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WHAT IS ORTHOREXIA NERVOSA?

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Singapore’s Healthier Choice Symbol (HCS) are increasingly seen in canteens, restaurants and supermarkets. Even a Coke Zero has the HCS too! People are increasingly turning towards healthier food options such as opting for brown rice, low fat products, and less oily food options. School canteens and food courts are promoting healthier meal options. Healthy eating has been idealized in the current sociocultural climate, with media messages, eating places and health professionals promoting the notion that healthy eating is a desirable lifestyle to keep future illnesses away and maintain good health. No doubt is living healthily great. But being overly healthy may cause more harm than good. Excessively done, people may develop restrictive diets, ritualized patterns of eating, and rigid avoidance of food believed to be impure or unhealthy. These are characteristics of a pathological obsession with proper nutrition now described as orthorexia nervosa (ON) (Koven & Abry, 2015).

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The pressure to eat well is echoed by an increasing number of reported eating disorders (ED) in hospitals and news articles about ON in Singapore (Ng, 2015; Yuling, L. , 2015). This shows that Singapore is increasingly aware and educating the public about this ‘new’ food-related disorder in light of our growing habits of healthy eating. This paper aims to discover more about ON, it’s similarities and differences with DSM-5’s ED and obsessive-compulsive disorder (OCD). Vulnerability factors, gender differences, assessments and treatments for ON will also be discussed. ON is maintained by a desire to optimize well-being and physical health, fuelled by Singapore’s increasingly healthy eating culture. Extreme preoccupation with food can result in impairment in the individual’s quality of life. Psychologically, individuals with ON may experience extreme irritation when their eating rituals are interrupted, disgust when food purity is compromised, and guilt when they diverge from their diet (Simpson & Mazzeo, 2017). They are at risk for social isolation and occupational impairment due to their high standards on maintaining control of their food environment and difficulties having meals with others who do not share their approach towards eating (Simpson & Mazzeo, 2017).

Despite growing evidence, studies on ON are sparse. ON is not formally recognized as an ED in DSM-5, and is commonly debated on whether it is an ED, like anorexia nervosa (AN) and bulimia nervosa (BN), or an obsessive-compulsive disorder (OCD). Similarities and differences with other disordersAlthough ON is commonly discussed as an ED, ON has distinct characteristics that set itself apart from DSM-5’s ED. Unlike in ED, orthorexic individuals are preoccupied with the quality, not quantity, of the food they consume. (Fidan et al. , 2010). Their goal is to attain the perfect diet, while the goal for AN and BN is weight loss. The fear factor for individuals with ON is not weight gain like in ED, but the fear of consuming what is considered impure food. Those with ON also carry a sense of pride and relatively higher self-esteem than those with ED (Larson, 2013). Despite ON’s distinct characteristics, it has several overlaps with DSM-5’s AN and BN. All three disorders give food an excessive place in the individual’s life. Their relationship with food is associated with social problems. They are commonalities in traits like perfectionism, obsessive-compulsiveness and the need for control. Sociocultural and psychological factors contribute to the development of the conditions. Individuals with ON or BN tend to be either normal-weight or overweight. ON and AN share symptoms of dietary restriction (Larsen, 2013). Emotionally, anorexic and orthorexic individuals experience guilt over food transgressions and ego-syntonic thoughts (Kovan & Abry, 2015).

ON has also been debated to overlap with OCD (Brytek-Matera, 2012; Kovan & Abry, 2015). Orthorexic individuals manifest some obsessive-compulsive tendencies such as intrusive and recurring thoughts about health and food at inappropriate times, inflated concern over impurity and contamination, and a strong need to eat in a ritualized manner (Koven & Abry, 2015). Consequently, these individuals have limited time for other activities, implicating their social life and daily routines.

In view of the overlapping symptoms, ON may have high comorbidity with ED and OCD. Some studies have also viewed extreme orthorexic attitudes toward food to be a potential risk factor for evolving into AN (Dell et al. , 2016). Given the high prevalence of OCD in ED and vice versa, accompanied by studies showing shared etiological and neuropsychological relationships, it is not surprising that ON falls into either one of these categories since it has similar symptoms to both ED and OCD (Alkman & Shankman, 2005; Kaye, Bulik & Thorton, 2004; Sherman, Savage & Eddie, 2006). In my opinion, ON seems to be more similar to OCD than ED as the focus of ON is on the individual’s cognition towards food, rather than one’s physical appearance. The rumination of food and eating rituals, and the harshness of one’s diet seems to be more related to OCD. Possible causes of ONAlthough ON is not in DSM-5, several vulnerability factors are found across studies. These contributory factors can be categorized according to psychological and social factors. Cognitive biases, such as heuristics and attentional bias, increase vulnerability of developing ON symptoms. Cognitive cues that trigger orthorexic-like thoughts include an over-evaluation of eating.

Overall, orthorexic individuals tend to perform worse in domains of external attention, working memory and set-shifting relative to non-orthorexic individuals (Kovan & Abry, 2015). Cognitive heuristics such as dichotomous thinking about ‘good’ or ‘bad’ food influences food choices (Mascioli, 2017). High attentional bias increases one’s vulnerability to develop ON. These individuals have reduced attention to external cues, such as eating with other people, accompanied by an inward attentional bias of focusing on what the individual is consuming and their ritualized eating habits. When cues trigger one’s security motivation system (SMS; a mechanism that orients the individual to potential threat with a specific behavioural output of information seeking), the orthorexic individual displays external attentional bias of searching their environment for information about the threats to their health (Szechtman & Woody, 2004). Consequently, these attentional biases affect food choice, where the orthorexic individual has been trained to attend to healthy food cues and tend to consume healthier food (Mascioli, 2017).

The need to control one’s eating is also seen in anorexic individuals. Thus, it is not surprising that some ON vulnerability factors overlap with AN. Additionally, there may be dysregulation in the neurological circuitry for reward and anxiety, and environmental induced disturbances within homeostatic epicentres that implicates the etiology and maintenance of ON (Head et al. , 2015). Social factors include culture of eating habits, education levels and social media engagement. Singapore today has an increasing cultural emphasis on healthy nutrition when considering health improvement issues. Food stores are advertising low calorie food, more salad bars and ‘cleaner’ food. Higher education levels have educated people with the nutritional knowledge. This is exceptionally pertinent for individuals working with nutrition because the daily confrontation with nutrition and healthy food may heighten their tendency to an ED (Kinzl et al. , 2006). However, there are mixed findings on the relationship between education level and the prevalence of ON (Ramacciotti et al. , 2011; Shah, 2012). The high engagement with social media in Singapore today increases users’ exposure to health-related issues. Companies use such platforms to promote healthy eating, and users display their good health through pictures. Particularly, being a public role model in terms of one’s physical appearance increases sensitivity to healthy eating (Ng, K. , 2015; Ramacciotti et al. , 2011). Altogether, these social factors and environmental changes prime individuals with an attitude of healthy eating, pressuring them to consume ‘purer’ food. I think that these social factors overlaps more with OCD while cognitive factors overlap more with AN because society seems to be focusing on healthy eating and not weight loss. It makes consumers constantly think about ‘clean’ food and in extreme cases, ruminate about it. Social factors seem to perpetuate cognitive factors in ON as it fuels dichotomous thinking. The constant exposure to healthy eating cues can cause one to be overly sensitive to healthy eating, which may result in ON symptoms.

Gender differences

Literature has found mixed findings on gender differences in ON. While some have shown that males have a higher tendency for ON, majority research showed no gender differences in likelihood of developing and display of ON behaviours (Brytek-Matera et al. , 2015; Bundros et al. , 2016; Fidan et al. , 2010). Relating this to Singapore, I would also hypothesize that there will be no gender difference since there is an increasing trend of exercising regularly and eating healthily among both genders.

Assessment

The current and limited literature on ON is dominated by studies using the ORTO-15. ORTO-15 is a 15 multiple choice questionnaire originally by Bratman (2000), now modified by Donini and colleagues (2005). It assesses beliefs about the perceived effects of consuming healthy food, habits of food consumption, attitudes towards food selection, and the extent that food concerns influence daily activities (Koven & Abry, 2015). ORTO-15 has reported a wide range of prevalence of ON ranging from 30% to 70% across different countries (Dunn & Bratman, 2016). But these alarming numbers are inconsistent with existing literature on the prevalence of ED of about 2% (Smink, van Hoeken & Hoek, 2012). The discrepancy can be attributed to a high false positive rate and the absence of items on ORTO-15 regarding health problems or interpersonal distress because of one’s diet (Dunn & Bratman, 2016). Other limitations of ORTO-15 include low construct validity and inconsistent internal consistency (Cronbach’s alpha = 0. 14 to 0. 83) (Fidan et al. , 2010; Varga et al. , 2014). ORTO-15 lacks basic features of test construction such as standardization methods and basic psychometric properties. Given the relatively recent development of ON, there is little validation data for ORTO-15. ORTO-15 thus has questionable reliability and validity. Despite its shortcomings, there is substantial evidence on using ORTO-15 to detect ON (Dunn & Bratman, 2016). However, I do not agree with these evidences of using ORTO-15 for ON. Just because the same measure has been used repeatedly across studies, does not imply a good reliability or validity. It could be commonly used because it is one of the only psychometric measure for ON, since ON is not formally recognized yet. The overall reliability and factor structure of ORTO-15 should be systematically evaluated in the future. Moreover, since ON is overlaps with OCD and ED, ORTO-15 questions may be skewed towards those conditions and result in identification of its comorbid disorders instead. ORTO-15 also does not account for obsessive-compulsive symptoms of orthorexic individuals. ON cannot be properly diagnosed until it is a formal disorder in DSM. Once officially recognized, symptoms will be standardized and more standardized tests can be created for proper diagnosis. No longer will it depend on people’s subjective amendment of ORTO-15 according to their beliefs of what ON is. Till then, ON can only be a suspected condition and not formally diagnosed.

Treatment

Current literature is lacking in evaluation of treatment effectiveness for ON. Ideally, a combination of cognitive-behavioural therapy (CBT), exposure and response prevention (ERP), medication and psychoeducation can be applied. CBT and ERP has been shown to be beneficial for the obsessive and compulsive aspects of ON. Cognitive distortions are targeted. This includes dichotomous thinking, catastrophizing and attentional bias of thoughts surrounding food, health and eating, and associated traits of perfectionism (Segura-Garcia et al. , 2015). ERP targets the obsession and compulsion aspects of ON (Koven & Abry, 2015). Medication such as serotonin reuptake inhibitors are reportedly helpful for ON, given their efficacy for AN and OCD (Mathieu, 2005; Simpson et al. , 2013). Antipsychotics like Olazapine help to decrease the obsessive nature of food-related thinking (Moroze et al. , 2015). Psychotherapy should be individualized according to the patient’s needs. Focusing on nutrition education via psychoeducation may increase the amount and variety of food consumed (Moroze et al. , 2015). ON could also be a residual symptom for patients who underwent ED treatment. ON symptoms tend to increase after ED treatments. This could be due to CBT for AN that focuses on developing a positive attitude towards eating, where individuals are taught positive mechanical reinforcements from eating (Segura-Garcia et al. , 2015). The structured eating that provides certainty on food quality and quantity may backfire as this mindset increases tendency of developing ON. Thus, ON can be seen as a side-effect of treatment for ED. My critique for ON treatment is that it is challenging and not as straightforward. While ON patients may be resistant towards medication as they may deem it to be impure, some ON patients may also be willingly adhere to treatment because of their preoccupation with good health. It is no surprise to me that ON may be a side-effect of ED treatments because patients could be used to being obsessed with something till it makes up their identity. Recovering from an obsession may cause them to feel directionless, hence the need to ‘cling onto’ something arises post-treatment in the form of ON symptoms. On top of targeting anorexic and obsessive-compulsive symptoms, and dysfunctional eating habits on quality and quantity of food, treatment should also target mindsets on identity. Medical professionals should be mindful of ON symptoms after ED treatments and take precautions to reduce the likelihood of developing ON as a side-effect.

CONCLUSION

Overall, I would classify ON as a type of OCD because involves excessive preoccupation of consuming healthy food and consequently experiencing associated psychological and physical dysfunctions in daily activities. ON should not be termed as an ED just because it is food-related. Instead of focusing on ON as a disorder by itself, ON can be seen as either a preceding disorder that leads to ED or a by-product of ED treatments. When ON symptoms are moderated or mild, it can be seen as an indication of good self-control. It maintains good health and prevents malnutrition. While it is good that Singaporeans are displaying more awareness on the value of nutritional principles of food choices, the community should ensure that this pattern does not become extreme to the extent of negatively affecting one’s quality of life and daily functioning. Who knows, maybe it is all just an exaggeration of a healthy eating lifestyle.

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