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The relationship between orthorexia and bulimia

Orthorexia nervosa (ON) is a more recently acknowledged eating disorder. While yet to be recognized by the DSM, orthorexia nervosa is on the rise, particularly in specific populations, such as those with health-related careers, perfectionist or obsessive-compulsive traits, and heavy social media users.1

Recent research is revealing that there may also be a link between orthorexia and bulimia nervosa (BN).

Last updated on 
February 9, 2023
Orthorexia and bulimia
In this article

What is orthorexia nervosa?

Bulimia nervosa (BN) is one of the more well-known eating disorders, characterized by cycles of binge eating followed by purging (via self-induced vomiting, fasting, excessive exercise, and diuretics or laxative use), which are used as compensatory behaviors.2

Orthorexia nervosa is a lesser-known eating disorder and one that is often misunderstood. Healthy eating is generally considered to be appropriate and beneficial. However, some people can become so fixated on a rigid and restrictive approach to "healthy eating" that it develops into the eating disorder, orthorexia nervosa.3

The focus of those living with orthorexia nervosa is not on the quantity of food but the quality.

Generally, the focus of those living with orthorexia nervosa is not on the quantity of food but the food quality. People with ON are obsessed with their perceived version of "healthy" eating habits rather than a preoccupation with thinness or a goal to lose weight and therefore have self-imposed dietary rules.3

Additionally, they have an obsessive focus on what they consider to be "clean" or "pure" foods, as well as an obsession with the benefits of eating healthy food.3 This may also be accompanied by severe anxiety and fear about foods they consider unhealthy, toxic, or harmful. 

Signs and symptoms of orthorexia nervosa

Although orthorexia nervosa doesn't currently have official diagnostic criteria, the disorder does have some common signs and symptoms, including:3,4,5

  • Obsession with healthy foods, nutrition, and eating
  • Intense fear of foods perceived to be "unhealthy" and avoiding these foods
  • Inability to eat foods not considered "clean" or "pure"
  • Compulsive checking of nutrition labels and ingredient lists
  • Cutting out an increasing number of entire food groups without a medical, ethical, or cultural reason for doing so
  • Exaggerated emotional distress when "safe" foods are unavailable
  • Unusual interest in the health of what others are eating
  • Fixating on preventing or curing illnesses with "clean eating"
  • Avoid events with food prepared by other people
  • Obsessive following of "healthy lifestyle" accounts on social media
  • Increasing the number of dietary restrictions followed
  • Obsessive focus on healthy meal planning

Relationship between bulimia nervosa and orthorexia nervosa

Further research is needed to learn more about the relationship between ON and other eating disorders. However, some studies have found that those with a previously diagnosed psychiatric disorder, including BN, go on to develop orthorexia nervosa,6 particularly following treatment for their eating disorder.7

Orthorexia nervosa symptoms are highly prevalent in those with BN, which tend to increase following eating disorder treatment. Research suggests that orthorexia nervosa is associated with the clinical improvement of BN and anorexia nervosa (AN) and the migration towards alternate forms of eating disorders that may be treated as more socially acceptable.7

A study found that 28% of AN and BN patients presented with symptoms of orthorexia nervosa on their first contact with an eating disorder treatment facility.7 Rather than decreasing after eating disorder treatment, the frequency increased to 53%.

This could be because of the tendency for those recovering from BN or other eating disorders to base their food choices on perceived "health benefits" compared to those with no history of eating disorders.7 These behaviors can be used to hide an attempt to control food intake and as a way to legitimize food avoidance/restriction, which is a form of compensation.7

Therefore, it has been hypothesized orthorexia nervosa is likely to be a common symptom among people recovering from BN and other eating disorders to disguise their need to maintain and control their nutritional intake and weight.7

Treatment could lead to the development of ON

In addition, it's been suggested that the form of eating disorder treatment could play a role in the development of orthorexia nervosa during recovery. Cognitive behavioral therapy (CBT) is one of the most common forms of psychotherapy for BN. CBT is more tailored towards shifting focus away from body size and shape as well as helping patients overcome their food phobias, teaching them how to eat in ways that are less focused on attempted weight manipulation (e.g., severe weight loss).

Food becomes the cure and a hyper-focus on healthy eating is the compromise.

Essentially, "food becomes the cure" with patients learning to accept and protect their bodies, and some patients may obsess about this as a more socially acceptable way to control food. A hyper-focus on healthy eating is the compromise. This could be an even more significant problem in those with BN, who also have obsessive personalities commonly seen in those with eating disorders.7 Of course, this is just a hypothesis yet to be tested. More research is needed to determine if the symptoms of orthorexia nervosa can be associated with relapse and recurrence of eating disorders like bulimia nervosa.

Orthorexia nervosa and binge eating

So, it is possible that having bulimia nervosa can increase the risk of developing orthorexia nervosa, but can having ON lead to the onset of bulimia nervosa symptoms?

It's believed that orthorexia behaviors can fuel the binge-purge cycle like other forms of restrictive dieting.8

The rigid diet those living with orthorexia nervosa impose upon themselves can increase the cravings for all of the foods they consider "unclean." Once these cravings become too much, people may break one of their strict food rules and eat something out of their safety zone. 

As with other types of restriction, physical and psychological deprivation from certain foods due to orthorexia can trigger binging or compulsive eating of those foods. People with orthorexia nervosa may also have an "all or nothing" mentality about their food rules. They may decide that "breaking" one of their food rules means that they will break as many additional food rules as they can before returning to their disordered eating, and those foods become off-limits again. 

This can lead to feelings of shame and guilt, which can lead to a return to restrictive eating and/or purging behaviors those with bulimia nervosa engage in to compensate for binging. Before long, the food restriction results in extreme cravings, and the binge-purge-restriction cycle starts again.

Treatment for bulimia nervosa and orthorexia nervosa 

Treatment is available for both BN and orthorexia nervosa, and if you believe you're struggling with both, it's important you tell your treatment provider, so your care plan can be tailored to both your BN and ON symptoms. This will also help address how the two disorders feed into each other and may also prove to be an effective relapse prevention technique, particularly as orthorexia nervosa symptoms often develop during eating disorder treatment.

While treatment plans for orthorexia nervosa have yet to be validated, therapeutic interventions for the disorder are similar to those for other eating disorders, including bulimia nervosa. However, treatment goals will be slightly different. 

Treatment for BN tends to concentrate on shifting the focus from an obsession with thinness or body shape. By contrast, the primary goal of orthorexia nervosa treatment is to restore a balanced relationship with food that allows variety, pleasure, and enjoyment of all foods without judgment instead of fixating on the perceived health value of food.

Eating disorders can be treated at home
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Common treatment methods

Whether you're suffering from BN, ON, or a combination of both, a personalized treatment plan based on your individual needs can be devised by a multidisciplinary care team, including psychotherapists, physicians, and dietitians. 

Common therapies for BN and ON include:

There are no current medications explicitly designed to treat BN or ON, but in some cases treating co-occurring mood disorders with medications can help decrease eating disorder symptoms.

There is an increasing body of evidence suggesting a link between bulimia nervosa and orthorexia nervosa. Early evidence indicates that bulimia nervosa patients in recovery are at increased risk of developing orthorexia nervosa and may adopt orthorexia behaviors as a more socially acceptable way to continue to engage in food restriction.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.

Resources

  1. Whitcomb, I. (2020, October 7). Orthorexia: Causes, symptoms and treatment. LiveScience. Retrieved September 27, 2022.
  2. Bulimia nervosa. (n.d.). Beat. Retrieved September 26, 2022.
  3. Davidson, K. (2022, March 3). What to know about orthorexia. Healthline. Retrieved September 26, 2022.
  4. Orthorexia. (2019, December 13) National Eating Disorders Association. Retrieved September 26, 2022.
  5. Orthorexia. (n.d.). Beat. Retrieved September 26 2022.
  6. Rania, M., de Filippis, R., Caroleo, M. et al. (2021). Pathways to orthorexia nervosa: a case series discussion. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity volume, 26, 1675–1683. 
  7. Segura-Garcia, C., Ramacciotti, C., Rania, M., Aloi, M., Caroleo, M., Bruni, A., Gazzarrini, D., Sinopoli, F., & De Fazio, P. (2015). The prevalence of orthorexia nervosa among eating disorder patients after treatment. Eating and weight disorders, 20(2), 161–166.
  8. Hansen, K. (2022, January 20). Orthorexia and binge eating: Guest post from Elisa Oras. Brain over Binge. Retrieved September 27, 2022.

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