the pattern of disordered eating Dispel harmful beliefs/attitudes about food and eating Nutrition information increases willingness to taste novel food in subjects for whom nutrition is important
By Olivia Curl
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What is Orthorexia Nervosa?
Classification of Orthorexia Nervosa
The Evidence: What does it tell us?
Obsessive Compulsive Disorder & Anxiety
Goals of Nutrition Care
Technique Tool Box
What is Orthorexia Nervosa
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The Illusion of Safety
P U R E
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Not included in the DSM-5
Similarities among anorexia nervosa
and bulimia nervosa
Avoidant/Restrictive Food Intake
Dominant awareness among eating
disorder professionals in Belgium
(Vandereycken W, 2011)Media-Induced or
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Thank you for listening
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