Orthorexia nervosa is an eating disorder characterized by an excessive preoccupation with healthy eating. Individuals affected by this disorder often concentrate intensely on achieving optimal nutrition, to the extent that it disrupts various aspects of their daily lives. While embracing a nutritious diet can lead to significant enhancements in overall health and well-being, for some individuals, this commitment to healthy eating can spiral into an obsession, ultimately resulting in a disorder known as orthorexia.

Similar to other eating disorders, orthorexia can have profound and detrimental effects on an individual’s health. Those suffering from this condition may become so engrossed in their eating habits that it adversely impacts their physical and mental well-being. The complexities of orthorexia are still being explored, and it remains a topic of ongoing research. In certain instances, it has been linked to other psychological conditions, such as obsessive-compulsive disorder (OCD) and various other eating disorders. Nevertheless, a segment of professionals advocates for the establishment of distinct diagnostic criteria and tailored treatment approaches specifically for orthorexia.

This article aims to provide comprehensive insights into orthorexia, covering its signs and symptoms, the potential negative health impacts it can provoke, and the treatment options currently available for individuals affected by this condition.

Understanding Orthorexia Nervosa

Orthorexia nervosa is a complex eating disorder characterized by an excessive preoccupation with healthy eating, leading individuals to develop an unhealthy obsession with the quality of their food choices. First introduced by the American physician Steve Bratman in 1997, the term “orthorexia” is derived from Greek, where “orthos” translates to “right” and “orexis” to “appetite.” However, it is more accurately interpreted as a “correct diet.”

In contrast to other eating disorders such as anorexia nervosa or bulimia nervosa, which focus on food quantity, orthorexia is primarily concerned with the quality of food consumed. Individuals with orthorexia are less focused on weight loss or achieving a thin physique; instead, they emphasize the perceived health benefits of their dietary choices.

This condition manifests as an acute fixation on the “purity” or “cleanliness” of foods, leading to an obsession with the advantages of eating healthfully. As this obsession intensifies, it can significantly disrupt an individual's health and daily functioning.

While the medical community is gradually recognizing orthorexia as a significant concern, it has yet to be formally classified as an eating disorder by the American Psychiatric Association or included in the current edition of the “Diagnostic and Statistical Manual of Mental Disorders.” Nevertheless, orthorexia nervosa represents a serious condition that affects individuals' relationship with food and nutrition.

Recognizing Orthorexia Nervosa: Key Signs and Symptoms

While orthorexia nervosa lacks official diagnostic criteria, it presents several common signs and symptoms that one should be aware of, including:

• an intense fear of consuming foods deemed “unhealthy” and actively avoiding them
• a preoccupation or obsession with healthy foods, nutrition, and dietary habits
• an inability to stray from a designated eating plan without experiencing significant anxiety
• frequent checking of ingredient lists and nutrition facts
• eliminating entire food groups without any valid medical, cultural, religious, or ethical justification (e.g., gluten, sugar, carbohydrates, fats, or animal-derived products)
• spending excessive time planning, purchasing, and preparing meals perceived as healthy, often at the expense of other life activities
• demonstrating an unusual interest in or overly critical perspective on the eating habits of others
• devoting significant time to reviewing menus or contemplating the foods available at social gatherings
• avoiding social gatherings and foods prepared by others
• bringing pre-prepared meals to events due to a belief that others' food will not meet their “healthy” standards
• experiencing unintentional malnutrition or weight loss due to stringent food restrictions
• focusing excessively on using food or “clean eating” as a means to prevent or treat diseases

For individuals grappling with orthorexia, breaching their self-imposed “healthy eating” rules or succumbing to cravings for foods they categorize as unhealthy can lead to profound emotional distress and a diminished sense of self-worth. Often, those with orthorexia believe their self-esteem is tied to their ability to strictly adhere to a lifestyle they consider to be healthy. Ultimately, the most prevalent indicator of orthorexia is an unhealthy obsession with healthy eating that adversely impacts one's life.

When the pursuit of a healthy diet transforms into an obsession that interferes with daily living, it can become detrimental. Individuals with orthorexia feel their self-esteem is contingent upon maintaining a diet they view as healthy, experiencing heightened anxiety when they feel they have lost control over it.

Important Note

While striving to “get it right” with nutrition may seem appealing, it can have unintended consequences. If you find yourself preoccupied with food or your weight, experiencing guilt regarding your food selections, or consistently engaging in restrictive dietary practices, consider seeking support. These behaviors may reflect a disordered relationship with food or an eating disorder.

Disordered eating and eating disorders can affect individuals of any gender identity, race, age, socioeconomic background, or other identities. They may arise from a complex interplay of biological, social, cultural, and environmental influences—not solely from exposure to diet culture. Feel empowered to consult with a qualified healthcare professional, such as a registered dietitian, if you are facing challenges. You can also communicate, call, or text anonymously with trained volunteers at the National Eating Disorders Association helpline for free, or explore the organization’s complimentary and low-cost resources.

What are the Causes of Orthorexia?

Initially, you may adopt a diet with the simple aim of enhancing your well-being; however, this focus can escalate over time. What starts as a genuine desire to support your health through dietary choices can evolve into a condition known as orthorexia. While the exact origins of orthorexia remain unclear to researchers, a multitude of factors appears to contribute to its emergence.

Identifying the Risk Factors for Orthorexia

Although research into the specific causes of orthorexia is limited, certain characteristics such as obsessive-compulsive tendencies and a personal history of eating disorders have been identified as significant risk factors. In some instances, orthorexia may serve as a more socially acceptable method of food restriction. Additionally, personal traits such as perfectionism, heightened anxiety levels, and a strong need for control are also noteworthy risk factors.

On a broader scale, social influences like nutritional knowledge, higher income levels, access to “clean” foods (like organic vegetables), frequent use of social media, and experiences of weight bias or stigma are linked to behaviors associated with orthorexia.

In academic environments, students pursuing degrees in health-related fields (including nutrition and dietetics, biology, and kinesiology) might exhibit symptoms of orthorexia more frequently compared to peers in other disciplines; however, it’s important to note that orthorexia can impact any student, irrespective of their field of study. Moreover, the rapid rise in the promotion of “clean eating” lifestyles via social media platforms could also contribute to the rise of orthorexia.

Advocates of clean eating emphasize the consumption of whole, minimally processed foods, which are indeed nutritious. Nonetheless, the term “clean eating” tends to moralize food choices, branding certain foods as “dirty” or undesirable. This moralization can stigmatize various foods, thereby exacerbating the risk of developing eating disorders like orthorexia.

Nonetheless, the absence of a formal diagnostic tool for orthorexia makes it challenging to pinpoint what specifically increases an individual's risk. Therefore, further investigation is essential.

While the precise causes of orthorexia are not fully understood, certain personality traits and social factors have been recognized, including heightened anxiety, a background of disordered eating, exposure to social media, and a keen interest in health and wellness.

Understanding the Prevalence of Orthorexia

Distinguishing between orthorexia and a genuine interest in healthy eating can often pose challenges. Furthermore, due to the absence of universally accepted diagnostic criteria for orthorexia, various studies may adopt different approaches in their assessments.

Research targeting populations more susceptible to orthorexia, including university students, vegans (????????), and healthcare professionals, tends to report elevated incidence rates compared to studies conducted on the broader public. For instance, a review highlighted that the prevalence of orthorexia varied significantly, from 6.9% within the general Italian populace to a striking 88.7% among nutrition students in Brazil.

Additionally, individuals following vegan and vegetarian diets often show increased instances of orthorexia. Interestingly, for these groups, the choice of a vegan or vegetarian lifestyle may act as a symptom of orthorexia rather than being a causal factor itself.

Moreover, some definitions of orthorexia fail to consider whether behaviors associated with orthorexia adversely impact a person's social, physical, or mental well-being, despite the fact that assessing psychological distress is pivotal in categorizing orthorexia as a disorder.

The transformation of a passion for healthy eating into orthorexia typically occurs when such enthusiasm evolves into an obsession that disrupts daily life, manifesting as an intense fear of consuming specific foods or an aversion to dining out with friends. This complexity makes it difficult to accurately gauge the prevalence of orthorexia within various communities. Nonetheless, when the adverse effects of orthorexia are factored in, the estimated rates plummet to less than 1% of the population, aligning more closely with the prevalence rates observed in other eating disorders.

In general, the occurrence of orthorexia appears to hover around 1% within the wider population, yet it tends to be more pronounced among specific cohorts, particularly university students in health-focused disciplines, healthcare providers, and those adhering to vegetarian and vegan diets.

How is Orthorexia Diagnosed?

Orthorexia is characterized by a lack of formal diagnostic criteria, leading to uncertainty about whether it stands alone as a distinct eating disorder, is a component of another disorder like anorexia nervosa, or perhaps represents a subtype of obsessive-compulsive disorder (OCD).

Nonetheless, various proposed diagnostic tools exist that healthcare professionals might utilize to identify orthorexia. These include:

• ORTO-15. This tool comprises 15 questions aimed at uncovering symptoms and behaviors associated with orthorexia. A score of 40 serves as the threshold for diagnosis; however, it has faced criticism for failing to distinguish between unhealthy eating patterns and ethical dietary preferences (e.g., ethical veganism and spiritual beliefs).
• ORTO-R. An updated version of ORTO-15, ORTO-R focuses on the six most pertinent questions regarding symptoms and behaviors indicative of orthorexia.
• Bratman Orthorexia Test (BOT). This screening tool consists of 10 questions requiring “Yes/No” responses, focusing on obsessive thoughts related to food, nutritional beliefs, dietary restrictions, and other relevant factors. Despite its utility, it is not widely adopted.
• Eating Habits Questionnaire (EHQ). This comprehensive 21-item questionnaire assesses knowledge, both positive and negative feelings toward healthy eating, as well as problematic behaviors. However, research indicates it requires further refinement before being deemed a reliable diagnostic tool for orthorexia.

To enhance the clarity between healthy eating and orthorexia, Bratman and Dunn proposed a two-part diagnostic criterion: an intense obsession with healthy eating and behaviors that interfere with daily life.

1. An Intense Obsession with Healthy Eating

The first criterion involves an intense fixation on healthy eating, leading to exaggerated emotional distress about food selections. This may manifest as:

• Compulsive Thoughts or Actions. Individuals may exhibit compulsive behaviors or persistent thoughts regarding dietary choices they believe will foster optimal well-being.
• Self-Inflicted Anxiety: Violating self-imposed dietary guidelines may provoke feelings of anxiety, shame, fear of illness, a sense of impurity, or other unpleasant physical sensations.
• Extreme Dietary Restrictions. Over time, these restrictions may intensify, potentially resulting in the exclusion of entire food groups, the incorporation of risky cleanses or fasting regimens, or both.

2. Behaviors Disrupting Daily Life

The second criterion highlights compulsive behaviors that hinder normal daily functioning. This disruption can manifest through:

• Health Complications. Consequences such as malnutrition, significant weight loss, or other medical issues may arise due to these compulsive behaviors.
• Social and Lifestyle Disruption. Personal distress or challenges in social or academic environments may stem from beliefs or behaviors tied to healthy eating, leading to disruptions in lifestyle.
• Emotional Overdependence. An individual's body image, self-esteem, identity, or overall satisfaction may become excessively reliant on adherence to self-imposed dietary restrictions.

Continued research into orthorexia will contribute to developing more effective diagnostic strategies. Currently, there is no universally accepted diagnostic tool for orthorexia. Although some tools like ORTO-15, ORTO-R, the Bratman Orthorexia Test, and the Eating Habits Questionnaire are available, they all possess inherent limitations.

Adverse Health Implications of Orthorexia

The adverse health implications associated with orthorexia generally categorize into three main areas:

1. Physical Implications

While research on orthorexia remains limited, this condition can lead to numerous medical complications akin to those observed in other eating disorders. For example, a deficiency in vital nutrients resulting from overly restrictive eating habits can trigger malnutrition, anemia, or an unusually low heart rate. Severe malnutrition can result in digestive issues, imbalances in electrolytes and hormones, metabolic acidosis, fatigue, and a compromised immune system. These physical ailments can pose serious health risks and should not be taken lightly.

2. Psychological Implications

Individuals grappling with orthorexia often experience significant frustration when their dietary routines are interrupted. Moreover, failing to adhere to their self-imposed dietary regulations can incite feelings of guilt, self-loathing, or a compulsive urge for “purification” through hazardous detoxes or fasting.

In addition, those with orthorexia dedicate substantial time to evaluating whether particular foods are “clean” or “pure.” This includes worries about the pesticide exposure of vegetables, the hormones present in dairy, and the use of artificial additives or preservatives. Beyond meals, they may invest extra time in researching, documenting, weighing, and measuring their food or strategizing meals for the future. This intense focus on diet can hinder their daily functioning, resulting in reduced productivity, diminished social interactions, and a lack of enjoyment.

3. Social Implications

Individuals with orthorexia often feel anxious or threatened at the thought of relinquishing their perceived control over food. They frequently adhere to strict self-imposed guidelines regarding which foods can be consumed together or at specific times throughout the day.

Such rigid eating behaviors can complicate participation in social engagements centered around food, like dinner gatherings or dining out. Intrusive thoughts about food and a sense of superiority regarding their eating habits can further complicate social interactions. Consequently, these implications can lead to social isolation, a common experience for those diagnosed with orthorexia. The strict eating habits, intrusive food-related thoughts, and feelings of moral superiority linked to orthorexia may result in numerous adverse physical, psychological, and social consequences.

Approaches to Treating Orthorexia

The health repercussions of orthorexia can be just as damaging as those associated with other eating disorders. If not addressed, orthorexia can lead to lasting harm to an individual’s overall health. The initial step in conquering orthorexia involves recognizing its existence.

Realizing the issue can prove difficult, as those affected by this disorder often struggle to acknowledge any detrimental effects on their health, well-being, or social interactions. In fact, many individuals may perceive their behaviors as beneficial for health instead of harmful. Once a person can identify these harmful effects, it is advisable for them to seek assistance from a comprehensive healthcare team comprising a physician, a mental health professional, and a registered dietitian.

In certain instances, specialists in eating disorders may address orthorexia similarly to forms of anorexia and/or obsessive-compulsive disorder (OCD), recommending treatments such as:

• psychotherapy aimed at underlying issues like anxiety, depression, or OCD
• gradual exposure and reintegration to previously avoided foods
• modifications in behavior
• cognitive restructuring or reframing techniques
• various relaxation methods (including meditation, yoga, tai chi, guided imagery, and breathing exercises)
• restoration of weight where necessary

Nonetheless, the efficacy of these treatments for orthorexia has not yet been scientifically validated. Moreover, it is crucial to recognize that orthorexia — similar to other eating disorders — can manifest in individuals of all shapes and sizes. Therefore, being underweight is not a diagnostic criterion, and not everyone’s recovery path will involve weight restoration.

Lastly, educating oneself about evidence-based nutritional information may assist individuals struggling with orthorexia in understanding, managing, and ultimately dispelling misguided beliefs about food. There are multiple strategies available for treating orthorexia, and obtaining support from a multidisciplinary healthcare team is highly recommended.

The Bottom Line

Maintaining awareness of the foods you consume and their impact on your health is widely considered beneficial. However, for some individuals, the distinction between healthy eating and the emergence of an eating disorder can be quite tenuous. If you find that your dedication to a nutritious diet adversely affects your physical health, emotional stability, or social interactions, it may indicate that your focus on health has shifted towards a condition known as orthorexia. This disorder, similar to other eating disorders, can lead to severe health complications and should not be overlooked. It’s important to understand that support is accessible, and eating disorders are treatable. Consulting with a qualified health expert—such as a physician, psychologist, or registered dietitian—is highly advisable for those in need of assistance.