Orthorexia Nervosa As A Cultural Phenomenon 

Abstract

This article is devoted to the analysis of the phenomenon of orthorexia as a new modern mental disorder. Orthorexia nervosa refers to a pathological fixation with healthy food consumption. The term orthorexia is used to describe a group of patients who have avoidant or restrictive eating behaviours that are not motivated by a body image disturbance or a desire to be thinner. This paper describes the ideas of patients suffering from orthorexia about healthy and proper food, triggering their restrictive eating behaviour and notes what problems for physical and mental health can orthorexia pose. There have also indicated a number of reasons why at the moment orthorexia is not included in the ICD-10 or DSM-V, despite the prevalence of this phenomenon in the population. Based on systematic reviews, the authors distinguish between orthorexia and other eating disorders, such as anorexia and obsessive-compulsive disorder and note that orthorexia can be described as a social phenomenon. According to the clinical observations of the authors, in Russian culture orthorexia is associated with the ideas of allergic to some foods products. These beliefs lead patients to extremely selective eating and restrictive behaviour, searching for the causes of “allergies”, close health monitoring, attempts to find “allergens” via different diagnostic tests, seeking medical treatments from allergologist-immunologists. To illustrate this, the authors propose a typical clinical case.

Keywords: Allergycultural phenomenonexternal eating behaviorillness behaviorillness perceptionorthorexia

Introduction

Currently a tendency to a healthy diet, bio- and eco-products produced without pesticides, artificial flavors, dyes, preservatives, etc. becomes more and more popular. A lot of material about products which are useful and which are harmful is produced by media and advertising. Various diets of losing weight, improving health, treating allergies, etc. are constantly appearing. On the one hand, this trend has a positive effect on well-being, it reduces the risks of various diseases, improves the quality of life, and increases the body's ability to cope with mental and physical stress. On the other hand, if the only criterion for including a product in the diet is its health benefits, any deviations from the ideal may increase anxiety, also this trend of healthy eating can gradually take the form of pathological fixation on the consumption of “right” and “clean” food. It becomes an obsession and then leads to various eating disorders, including orthorexia.

Orthorexia nervosa - a pathological fixation with healthy food consumption (Simpson & Mazzeo, 2017) and bounded up with it restrictive behavior. The prevalence of orthorexia recently so increased in the population that it has caused a concern among clinicians (Cinquegrani & Brown, 2018). Despite the prevalence, at the moment, orthorexia is not included in the ICD-10 or DSM-V. If a DSM diagnosis is necessary, it is classified as “Uncertain Behavior Disorder (UFED)” (Costa et al., 2017). This category of disorders is used in cases where a functional impairment is observed, but there is no full compliance with any of the criteria for eating disorders or eating disorders (American Psychiatric Association, 2013).

The main reason that orthorexia is currently not included in international classifications is the lack of a descriptive and research base. In one of the works (McInerney-Ernst, 2011), the author explores the possibility of including the diagnosis of orthorexia in DSM, according to the accepted methodology of diagnostic reliability. The process for evaluating a potential diagnosis includes clinical description, laboratory tests, distinction with other disorders, and long-term studies. According to the existing procedure for including a diagnosis in DSM, at least 50 articles over the past 10 years should be published, at least two independent empirical studies should be carried out (with a conclusion on the difference from similar diagnoses and with a coincidence of results from 0.7 and above), and the literature on the disorder should contain a set of diagnostic criteria for its assessment - orthorexia does not yet correspond to virtually any of these criteria. The full clinical description of the disorder is missing in current studies, as it is done, for example, for anorexia or anxiety disorders. No laboratory studies have been performed; unique physical symptoms, have also not been described. Differential criteria delimiting orthorexia from other disorders are poorly defined. Due to the fact that orthorexia is a new phenomenon, long-term studies and observations on it are also absent.

In a recent review in 2017, more than 60 publications on orthorexia were found in English only (Costa et al., 2017), but the authors also note that qualitative studies that establish clear diagnostic criteria and symptoms, so far too little, and quantitative studies are difficult to compare with each other, because often their authors use self-developed questionnaires and assessment methods.

In addition, as mentioned above, there is a problem of the classification of orthorexia. It is believed that orthorexia may be a form of anorexia. Anorexia nervosa sometimes also begins with a certain diet and rituals associated with food, and when using questionnaires for the diagnosis of orthorexia, there was no significant difference between the attitude to food in orthorexics and anorexics (Gramaglia et al., 2017; Cena et al., 2018). Also, similar signs are the importance of self-control, adherence to diet, denial of functional disorders associated with the disease, perfectionism. At the same time, the significant difference is that anorexics tend to hide their habits, and orthorexics more often, on the contrary, show and tell others about them, trying to attract as many people as possible (Koven & Abry, 2015).

The relationship between orthorexia and obsessive-compulsive disorders (Koven, & Abry, 2015) has also not been adequately studied. With orthorexia, there are some signs of obsessions (for example, regarding the composition of “wholesome” and “unhealthy” foods, “clean” foods) or repeated actions (for example, when cooking “the right” way) (Bratman & Knight, 2000). But there is not enough information to determine whether it causes suffering, whether rituals reduce anxiety. At the same time, studies show a relationship between anorexia and OCD, which means that similar comorbidity can be characteristic of orthorexia, which is confirmed by a few studies (Brytek-Matera, 2012). There is no consensus among scientists whether orthorexia is an eating disorder or obsessive-compulsive disorder. Some therapists believe that obsessive observance of strict dietary requirements, detailed planning of the eating process, anxiety about non-compliance with rules or deviations from personal restrictions are better conceptualized as anxiety disorder (Koven & Abry, 2015; Mathieu, 2005), but still in most of the studies orthorexia is considered as one of the types or symptoms of an eating disorder.

Problem Statement

In orthorexia, a person is most concerned about the origin, growing conditions and composition of the product, the way it is prepared, conditions of eating (Mathieu, 2005). At the same time, a person may not seek for reducing body weight. A systematic review (Bourne et al., 2020) has found 291 scientific references to avoidant / restrictive food intake disorder (ARFID). It was noted that its introduction to DSM-5 was made to describe a group of patients who have avoidant or restrictive eating behaviour that is not motivated by a body image disturbance or a desire to be thinner. A systematic review (Strand et al., 2019) of 23 studies of a new disorder in DSM-5 - avoidant / restrictive food intake disorder (ARFID) emphasizes the problem of demarcation of this disorder with others. The following criteria are identified for ARFID based on a three-dimensional model: of interest in food, selectivity based on sensory sensitivity, and fear of aversive consequences. The main thing in orthorexia is the absolute confidence that he is doing the right thing and improving his health (Bratman & Knight, 2000; Brytek-Matera, 2012). Of course, not in every case this type of behavior reaches a pathological level. Orthorexia begins when such eating behavior becomes dominant in planning daily activities, and any deviation from what is considered correct causes anxiety, guilt, or leads to a tightening of the diet (Bratman & Knight, 2000; Costa et al., 2017; Duran et al., 2020). In addition, orthorexia can lead to poor physical health, nutritional deficiencies, the exacerbation of chronic diseases and adverse psychological and social consequences (e.g., social isolation, distance from the usual social environment) (Costa et al., 2017; Korinth et al., 2009).

Some authors note that athletes, doctors and medical students, nutritionists, as well as artists and musicians can be a risk group in various studies (Tremelling et al., 2017). Fears of unhealthy foods can arise due to genetic predisposition, perfectionism, disinformation or social pressure (Brytek-Matera, 2012). Thus, according to findings (Worsfold & Sheffield, 2020), the professionals themselves - psychologists, fitness instructors and naturopaths working with people prone to orthorexia and health and fitness obsessiveness, cannot always correctly identify the pathological nature of this behavior in their patients.

Research Questions

As we have shown above, the subjective reasons leading the patient to orthorexia can be different - belonging to any social activity, family eating scripts, hypochondriacal fixation on one’s health after an illness and an attempt to prevent its relapse. In this paper, we show a clinical example of orthorexia masking as a food allergy. According to our observations, this option of patient interpretation is becoming more common in our country, which leads to increasing number of clients of nutritionists, nutritionists, intuitive nutrition specialists, as well as increasing number of patients applying for medical care in allergic clinics. We chose a clinical case of allergy to tree pollen, the owner of which was not worried about this, did not avoid the allergen and did not undergo treatment. However, she was worried about a suspected food allergy that was not supported by diagnostic tests, and showed extremely selective eating and restrictive behavior. The choice of the cause of allergies is not accidental and can be attributed to a certain social fashion in our culture, as well as the choice of coping strategies - trips to detox tours to Thailand and Cyprus. Various studies of patients with allergies (Polloni & Muraro, 2020) show that food allergies are characterized by excessive anxiety and avoiding behavior, which leads to non-adaptive coping and overly restrictive behavior of patients, which worsens their quality of life and mental state. However, unexpressed anxiety is helpful in avoiding encountering an allergen. Describing this clinical case, we would like to show what “masks” orthorexia may have and outline ways of primary prevention of patients' misinterpretation of their well-being as allergies and “immunity problems”.

Purpose of the Study

The aim of this study is to describe the clinical case of orthorexia, in which the pathology of eating and restrictive behavior was associated with the interpretation of one's well-being as an allergy to food products. This subjective interpretation led the patient to an allergist.

Research Methods

Considered a clinical case of orthorexia, not related to dissatisfaction with physical appearance, desire for weight loss or compliance with "beauty standards". The patient of the allergologist considered herself as a person with a severe form of food allergy, looked for its causes, improved her health literacy in this field of medicine and showed selective or restrictive behaviour.

The Structured Clinical Interview was conducted to find out patient's eating habits, ideas about “proper and healthy” food that prompted selective eating behaviour and formed subjective perception criteria of her health deteriorating and its causes.

To determine orthorexia was used the following list of diagnostic criteria (Moroze et al., 2015):

• obsession with “healthy food”: control of the product origin, details of its producing and packaging, quality, composition, "purity" of food and its impact on physical and emotional health;

• strict avoidance of food that a person considers harmful and leading to a dietary unbalanced diet;

• spending much time (more than three hours per day) for the analysis, purchase and special preparation of certain foods based on their composition (for example, different foods are consumed at different times of the day based on the belief that the digestion of one type of food is optimal after of eating another);

• anxiety and guilt while eating “unhealthy” foods, intolerance of other people's eating habits;

• excessive (relative to income) spending of money on products due to perceived compliance with required quality;

• social exclusion due to difficulty finding people who would share this commitment to healthy eating in their immediate social environment;

• difficulty concentrating on professional duties due to the constant focus on adherence and preparing a “healthy” diet;

• it is important to consider that the above symptoms are not a manifestation of another disorder, a special medically recommended diets or compliance with the religious rules.

Findings

In April 2019 a 31-year old female patient presented herself to the allergic clinic with nasal congestion, sneezing, itching of the eyelids in April-May, as well as itching in the oropharynx, sneezing and nasal congestion when eating fruits and nuts.

The symptoms appeared 4 years ago when she “incorrectly left the next process of detox and starvation, having started eating everything at once”. She leaves to another climatic zone during pollination. Also (and the patient pays more attention to these manifestations) when drinking coffee with goat milk ("maybe gluten there") – notices the nose running. Weakness and constipation when using curd, whole milk causes stomach pain, chicken and turkey occasionally - constipation. Lactose-free milk - without reactions. According to the patient, while resting in Crete, she does not notice any reactions to food at all, eats all products. It is surprising that in Moscow, despite the abundant intake of pro- and prebiotics, constipation disturbs. In January 2019 she visited a detox program in Thailand, where she underwent hydrocolonotherapy and enemas with garlic “with excellent effect”, after returning she ate all products with no reactions and problems with stool, but after 3-4 weeks all symptoms (weakness, lethargy, abdominal pain, bloating and constipation) returned again.

Self-diagnosed with IBS and depression. The patient has no worries about main disease (seasonal allergic rhinitis and oral allergies to fruits and nuts), but she worries about the potential allergy to cow's milk proteins and gluten.

She believes that the disease is caused by "psychosomatics", worried about "why all this is happening." Immunity is like something that plays an important role in the quality of life, the acceptance of events, the protection against disease, long life and good mood. The patient reads a lot of literature about a healthy lifestyle, takes a lot of dietary supplements, and tries to be an expert in health matters.

Conclusion

Despite the attention of specialists to the problem of orthorexia, its status does not yet determined clearly. Regardless of the opinion that clinicians come to, will orthorexia be recognized as a symptom, predictor, or a unique disorder, many works confirm the existence of this phenomenon. But the vast majority of orthorexia studies are based on limited samples, including small or too homogeneous sample selections. There are also no longitudinal researches, and diagnostic criteria for existing works are heterogeneous, insufficiently strict and verified. Currently, there is a need for further research to clarify the nature of orthorexia and its consequences, identify its place not only in the classifiers of mental disorders but in the mental organization of a modern person.

Possibly orthorexia is just a social trend, specific cultural phenomenon in countries with a focus on nutrition and health, as some researchers suppose (McInerney-Ernst, 2011; Barthels et al., 2019). New trends, tendencies, ways of communication (for example, social networks) are the determinants for society to impose some ideas, for example, the case of widespread anorexia among women after the trend of thin fashion models. Nevertheless, in the modern world with an increasing demand for healthy wholesome nutrition and healthy lifestyle, there is a need for additional research on whether “healthy behaviour” will finally lead to positive or pathologically harmful impact on health.

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