Lorenzo M. Donini

Massimo Cuzzolaro

Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity

English

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EDITORIALOrthorexia nervosa by proxy?Massimo Cuzzolaro1 · Lorenzo M. Donini2Received: 27 July 2016 / Accepted: 30 July 2016 / Published online: 6 August 2016© Springer International Publishing Switzerland 2016In 1997 the US physician Steven Bratman called “healthfood junkies” some individuals led to consequences detri-mental to health by dietary rules intended to promote healthand introduced the term “orthorexia”. Three passages ofBratman’s article may be significant and expressive: “Asoften happens, my sensitivity to the problem of orthorexiacomes through personal experience. I myself passed througha phase of extreme dietary purity (…) too often patient andalternative practitioner work together to create an exagger-ated focus on food (…) a novel eating disorder, for which(I) have coined the name orthorexia nervosa”[1].Orthorexia is a neologism coined from the Greek (ὀρθóς,right and ὄρεξις, appetite). The term literally means ‘correctappetite’ but it is used to indicate ‘healthy eating’. Orthor-exia nervosa (ON) is an expression modeled on anorexianervosa to indicate a possible new eating disorder [2].A growing number of PubMed articles contain the wordorthorexia in the title (Fig. 1).However, at the present time ON is not recognized as anofficial psychiatric diagnosis and is not mentioned in DSM-5 as an autonomous eating disorder [3]. As regards psy-chometric instruments the Bratman Orthorexia Test (BOT)[2] and the ORTO-15 [4] were the first tools aimed toidentify orthorectic attitudes. Both revealed some flaws[5, 6] and a revision of ORTO-15 is in progress.Point prevalence rates of ON are especially variablewhich is mainly due to the above-mentioned absence ofdetailed diagnostic criteria shared by the scientificcommunity.In 2016 Dunn and Bratman proposed two main diag-nostic criteria for ON [7] that are summarized in Table 1.The proposal is a constructive first step, but at present wedo not have robust evidence of its reliability and validity.A noteworthy fact is that body image disturbance andbody weight concerns are not required for this diagnosis.However, the following features are often associated withorthorectic attitudes in the literature and in the clinicalpractice: sense of physical impurity due to incorrect foodchoice; persistent belief that dietary practices are health-promoting despite significant medical complications andevidence of malnutrition. Assuming that ON is an auton-omous syndrome, should these features be included amongthe diagnostic criteria? Should the insight (good, poor,absent) be specified? Should the possible presence ofmedical complications and/or malnutrition be used tospecify different severity levels? Further work is needed todefine reliable and valid diagnostic criteria and psycho-metric tools for ON.In 1998 Gerald Russell et al. [8] described some motherswith anorexia nervosa who underfed their children but theauthors did not use the expression anorexia nervosa (AN)by proxy that had been introduced 13 years before. Afterthe 1985 article [9] some other scientific papers havedepicted cases or discussed the concept of AN by proxy[10–15]. On the contrary, till now no scientific study hasbeen devoted to a condition that could be called orthorexianervosa by proxy: i.e., a person with ON who is obsessedThe authors contributed equally to this work.& Massimo Cuzzolaromassimo.cuzzolaro@gmail.comLorenzo M. Doninilorenzomaria.donini@uniroma1.it1 Formerly Medical Pathophysiology, Experimental MedicineDepartment, Sapienza University of Rome, Rome, Italy2 Food Science and Human Nutrition Research Unit,Food Science and Endocrinology Section, MedicalPathophysiology, Experimental Medicine Department,Sapienza University of Rome, Rome, Italy123Eat Weight Disord (2016) 21:549–551DOI 10.1007/s40519-016-0310-8with imposing inflexible and unhealthy eating habits onsomeone else.Does ON by proxy exist?The question arises from a recent episode described by theItalian press [16]. In July 2016 a 13-month-old child indanger of death was hospitalized in Milan against hisparents’ will. The physicians found that the infant’s weightwas 5.2 kg, the growth was below the 3rd percentile withserious hypotonia and psychomotor impairment. Lab val-ues were alarming and consistent with extremeundernutrition. An inflexible vegan diet imposed by theparents was reported as the main cause of the problem.It is well known that veganism in adults requires a well-balanced diet including supplements or fortified products[17]. As regards infants and toddlers uncontrolled vegandiets may be particularly dangerous. Composition of breastmilk from vegan women, appropriate breast milk substi-tutes, supplements (e.g., vitamin B-12, vitamin-D, iron,zinc, calcium) and type and amount of dietary fat should beevaluated on a regular basis [18].In the last few years newspapers reported several storiessimilar to the previously examined case. Is the expressionorthorexia nervosa by proxy suitable to describe suchepisodes?We do not have first-hand medical and psychologicaldata to answer with reasonable arguments. Furthermore, aswe said above, a commonly established definition of ON isstill missing. Finally, a new name does not add significantknowledge per se and the current psychiatric diagnostic fadis not in urgent need of ‘new syndromes’.However, the problem in itself requires attention and itmay be useful to know that, as Steven Bratman franklyacknowledged [1], “orthorexia begins innocently enough”and it is entirely possible that a wholehearted, fanaticaladvocate of healing through food develops a true obsessionand imposes inflexible and dangerous eating habits onsomeone else, for example on a child.Compliance with ethical standardsConflict of interest On behalf of all authors, the correspondingauthor states that there are no conflicts of interest. The authors con-tributed equally to this work.Ethical approval This article does not contain any studies withhuman participants performed by any of the authors.Informed consent For this type of study formal consent is notrequired.References1. Bratman S (1997) Health food junkie. Yoga J (September/Octo-ber): pp 42–50 (http://www.orthorexia.com/original-orthorexia-essay. Accessed 17 July 2016)2. Bratman S, Knight D (2000) Health food junkies. Orthorexianervosa. Overcoming the obsession with healthful eating.Broadway Books, New York0123456782002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016July 17Fig. 1 PubMed articles with theterm orthorexia in the titleTable 1 Proposed diagnostic criteria for orthorexia nervosa [7]Obsessive focus on dietary practices believed to promoteoptimum health (healthy eating)E.g., inflexible dietary rules, recurrent and persistent preoccupations related tofood, compulsive behaviorsConsequent clinically significant impairment E.g., consequent medical complications, significant distress, and/or impairmentin important areas of functioning550 Eat Weight Disord (2016) 21:549–5511233. American Psychiatric Association (2013) Diagnostic and statis-tical manual of mental disorders DSM-5, 5th edn. AmericanPsychiatric Publishing, Arlington4. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C(2005) Orthorexia nervosa: validation of a diagnosis question-naire. Eat Weight Disord 10(2):e28–e325. Missbach B, Hinterbuchinger B, Dreiseitl V, Zellhofer S, Kurz C,Konig J (2015) When eating right, is measured wrong! A vali-dation and critical examination of the ORTO-15 Questionnaire inGerman. PLoS One 10(8):e0135772. doi:10.1371/journal.pone.01357726. Missbach B, Dunn TM, König JS (2016) We need new tools toassess Orthorexia Nervosa. A commentary on Prevalence ofOrthorexia Nervosa among College Students Based on Bratman’sTest and Associated Tendencies. Appetite. doi:10.1016/j.appet.2016.07.010 (in press)7. Dunn TM, Bratman S (2016) On orthorexia nervosa: a review ofthe literature and proposed diagnostic criteria. Eat Behav 21:11–17. doi:10.1016/j.eatbeh.2015.12.0068. Russell GF, Treasure J, Eisler I (1998) Mothers with anorexianervosa who underfeed their children: their recognition andmanagement. Psychol Med 28(1):93–1089. Katz RL, Mazer C, Litt IF (1985) Anorexia nervosa by proxy.J Pediatr 107(2):247–24810. Money J (1989) Paleodigms and paleodigmatics: a new theoret-ical construct applicable to Munchausen’s syndrome by proxy,child-abuse dwarfism, paraphilias, anorexia nervosa, and othersyndromes. Am J Psychother 43(1):15–2411. Scourfield J (1995) Anorexia by proxy: are the children ofanorexic mothers an at-risk group? Int J Eat Disord 18(4):371–37412. Honjo S (1996) A mother’s complaints of overeating by her25-month-old daughter: a proposal of anorexia nervosa by proxy.Int J Eat Disord 20(4):433–437. doi:10.1002/(SICI)1098-108X(199612)20:4\433:AID-EAT12[3.0.CO;2-Z13. Moszkowicz M, Bjornholm KI (1998) Factitious illness by proxypresenting as anorexia and polydipsia by proxy. Acta Paediatr 87(5):601–60214. Birmingham CL, Sidhu FK (2007) An algorithm for the diagnosisof Munchausen’s syndrome in eating disorders. Eat WeightDisord 12(4):e75–e7715. Sirois F (2011) Anorexia nervosa by proxy: an unusual case.Presse Med 40(5):547–550. doi:10.1016/j.lpm.2010.12.00716. Andreis E (2016) Il dilemma del bimbo sottopeso sottratto aigenitori vegani (The dilemma of the underweight child hospi-talized against his parents’will). Corriere della Sera 141(163):2117. Schüpbach R, Wegmüller R, Berguerand C, Bui M, Herter-Ae-berli I (2015) Micronutrient status and intake in omnivores,vegetarians and vegans in Switzerland. Eur J Nutr pp 1–11.doi:10.1007/s00394-015-1079-718. Mangels AR, Messina V (2001) Considerations in planning vegandiets. J Am Diet Assoc 101(6):670–677. doi:10.1016/S0002-8223(01)00169-9Eat Weight Disord (2016) 21:549–551 551123

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