See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/51708789
Orthorexia nervosa in the general population: A preliminary screening using a
self-administered questionnaire (ORTO-15)
Article in Eating and weight disorders: EWD · June 2011
DOI: 10.1007/BF03325318 · Source: PubMed
CITATIONS READS
190 4,560
7 authors, including:
Carla E Ramacciotti Ciro Conversano
Università di Pisa Università di Pisa
35 PUBLICATIONS 1,457 CITATIONS 164 PUBLICATIONS 4,893 CITATIONS
SEE PROFILE SEE PROFILE
Gabriele Massimetti Liliana Dell'Osso
Università di Pisa Università di Pisa
181 PUBLICATIONS 4,659 CITATIONS 869 PUBLICATIONS 23,870 CITATIONS
SEE PROFILE SEE PROFILE
All content following this page was uploaded by Liliana Dell'Osso on 22 January 2014.
The user has requested enhancement of the downloaded file.
Vol. 16: e127-e130, June 2011
BRIEF
REPORT Orthorexia nervosa in the general
population: A preliminary screening
using a self-administered
questionnaire (ORTO-15)
C.E. Ramacciotti1, P. Perrone1, E. Coli2, A. Burgalassi1, C. Conversano1,
G. Massimetti1, and L. Dell’Osso1
1Department of Psychiatry, Pharmacology, Neurobiology and Biotechnologies, Section of Psychiatry,
University of Pisa, Pisa, 2Department of Psychiatry, ASL 3-Pistoia, Pistoia, Italy
ABSTRACT. OBJECTIVE: Orthorexia, from the Greek words orthos (straight, proper) and
orexis (appetite), is a newly conceptualized disorder characterized by distorted eating habits
and cognitions concerning supposedly healthy nutrition. In this article we present prelimi-
nary results of a wider research aimed to investigate the diffusion of Orthorexia in the gener-
i s
al population and to highlight its characteristics and particularly the relationship with Eating
t
ur
Disorder and Obsessive-Compulsive Disorder. METHOD: One-hundred and seventy seven
adult subjects from the general population, were administered the ORTO-15 test, a self-
e K
administered questionnaire specifically designed to assess orthorexic symptomatology; note
that statistical analyses were repeated twice, referring to different diagnostic thresholds
t r i c (40/35). RESULTS: Orthorexia had a 57.6% prevalence in our sample, using the 40-point
threshold, with a female/male ratio 2:1; the figure was sensibly lower with the 35-point
LY
d i threshold (21%). CONCLUSION: The results of this study highlight the diffusion of
N
Orthorexia which may constitute an important risk factor for mental and physical health, but
O
, E U S E
also the opportunity of more specific diagnostic instruments, so to facilitate a thorough
understanding of this disorder.
1 1 AL
(Eating Weight Disord. 16: e127-e130, 2011). ©2011, Editrice Kurtis
© 20 O N
R S INTRODUCTION impact on functioning that the disorder lies
PE (1, 2). Thus Orthorexia Nervosa (ON) bears
FOR
New clinical presentations focused on dis- many similarities to Anorexia and Bulimia
turbed eating have been growing in devel- Nervosa as all three disorders give food an
oped countries with the increasing cultural excessive place in the scheme of one’s life
emphasis on a healthy life-style, including but is also highly reminiscent of Obsessive-
what is considered proper food (e.g., bio- Compulsive Disorder (OCD); the defining
logical vs junk food), leading to the identifi- feature of Orthorexia, in fact, is that
cation of “Orthorexia” (1) the term coming patients are focused on the quality, rather
from the Greek words orthos (right, cor- than on the quantity of food they eat, scor-
Key words: rect) and orexis (appetite). Orthorexic ing high on obsessionality and hypochon-
Orthorexia, eating disorders, patients may exclude foods from their diets driasis better than on and pursuit of an
questionnaire, threshold, in fear of pesticides, hormones or genetical- ideal body appearance. Patients with ON
prevalence. ly-modified organism contamination; others unlike those with Anorexia Nervosa (AN) or
Correspondence to: focus on animal diseases such as mad cow Bulimia Nervosa (BN), are generally less
Carla E. Ramacciotti, and avian flu, or worry about techniques concerned about their weight but are long-
Department of Psychiatry,
Pharmacology, Neurobiology and materials used in the preparation, in ing for being healthy, natural and spiritually
and Biotechnologies, Section the attempt to improve their health, treat a pure, or interested in decreasing real or
of Psychiatry, University of disease or even lose weight. Note that the supposed physical symptoms. Obsession
Pisa, Via Roma 67, 56100 attention in food selection is not pathologi- with eating what is considered healthy food
Pisa, Italy. leads to important dietary restrictions and
E-mail: c.ramacciotti@psico.
cal itself, considering the emphasis given by
med.unipi.it media on this issue; it is in the persistent, stereotyped eating (e.g., rawfoodism, mac-
Received: July 22, 2010 obsessive approach to diet taken by robiotics, veganism and fruitarianism).
Accepted: November 23, 2010 orthorexic patients and in the negative Indeed, Orthorexia is usually a source more
e127
C.E. Ramacciotti, P. Perrone, E. Coli, et al.
of psychological distress than of real physical by the authors. In their validation study differ-
danger; however, in some cases, (mainly raw ent threshold values (<35 and <40) were
foodists and vegans) weight loss becomes a applied, the results confirming the substantial
significant feature, and all the risks of AN validity of the test only for the 40-point cut-off
apply; furthermore an orthorexic attitude (sensitivity 100%, specificity 73.6%, positive
towards food can also trigger a true case of predictive value 73.6%, negative predictive
AN. In any case treatment is difficult, because value 0%).
people with ON will consider drugs to be
unnatural and will reject weight gain aids, Statistics
because they may contain artificial colours or Statistical analyses were performed using
flavourings. SPSS10.1 for Windows; dichotomizing using
The present study was designed to investi- first a 40-point threshold and then the 35-point
gate the prevalence of ON in a sample of sub- one. T-test for unpaired data or analysis of
jects from the general population by using a variance (ANOVA plus Fisher exact test) were
psychometric instrument, developed by Doni- used for parametric variables whereas categor-
ni et al., the ORTO-15 (3). The current investi- ical ones were compared using chi-square test
gation is preliminary to a second-phase and Z-test. Statistical significance was set at the
research aimed to investigate the relationship 5% level (p<0.05).
between ON and either Eating Disorder (ED)
or OCD.
RESULTS
t i s
METHOD
Subjects
K ur
One-hundred and two subjects (57.6%) were
diagnosed ON according to the ORTO-15 test
using the established 40-point threshold (Table
i c e
The study population consisted of 177 sub-
jects from the general population. Our sample
1). Subjects with ON in our sample were mostly
females (female/male ratio 2:1). There were no
t r LY
was selected putting together 52 subjects
i N
significant differences comparing ON and non-
E d
included in a wider epidemiological study and
O
125 subjects taken random from the general
E
ON subjects as regards socio-demographic
1 , U S
population. Exclusion criteria were the follow-
ing: subjects younger than 18 years-old (as
AL
1
they were considered insufficiently
© 20
N
autonomous in their food choices) and subjects
S O
undergoing specific nutritional schemes for a
TABLE 1
Socio-demographic characteristics of the sample. The diagnosis
of Orthorexia Nervosa (ON) was based on the ORTO-15 test,
PE R
diagnosed health problem (e.g., diabetes or
kidney failure). Subjects were asked to com-
using the established 40-point threshold.
FOR
ON present ON absent p
plete the ORTO-15 questionnaire, Italian ver- N=102 N=75
sion (3), for the diagnosis of ON. Written
Age (yrs, mean±SD) 39.8±15.8 35.6±14.1
informed consent was given before the assess-
ment began. Gender (%)
Females 66.7 60
Males 33.3 40
Instruments
The ORTO-15 is a self-administered ques- BMI (kg/m2, mean±SD) 23.7±4.3 22.8±3.5
tionnaire designed to investigate the presence Marital status (%)
of Orthorexia, derived from a previously exist- Single 47.1 64
ing model by Bratman et al. (1). It contains 15 Married 45.1 24
Separated/ Divorced 5.9 10.7
closed multiple-choice items (always, often, Widower 2 1.3
sometimes, never) investigating the obsessive
attitude of the subjects in choosing, buying, Education (%) <0.015
Post-graduate/University degree 29.4 50.7
preparing and consuming food they consider Senior high school 41.2 30.7
to be healthy. Answers suggestive of a patho- High school/primary school/Less 29.4 18.7
logic “orthorexic” attitude towards nutrition than 5 yrs of education
were given a score of “1” (given to always or Occupation (%)
never, according to the specific item), while Employed 60.7 70.7
healthier one receive a “4” score. The sum of Unemployed 0 1.3
scores gives the final score of the test, which Student 21.6 18.7
Housewife 7.8 2.7
is considered positive for a diagnosis of ON Retired 8.8 6.7
for a threshold value under 40 points as stated
e128 Eating Weight Disord., Vol. 16: N. 2 - 2011
Orthorexia: a preliminary screening
practicing sports. This second part of the sam-
TABLE 2 ple was probably less representative of the
Number of subjects diagnosed with Orthorexia using the ORTO-15
test using different thresholds.
general population, although the prevalence
of ON did not significantly differ. Aksoydan et
Cut-off al. (7) with the same instrument recorded a
40 35
similar prevalence of ON, 56.4%, among the
performance artists in the State Opera and
Subjects with Orthorexia 102 (57.6%) 21 (11.9%) Ballet in the Bilkent University Symphony
Subjects without Orthorexia 75 (42.4%) 156 (88.1%) Orchestra (N=94, mean age 33 yrs), with the
highest prevalence among opera singers
(81.8%). The authors suggest that the high
socio-economic and education level of the
variables, except for educational level, due to a subjects, and the fact of being a public role
sensibly lower prevalence of subjects with a model in terms of one's physical appearance
graduate or post-graduate degree among and lifestyle, could explain why artists are
Orthorexics; similar results were obtained more sensitive to this issue in Turkish society.
using the 35 points cut-off. Note that in our sample, instead, there was a
Orthorexics subjects were prominent in the significantly lower percentage of subjects with
sample using a 40-point (57.6%); when statistical a graduate or post-graduate level of educa-
analyses were repeated with the 35-cut-off, the tion. Bagci Bosi et al. (8) found a 45.5% preva-
prevalence of ON was sensibly lower (11.9%)
t i s
lence of the ON among MD residents, with a
significantly greater severity among women:
ur
(Table 2).
female medical doctors, in fact, were more
DISCUSSION
e K careful than men about their physical appear-
ance and weight control, consumed less
c
caloric food, and were highly influenced by
r i
The spectrum of ED has been progressively
t LY
broadened during recent years so to include
i N
the media (p<0.05).
Apparently, there are as many men with
E d
also Binge Eating Disorder (BED) and/or Obe-
O
sity, Bigorexia (or Muscle Dysmorphia), and
E
Orthorexia as there are women. The gender
distribution in our sample shows a prevalence
1 , U S
finally Orthorexia Nervosa (ON). The latter is
characterized by highly sensitive cognitions
AL
of females over males, in any case with a ratio
lower than that typical of AN and BN (2:1 vs
© 20
1and worries about healthy nutrition leading to
N
such an accurate food selection that a correct
S O
diet becomes the most important part of their
10:1, respectively). We can hypothesize that
men may be more sensitive to issues regarding
health compared to aesthetic ones: in fact, for
PE R
lives (1, 4).
Epidemiology of ON is still unknown partly
men nourishing themselves healthfully, follow-
ing socially and culturally accepted terms of
FOR
due to its recent codification, partly as data beauty may be a more accepted alibi.
from literature are inconsistent. Kinzl et al. (5) Korinth et al. (9), investigating eating habits
using Bratman’s test in a sample of female in nutrition students found that, compared to
dieticians diagnosed ON was in 12.8% of the other students, they tended to restrict their
subjects; the authors highlight that a sub- food intake in order to control their weight, but
threshold disorder was present in 34.9% of they did not have more disturbed or disordered
the sample. Similar results have been found by eating patterns. Moreover, during the course of
Donini et al. (6) who, in their research, found a their studies, they adopted slightly more
prevalence of 6.9% of ON in the general popu- healthy food choices and decreased their ten-
lation, basing the diagnosis on the contempo- dency to be obsessive in their eating behaviour.
rary presence of obsessive-compulsive per- Even if Bratman himself claimed an alert
sonality traits and an exaggerated healthy eat- about a particularly alarming situation in the
ing behaviour pattern. Using the specific United States, and some groups may indeed be
questionnaire they had then developed (3), we more vulnerable to orthorexic stimuli, in any
found a high prevalence of ON that was repre- case such high figures recorded in some of
sented in more than a half of our sample of these studies raise doubts about the diagnosis
individuals from the general population of ON and in particular about reliability of the
(57.6%). Our sample has been collected from ORTO-15 test.
the general population following the strict epi- Our study was preliminary to a second
demiological criteria (N=52), and from a popu- phase dedicated to the investigation of the
lation selected using subjects from the AA’s specific characteristics of ON patients and,
social environment, many of them regularly particularly, its relationship with ED and
Eating Weight Disord., Vol. 16: N. 2 - 2011 e129
C.E. Ramacciotti, P. Perrone, E. Coli, et al.
OCD. The precise clinical connotation of the REFERENCES
ON and mainly its pertinence to either EDs’ or
OCD’s spectrum, in fact, is still under debate 1. Bratman S, Knight D. Health food junkies: Orthorexia
and represents indeed a crucial issue, for its Nervosa: overcoming the obsession with healthful eat-
ing. New York, NY, Broadway Books, 2001
relevance to treatment strategy. Although ON
is indeed highly reminiscent of OCD, on the 2. Di Maria F, Formica I. Ortoressia Nervosa: l’ossessione
del mangiar sano. Psicologia contemporanea n.194,
other hand ED phenomenology has been 2006 (in Italian).
changing over time and, actually, many 3. Donini LM, Marsili D, Graziani MP, et al. Orthorexia
patients with AN present without the typical nervosa: validation of a diagnosis questionnaire. Eat
relentless pursuit of thinness once considered Weight Disord 2005; 10: e28-e32.
core to the diagnosis of AN and BN (10). 4. Catalina Zamora ML, Bote Bonaechea B, García
Instead, other psychopathological motivations Sánchez F, et al. Orthorexia nervosa. A new eating
such as overcontrol, maturity fears and drive behavior disorder? Actas Esp Psiquiatr 2005; 33: 66-8.
for healthy eating, for instance, are emerging, 5. Kinzl JF, Hauer K, Traweger C, et al. Orthorexia Nervosa
in Dieticians. Psychother Psychosom 2006; 75: 395-6.
leading through different pathways to the
6. Donini LM, Marsili D, Graziani MP, et al. Orthorexia
development of an Eating Disorder (11). Actu- nervosa: a preliminary study with a proposal for diag-
ally Eriksson et al. in their study (12) found a nosis and an attempt to measure the dimension of the
relationship between orthorexic issues and phenomenon. Eat Weight Disord 2004; 9: 151-7.
some cultural attitudes towards appearance 7. Aksoydan E, Camci N. Prevalence of orthorexia ner-
leading to social anxiety which are a common
feature also in Eating Disorders. In any case Disord 2009; 14: 33-7.
t i s
vosa among Turkish performance artists. Eat Weight
ur
data from our study and current literature 8. Bağci Bosi AT, Camur D, Güler C. Prevalence of
orthorexia nervosa in resident medical doctors in the
underline the need for an increase in diagnos-
tic reliability for instruments related to ON
(e.g. ORTO-15 cut-off), so to facilitate the K
faculty of medicine (Ankara, Turkey). Appetite 2007;
49: 661-6.
e
ic
9. Korinth A, Schiess S, Westenhoefer J. Eating behav-
selection of homogeneous patients’ groups iour and eating disorders in students of nutrition sci-
and to allow a more thorough investigation of
the disorder.
i t r LY
ences. Public Health Nutr 2009; 12: 1-6 [Epub ahead of
print].
N
SE E d O
10. Ramacciotti CE, Dell’Osso L, Paoli RA, et al.
Characteristics of eating disorders patients without a
L U ,
ACKNOWLEDGEMENT
1
drive for thinness. Int J Eat Disord 2002; 32: 206-12.
11. Ramacciotti CE, Coli E, Marcacci G, et al. Different
© 20
1 N A
The present investigation is part of a wider research
O
supported by the Ferragamo Group. The authors
S
pathways towards anorexia nervosa. Nova Science
Publishers, 2005.
12. Eriksson L, Baigi A, Marklund B, et al. Social physique
ER
have not received any fee and do not serve as paid anxiety and sociocultural attitudes toward appearance
consultants and consequently have no financial inter-
R Pests or potential conflicts of interest.
impact on orthorexia test in fitness participants. Scand
J Med Sci Sports 2008; 18: 389-94.
F O
e130 Eating Weight Disord., Vol. 16: N. 2 - 2011
View publication stats
