Orthorexia nervosa is a fairly new nonspecific eating disorder (Michalska, Szejko, Jakubczyk, & Wojnar, 2016), and given societal emphasis on health and healthy diets, nurses should be familiar with the disorder and its consequences.

What is orthorexia nervosa (ON)? Orthorexia nervosa is considered a "pathological obsession with proper nutrition that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure" (Koven & Abry, 2015, p. 385). Quality, rather than quantity, of food is more important to those with ON. They will spend considerable time assessing how foods are processed, the source of foods (e.g., use of pesticides or hormone supplements), and how foods are packaged. The focus is on eating foods that will boost their physical health and is not predicated by religious beliefs or concerns such as sustainable agriculture.

Although definitive criteria have not been established, experts agree that individuals with ON demonstrate compulsive behaviors and preoccupation about eating practices, experience distress and frustration when their eating practices are interrupted, and may omit entire food groups (Dunn & Bratman, 2016; Koven & Abry, 2015). These behaviors escalate over time and are sometimes confused with behaviors of those who have anorexia or obsessive-compulsive disorder. Although these three eating disorders have similarities, Koven and Abry emphasize the critical attributes of ON are a "focus on food quality, unrealistic food beliefs, desire to maximize health, and flaunt behaviors" (p. 387). Characteristics shared by all three include: "perfectionism, cognitive rigidity, trait anxiety, impaired functioning, poor external monitoring, and impaired working memory" (p. 387). The behaviors can have significant negative health outcomes; for example, susceptibility to medical conditions such as hyponatremia, anemia, osteopenia, and bradycardia. They may experience "guilt and self-loathing when they commit food transgressions" (p. 386) and struggle with feelings of imperfection. Because they may think they can only maintain their eating behaviors when they are alone, they can suffer social isolationism. Eating alone may be driven by their desire for control over eating environment or belief their feelings of moral superiority preclude their eating with others.

How much of an issue is ON? Experts report various rates, in part because of measurement issues. Dunn, Gibbs, Whitney, and Starosta (2016) reported a prevalence of 71% in their sample of 275 U.S. college students. However, these investigators question whether prevalence was that high, suggesting that the instrument used cannot distinguish between pathological and healthy eating behaviors. Michalska et al. (2016) report prevalence rate of 7% for the general population and suggest it is more common in men than in women.

What does this mean for nurses? Nurse can include the following additional questions during interactions with family members about nutrition that can highlight possible unhealthy eating behaviors couched under the guise of healthy eating behaviors (Michalska et al., 2016, p. 503). Do you plan your meals one day before? What is more important to you: what you eat or the pleasure you have from eating? Do you feel guilty when you do not follow your diet? Do you consider your diet as an isolating factor in social contacts? Do you experience sensations of total control when you eat properly? These types of questions can be particularly helpful when interacting with individuals who present with nutritional deficiencies or who express extreme frustration when describing interruptions to their normal eating behaviors. Noting these issues and further assessment are critical to initiating interventions. Who better than nurses to obtain this information and implement appropriate interventions?

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