ORTHOREXIA, OTHER EATING DISORDERS, & PATHOLOGICAL …

O R T H O R E X I A , O T H E R E AT I N G D I S O R D E R S , & PAT H O L O G I C A L E X E R C I S E

J E N N I F E R B A R N O U D, M S , R D N , L D, C E D R DU N I V E R S I T Y O F T E X A S AT A U S T I N

OBJECTIVES

1. Discuss current classification of eating disorders(AN, BN, BED ARFID, OSFED)

2. Define orthorexia and proposed criteria for diagnosis

3. Differentiate between orthorexia and other eating disorders

4. Define pathological exercise and understand associated health risks

5. Recognize signs of orthorexia and/or unhealthy exercise

6. Provide brief counseling tips and appropriate referrals

7. List top Take Home Messages

OFFICIAL DSM DIAGNOSES• Anorexia Nervosa• Bulimia Nervosa• Binge Eating Disorder• Avoidant/Restrictive Food Intake Disorder• OSFED• USFED• Body Dysmorphic Disorder

– Subtype: with muscle dysphoria

• Pathological Exercise– **NOT an DSM diagnosis**

• OSFED– Atypical Anorexia Nervosa

– BN or BED of low frequency/limited duration

– Purging Disorder

– Night Eating Syndrome

– Rumination Disorder

– Pica

• USFED– Does not meet official criteria but is clinically

significant• Orthorexia

• Chewing/spitting

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 2013

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDERCriterion Description

A

An eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following1. Significant weight loss or failure to grow as expected2. Significant nutritional deficiency3. Dependence on enteral feeding or oral nutrition supplements4. Marked interference with psychological functioning

B The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice

CThe eating disturbance does not occur exclusively during the course of AN or BN and there is no disturbance in the way in which one’s body weight or shape is perceived

D

The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention


OTHER SPECIFIED FEEDING & EATING DISORDERSDiagnosis Description

Atypical Anorexia Meets AN criteria except for body weight

Purging Disorder Recurrent purging behaviors to influence weight/shape in the absence of binge eating

Rumination Disorder

Repeated regurgitation of food that may be re-chewed, re-swallowed, or spit out not attributable to GI or other medical condition

Night Eating Syndrome

Recurrent episodes of night eating as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal.

Pica Eating of non-food objects


BODY DYSMORPHIC DISORDERCriterion Description

A Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable by others or appear slight to others

B At some point during the course of the disorder, the individual has performed repetitive behaviors or repetitive mental acts in response to the appearance concerns

C The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

D The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

With muscle dysmorphia

The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is also preoccupied with additional body areas.


ORTHOREXIACriterion

Description

A

Pathological preoccupation with nutrition and diet far beyond that which is necessary for health and undue influence of diet on self-evaluation, evidenced by1. Phobic avoidance of foods perceived to be unhealthy2. Severe emotional distress or self-harm after eating a food considered unhealthy3. Persistent failure to meet nutritional needs leading to deficiency and/or psychological

dependence on supplementation in place of food4. Following a restrictive diet for a medical condition the individual does not have or in

order to prevent illness not influenced by diet5. Insisting on health benefits of diet in the face of contrary evidence6. Marked interference with social functioning or daily living

B Not the result of a lack of available food or culturally sanctioned practice

C The individual endorses a drive for health or life extension rather than a drive for thinness

DThe eating disturbance is not attributable to a medical condition or another mental disorder such as AN, BN, or OCD

Setnick: The Eating Disorders Clinical Pocket Guide, 2nd Edition

ORTHOREXIACriterion

Description

A

Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue, but this is conceptualized as an aspect of ideal health rather than as the primary goal. As evidenced by the following:1. Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive

dietary practices* believed by the individual to promote optimum health.**2. Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of

personal impurity and/or negative physical sensations, accompanied by anxiety and shame. 3. Dietary restrictions escalate over time.***

B

1. Malnutrition, severe weight loss or other medical complications from restricted diet2. Intrapersonal distress or impairment of social, academic or vocational functioning

secondary to beliefs or behaviors about healthy diet.3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on

compliance with self-defined “healthy” eating behavior

Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17.

ORTHOREXIA VS HEALTHY EATING

• Enthusiasm for a dietary theory is NOT orthorexia

• Orthorexia is when progressive dietary restrictions cause clinically significant impairment in physical and/or mental health and/or functioning

Promote Health Harm Health

Eating Behaviors

THE TOXIC SIDE OF WELLNESS CULTURE• “It has an aspirational, idealistic, spiritual component which allows it to become deeply rooted

in a person’s identity.”

ORTHOREXIA VS ANOREXIAORTHOREXIA

• Focus on food quality

• Unrealistic food benefits

• Desire to maximize health

• Feelings of superiority

• Inability to reason

• Guilt over breaking food rules

• Pursuit of idealized self-image

• Lack of self-awareness

• Perfectionism

• Intrusive thoughts

• Anxiety

ANOREXIA

• Focus on food quantity• Body dysmorphia• Preoccupation with weight gain• Obsessive exercise for weight loss and/or

anxiety management• Inability to reason• Guilt over breaking food rules• Pursuit of idealized self-image• Lack of self-awareness• Perfectionism• Intrusive thoughts• Anxiety

McGregor R. Orthorexia When Healthy Eating Goes Bad. 2017.

PATHOLOGICAL EXERCISECriterion Description

A Preoccupation with exercise beyond that which is necessary for health and the reasonable demands of employment or recreation and refusal to rest appropriately characterized by one or more of the following:1. Insistence that an exercise regime is healthy in the face of evidence to the contrary, such as

stress fracture, tendinitis, or other overuse injuries2. Intense fear of missing or refraining from exercise or taking recommended rest days and

exercising when injured, ill, or advised to rest by a professional3. Continuing to exercise beyond unequivocal mental or physical limits, such as while crying,

vomiting, bleeding, or fainting4. Extreme emotional distress, guilt, or shame when unable to exercise/disproportionate

response to disruption in exercise routine5. Impairment of functioning6. Sneaky behaviors to circumvent limits on exercise7. Exercising even when exercise is potentially unsafe

B The excessive exercise is not attributable to another mental disorder such as AN, BN, OCD, or BDD


PATHOLOGICAL EXERCISE• Risk Factors

– Participating in appearance or weight driven sports

– Family culture of excessive exercise

– Genetics

– Personality traits

– Substance abuse in parents

• May be used as – A conscious or unconscious mood regulator

– Anxiety/stress/anger management tool

– An addiction like “escape” from reality

• Addictive vs. Compulsive vs. Compensatory


HEALTH RISKS OF EXCESSIVE OR PATHOLOGICAL EXERCISE• RED-S

• Stress fractures

• Overuse injuries

• Delayed healing of injuries

• Repeat injuries

• Dehydration

• Electrolyte imbalances,

• Hormone imbalances (low testosterone or estradiol)

• Irregular menses

• Decreased libido

• Rhabdomyelosis

• Impaired performance

• Immunosuppression

• Autonomic sympathetic insufficiency

• Increased cortisol response and muscle wasting

RED FLAG SIGNS AND SYMPTOMS• Repeated sports related injuries or

delayed healing

• Stress fractures

• Anemia or other nutrient deficiencies

• Cold intolerance

• Amenorrhea

• Hypotension

• Bradycardia

• Low body weight

• Abdominal complaints in context of weight loss

• Orthostatic tachycardia/hypotension

• Complaints of fatigue, weakness, dizziness, fainting

• Abnormal labs (kidney function, BUN, glucose, K, CK, Cl, elevated bicarb, hormones)

• Eating “clean” or “really healthy” with any of the above listed symptoms

• Expressing excessive concern or anxiety related to health and nutrition

WHAT TO DO• ESP and/or SCOFF

• “Does your weight affect the way you feel about yourself?”

• “Are you satisfied with your eating patterns?

• “What percentage of your exercise is aimed at controlling your weight?”

• “Do you feel guilty if you don’t exercise?”

• Assess nutritional adequacy and/or other purging behaviors

• Assess for lab abnormalities (CMP, CK, Testosterone, Estradiol)

• Assess for co-occurring conditions such as depression, anxiety, OCD, substance use disorders as well as family history

• Include a treatment team and utilize your campus dietitians

Cotton MA, Ball C, Robinson P.Four simple questions can help screen for eating disorders.J Gen Intern

Med2003;18:53–6.Better Defining ‘Excessive Exercise.’

Eating Disorders ReviewJuly/August 2006 Volume 17, Number 4

Zipfel S, Mack I, Baur LA, Hebebrand J, Touyz S, Herzog W, Abraham S, Davies PSW, Russell J. Journal of Eating

Disorders20131:37

TAKE HOME MESSAGES

• Most eating disorders do not fit perfectly within AN, BN, and BED but remain clinically significant

• Patients may present themselves as "healthy" and "active" while they are causing serious harm or having significant psychological distress

• Asking a few questions and making appropriate referrals can help improve their health and health related behaviors

Documents

ORTHOREXIA, OTHER EATING DISORDERS, & PATHOLOGICAL …