How Orthorexia Is Diagnosed

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Orthorexia occurs when a person has a fixation with eating "healthy" foods. This manifests as restrictive or obsessive behaviors around food. Some researchers have described orthorexia as "extreme dietary purity" and as an extension of "clean eating" or self-imposed diets that were originally meant to promote health but unfortunately have the opposite effect.

Woman in nutrition store comparing grain products on shelves looking anxious

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It can be challenging to diagnose orthorexia because it is a relatively new eating disorder, and it does not have a universally recognized definition at this time.

Additionally, unlike other eating disorders such as anorexia nervosa or bulimia nervosa, orthorexia is not a separate diagnosis within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This is the handbook used to diagnose mental health conditions.

Orthorexia occurs when "healthy eating" becomes pathological.

Professional Screenings

Lack of official diagnostic criteria means that it is unclear if orthorexia is a separate eating disorder, a type of existing eating disorder, or a subtype of obsessive-compulsive disorder. Nevertheless, some screening tools have been developed, and it is possible to get diagnosed with orthorexia.

Your doctor or mental health professional may ask you to complete one of these screenings to diagnose you with orthorexia. Some screening questionnaires are also available online.

Bratman Questionnaire

Bratman and Knight originally developed the Bratman Questionnaire in 2000. Steven Bratman, a doctor from the United States, was actually the first person to use the term "orthorexia," which he did in a yoga magazine in 1997.

The Bratman Questionnaire is a self-reported 10-item rating scale. It is not as commonly used in either research or clinical practice as the ORTO-15.

ORTO-15

The ORTO-15 is a self-administered 15-question screening measure for orthorexia and is currently the most commonly used screening measure for orthorexia. It was originally developed and validated in 2005 and has since been used in more recent research on orthorexia prevalence and screening.

The questionnaire asks respondents to answer a series of questions with a four-point rating scale, and a score of 40 has been determined to be the clinical cut-off for orthorexia diagnosis. Questions on the ORTO-15 include:

  • Do you think that consuming healthy food may improve your appearance?
  • At present, are you alone when having meals?
  • Are your eating choices conditioned by your worry about your health status?
  • Does the thought about food worry you for more than three hours a day?

The ORTO-15 has been critiqued, however, for its construct validity, such as its ability to differentiate between pathological eating behavior versus eating values in certain groups such as vegans.

ORTO-R

A revision of the ORTO-15 was proposed in 2020 due to the concerns related to the ORTO-15's construct validity across populations. This revision is called the ORTO-R and contains six items from the original ORTO-15 that were determined to be the best markers of a person having orthorexia.

Due to how recently the ORTO-R was developed, it may not be used as frequently in clinical practice yet.

Labs and Tests

Like most eating disorders and other mental health conditions, there is no single lab or blood test that can diagnose orthorexia. However, eating disorders can lead to unusual biochemical and hematological measures, and monitoring these is a recommended part of the diagnosis and treatment process.

Through an obsession with perceived "healthy eating," orthorexia can actually lead to malnutrition, just like other eating disorders. This might occur due to juice cleanses, restricted eating times, the elimination of major food groups, and more.

Although there has not been any research on specific blood tests to monitor orthorexia, guidance for eating disorders in general includes labs for:

Abnormalities (either deficiency or excess levels) in any of these tests could indicate orthorexia or another possible eating disorder or health condition. Physicians are encouraged to use these results in the assessment and to create an individually tailored treatment plan.

Self-Testing

It is possible to find the Bratman Questionnaire and ORTO-15 online, but it is recommended to talk to your primary healthcare professional or a mental health professional if you are concerned about orthorexia or disordered eating behaviors.

However, it can be helpful to know more about orthorexia if you wonder if your healthy eating habit may have crossed a line into orthorexia.

While there is no universal definition for orthorexia, there are suggested diagnostic criteria within the scientific literature. Some people might find it helpful to reflect on these criteria as they assess their own eating patterns and relationship with food.

The suggested diagnostic criteria for orthorexia include:

Criterion A: Obsessive Focus on Healthy Eating

This obsession will be dictated by a set of beliefs or specific diet, although the details of each diet will differ from person to person. While weight loss may occur, it is not the goal of the diet.

There is significant emotional distress related to "unhealthy" food choices, with "unhealthy" being perceived individually. This obsession is shown through:

  • Compulsive behavior and mental preoccupation with the restrictive diet believed to promote health
  • Exaggerated fear, anxiety, shame, negative physical sensations, and a sense of impurity associated with violation of the diet
  • Escalation of the dietary restrictions over time such as eliminating entire food groups and partaking in severe "cleanses"

Criterion B: Clinical Impairment

The compulsive behaviors and mental preoccupations with the self-imposed restrictive diet, from criterion A, must also impair the person's daily functioning. This is evidenced by:

  • Malnutrition, significant weight loss, or medical complications resulting from the diet
  • Distress and impairment relating to relationships, work, or school due to the restrictive diet
  • Dependence on compliance with the restrictive diet for self-worth, identity, and positive body image

Lifestyle Indications

Since the term "orthorexia" was first used in a yoga magazine in 1997, there has been much media interest in the condition. Media use may also be tied to developing orthorexia.

A 2017 study found that participants who used Instagram more often had a greater tendency to develop orthorexia. According to that study, the healthy eating community on Instagram has a high degree of orthorexia, which was an association that was not found in any other social media channel.

A person with orthorexia will also have a lifestyle that revolves around a self-imposed, particularly restrictive diet. They will view this diet as "healthy" and follow it with the goal to increase their own health.

If you have orthorexia, you may find yourself obsessing over ingredient labels or unable to participate in social events that involve food. You might think or ruminate about your diet for over three hours a day. When you stray from your diet you might feel extreme shame or guilt.

According to the National Eating Disorders Association, other warning signs of orthorexia include cutting out increasing numbers of food groups (such as eliminating all carbs, sugar, or dairy), obsessively following "healthy lifestyle" blogs on Instagram or Twitter, and having an unusual interest in what the people around you are eating.

A Word From Verywell

If you find your diet becoming increasingly restrictive or your focus on "healthy" eating is affecting your daily functioning, roles, and relationships, then you may have orthorexia.

Due to being a newer eating disorder and lacking official diagnostic criteria in the DSM-5, it may be more difficult to get an orthorexia diagnosis compared to other eating disorders.

Still, it is important to talk to your primary care doctor or mental health professional about your concerns. They may administer a screening measure; interview you about your diet, lifestyle, and thoughts around food; or take a variety of blood tests. All of these tools will help your physician reach the correct diagnosis for you.

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