Introduction

Orthorexia nervosa (ON) is not yet a clinically recognised eating disorder; i.e. it is not listed in the two main diagnostic manuals for mental health disorders, the International Classification of Diseases-10 [1], the Diagnostic and Statistical Manual of Mental Disorders-5 [2]. This is partly because we do not yet know enough about the aetiology of proposed condition [3, 4]. However, four research groups have proposed clinical diagnostic criteria for ON [3]. One of these groups, Dunn and Bratman [4] specify that ON should be a condition separate to avoidant restrictive food intake disorder (AFRID). This is primarily because the drive behind AFRID is not about eating healthily—like it is in ON—but involves worry about the negative consequences of eating (usually as a result of previous traumatic experiences with food) [4]. Additionally, on the websites of many national eating disorder organisations, ON is discussed as an independent eating disorder, distinct from other diagnoses such as AFRID and anorexia nervosa (AN), e.g. the National Eating Disorder Association in the US [5]. Koven and Abry [6] discuss the diagnostic boundaries of ON and clinically recognised mental disorders; specifically the overlap of ON with AN, obsessive compulsive disorder (OCD), obsessive–compulsive personality disorder (OCPD), the health anxiety classifications in somatic symptom disorder and illness anxiety disorder, and psychotic spectrum disorder. The main distinguishing feature of ON when compared to AN is the motivating factor to be healthy, rather than to lose weight [6]. Additionally, in ON an individual’s obsessions are perceived as ego-syntonic (consistent with someone’s ideal self), as opposed to ego-dystonic (in conflict with someone’s ideal self) as in OCD [6].

Vandereycken [7] importantly discusses the pros and cons of including a new diagnosis in a classification system such as the DSM-5 [2], such as better detection of a treatable disorder vs. stigmatisation. He also analysed the opinions of 111 professionals about night-eating syndrome, ON, muscle dysmorphia, and emetophobia [7]. At the time of survey, there were no published, proposed diagnostic criteria for ON; so, the author combined descriptions of ON from three publications [8,9,10]. Over two-thirds of professionals answered ‘Yes’ to the question, ‘ON deserves more attention from researchers and clinicians’ [7].

Due to the debate if ON should be a clinically recognised eating disorder, or not, plus the lack of one clear proposed set of diagnostic criteria, when prevalence surveys are undertaken, a very large range of figures result [3]. If ON were to be clinically recognised, official diagnostic criteria would mean that reliable prevalence figures could be obtained.

The present study is the first of its kind to analyse the opinions of health professionals involved in eating disorder diagnosis and treatment on whether ON should be a clinically recognised eating disorder, based on the most recent proposed diagnostic criteria [4]. Clinical experience with psychiatric abnormalities is essential in psychopathology assessment, diagnosis and treatment [1, 2]. This is vital to further our understanding of the clinical relevance of ON and best practice treatment of obsessive healthy eating.

Methods

Data for this descriptive, cross-sectional pilot study were collected between 2016 and 2018. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation, and with the Helsinki Declaration of 1975, as revised in 2008. All the procedures were approved by the UNSW Sydney Human Research Ethics Committee (approval number HC15714).

Participant inclusion criteria were as follows: (1) a psychiatrist registered as a fellow with The Royal Australian and New Zealand College of Psychiatrists; or a psychologist registered with the Psychology Board of Australia or with the New Zealand Psychologists Board; or an Accredited Practising Dietitian registered with the Dietitians Association of Australia; or a Registered Dietitian with the Dietitians Board of New Zealand; or a Registered Nutritionist with the Nutrition Society of Australia or the Nutrition Society of New Zealand; or a Fellow of Royal Australian College of General Practitioners or of the Royal New Zealand College of General Practitioners; or a relevant health professional approved by RR (e.g. a mental health nurse); (2) previous and/or current experience working with clients with feeding and eating disorders; (3) currently live and practice in Australia or New Zealand; and (4) fluent in English.

A recruitment email was sent from a generic Gmail address (orthorexianervosasurvey) to health professionals. Email addresses of health professionals were sourced from RR’s professional contacts and publicly available lists online, e.g. Accredited Practising Dietitians who specialised in eating disorders via https://daa.asn.au/find-an-apd. A recruitment notice was also placed in some online media (e.g. website) of certain regulatory or representative bodies of health professionals, e.g. Australia and New Zealand Academy for Eating Disorders. There was a possibility for participants to be reimbursed for their time via a prize draw, where three Coles Myer e-gift cards of AUD$50 were randomly allocated to participants who completed the survey.

The survey was hosted at www.surveys.unsw.edu.au. Online implied, informed consent was obtained from all individual participants included in the study. The survey assessed participants regarding the following: demographics; profession and qualifications; experience with clients with clinically diagnosed feeding and eating disorders; experience and opinions of ON, including diagnostic criteria proposed by Dunn and Bratman [4].

Sample size was based on the primary outcome of a participant answering ‘Yes’ or ‘No’ to the question in the survey that asked, ‘Q. Do you feel that there is value in a separate clinical diagnosis of orthorexia, or do you feel that ON is only a variation of other feeding/eating disorders, such as anorexia nervosa? A. There should be a separate clinical diagnosis for ON: Yes/No’. Based on the finding that 68.5% of professionals involved in the research, prevention, or treatment of ON believed that the disorder was deserving of more scientific attention in a previous study [7], we assumed that all of these professionals would go further to say that ON should be a clinically recognised eating disorder. With a confidence interval of 95%, we reached a required sample size of 332 participants for a full study and 10% of this for a pilot [11]. Quantitative results were descriptively analysed using SPSS statistical software (Table 1). Any qualitative text comments made by some health professionals on some of the survey questions were manually grouped into common topics (Table 2).

Table 1 Characteristics of the 52 health practitioners
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Table 2 The opinions of the 52 health practitioners about orthorexia nervosa
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Results

365 participants clicked on the link to the survey, with 52 completing it, 37 people leaving it unfinished, and 7 responses being removed due to incomplete answers (a response rate of 14.2%). Descriptive quantitative statistics of the 52 health professionals who completed the survey are shown in Table 1. Ninety-six percentage of the professionals were female, 48% psychologists and 48% dietitians, and 90% practising in Australia. Seventy-one percentage of the professionals believed that there should be a separate clinical diagnosis for ON, while 21% disagreed, and 8% were unsure.

Table 2 shows text comments made by some health professionals on some of the survey questions. Common comments were regarding the belief that there was no body weight component in ON; and that ON is a variation of current eating disorder categories [1, 2], especially AN.

The data generated and analysed during the current study are available in the Figshare repository at this link: https://figshare.com/articles/Reynolds_orthorexia_health_professional_pilot_survey_Oct18/8093702.

Discussion

In our sample of 52 mostly Australian psychologists and dietitians involved in eating disorder diagnosis and treatment, nearly 3/4 (71%) stated that they believe that there should be a separate clinical diagnosis for ON (Table 1). This figure builds on the similar statistic of 68.5% in the study by Vandereycken [7], where 68.5% of health professionals (mainly psychologists) stated that they thought that ON ‘deserved more attention from researchers and clinicians’. Text comments to the primary outcome question (Table 2) showed that some professionals agreed that there was no body weight component in ON, but others believed that ON is variation of current eating disorder categories [1, 2], especially AN.

The current study is the first of its kind to investigate the views of health professionals on the diagnostic relevance of ON, i.e. in the context of proposed diagnostic criteria [4], and of the two main diagnostic manuals for mental health disorders that are used in clinical practice [1, 2]. Most health professionals believed that the diagnostic criteria proposed by Dunn and Bratman [4] were sufficient for any future diagnosis of ON, although some disagreed that these criteria were accurate—or indeed necessary. Again, concerns about overlap with AN diagnostic criteria [2] were mentioned, as were problems ascertaining whether weight loss is a result of—or a goal in—ON (a central point in the ON vs AN debate); and the relevance of excessive exercise [2] to the proposed condition.

Most professionals had seen clients who would fulfil the Dunn and Bratman [4] criteria, with some stating that numbers were increasing, and that the majority—or all of—possible ON cases were female. This corroborates data from eating disorder research that shows that eating disorder behaviours are on the rise and disproportionately affect females [12].

Risk factors or characteristics that were listed by professionals to be associated with ON were similar to those often linked to eating disorders [6, 13] and/or OCD [6, 14], including excessive exercise [2], anxiety, obsessiveness, low self-esteem, problems making space for feelings, perfectionism, detail-focus, ego-syntonicity, high socioeconomic status, use of social media, thin ideal internalisation, and harm avoidance and low self-directedness [14]. However, risk factors that may be particularly relevant to ON could include: problems with health literacy [6], including strict adherence to dietary theories, such as ‘no sugar’, ‘clean eating’ and vegetarianism or veganism; worry about health problems developing, especially related to the amount of body fat, e.g. after learning about lifestyle-related diseases at secondary school, and higher spiritual transcendence [14].

Three-quarters of surveyed professionals believed that a similar treatment approach to that taken for clinically diagnosable eating disorders was appropriate for someone with ON. Text comments highlighted the importance of dietary education, possible treatment as per AN, discussion of spiritual and ethical reasons behind dietary choices, collaboration with other health professionals such as a dietitian, targeting obsessiveness, food exposure and helping the client to “check in whether their ‘healthy’ choices are leading to a ‘healthy’ outcome”.

Limitations of our study include our small sample size, low response rate (possibly due to lack of time and increasing pressure to take part in research activities), and a lack of diversity of health professionals who completed the survey. However, this is a pilot study and was intended to provide an indication of the views of health professionals on the clinical validity of ON to ascertain whether further research was warranted. It is indeed important that this study is built upon in future with a larger, more diverse sample size. Topics to focus on in future research when surveying health professionals include the overlap of ON with AN and OCD; and the relevance of weight loss, body fat, excessive exercise and spirituality to ON. Results from a future survey would help to determine if official diagnostic criteria are needed for ON, and if yes, what should they be? Official criteria would not only help the work of professionals in practice, but also further research—partly because more reliable prevalence estimates could be obtained.

In conclusion, nearly two-thirds of the Australian health professionals (psychologists, dietitians, psychiatrist and nutritionist) who participated in this pilot survey believe that ON should be a distinct, clinically recognised eating disorder separate to the current clinically diagnosable feeding and eating disorders [2]. However, the surveyed health professionals expressed concern around the potential overlap of ON with AN, with a body weight-focus thought to be important in half of potential ON patients. Further research is needed, with a larger sample size in a more diverse range of health professionals, to more fully inform how obsessively healthy eating may be incorporated into diagnostic criteria. However, this would only be one of the steps that would be necessary—alongside the proposed diagnostic criteria [3]—to the creation of suggested assessment instructions to appropriately identify orthorexic individuals [6] to then trial in clinical practice.