Orthorexia – When ‘Healthy Eating’ Becomes Unhealthy

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This article was written by Grace O’Brien (Registered Dietitian), and reviewed by Maeve Hanan (Registered Dietitian & Founder of Dietetically Speaking).


Orthorexia Nervosa is a form of disordered eating, however, it is not yet recognised as an eating disorder, meaning you can’t be formally diagnosed with it. Despite this, it is still a serious condition that can cause significant health issues, and with the prevalence of eating disorders increasing, it is important to raise awareness about this condition.

What is Orthorexia Nervosa?

Orthorexia nervosa can be described as an unhealthy obsession with ‘healthy eating’.

But where is the line between taking an interest in healthy eating and disordered eating? Well, for someone living with orthorexia nervosa – ‘healthy eating’ or ‘clean’ eating becomes an intrusive or obsessive thought process. This evolves into an overwhelming preoccupation, leading to significant distress and anxiety around eating (1). This often results in an extreme diet based on food rules or food ‘purity’ which can harm a person’s overall health, and even lead to malnutrition (2, 3).

People with orthorexia nervosa often use these restrictive eating behaviours to cope with negative thoughts or to feel more in control. The preoccupation with food can dominate their mindset to the extent that it interferes with daily activities and can cause considerable anxiety if self-imposed dietary rules are not followed (2, 4, 5). 

Orthorexia nervosa (or simply orthorexia) is a relatively new term still – only proposed in 1997 by Steven Bratman after he noticed an increase in the number of people with what he believed to be an unhealthy fixation on healthy eating (6). He gives his perspective, written from a third-person point of view, into the process of developing orthorexia and how over time food can overwhelm and preoccupy your mindset.

‘Over time, what they eat, how much, and the consequences of dietary indiscretion come to occupy a greater and greater proportion of the orthorexic’s day’(19)

Unfortunately, as orthorexia is not an official diagnosis yet, and there is no clear definition, or one set of diagnostic criteria, this makes it difficult to know the true prevalence of this disease (2). Even more, there is also still a dispute about whether or not orthorexia is strictly an eating disorder, a manifestation of another eating disorder, a subtype of a mental disorder such as obsessive-compulsive disorder or even in its own category altogether (2, 8-10). While exact rates of orthorexia can’t be identified, cases are believed to be becoming more and more prevalent, especially in Western societies (11). Hence the importance of raising awareness to promote further research in the area.

Signs and Symptoms of Orthorexia Nervosa 

Symptoms of orthorexia often start with what’s seen as innocent or harmless goals such as eating healthier, losing weight or sometimes trying to cure or better manage a disease (2). Over time this can evolve into orthorexia and more serious symptoms such as the ones listed below. 

Remember that there is no set list of signs and symptoms as orthorexia is not a standard diagnosis, but common traits may include (4,5):

  • Strict dietary rules
  • Avoiding entire food groups e.g. avoidance of dairy
  • Becoming more preoccupied with meal preparation and/or its nutritional content
  • Guilt after having food you believe to be unhealthy
  • Spending an excessive amount of time researching food
  • Avoiding certain social situations due to fear of not being able to follow your dietary restrictions
  • Distress or anxiety when confronted with foods you believe to be unhealthy
  • Difficulty concentrating on things other than food/’healthy’ eating
  • Poor self-esteem
  • Judgement towards others for eating what you believe to be unhealthy

Causes and Risk Factors

Risk factors for orthorexia may include (12):

  • Personality traits such as ‘perfectionism’
  • Obsessive-compulsive traits 
  • Disordered eating behaviours
  • History of having an eating disorder
  • Dieting
  • Poor body image
  • Drive for thinness

Today’s societal influences are also believed to contribute towards the increasing prevalence of eating disorders –  including the media’s constant portrayal of unrealistic body standards, misinformation on social media, unhealthy trends such as ‘clean eating’ trends, and social pressures to look a certain way (12,13).

Interestingly, a systematic review observed a generally higher prevalence of orthorexia 

among dietitians, nutritionists and dietetic and nutrition students, compared to the general population (14). However, the reasons behind why this may be are unknown. Nonetheless, there is some existing research out there to show that being a nutrition student or similar, or even just having a greater food knowledge, may in itself be a risk factor for orthorexia (15).

Health Implications of Orthorexia Nervosa

Because someone living with orthorexia may overly restrict their food intake and/or avoid whole food groups altogether, this may result in having an unbalanced diet. Over time, this can lead to nutritional deficiencies and other long-term effects listed below (4, 16 – 18):

  • Nutritional deficiencies e.g. protein deficiency 
  • Anaemia
  • Weight loss
  • Malnutrition
  • Other specific micronutrient deficiencies e.g. B12, folate
  • Hormonal disturbances
  • Irregular periods or loss of period and fertility issues
  • Becoming underweight
  • Osteoporosis
  • Weakened immune system
  • Increased injuries
  • Reduced sports performance 

Remember that this is not an exhaustive list of possible consequences of orthorexia.

Diagnosing Orthorexia Nervosa

Orthorexia is not recognised in the Diagnostic and Statistical Manual of Mental Disorders (DSM), unlike other eating disorders such as anorexia nervosa, bulimia, binge eating disorder, and ARFID, which are. There are no clear-cut medical tests or even an agreed-upon and verified questionnaire to use as a diagnostic tool, so it’s difficult to diagnose (3).

However, this is not to say that healthcare professionals don’t use existing tools to screen or aid in the identification of orthorexia. For example, some widely used questionnaires include the ORTO-15, ‘Bartman Orthorexia Test’, and the ‘Dusseldorf Orthorexia Scale’ (19,20). However, further research is needed into the true effectiveness and accuracy of these screening tools. 

Another difficulty in the diagnosis of orthorexia is differentiating it from other eating disorders and mental illnesses in which there can sometimes be some overlap, or they may even co-exist. 

For example, both orthorexia and anorexia nervosa share some similarities in that they both include restrictive eating behaviour, however, people with orthorexia often restrict their diet more so in terms of quality rather than quantity (2). In other words, it’s more about the types of foods they eat that they are concerned with, rather than the overall volume. 

Psychiatric disorders such as anxiety, OCD and depression are unfortunately very common among those living with eating disorders and while they may have some similar symptom overlaps, can often co-occur with an eating disorder (21). So diagnosis by experienced medical and mental health professionals is needed. 

Treating Orthorexia Nervosa

There are many types of treatments used in orthorexia, however, the overall treatment approach usually involves a mix of both therapy and nutrition counselling. 

For example, different types of therapies used include cognitive behavioural therapy (CBT), and psychoeducation (4). These techniques can help challenge distorted thought processes around food. This, paired with nutrition support from a registered dietitian can help with establishing a healthy and peaceful relationship with food (22,23). See below for an example of different treatment approaches used in orthorexia and their purpose (24):

  • Psychoeducation and cognitive behavioural therapy:
    • To inform about what orthorexia is and its effect on health
    • To look at the thoughts and behaviours connected to orthorexia and work to reframe them
    • Encourage the reintroduction of avoided foods/triggers 
  • Nutritional Counselling & Mindfulness
    • Help to restore balance in the diet 
    • Focus on internal cues and mindfulness when eating 
    • Encourage self-compassion 
    • Promote a positive relationship with food 
    • Become more aware of your thoughts and emotions 
  • Family and Social support
    • Reduce isolation
    • Promote support and understanding 

Conclusion

Orthorexia, while not yet officially recognised, is a condition that demands our attention due to its potentially severe health implications. Recognising the signs early, like strict food rules and anxiety about eating, is important for getting help. 

Raising awareness about orthorexia, and encouraging balanced, healthy eating without going to extremes is crucial in reducing the impact of this condition. Creating a supportive environment for those affected is also important. As we learn more about orthorexia, it’s important to keep developing more effective strategies for managing and preventing it.

If you feel as though you, or someone you know, may be suffering from an eating disorder or mental illness after reading this article please reach out to your doctor or a suitable healthcare professional for help.

If you are interested in support from specialist disordered eating dietitians, you can find out about our support services and online courses here. 

References

1. Cena H, Barthels F, Cuzzolaro M, Bratman S, Brytek-Matera A, Dunn T, et al. Definition and diagnostic criteria for orthorexia nervosa: A narrative review of the literature. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity. 2018 Nov 9;24(2):209–46. doi:10.1007/s40519-018-0606-y

2. Dunn TM, Bratman S. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors. 2016 Apr;21:11–7. doi:10.1016/j.eatbeh.2015.12.006

3. Ng QX, Lee DY, Yau CE, Han MX, Liew JJ, Teoh SE, et al. On orthorexia nervosa: A systematic review of reviews. Psychopathology. 2024 Mar 1;1–14. doi:10.1159/000536379

4. Koven N, Abry A. The clinical basis of orthorexia nervosa: Emerging perspectives. Neuropsychiatric Disease and Treatment. 2015 Feb;385. doi:10.2147/ndt.s61665

5 . Donini LM, Barrada JR, Barthels F, Dunn TM, Babeau C, Brytek-Matera A, et al. A consensus document on definition and diagnostic criteria for orthorexia nervosa. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity. 2022 Nov 27;27(8):3695–711. doi:10.1007/s40519-022-01512-5

6. Hanganu-Bresch C. Orthorexia: Eating right in the context of healthism. Medical Humanities. 2019 Jul 29;46(3):311–22. doi:10.1136/medhum-2019-011681

7.  Bratman S. Health food junkie. Yoga J. 1997 Sept ;136:42–50.

8. Varga M, Dukay-Szabó S, Túry F, van Furth Eric F. Evidence and gaps in the literature on orthorexia nervosa. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity. 2013 Apr 12;18(2):103–11. doi:10.1007/s40519-013-0026-y

9.  Atchison AE, Zickgraf HF. Orthorexia nervosa and eating disorder behaviors: A systematic review of the literature. Appetite. 2022 Oct;177:106134. doi:10.1016/j.appet.2022.106134

10. Zagaria A, Vacca M, Cerolini S, Ballesio A, Lombardo C. Associations between orthorexia, disordered eating, and obsessive–compulsive symptoms: A systematic review and meta‐analysis. International Journal of Eating Disorders. 2021 Dec 18;55(3):295–312. doi:10.1002/eat.23654

11.  Niedzielski A, Kaźmierczak-Wojtaś N. Prevalence of orthorexia nervosa and its diagnostic tools—a literature review. International Journal of Environmental Research and Public Health. 2021 May 20;18(10):5488. doi:10.3390/ijerph18105488

12.  McComb SE, Mills JS. Orthorexia nervosa: A review of Psychosocial Risk Factors. Appetite. 2019 Sept;140:50–75. doi:10.1016/j.appet.2019.05.005

13.  Aparicio-Martinez, Perea-Moreno, Martinez-Jimenez, Redel-Macías, Pagliari, Vaquero-Abellan. Social media, thin-ideal, body dissatisfaction and disordered eating attitudes: An exploratory analysis. International Journal of Environmental Research and Public Health. 2019 Oct 29;16(21):4177. doi:10.3390/ijerph16214177

14.  Ephrem C, Rizk R, Saadeh D, Souheil Hallit, Obeid S, Carolien Martijn. Orthorexia nervosa in dietitians and dietetics students—prevalence, risk factors, and interventions: a scoping review using a systematic approach. Nutrition Reviews. 2024 Feb 21;

15. Villa M, Opawsky N, Manriquez S, Ananías N, Vergara-Barra P, Leonario-Rodriguez M. Orthorexia nervosa risk and associated factors among Chilean nutrition students: a pilot study. Journal of Eating Disorders. 2022 Jan 11;10(1).

16.  Marcos A. Eating disorders: A situation of malnutrition with peculiar changes in the immune system. European Journal of Clinical Nutrition. 2000 Mar 1;54(S1). doi:10.1038/sj.ejcn.1600987

17.  Powers PS. Osteoporosis and eating disorders. Journal of Pediatric and Adolescent Gynecology. 1999 May;12(2):51–7. doi:10.1016/s1083-3188(00)86626-7

18.  Rock C, Yager J. Nutrition and eating disorders: A Primer for clinicians. International Journal of Eating Disorders. 1987 Mar;6(2):267–80. doi:10.1002/1098-108x(198703)6:2<267::aid-eat2260060210>3.0.co;2-j

19.  Mitrofanova E, Pummell E, Martinelli L, Petróczi A. Does Orto-15 produce valid data for ‘orthorexia nervosa’? A mixed-method examination of participants’ interpretations of the fifteen test items. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity. 2020 May 22;26(3):897–909. doi:10.1007/s40519-020-00919-2

20.  Meule A, Holzapfel C, Brandl B, Greetfeld M, Hessler-Kaufmann JB, Skurk T, et al. Measuring orthorexia nervosa: A comparison of four self-report questionnaires. Appetite. 2020 Mar;146:104512. doi:10.1016/j.appet.2019.104512

21.  Juli R, Juli MR, Juli G, Juli L. Eating Disorders and Psychiatric Comorbidity. Psychiatr Danub. 2023 Oct;35(Suppl 2):217-220. PMID: 37800230.

22.  Herrin M. Nutrition counseling in the treatment of eating disorders. New York: Taylor and Francis; 2012.

23.  Koller KA, Thompson KA, Miller AJ, Walsh EC, Bardone‐Cone AM. Body appreciation and intuitive eating in eating disorder recovery. International Journal of Eating Disorders. 2020 Feb 5;53(8):1261–9. doi:10.1002/eat.23238

 24. Horovitz O, Argyrides M. Orthorexia and orthorexia nervosa: A comprehensive examination of prevalence, risk factors, diagnosis, and treatment. Nutrients. 2023 Sept 3;15(17):3851. doi:10.3390/nu15173851



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