---

An increasingly common condition in developed countries that has not been formally recognized as an eating disorder and is, therefore, not classified as an independent diagnosis is orthorexia. Orthorexia or 'orthorexia nervosa' is consequently classified as Eating Disorders Not Otherwise Specified (EDNOS), i.e., still atypical and of alarming proportions. Usually, people suffering from these disorders believe that they do not have an eating disorder and, therefore, do not deserve the help of a specialist. EDNOS also requires preoccupation and concern about body shape and size, which are related to the person's self-confidence. It is less clear whether there is a movement of the individual from EDNOS to the classic forms of psychogenic anorexia and psychogenic bulimia.

What is orthorexia?

The term orthorexia comes from the Greek word ortho, which means right/correct and appetite. It is characterized by an obsessive obsession with biologically "clean" or proper, healthy food, leading to significant dietary restrictions. Its main characteristics are the compulsive avoidance of "unhealthy" foods such as sugar, salt, caffeine, alcohol, sweets, fried foods, wheat, animal fat, soy, corn, and dairy.

What are the characteristics of an orthorexic?

People who suffer from orthorexia show an obsessive focus on healthy eating, by taking special care of their diet and then perpetuate an obsession or fixation on restrictive food in terms of quality. They remove fats from their diet, eat foods that do not contain additives and fats, and eventually develop a mania against eating "bad" food. It is essential to distinguish that those who follow a way of eating with fully conscious choices that happen to be healthy, such as strict vegetarianism, are not classified as people suffering from orthorexia. In addition, individuals usually adopt antisocial behavior, as they cannot easily manage dietary issues in the presence of others.

How does an orthorexic person behave?

There are specific ways to understand whether a person shows signs of orthorexia. Below, there are some of the most common symptoms of orthorexia that can reveal this particular eating behavior.

• They think about nutrition for more than three hours a day and plan their meals several days before eating them, showing an obsession with their meals and eating habits.
• The meal's nutritional value is more important than the pleasure of eating it.
• They feel a strong sense of confidence when they eat healthily.
• They follow certain rules scrupulously and take great pride in their work. In many cases, the more challenging the rules, the greater their satisfaction with following them.
• When their diet goes wrong, they punish themselves, e.g., "I dared to eat a bowl of chips, so no food for me for the rest of the day.”
• They avoid foods with artificial colors, flavors or preservatives, pesticides, genetic modification, unhealthy fats and added sugar or salt.

• The utensils they use must meet certain requirements such as a high degree of sterilization.
• Feelings of guilt, disgust and guilt will follow after any deviation from the rules.
• They find it difficult to enjoy the social aspects of food, such as going out to dinner with friends or even accepting an invitation to a family meal. The strict rules surrounding food mean that eating out is increasingly restricted.
• They remember and describe their 'right' and 'healthy' choices in detail.

What are the warning signs of orthorexia?

According to the National Centre for Eating Disorders in the UK, the warning signs of orthorexia include compulsory checking of ingredients on food labels, exclusion in the variety of foods so that high levels of psychological distress are experienced when there are no 'healthy' foods in the diet, heavy use of social networking accounts and blogs. People with orthorexia usually exclude processed grains and added sugars and may cut out gluten, dairy, soy and other foods or whole food groups. In severe cases, orthorexia eventually leads to malnutrition when essential nutrients are eliminated from the diet. It does not mean, of course, that a person with orthorexia is thin or skinny. In fact, many of those are obese individuals.

How will you know if you have orthorexia?

Dr. Steve Bratman, the first person to describe orthorexia in 1997 states

"A person who spends their days eating oats can feel as holy as if they had dedicated their entire life to helping the homeless."

Thus the emphasis is placed on devout, almost ascetic adherence to a particular diet with devotion, and thus the person feels "pure". In contrast, in the possibility of regression in eating behaviour, feelings of guilt and inadequacy are experienced. This behavior is similar to that of individuals suffering from Psychogenic Anorexia Nervosa or Psychogenic Bulimia Nervosa, except that those people are concerned about the quantity of food they consume, whereas people with orthorexia are concerned about the quality of food.

The Bratman test for orthorexia

The Bratman Orthorexia Test (BOT) is a tool developed by Dr. Steven Bratman, who first identified orthorexia nervosa. It's designed to help identify individuals who may be at risk for orthorexia nervosa, which is characterized by an obsession with "healthy" eating. It assesses beliefs, thought patterns, and behaviors related to food and nutrition.

The original BOT is a self-assessment consisting of a series of questions with "yes" or "no" answers. It examines how much time and emotional energy a person invests in their dietary restrictions.

Do you spend more than 3 hours a day thinking about what you will eat?

Do you plan your meals several days in advance?

Is the nutritional value of your meal more important than the pleasure of eating it?

Has your quality of life decreased as the quality of your diet has increased?

Have you become more strict with yourself recently?

Does your confidence increase when you eat healthily?

Have you stopped eating the foods you used to enjoy in order to eat the "right" foods?

Does your diet not easily allow you to eat out, taking you away from your family and friends?

Do you feel guilty when you "mess up" your diet?

Do you feel good about yourself and that you are in control when you eat healthy?

If you answered positively in 4-5 positive answers, it is recommended that you take a break from worrying about your diet and visit a specialist ASAP. If there are more positive answers, then dealing with good nutrition has reached the point of obsession. Orthorexia needs to be approached by a multidisciplinary team. The cooperation of specialized therapists—both a psychiatrist or psychologist and a dietician or physician—is essential.

Orthorexia and treatment

Orthorexia is one of the most common atypical eating disorders and the most difficult to diagnose.

Psychological treatment generally converges towards those of anorexia nervosa and obsessive-compulsive behavior. However, as the experts note, the individual's decision and commitment to change their eating behavior is more important than the method used to achieve change. A prerequisite for this to happen, however, is that the individual recognizes that the way they think and act is a real obstacle in their life and that it impacts something that they consider to have more substantial value and meaning.

Orthorexia is a serious disordered eating pattern that can have serious mental and physical health consequences since it impacts their mental health and people who suffer from it need professional help. The main treatment is psychotherapy. To better frame the treatment, a registered nutritionist can debunk misinformation they may believe about what looks like a healthy eating pattern and help re-educate them to improve their relationship with food.