Case presentations
Descriptive Data
For each case, the individual scores on the questionnaires’ subscales are presented in Table 3 and 4.
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Table 3 reveals that Ms. A, Mr. C and Ms. E displayed high scores on most of the EDI-2’s subscales. The scores of Mr. D were not elevated, whereas the scores of Ms. B were very low.
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Table 4 reveals that on the subscale Unconditional Permission to Eat, all individuals displayed low levels, whereas on the subscale Eating for Physical rather than Emotional Reasons, all individuals reached moderate scores. On the subscale Reliance on Internal Hunger and Satiety Cues, Mr. C and Ms. E displayed slightly higher scores than the other individuals. On the subscale Body-Food Choice Congruence, nearly all individuals displayed very high scores.
Case reports
Ms. A: Fear of unhealthy overweight[1]
Description of eating behavior
Ms. A described her eating behavior as “very healthy, very disciplined and quite monotonous”. She paid close attention to only eating unprocessed, fresh foods and to the composition of her diet. She kept track of her nutrient intake, especially of her protein intake which she has defined to be at least 1.5 g per kg of her ideal weight. Furthermore, she has determined to not eat more than 1,700 to 1,800 kilocalories per day. She has established a regular schedule for her meals and declared that it was important for her to combine foods of animal and plant origin in her meals. In total, she stated to spend about 4 to 5 hours a day focusing on her eating behavior, which sometimes interfered with her daily tasks. For example, she occasionally took less care of her daily tasks, put them off, or was not fully focused when she completed them. Her main motivation for her keeping up with her healthy eating behavior was to prevent diseases and to promote her health. She was afraid of a stroke, “fatty arteries” and high blood pressure and was desperate to prevent herself from falling back into old habits and to gain weight again (she used to weigh more than 150 kg several years ago). She said that her eating behavior was often detrimental to her mental well-being, because she had to ruminate a lot about her eating behavior and that this took up very much time.
Classification according to preliminary diagnostic criteria
Ms. A's eating behavior was determined by her fear of overweight and related consequences for her health. With regard to the preliminary diagnostic criteria (see Table 2 and 5), it can be stated that Ms. A clearly fulfilled two of these criteria and partly fulfilled three of them, while criterion C(1) was not fulfilled and there were not enough information to evaluate criterion D(2). Regarding criterion E, although Ms. A intended to lose weight, it has to be stated that her worries about her weight were clearly health-related and not shape-related. Overall, it can be said that Ms. A. displays orthorexic eating behavior to a mild extent.
Ms. B: Orthorexic eating behavior as a coping strategy for anorexia nervosa1
Description of eating behavior
Ms. B declared to only eat plant-based, “healthy and fresh” food. She bought organic food whenever possible and didn’t eat any processed food. Her diet included legumes, whole grains, oatmeal, ancient grains such as quinoa and buckwheat, fresh vegetables, fruit, and plenty of water. Her friends said that her diet looked "colorful and healthy" but that they could never follow it. She forwent plenty of things in her life, but it did not feel that way to her. She stated that in general, her diet was very well planned, so she didn’t even get into the situation of having to eat something unhealthy. For example, she scheduled her meal times and sometimes went home earlier, in order to stick to them. She would rather endure hunger than eat something unhealthy. Ms. B. stated that she started to focus on her diet when she was 12 years old. She also had an anorexia nervosa for several years and the focus on healthy eating had helped her to "transform nutrition into something healthy". The fact that she did not eat meat, however, is exclusively for ethical reasons. She said to feel more connected to her body and to give her body more of what it needed since eating healthily Occasionally, however, she got into trouble because of her diet, especially with her mother and with her friends, who both missed her spontaneity in the context of eating. She stated that the occupation with her eating behavior takes about 5 hours per day. Hence, it sometimes interfered with her daily tasks, for example because she was unconcentrated or due to time constraints. Although she said that the routines were good for her, she occasionally missed a bit of flexibility, too, which made her feel affected by her diet quite often. This is why she would like to be more relaxed about her diet now and then. At that moment, however, the feelings of being satisfied and proud that she was able to manage her eating behavior so well dominated, so she did not want to change it.
Classification according to preliminary diagnostic criteria
Ms. B’s eating behavior was determined by overcoming her former eating disorder by now focusing on a healthy diet. With regard to the preliminary diagnostic criteria (see Table 2 and 5), it can be stated that Ms. B fulfilled three criteria clearly and two criteria partially. Overvalued ideas (C(1)) were absent, as well as nutrient deficiencies (D(2)). Regarding the differentiation from eating disorders, she did not declare any worries about weight and shape, although she was still severely underweight. Hence, her previous anorexia nervosa seemed to be in remission, and therefore, the presence of anorexic symptoms did not speak against the simultaneous existence of orthorexic symptoms. Overall, it can be stated that Ms. B displayed orthorexic eating behavior to a moderate extent.
Mr. C: Only meat, no vegetables1
Description of eating behavior
Mr. C. stated that his diet consisted exclusively of animal products, like meat, fish, butter and eggs. He did not eat any fruits or vegetables. He followed a very high-fat and high-protein diet, and he considered fat to be the most important nutrient, while he completely avoided carbohydrates. He emphasized he did not consume any sugar, alcohol or caffeine. He regularly went on fasting diets, which he only interrupted if he got too thin. Apart from that, he could fast "forever" because he saw it as a "cure" in which stem cells and growth hormones were activated.
Mr. C. has been following this diet for health reasons for about 15 years. At that time, rheumatism had caused him "insane pain", which “had not interested anyone”, including his family and medical professionals. No treatment helped, which is why today he has lost all respect for conventional medicine. Only the exclusion of several foods led to an improvement of his rheumatism. He developed this diet after intensive research and found out, among other things, that some fruits and vegetables were toxic. As an example, he mentioned spinach and strawberries containing oxalate, which could lead to kidney stones. He also stated that eating fruit would give you a "non-alcoholic fatty liver" and that "anything with more than two ingredients is garbage." Furthermore, he considered claims that fat is unhealthy to be “propaganda”. Additionally, it was "extremely important" for him to exercise. He declared to walk 30 kilometers a day, and he also cycled, did fitness and used to swim.
Currently, Mr. C. declared to feel "fit as a fiddle,". His rheumatism symptoms have disappeared, and he had "blood levels like a 16-year-old”. He always felt awake and could "talk to 10 people at once" because he was not in "that carbohydrate fog." As soon as he deviated from his current diet, he immediately felt worse, for example, his eyes started to cause problems and he was in more pain again.
However, his diet also led to difficulties. Mr. C. felt "disgust and horror" in view of what other people eat. He recognized from their "aura" that they were "metabolically ill". He had to go "sneaky ways" to avoid food smells in the city and also the smells of other people. As a result, he no longer had contact with his family or friends. He is sometimes dismissed as “a crank”, even by doctors, but they are "totally clueless"; he thought he was the only person who is educated in metabolic issues. Occasionally, people also made fun of him.
Classification according to preliminary diagnostic criteria
Mr. C’s eating behavior was clearly focused on health aspects in all points. A certain body weight only plays an indirect role, as he was careful not to lose too much weight during his fasting episodes. Regarding the diagnostic criteria (see Tables 2 and 5), it can be stated that Mr. C clearly fulfilled five criteria. Regarding the presence of overvalued ideas, he was the only case in this study fulfilling criterion C(1). Criterion C(2) was considered to be partially fulfilled, because he did not describe any rituals, albeit his diet is extremely rigid. Regarding criterion D(2), it could not be clearly stated whether nutrient deficiencies were present or not. While he declared to have “blood levels like a 16-year-old”, he also said that he had no trust in conventional medicine, which raises doubts about his claim to have had checked his blood levels. All in all, it can be stated that Mr. C’s orthorexic eating behavior was very pronounced.
Mr. D: Healthy eating and exercise
Description of eating behavior
Mr. D described his eating behavior as very controlled and healthy. He aimed to consume about 25% of his total daily calories from proteins in order to support his scheduled exercise routine of five to six training sessions per week. He ate very regularly throughout the day to ensure a continuous intake of nutrients and he preferred unprocessed foods. For ethical reasons, he was a vegetarian, and apart from his focus on proteins, he also paid close attention to eating fruits and vegetables in every meal. He used an app to track his food intake and sometimes he entered his meals one day ahead in the app. He also kept track of his calorie intake not only to shape his body, but also to promote his health.
He was preoccupied with his eating behavior for about 2 to 3 hours a day, which sometimes interfered with his daily tasks. Once, he did not turn in an assignment for university on time because he was busy figuring out "the best food" and researching the quantities of the nutrients. Although there were no foods that really scared him, he nonetheless avoided certain foods, for example fatty foods, because otherwise he would be very upset about the “wasted calories”. He claimed that usually, his diet made him feel fit and powerful, but he sometimes also experienced negative emotions due to his eating behavior. For example, eating meals that other people have cooked is an “inner struggle”, because he could not control how the meals were cooked. Furthermore, he frequently forwent indulgences in order to eat healthily. He paid close attention to stick to his schedule because he wanted to promote his health and also tried to increase his well-being and to regulate his mood with his eating behavior. This is why he almost never transgressed his nutritional rules. He rather endorsed hunger or appetite for specific foods than eat something unhealthy. However, he did not worry about getting a specific disease, he rather tried to „optimize everything“.
Classification according to preliminary diagnostic criteria
Mr. D’s eating behavior was focused on a healthy diet designed to support his athletic goals. With regard to the preliminary diagnostic criteria (see Tables 2 and 5), he clearly fulfilled one criterion, while he partially fulfilled four criteria. Overvalued ideas were absent and there was not enough information to evaluate the presence of nutrient deficiencies. In this case, the ambitions to eat healthily could hardly be separated from worries about weight and shape because of the interaction with his athletic goals. However, since he did not aim to lose weight, criterion E was considered to be fulfilled. His overall orthorexic eating behavior was classified as being mild, with a strong focus on scheduled eating and exercising and with no ambitions to directly control his weight.
Ms. E: Vegan and unprocessed
Description of eating behavior
Ms. E claimed to follow a vegan diet and reported to pay close attention to a balanced eating behavior in order to promote her health and to avoid diseases. It was very important for her that her food was minimally processed or unprocessed, free from artificial additives and that it is seasonal, organic and produced locally. Furthermore, she preferred food with a low content of fat and sugar. She used to record her food intake but eventually stopped it when she noticed that it had a negative effect on her mental health. In total, she spent about 4 to 5 hours a day focusing nutrition, which sometimes interfered with her daily tasks. For example, at times, she lost herself in thoughts like "Do I need to buy food? Is the shop still open? What do I need for my next meal?" which hampered her concentration. Furthermore, she experienced negative effects in her social life. Sometimes, her friends and her partner made fun of her eating habits and she reported feeling stressed by the urge "that you always have to explain yourself, for example, why you can't eat the cake someone brought to work“. Additionally, regarding her rule to only eat very small amounts of fat and no sugar, she declared to have "strong mental barriers“. She could not enjoy food with these ingredients. She also reported that her self-esteem was very strongly linked to what she ate. When she transgressed her own rules, she felt like a failure. Although she knew that in the long term, a transgression now and then would not affect her overall healthy nutrition, she felt bad in the specific moment and was also afraid of the additional calories she had taken in when eating food with fat or sugar. Sometimes, she was afraid that she might get cancer if she did not stick to her strict rules. That is why feelings of guilt and anxiety arose when she transgressed her rules and she could not understand her own weakness. Apart from eating healthily, she also paid attention to living healthily in other areas of life. For example, she did not smoke, she did not drink alcohol and she exercised on a regular basis, even though she believed that healthy eating has the greatest impact on her overall health.
She declared to have sought psychotherapeutic help in the past, due to being underweight at that time and due to her strong preoccupation with health and illness. However, in general, she was satisfied with her eating behavior and would only change it „occasionally, when I feel like it“, but she could not deny that she sometimes also felt affected by it.
Classification according to preliminary diagnostic criteria
Ms. E’s eating behavior was focused on a clean, unprocessed and vegan diet. With regard to the preliminary diagnostic criteria (see Tables 2 and 5), it can be stated that Ms. E’s eating behavior fulfilled three criteria clearly and two partially. Also in this case, overvalued ideas were absent and there was not enough information to evaluate the presence of nutrient deficiencies. Overall, it can be stated that Ms. E displayed orthorexic eating behavior to a moderate extent.
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