What is orthorexia nervosa?
Orthorexia nervosa is a term coined by Steven Bratman in 1997 for an obsession with healthy or “clean” eating. This obsession leads to restrictive behaviors. But, unlike other eating disorders, the person is focused on food quality as opposed to quantity. (1)
Although it’s not currently classified as an eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), many mental health providers acknowledge the negative consequences of obsessive “pure” eating. (1)
Without formal diagnostic criteria and recognition by the American Psychological Association, it’s difficult to approximate how many people struggle with orthorexia nervosa. But various studies have estimated prevalence to be between 1% and 6.9%, with a higher rate in health care professionals and performance artists. (1)
Regardless of its status, professionals can agree that orthorexia is a serious concern that often requires treatment and medical care.
What are the symptoms of orthorexia nervosa?
If you are concerned that you or someone you love may have orthorexia nervosa, you’ll want to familiarize yourself with some of the most common symptoms of this eating disorder. Remember, prioritizing nutritious eating doesn’t necessarily mean you have an orthorexia. Rather, orthorexia nervosa is present when you are extremely obsessed with healthy eating, despite your academic, occupational, or social functioning may be impaired due to your fixations.
1. Cutting out entire food groups
Cutting out entire food groups, such as all dairy, all carbohydrates, or all sugar, is a common behavior associated with orthorexia. This may be because you believe that all foods in that particular food group are unhealthy or unclean. This practice typically escalates as well, with several groups being eliminated. And over time, you may engage in more frequent or rigid cleanses that you view as detoxifying. Although this escalation can lead to weight loss, that isn’t the ultimate goal of this restriction—rather, it is to achieve optimum health. (1,2)
2. Experiencing emotional distress when healthy foods aren’t accessible
If you think you or someone you know may be struggling with orthorexia, you may experience a preoccupation with the types of foods that may be served at an upcoming event, such as a party, conference, or work dinner. You may spend a significant amount of time worrying about this upcoming event—so much so that it may cause you anxiety and distress. (3)
Moreover, once the event arrives, if there are not “approved” foods present, you may experience great emotional distress and find you can’t enjoy yourself or allow yourself to consume these forbidden foods. (3)
3. Compulsively checking nutritional labels and ingredient lists
Another common orthorexia symptom is compulsively checking nutrition labels and ingredient lists to make sure that the food is “pure” or healthy according to your standards. This may involve checking for carbohydrates if you have cut out that food group or making sure there is no added sugar or artificial sweeteners. Along with this compulsive checking, there is often an increasing anxiety about the health of various ingredients. Much like restricting food groups, this anxiety can escalate over time. (3)
4. Obsessing over “clean” food planning, preparation, and consumption
Many eating disorders involve very strict food rituals, and orthorexia is no exception. You may spend a great deal of time obsessing over what meals you are going to eat that week, as well as where you’re going to buy your food, how you’re going to prepare it, when and how much you’re going to consume. You may spend several hours each day preparing your healthy food. You may also decline dinner invitations unless you can bring the food you’ve prepared. This type of behavior can lead to social isolation and frustration. (1)
5. Experiencing extreme guilt or anxiety when eating forbidden foods
With the restrictive eating patterns of orthorexia also comes profound guilt, shame, and anxiety when you violate your dietary rules. This may be because your self-worth is dependent upon strictly following your healthy eating rules you’ve designated for yourself. You may also experience an exaggerated fear of developing a medical condition or illness, as well as a feeling that are you are now “impure.” (1,2)
Additionally, even if you don’t consume forbidden foods, you may feel extremely distressed or disgusted when you’re near those foods. (1) For example, at work, you may feel grossed out by a co-worker’s fast-food lunch.
6. Viewing food as a source of health as opposed to pleasure
One of the major differences between orthorexia and anorexia is that orthorexia is not weight or image based. Your entire focus is on consuming self-defined healthy foods, and you may derive little to no pleasure from eating. (1)
You may also continue to engage in your eating patterns, believing they are health-promoting, despite evidence to the contrary. For instance, you might have lost an unhealthy amount of weight due to restricting all carbohydrates and all dairy, but you are steadfast in your belief that this is the healthiest eating practice. (1)
7. Caring a great deal about what others are eating
An inappropriate investment in the dietary habits of others is a common symptom of orthorexia. This may present as talking to or lecturing friends and family members about pure or clean foods they should eat. It often involves judging others based on their eating habits, as well, and having a self-righteous attitude about your consumption of healthy foods. (3)
8. Obsessing over healthy lifestyle influencers on social media
If you look at the accounts you follow on Instagram and Twitter, you may come to realize you follow an alarming number of healthy lifestyle influencers. Your timeline may be full of topics related to clean eating, food preparation, and trendy diets, such as the ketogenic diet. You may follow many accounts that post recipes that adhere to your strict dietary regimen. (3)
Possible physical symptoms of orthorexia
Similar to anorexia, people with orthorexia severely restrict the amount and variety of foods they consume, which can cause malnutrition and nutritional deficiencies. (4) Although more long-term research is needed, anecdotal evidence indicates that orthorexia nervosa affects the body similarly to anorexia nervosa and may result in the following physical symptoms: (1,4,5)
- Severe weight loss
- Weak bones and loss of bone mass
- Fatigue, weakness, lethargy
- Fainting or dizziness
- Vomiting and rapid breathing (due to metabolic acidosis)
- Stomach bloating
- Constipation
- Stomach pain, nausea, and vomiting (due to pancreatitis)
- Abnormally slow heart rate
- Difficulties falling or staying asleep
- Numbness or tingling in extremities
- Muscle cramps
- Feeling cold due to a drop in body temperature
- Brittle hair and dry skin
- Fine hair growth all over the body (lanugo)
Isn’t healthy eating a good thing?
Eating nutritious and balanced meals has countless benefits on your life. But when your pattern of eating becomes pathological and obsessive to the point of restricting food, engaging in ritualized eating, and avoiding various food types deemed “unhealthy,” the consequences can be significant. Over time, these restricting behaviors due to a fixation on healthy food can lead to malnutrition, medical complications, and nutritional deficiencies, as well as poor well-being. (3)
One study called orthorexia nervosa “a disease disguised as a virtue.” (6) Indeed, this eating disorder may go under-diagnosed, because it presents differently than other eating disorders and some of the behaviors are glorified, especially on social media.
Another study on the link between Instagram use and orthorexia nervosa symptoms found that frequent Instagram use was associated with higher rates of orthorexia nervosa. The authors found a high prevalence of orthorexia nervosa symptoms among healthy eating influencers, who in turn affect the mental health of users consuming their content. (6)
What causes orthorexia nervosa?
Like other eating disorders and mental health conditions, there is not one isolated cause of orthorexia nervosa. Rather, several factors, known as risk factors, influence the development of orthorexia. Risk factors that increase the likelihood of developing orthorexia nervosa may include: (1,4,6,7)
- Perfectionism
- Anxiety
- A need for control
- Achievement-oriented attitude
- Fearful and dismissing attachment styles
- Past trauma
- A belief in food as medicine
- Exposure to extreme views as a child
- Preoccupation with being overweight
- History of an eating disorder
- Parent with a history of an eating disorder
- Preoccupation with appearance
- Impaired flexible problem solving
- Excessive Instagram use
- Obsessive-compulsive disorder
Additionally, some demographics may have a higher prevalence of orthorexia than the general population. These may include: (1, 8)
- Athletes
- People who work in healthcare
- Performance artists
Lastly, research has shown that following a restrictive diet, such as paleo, ketogenic, or raw food diets, may increase your risk of developing orthorexia. People who believe in the health benefits of these diets and engage in this type of rigid eating tend to engage in compensatory behaviors, such as increased restriction or fasting, if they violate their diet. (9)
How is orthorexia treated?
There is no established treatment protocol for orthorexia nervosa, although professionals have suggested best practices, such as: (1,4)
- Individualized treatment plan
- Multidisciplinary team comprised of dieticians, doctors, and therapists
- Cognitive behavioral therapy
- Psychoeducation
- Selective serotonin reuptake inhibitors (SSRIs)
- Antipsychotics, such as olanzapine
- Exposure and response prevention
- Habit reversal training
- Cognitive restructuring
- Relaxation methods
- Psychoeducation related to dietetic science
- Physical exam and lab studies
Individuals with orthorexia may reject medications, since they are not natural or pure, so pharmaceutical intervention may not be possible, at least not until they are committed to recovery.
Treatment for orthorexia may occur on an inpatient or outpatient basis. Inpatient programs involve living at the facility for the duration of the eating disorder treatment program. Outpatient care is more flexible and involves living at home and attending scheduled treatment sessions. Still, many treatment barriers exist. If you lack treatment access, either due to geography, transportation, or scheduling, virtual care may be a viable option.
If you think you or a loved one have experienced any symptoms of orthorexia nervosa, it’s important to seek eating disorder treatment right away.
