Monthly Key Publication Reviews

Publication: Sifakaki M, Gkiouras K, Lindqvist HM, Marakis G, Petropoulou A, Donini LM, Bogdanos DP, Grammatikopoulou MG. Orthorexia Nervosa Practices in Rheumatoid Arthritis: The DORA Study. Nutrients. 2023; 15(3):713. doi: 10.3390/nu15030713

Reviewer: Chameera Hettige, MBBS, IOC Dip.(Sports Nutrition), MSc (Human Nutrition), MD (Clinical Nutrition), Senior Registrar in Clinical Nutrition, Post Graduate Institute of Medicine, Colombo, Sri Lanka

Why is This Paper Important: Orthorexia Nervosa (ON) is a feeding and eating disorder that is characterized by an obsession with healthy, “pure” eating. These patients are pathologically fixated on the caliber and nutritional value and perceived health-promoting aspects of food. To regulate their diet, they apply rigid, self-imposed rules. This leads to restrictive diets, resulting in inadequate intake, nutritional deficiencies, hormonal disturbances, and a negative impact on psychosocial and personal functioning. Recent studies have highlighted the prevalence of ON in chronic diseases such as diabetes mellitus,1 coeliac disease,2 and cancer.3 Rheumatoid Arthritis (RA) is a chronic disorder with inflammatory arthritis with or without extra-articular manifestations. Despite pharmacological advances in the treatment of RA, some patients are unable to attain sustained remission. Therefore, medical nutrition therapy (MNT), lifestyle modification, and physiotherapy play an important role in disease management. RA patients receive MNT where healthy eating takes center stage as part of a long-term approach to disease management.

Summary: This DORA (Diet and Orthorexia in Rheumatoid Arthritis) study aimed to assess ON tendencies in adult patients with RA in Greece. It was conducted as a cross-sectional study on 133 adult patients with RA during May-August 2022. A structured online questionnaire was utilized to assess demographic data and disease characteristics. The participant’s body weight and height were self-reported while body mass index (BMI) was calculated.  World Health Organization BMI cut-offs were used for classification into weight categories. ON tendencies were evaluated using a translated, culturally adapted ORTO-15 questionnaire (screening tool), which assessed the frequency of ON tendency occurrences. It has 15 questions, each with 4 possible answers that express the frequency of occurrence on a Likert scale (never, sometimes, often, and always) with a score ranging from 1 to 4. The total score was calculated for all 15 questions. Most participants were women (126 out of 133), and the median BMI was 25.83 kg/m2. The majority of patients were overweight and obese (53.4%). The median duration of RA was 5 years with 54.9% of participants reportedly in remission. The median ORTO-15 score was 36 (IQR 33-39).

None of the examined associations of the study variables were significant. Following univariable linear regression analyses, advancing age (β coeff: 0.07, 95%BCaCI: 0.001 to 0.14; p = 0.037) and BMI (β coeff: 0.13, 95% BCaCI: 0.02 to 0.25; p = 0.020) both increased the ORTO-15 score, whereas in females (β coeff: 2.50, 95% BCaCI: 4.17 to 0.88; p = 0.002) the score was lower. Other factors, such as the duration of RA, the number of years of smoking, and single divorced status, were non-significantly associated with higher ORTO-15 scores. The authors concluded that this study revealed patients with RA have high ON tendencies. There were greater tendencies of ON associated with females and lowered tendencies with advancing age and BMI.

Limitations of this study include small sample size, online recruitment of those able to communicate in the Greek language, lack of a control group, disease status reported by the patient, and self-reported anthropometric measurements. In addition, any other comorbidities that could have contributed to dietary changes were not assessed. The authors further acknowledged the use of the much-criticized ORTO-15 questionnaire as a screening tool for this study where the interpretation of the score in its Greek version was controversial.

Commentary: There is an unmet need for more research to gain a better understanding of the occurrence of ON in chronic diseases as this study indicates. The combination of several tools might be more pertinent than the use of a single tool when dealing with ON. However, following the consensus for the definition and diagnostic criteria of ON,4 all the pre-existing tools for screening need revision, re-evaluation for suitability, and validation.

As ON is a recently discovered entity, it is crucial to be aware of this disorder to take preventative measures when treating susceptible individuals with chronic diseases. Medical nutrition therapy should be delivered by professionals, with parallel evaluation and close routine monitoring of a person's dietary changes.


  1. Grammatikopoulou MG, Gkiouras K, Polychronidou G, Kaparounaki C, Gkouskou KK, Magkos F, Donini LM, Eliopoulos AG, Goulis DG. Obsessed with Healthy Eating: A Systematic Review of Observational Studies Assessing Orthorexia Nervosa in Patients with Diabetes Mellitus. Nutrients. 2021; 13(11):3823.
  2. Kujawowicz K, Mirończuk-Chodakowska I, Witkowska AM. Dietary Behavior and Risk of Orthorexia in Women with Celiac Disease. Nutrients. 2022; 14(4):904.
  3. Waterman M, Lee RM, Carter JC, Garland SN. Orthorexia symptoms and disordered eating behaviors in young women with cancer. Eat Behav. 2022;47:101672. doi:10.1016/j.eatbeh.2022.101672
  4. Donini LM, Barrada JR, Barthels F, et al. A consensus document on definition and diagnostic criteria for orthorexia nervosa. Eat Weight Disord. 2022;27(8):3695-3711. doi:10.1007/s40519-022-01512-5

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