Eating Disorders

Screening for Orthorexia Nervosa (Part 1 of 3)

Dietitians are the most important clinician group to be on the look out for orthorexia nervosa (ON). This blog is Part 1 in a three-part series that will define ON, explain why RDs are best positioned to screen for it, and provide three simple strategies for doing so in practice. Parts 2 and 3 will discuss research and specific strategies on how to manage ON in patient care.

You’ve likely heard the term orthorexia nervosa (ON) at some point this past year. It’s been making a stir in social media, yet it’s not actually a new term. Integrative physician Steven Bratman, MD, MPH, coined it in 1997 in Yoga Journal, and then published a book about it in 2001 called Health Food Junkies: Orthorexia Nervosa—Overcoming the Obsession With Healthful Eating. Despite not being an eating disorder specialist, his observations were pretty accurate.

What Is ON?
While ON has an official-sounding name, currently is isn’t a disorder that has an eating disorder diagnosis as classified by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, the diagnostic bible of all psychiatric illnesses. Bratman and fellow researcher Thomas Dunn, PhD, are collaborating on the following proposed diagnostic criteria. (See the full criteria here.)

Criteria A
All of the following are met:

  • Client experiences compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices (which may include the use of concentrated “food supplements”) believed by the individual to promote optimum health, often defined by exercise performance and/or a “fit” body.
  • Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity, and/or negative physical sensations, accompanied by anxiety and shame.
  • Dietary restrictions escalate over time and may come to include elimination of entire food groups; they also may involve progressively more frequent and/or severe “cleanses” (ie, partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent—hidden or subordinated to ideation about healthful food.

Criteria B
Any one of the following is met:

  • malnutrition, severe weight loss, or other medical complications from restricted diet;
  • intrapersonal distress or impairment of social, academic, or vocational functioning due to beliefs or behaviors about a healthful diet; or
  • positive body image, self-worth, identity, and/or satisfaction excessively dependent on compliance with self-defined “healthful” eating behavior.

Bratman emphasizes that an interest in healthful eating absolutely isn’t pathological; if it were, every dietitian could be diagnosed. You can learn more about Bratman’s thoughts on his website.

Jessica Setnick, MS, RD, CEDRD, an eating disorder expert, developed her own proposed criteria and published them in her book the Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders (now in its 2nd edition). You can download a PDF of her criteria, or better yet, purchase her pocket guide, which is a fantastic resource.

The RD’s Critical Role
RDs are nutrition experts. So it only makes sense that individuals will seek our services when they feel they have a problem with their eating behavior or want to improve it. We’re best positioned to assess for adequate fueling and problematic ideas about eating and nutrition, as well as interventions to support balanced but joyful eating.

Screening Strategies
I’m going to share with you three screening strategies you can integrate into your work to feel more confident about assessing for ON or any type of disordered eating or eating disorder. But, more importantly, listen to your intuition. As we teach our clients, let your gut be your guide.

  1. Have your exercise or eating habits changed in any significant way over the past six months? If yes, how so, and how are you feeling about it?
  2. Do you feel you can be flexible with your eating? Can you be spontaneous or eat socially? Are those things important to you?
  3. How do you feel when you don’t eat or exercise according to your desired plan?

I hope this first part of the ON series has been helpful. Let me know below what burning questions you have about ON and your role as the RD.

— Marci Evans, MS, RD, CEDRD-S, LDN, CPT, is a Food and Body Image Healer™. In addition to managing her group practice in Cambridge, Massachusetts, Marci is shaping the future of dietetics by bringing her passion and skill into the eating disorders field to students, interns, and clinicians with online training and clinical supervision. Connect with her at www.marciRD.com and at all social media outlets @marciRD.

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