Eat Weight Disord
DOI 10.1007/s40519-014-0171-y
ORIGINAL ARTICLE
The prevalence of orthorexia nervosa among eating disorder
patients after treatment
Cristina Segura-Garcia • Carla Ramacciotti • Marianna Rania
Matteo Aloi • Mariarita Caroleo • Antonella Bruni •
Denise Gazzarrini • Flora Sinopoli • Pasquale De Fazio
Received: 19 October 2014 / Accepted: 13 December 2014
Ó Springer International Publishing Switzerland 2014
Abstract
Background The pursuit for healthy food consumption is
considered a laudable habit. This attitude can turn into
pathological when cognitions and worries about healthy
nutrition lead to such an accurate food selection that cor-
rect diet becomes the most important part of one’s own life
leading to important dietary restrictions, stereotyped eating
or impairment in important areas of functioning. This
behaviour is coined orthorexia nervosa (ON) and can share
common characteristics with anorexia nervosa (AN) and
bulimia nervosa (BN). The purpose of the present study
was to examine the frequency of ON among women with
eating disorders (EDs) and to evaluate if it changed after
treating the ED.
Methods Thirty-two patients with AN or BN were eval-
uated by means of the ORTO-15, the Yale-Brown-Cornell
Eating Disorder Scale (YBC-EDS) and the Eating Attitude
Test (EAT-26) before (t0) and 3 years after the treatment
of their ED (t1), and compared to 32 female healthy con-
trols (HC) matched by gender, age, and BMI at t1.
Results A significantly higher percentage of patients
either at t0 (28 %) or t1 (58 %) resulted positive to ORTO-
15 compared to controls (6 %). YBC-EDS and EAT-26
C. Segura-Garcia (&)
M. Rania
M. Caroleo
A. Bruni

P. De Fazio
Department of Health Sciences, University Magna
Graecia of Catanzaro, Viale Europa, Località Germaneto,
88100 Catanzaro, Italy
e-mail: segura@unicz.it
C. Segura-Garcia
M. Aloi
F. Sinopoli
University Hospital Mater Domini, Catanzaro, Italy
C. Ramacciotti
D. Gazzarrini
Department of Clinical and Experimental Medicine, University
of Pisa, Pisa, Italy
•
scores were higher among ED patients than in HC, but they
decreased from t0 to t1.
Conclusions Orthorexia nervosa symptoms are highly
prevalent among patients with AN and BN, and tend to
increase after treatment. ON seems associated both with the
clinical improvement of AN and BN and the migration
towards less severe forms of EDs. It is necessary to clarify
if ON residual symptomatology can be responsible for a
greater number of relapses and recurrences of EDs.
Keywords Orthorexia nervosa
Anorexia nervosa

Bulimia nervosa
Introduction
The pursuit for healthy food consumption can be consid-
ered a laudable habit specially when intended to prevent
the risk for metabolic dysfunctions or danger from recog-
nized or suspected harmful substances, such as pesticides,
hormones, genetically modified organisms or to follow a
diet to prevent the relapse of some kind of disease. The
same habit can also be frequently observed among healthy
people who want to achieve a good physical performance
(e.g. dancers, athletes) or a pleasant physical appearance
(e.g. models, actors, hostesses/stewards, shop assistants) or
among those who possess some kind of knowledge in the
nutraceutical (e.g. doctors, dietitians, nurses).
When cognitions and worries about healthy nutrition
lead to such an accurate food selection or a correct diet
becomes the most important part of their lives, this attitude
can become pathological and alter eating behaviour to
important dietary restrictions and stereotyped eating (i.e.
he/she will eat only certain foods and avoid many others
sometimes with a shortage of essential nutrients or in worst
123

cases thinking all day about what to eat, how and where to
get it, and how to prepare it, etc.), and may cause impair-
ment in important areas of functioning (e.g. social:
detachment from family members or friends who do not
share similar views about food) or for health. Bratman [1]
coined the term orthorexia nervosa (ON) for this behaviour.
Orthorexia is usually a source more of psychological dis-
tress (including loneliness, spending too much time buying
and planning out meals, avoidance of social situations that
include eating, poor relationships) than of real physical
danger, but in severe cases it can also lead to medical
complications [2, 3].
Although symptoms have been well described [4, 5],
only very recently new criteria have been proposed to
frame this type of eating altered behaviour [3]. According
to literature, orthorexic phenomenon can be seen as a
continuum of states from the healthy behaviour to the
pathological interest on healthy food when purity replaces
pleasure [6]. The term orthorexia nervosa should be limited
only for the pathological condition.
ON is not recognized as a mental disorder and thus it is
not included among the eating disorders (EDs) or consid-
ered as an obsessive compulsive disorder (OCD) either
according to DSM-IV TR [7] or DSM-5 [8]. However, EDs
and ON share a lack of pleasure linked to food consump-
tion and exhibit the need to control food intake as a tool to
reach control over one’s own life, or the search for self-
esteem and self-realization through the control of food
intake. The main difference between EDs and ON lies in
the fact that patients with anorexia nervosa (AN) or bulimia
nervosa (BN) are related more to the quantity of food
consumption [9], whereas ON is related to the quality of
food. This difference can also be formulated as follows: ED
patients look for an ideal body image while people with
ON look for a pure body; in other terms, AN patients do
not take care of their body and realize their purpose despite
it, while those with ON intend, at least initially, to take too
much care of it.
Even if the difference seems clear-cut, the relationships
between ON and EDs can be complex [10]. ON may pre-
cede or follow an ED and, at least theoretically, they could
also coexist and be confused. Health care professionals
usually worry when individuals are at risk for EDs [11] or
with a suspected or diagnosed ED adopt particular eating
habits (e.g. vegetarian or vegan diets) as a socially
acceptable way to legitimize their food avoidance [12].
Analogously it is not uncommon to observe that ED
recovered women are more likely to base food choice on
‘‘health benefits’’ when compared with control women
[13]. This ‘‘orthorexic’’ behaviour can hide the real attempt
to control the amount of food intake with the excuse to eat
high-quality foods.
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Eat Weight Disord
Considered what above described, it was hypothesized
that ON is a frequent symptom among ED patients, espe-
cially after treatment, to disguise the real need to maintain
their control on nutrition and thus on weight. Accordingly,
the purpose of the present study was to examine the fre-
quency of ON among ED women and evaluate if it changes
after treating the ED.
Methods
Participants
To verify the objective, the study was performed with two
samples. The first one included female patients attending
an outpatient clinic for ED. All patients had received a
diagnosis of AN or BN, according to DSM-IV TR [7], at
the time of their first contact with the clinic and had
undergone an individual intervention for 12 months as
elsewhere described, [14] and a 3 years minimum follow-
up (mean = 4.1; SD = 1.2). Forty-eight patients were
enrolled at their first visit (t0) and 32 of them (66, 7 %)
completed the minimum follow-up (t1), so only these 32
patients were taken into consideration for the present study
and they all agreed when they were proposed to.
The second sample of female healthy controls was
collected among high school and college students in the
same city. Control subjects were recruited via advertise-
ments placed on notice boards at school or university
seeking adolescents interested in participating in research
examining eating behaviours and were age and BMI-mat-
ched with patients at t1.
All participants were informed about the aim of the study,
that the participation was voluntary, that personal data would
be kept confidential and that no extra grants would be given
to students for their participation. All partakers, or their
parents in behalf of those younger than 18, signed a written
informed consent according to the local Research Ethics
Committee, before entering the study.
Materials
Evaluation of orthorexia nervosa
The Italian version of the 15 items multiple-choice ORTO-
15 [15] questionnaire for the diagnosis of orthorexia was
used to identify ON subjects in choosing, buying, prepar-
ing, and consuming food they consider to be healthy. Items
of ORTO-15 are designed within the framework of a 4-step
Likert scale assessment (i.e. always, often, sometimes, or
never); those that reflect an orthorexic tendency are scored
one, whereas four are assigned to those showing normal
Eat Weight Disord
eating habits. The questionnaire, translated in several lan-
guages [16–19], seems to be the most widely used test in
the literature to evaluate this behaviour and was the only
available tool to measure this phenomenon at the time
when data were begun to be collected. Authors [15, 20]
have proposed different cut-offs (i.e. \35, \40) but an
ORTO-15 \ 35 ensures the best predictive capability to
correctly identify ON through the highest sensitivity
(86.5 %), specificity (94.2 %), and negative predictive
value (91.1 %) among the tested cut-offs. Thus, in the
present study, according to previous research [21], the most
restrictive threshold has been used (i.e. ORTO-15 \ 35), to
guarantee the highest specificity for diagnosis purposes in a
population with eating altered behaviours. Cronbach’s
alpha coefficient for ORTO-15 in the present study was
0.810.
Evaluation of obsessive–compulsive symptoms
To assess symptom severity in patients with EDs diagnosis,
the Yale-Brown-Cornell Eating Disorder Scale (YBC-
EDS) [22] was used. The test is divided into two sections: a
comprehensive checklist of 21 preoccupations and 44 rit-
uals, and a second part of 19 items on a 0–4 Likert scale,
where high scores indicate more severity and impairment.
The definition of eating-related disordered thoughts or
‘‘preoccupations,’’ and behaviours or ‘‘rituals’’ is first
reviewed with the participants. Total YBC-EDS scores \7,
8–15, 16–23, 24–31, and 32–40 have been, respectively,
considered sub-clinical, mild, moderate, severe, and
extreme [21]. Total YBC-EDS score C16, simultaneously
with YBC-EDS preoccupation scores C8 and YBC-EDS
rituals scores C8, has been considered the cut-off for
positivity to the test [21]. Cronbach’s alpha coefficient for
YBC-EDS was 0.882 in the present study.
Evaluation of the eating disorders
To assess abnormal eating habits and concerns about weight,
the validated Italian version [23] of the Eating Attitude Test
(EAT-26) [24] was administered to participants. This
26-item questionnaire is based on a 4-point agreement scale
(from 4 = strongly agree to 1 = strongly disagree), and
identifies three factors (i.e. dieting, bulimia and food pre-
occupation, and oral control). In the present research Cron-
bach’s alpha coefficients was 0.795. According to authors,
participants with an EAT-26 total score[20 are considered
to be at risk of having a clinical disorder.
Procedures
With regards to the clinical sample, ORTO-15, YBC-EDS,
and EAT-26 were administered at the time of the first visit
at the ambulatory (t0) and after a minimum of 36 months
from the end of treatment (t1).
The control sample was assessed only once. The paper
and pencil tool administration was carried out in a col-
lective manner at their own study centres under the
supervision of three researchers with adequate training in
this field.
Statistical design
Data were analysed using the Statistical Package for the
Social Science, version 21.0 (SPSS Inc., Chicago, Illinois)
and are presented as means, standard deviations, and fre-
quency of occurrence (%). Univariate analysis was applied
to group comparisons by means of t test and paired sample
t test for continuous variables (two-tailed test) and Chi-
square test with Yate’s correction for categorical ones. The
level of statistical significance was set at p \ 0.05. Cohen’s
d effect sizes measures (ES) were calculated for all sig-
nificant findings, respectively, after t test comparison with
values (negative or positive) of 0.2, 0.5, and 0.8 indicating
one-to-one small, medium, and large effects sizes [25, 26].
Results
The clinical sample was made of 32 ED patients (18 AN
and 14 BN at t0) and the control group of 32 healthy
subjects. Both groups were matched by gender, age, and
BMI with the clinical sample at t1.
Table 1 provides the results and comparison of mean
scores to tests.
As seen in Table 1, the clinical sample showed signifi-
cantly lower ORTO-15 scores, and though more patho-
logical, than the control group. The lowest scores were
reached by the clinical sample at t1.
The clinical sample also showed the highest scores in
YBC-EDS and EAT-26 at t0; at t1 these scores, although
lower and no more pathological, were still significantly
higher in comparison to the control group.
Table 2 shows the rates of individuals positive to each
questionnaire. According to the results described above,
the highest percentage of subjects positive to ORTO-15
was evident among the clinical sample at t1. As expected,
the clinical sample reached the highest rates of positivity to
YBC-EDS and EAT-26 at the time of the first psychiatric
consultation (t0) and they decreased at t1.
Discussion
The main advantage of this study stems from the fact that,
to our knowledge, it is the first longitudinal study that
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 Eat Weight Disord

Table 1 Samples description and test scores comparison

Clinical sample t0 Clinical sample t1 Healthy controls Clinical sample t1 vs Clinical sample t1 vs
t0a healthy controlsb
Mean ± SD Mean ± SD Mean ± SD T p d t p d

Age 17.7 ± 3.5 22.2 ± 3.4 21.9 ± 3.4 5.217 <0.001 1.304 0.353 0.73 –
BMI 16.5 ± 3.3 20.7 ± 2.7 21.6 ± 2.4 5.572 <0.001 1.393 1.409 0.164 –
ORTO-15 37.4 ± 3.7 35.2 ± 4.7 41.8 ± 3.3 2.131 0.05 0.524 6.501 <0.001 1.650
YBC-EDS preoccupations 9.9 ± 5.1 7.4 ± 4.2 1.4 ± 1.3 2.141 0.04 0.535 7.720 <0.001 1.930
YBC-EDS rituals 8.9 ± 5.5 6.2 ± 6.7 0.9 ± 1.1 1.762 0.08 – 4.416 <0.001 1.119
YBC-EDS total score 18.8 ± 10.5 13.4 ± 10.6 2.3 ± 2.1 2.047 0.04 0.514 5,.811 <0.001 1.323
EAT-26 food preoccupation 6.4 ± 3.1 4.6 ± 3.1 3.4 ± 1.9 2.323 0.02 0.581 1.867 0.07 –
EAT-26 diet 10.8 ± 5.5 8.8 ± 6.8 5.4 ± 5.3 1.294 0.201 – 2.231 0.03 0.558
EAT-26 oral control 6.1 ± 3.9 4.1 ± 3.9 1.9 ± 2.4 2.051 0.05 0.513 2.717 0.009 0.679
EAT-26 total score 23.4 ± 11.2 17.2 ± 11.2 10.7 ± 7.3 2.214 0.03 0.554 2.750 0.008 0.687
Significant results in bold letters
a
Paired sample t test
b
Independent samples t test

Table 2 Subjects positive to ORTO-15, YBC-EDS and EAT-26

Clinical sample t0 Clinical sample t1 Healthy controls Clinical sample t1 vs t0 Clinical sample t1 vs healthy controls
2
Fr (%) Fr (%) Fr (%) X p X2 p

ORTO-15 \ 35 9 (28) 17 (53) 2 (6) 3.17 0.08 14.67 0.0001

YBC-EDS [ 16 14 (44) 10 (31) 2 (6) 0.60 0.44 5.03 0.03
EAT-26 [ 20 20 (63) 11 (34) 2 (6) 4.00 0.05 6.18 0.01
Significant results in bold letters

allows the evaluation of long-term changes in ON with a
matched control sample through validated and standardized
questionnaires.
Since the first studies, a growing body of evidence has
developed showing that ON is frequently observed in both-
gender athletes [21], ballet dancers [27], yoga practitioners
[28], and healthcare professionals [29] among others. Most
of them are groups of population concerned or interested in
their own body to achieve a good physical performance.
ED patients also worry about their own bodies so we
hypothesized that ON may be a frequent condition for
them. Our findings indicate that ON is a frequent comorbid
condition (28 %) among patients with AN or BN at the
moment of their first contact with a health care facility and,
even more important, that rather than decreasing after ED
treatment, the frequency increases over time (53 %). At
this point, we will try to discuss this outcome.
Positivity to YBC-EDS and to EAT-26 has been iden-
tified as an independent predictor of ON [21]; current data
confirm the coexistence of orthorexic symptoms, ED
pathology and related preoccupations and rituals in many
ED patients at the time of their first contact with the out-
patient clinic for EDs. However, interestingly, ON does not
follow a parallel course to other symptoms: as a reduction
of typical ED psychopathology is evident after treatment
(i.e. EAT-26 and YBC-EDS scores decreased at t1), one
would also expect amelioration in orthorexic symptoms;
yet ORTO-15 score significantly worsens and the rate of
patients positive to test almost duplicates. Different
explanations can be given to this fact.
Orthorexia nervosa bears many similarities to AN and
BN as people with any of these pathological behaviours
give food an excessive place in the scheme of one’s life but
is also highly reminiscent of OCD. The precise clinical
connotation of ON and mainly its pertinence to either EDs’
or OCD’s spectrum [21], in fact, is still under debate and
represents indeed a crucial issue, for its relevance to
treatment strategy. Unlike people with AN, subjects with
ON are apparently unconcerned about their weight, claim
an unwillingness to be thin and no fat phobia, but are
longing for spirituality (feeling ‘‘pure’’), being healthy and
natural, or to supposedly decrease physical symptoms,
which can be real or exaggerated. ON subjects often score
high on obsessiveness and hypochondriasis instead than on
pursuit of an ideal body appearance. In any case, even AN
patients are focused on eating ‘‘proper’’ food, rather than

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on the quantity of food they eat, and in some cases different
pathways including orthorexia can lead to a final common
picture. In fact, though the majority of AN patients are
characterized by high drive for thinness as a motivation for
weight loss, a substantial percentage lacks this feature and
other psychopathological motivations such as over-control,
maturity fears and drive for healthy eating, for instance, are
emerging, which lead through different pathways to the
development of an ED. In fact, weight phobia is a highly
culture-bound phenomenon and should not be viewed as
critical to the diagnosis of AN and ED in general [30].
In the light of a transdiagnostic approach [31], if ON is
considered an altered behaviour within the ED spectrum,
changes in the scores could be interpreted (in a psycho-
pathological sense) as an evolution of the illness: patients
shift their interest from the amount of food towards quality
of food. From this perspective, ED symptoms improve and
AN and BN patients move to a less serious condition (i.e.
ON). Data from literature demonstrate a moderate to poor
long-term outcome of EDs after treatment [32–34] with an
overall reduction of symptoms and a high proportion of
patients with residual symptoms who fall into the ED-NOS
category [14]. So from this point of view, ON could be
considered a residual symptom for those patients who
resulted orthorexic at the beginning of treatment.
As ON becomes more frequent after treatment, it could
also be interpreted as a result of cognitive behavioural
therapy (CBT). CBT seems to be ‘‘tailored’’ more on the
reduction of shape and bodyweight control and not so
much on self-control. This therapy teaches patients a way
of eating that works as a positive mechanical reinforce-
ment, eliminates the phobic meaning of the food and
reassures them to eat without the threatening fears of body
changes. ‘‘Food becomes the cure’’ and so patients learn a
new way to control their body weight and shape [35, 36].
At the end, patients shift from destroying their own bodies
to protecting them, and this structured/mechanical feeding
reduces patients’ anxiety by providing precision, exactness
and certainty on the quality and quantity of food so that
they can gather information that show the influence of what
they eat on their weight. So from another position, ON
could be considered an ‘‘iatrogenic-like side effect’’ for
those patients who become orthorexic after the treatment of
the ED. They learn to respect their body more, but they
simultaneously look for a compromise allowing them to
control food as well. In fact, studies have demonstrated that
the obsessiveness trait is difficult to improve after CBT
[37]; in our case, even if YBC-EDS scores significantly
decrease, patients yearn to food control as eating preoc-
cupations and rituals still persist to a certain extent.
Several organizations and government agencies endorse
the benefits of a healthy diet and life style [38, 39]. If not
adequately understood, society risks to give rise to new
obsessions [40], and when obesity becomes a world health
problem it is difficult to consider the interest for the ‘‘eating
right’’ as a problem but something to pursuit at any cost. So
the last interpretation of these results could be that patients
act a double mechanism of displacement and intellectual-
ization that it is more ‘‘useful’’ and allow them to move
from the outcast status of ‘‘sick person who refuses food’’
to the privileged and socially accepted position of ‘‘person
who pursues the goal of health’’. In this sense, ON could be
considered a hidden but convenient tool to conserve a
certain degree of control on one’s own body. If we accept
that the core psychopathological issue among EDs patients
is the need to control something that they think is possible
rather than to carry out their unresolved needs, ON could
be then considered a different way of maintaining the ED
(supported by the similar scores in YBC-EDS rituals and
EAT-26 Diet after treatment) that needs specific treatment.
It is necessary to put attention into some obvious limi-
tations of this research. First, this was a longitudinal study
and the control group was only interviewed once corre-
sponding to the last interview with the clinical sample, so
no data about possible ON behaviour during the previous
4 years (i.e. corresponding to t0 of patients) are available
for this group. Second, the diagnosis of ON was based on a
paper and pencil tool as only very recently operational
diagnostic criteria have been proposed [3]. Despite these
limitations, the results of this study suggest that ON fea-
tures are highly prevalent among patients with AN and BN
and that they tend to increase after the treatment of the ED.
The presence of ON symptoms seems associated both with
the clinical improvement of AN and BN and the migration
towards less severe forms of EDs. It is necessary to clarify
if, as it happens with some psychiatric disorders, ON
residual symptomatology can be responsible for a greater
number of relapses and recurrences of EDs.
Practical applications: present results support the need to
recognize worries and symptoms of other altered eating
behaviours as ON among patients with EDs. New opera-
tional diagnostic criteria for ON have recently been sug-
gested [3] whose reliability can only be confirmed by
further studies that authors aim to put into practice.
Acknowledgments No grant was obtained for this research.
Conflict of interest All authors declare that they have no conflicts
of interest.
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