Findings of this study support the conceptualization of orthorexic symptoms (ONs) within the spectrum of disordered eating attitudes and behaviors. The focus of orthorexic pathology is eating behavior. ONs were significantly correlated with disordered eating as measured by the EDE-Q-13, as well as with insecure attachment, emotional dysregulation and alexithymia, emotional correlates of disordered eating. ONs were also associated with retrospectively reported childhood memories of oneself and one’s mother being overweight, of maternal restriction and monitoring of one’s food consumption, and of maternal concern about one’s (over)weight. These factors may be precursors of disordered eating and even eating disorders (Lev-Ari and Zohar, 2013; Wang et al., 2022). The distinction between the profiles of participants likely to have ON (DOS scores > 30) and those less at risk was quite dramatic. Between-group differences were significant for all study variables, including all five disordered eating subscales.
Our results also support a close connection between orthorexic symptoms and compulsive exercise. These variables were highly correlated, and both were associated in our SEM model with disordered eating, and with emotional and behavioral factors that contribute to risk for eating disorders. Participants who scored above the DOS clinical cutoff reported significantly higher levels of compulsive exercise than those who did not. A link between ONs and compulsive exercise has been observed in previous research. Oberle et al. (2018) reported that students with high levels of ON symptoms had high levels of physical activity and exercise addiction, including intensive exercise despite injury or illness that could lead to physical impairment. In their consensus statement on risk factors for ON, Donini et al., (2022) agree that “competitive sports, athletic performance concerns, and high physical exercise frequency” are risk factors for ON.
Although there is reason to conceptualize ONs within the restrictive eating disorders spectrum, the similarities and differences between them remain to be clearly defined. The question arises as to whether or not ONs differ from the restrictive eating disorders already defined in the DSM-5 (APA, 2013) – anorexia nervosa (AN) and avoidant restrictive food intake disorder (ARFID).
There are similarities between symptoms of ON and AN. On the one hand, both are characterized by a preoccupation with food, choice of foods according to cognitive assessment rather than appetite and enjoyment, a distinction between “good” and “bad” foods, and rigidity (Bhattacharya et al, 2021). Bratman, who coined the term “orthorexia nervosa” (Bratman, 1997), assumed that a desire to be thin, intentional weight loss and body image distortion were characteristic of AN but not ON (Bratman, 2000). Yet research findings have called these assumptions into question. Orthorexic eating behavior has in fact been shown to be significantly associated with drive for thinness (Barthels et al. 2015a) and body image problems (Barthels et al., 2015b). High levels of ONs have even been linked to dieting (Varga et al., 2014) and repeated weight loss attempts (Tomsa et al., 2012). Similar personality traits, such as perfectionism and trait anxiety, have also been linked to both AN and ON (Dunn & Bratman, 2016). These findings point to greater similarity between anorexic and orthorexic symptoms than was previously assumed. In their consensus statement, Donini et al. (2022) agree that the distinction between AN and ON is motivational rather than behavioral, i.e. that in ON, weight and shape concerns are not the main motivation and that the over-evaluation of appearance and weight are less central in ON than maximizing subjectively perceived health.
Dunn and Bratmen (2016) point out the similarity between ON and ARFID as defined in the DSM-5 (APA, 2013). Whereas both disorders are defined by avoidant and restrictive food intake, the motivation underlying the same behaviors differs. Individuals with ARFID are often concerned about the aversive consequences of eating, such as choking, vomiting, bloating or nausea (Bryant-Waugh & Kreipe, 2012), i.e. short-term negative outcomes, while individuals with ON are usually preoccupied with long-term negative impact on their health, such as the metabolic syndrome, or cancer (Donini et al., 2022). In addition, Donini et al. (2022) point out that sensory sensitivity is a powerful correlate of ARFID and is not central to ON.
As we have pointed out, much research has focused on restriction as the cognitive and behavioral basis for ON, necessitating differentiation from AN and ARFID. Nevertheless, in this study we found that higher levels of ON symptoms are significantly related not only to restriction, but also to bingeing and purging. The questionnaire we used to assess orthorexic symptoms did not ask about these behaviors, but correlations with the bingeing and purging subscales of our measure of disordered eating and comparisons of bingeing and purging behaviors between groups with high, intermediate and low levels of orthorexic symptoms indicated that these symptoms were all linked. Our findings therefore point to the likelihood that ONs may be better conceived in the realm of eating pathology characterized, inter alia, by bulimic symptoms – binging and purging. It would seem that at high levels of ON pathology, symptoms are intertwined with disordered eating of all kinds. It could be, that the individuals who scored above the clinical cut-off in the current study had coexisting EDs, or were masking an eating disorder with health-related cognitions, or were trying to overcome an eating disorder such as AN by turning their perfectionism and obsessiveness from weight and appearance to health concerns (Donini et al., 2022).
ON is ego-syntonic by definition; affected individuals adopt beliefs about healthy nutrition and then structure their lives around them. Moreover, individuals with ON symptoms experience a sense of pride and superiority, as reflected in DOS item 5: “I like that I pay more attention to healthy nutrition than other people”. Individuals contending with ONs, like those with AN symptoms, are therefore unlikely to seek medical or psychological help of their own accord. Requests for treatment might emerge from distress associated with the violation of the regimen dictated by the individual’s beliefs or from the concern of others. By the time distress or pressure from significant others peak, self-imposed restrictions are likely to be spiraling, so that people with ON may present for treatment with severe and extreme symptoms and require treatment for physical impairment as well as maladaptive behavioral and cognitive patterns. However, when they do present for treatment, it may be unclear how distinct their symptoms are from those of another eating disorder. What does seem clear is that adopting very rigid health beliefs and structuring one’s daily life around them can be a warning sign for the onset of what may become severe eating pathology.
Strengths and limits
Strengths of this study include the large community sample, the use of well-validated measures, and the combination of variables studied in the context of ON, all contributing explained variance. Weaknesses include reliance on self-report alone and the under-representation of men, since ON may well differ between males and females (Strahler et al., 2021). We assessed orthorexic symptoms using the DOS (Chard et al., 2019), which includes only three ON criteria. The percentage of participants scoring above the suggested DOS cutoff was low. The study was cross-sectional, with all data collected at one single time point, limiting our ability to reach conclusions about risk factors and the chronological emergence of the characteristics studied.