What Is Orthorexia Nervosa?

Orthorexia Nervosa
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What Is Orthorexia Nervosa?

Orthorexia is not recognized by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as an official eating disorder. It remains a proposed diagnosis that is attracting increased interest by researchers, treatment professionals, bloggers, and the public, especially as a desire for healthy food has become more mainstream.

Dr. Stephen Bratman first coined the term in 1997 to describe the obsession with healthy eating he had seen in several of his patients. While many “healthy” diets were touted as alternatives to medications, he noted that there were significant costs to this approach. These included an inability to share food with others; an inability to eat foods previously enjoyed; an identity wrapped up in food; and guilt, shame, and fear associated with straying from the diet.

The term “orthorexia nervosa” was coined as an analogy to anorexia nervosa. It means an obsession with eating the right food; “ortho,” meaning right, “orexia,” meaning hunger, and “nervosa” meaning fixation or obsession.

Bratman published the term in a 1997 Yoga Journal article—from there it was quickly taken up by popular magazines. While he not originally take the diagnosis seriously, he later discovered that people were experiencing serious health consequences as a result of the condition. Since then, the proposed condition has continued to generate interest an

Symptoms

Orthorexia is not merely veganism, a gluten-free diet, or a general appreciation for healthy eating. As long as a diet provides adequate nutrients, it is possible to adhere to a healthy eating plan without having an eating disorder.

Orthorexia commonly begins as an “exuberant” interest in healthy eating that escalates over time.

Symptoms of the condition include:

  • Compulsive adherence to an eating plan: What was originally a choice becomes a compulsion and the individual can no longer choose to relax their own rules.
  • Eating only healthy foods. People with symptoms of this condition restrict foods perceived as unhealthy and embrace certain “superfoods” perceived as providing special health benefits according to their belief system about what constitutes healthy food.
  • Feelings of shame and guilt: A person’s self-esteem becomes very closely tied to their adherence to their selected diet. Consequently, any deviation from the diet typically causes extreme feelings of guilt and shame.
  • Negative impact on normal functioning: Eventually, the person’s restrictive eating starts to negatively impact both their health and social and occupational functioning; eating the right foods becomes increasingly important and squeezes out other pursuits.

While the condition begins as the pursuit of healthy eating, it backfires and becomes unhealthy and even destructive.

Diagnosis

Orthorexia nervosa was the subject of an Italian study in 2004, which gave further credibility to the condition. In 2014, Jordan Younger, a popular blogger discussed having had orthorexia. At this point, Dr. Bratman decided to study and write about the condition he had first recognized.

While the condition is not found in the DSM-5 and is not considered an official diagnosis, many suggest that there is enough evidence to warrant further research on whether the observed symptoms represent a distinct condition.

A 2018 study estimated that the prevalence of orthorexia was less than 1% based on a sample from a U.S. population.

In a 2016 paper in the journal Eating Behaviors, Bratman and his co-authored with Thom Dunn proposed the following diagnostic criteria:

Criteria A

All of the following:

  1. Compulsive behavior and/or preoccupation with a restrictive diet to promote optimum health
  2. Violation of self-imposed dietary rules causes exaggerated fear of disease, a sense of personal impurity, and/or negative physical sensations, anxiety, and shame
  3. Dietary restriction increases over time and may come to include the elimination of food groups and cleanses. Weight loss commonly occurs but the desire to lose weight is not the focus.

Criteria B

Any of the following:

  1. Malnutrition, severe weight loss, or other medical consequences from a restricted diet
  2. Intrapersonal distress or impairment of social, academic, or occupational functioning due to beliefs or behaviors about healthy diet
  3. Self-worth, identity, and body image unduly dependent on compliance with one's “healthy” diet

Causes

There is little research on the causes of orthorexia nervosa, but it is likely that a number of different factors may be involved. Dr. Bratman has described what he believes are several risk factors for orthorexia:

  • Adoption of a highly restrictive dietary theory
  • Childhood illness involving diet and/or digestive issues
  • Fear of disease
  • Medical problems that can’t be addressed by medical science
  • Parents who place undue importance on healthy food
  • Traits of perfectionism, obsessive-compulsive disorder (OCD), and extremism

Studies have also suggested that people in certain professions, particularly in health-related careers, might be more likely to develop orthorexia. 

Other Risks

Dr. Bratman reported that the condition of orthorexia has already shown signs of evolution since he first conceived of it. He noted that exercise is more commonly a part of it than it was in the 1990s. He also reported that incorporating low-calorie foods has also become a bigger part of the healthy eating associated with orthorexia.

In cases where individuals pursue both purity and thinness, there may be an overlap between anorexia nervosa and orthorexia nervosa.

Orthorexia may also, on occasions, be a disguise for anorexia by individuals presenting a more socially acceptable way of staying thin. Orthorexia nervosa may also cross over with bulimia nervosa and Avoidant/Restrictive Food Intake Disorder (ARFID).

Belief System of Orthorexia

Although the behaviors (dietary restriction) and consequences (weight loss, malnutrition, bingeing and/or purging) associated with orthorexia nervosa may look similar to anorexia nervosa or bulimia nervosa, the main difference is in the content of the belief system.

Orthorexia
  • Focus on health

  • Does not hide their behavior

  • Typically do not skip meals

  • May resist treatments not perceived as healthy

Anorexia
  • Focus on weight loss

  • Shame, guilt, and attempts to hide their behavior

  • Skips meals and avoids eating

  • May resist treatments for fear of gaining weight

People with orthorexia primarily think about ideal health, physical purity, enhanced fitness, and avoiding disease. In contrast, patients with anorexia consciously focus on weight and restrict foods primarily based on calories.

People are usually ashamed of their anorexia and attempt to hide it, but persons with orthorexia may actively attempt to persuade others to follow the same health beliefs.

Those with anorexia nervosa often forego meals; people with orthorexia typically do not (unless they are intentionally “cleansing”).

Finally, when a person with anorexia is in treatment, they have no particular objection to being fed with products such as Ensure or Boost except regarding the calories, whereas a person with orthorexia would object to the chemicals in those supplements.

These distinctions in beliefs may be important. Treatment professionals’ misunderstanding of the concerns of someone with orthorexia may contribute to treatment failure.

Treatment

Although treatments have not been specifically validated for orthorexia, clinicians have reported that treatments that challenge the dietary theory and builds more flexible eating have been successful in the treatment of orthorexia.

If you or a loved one shows signs of orthorexia, please seek help from an eating disorder treatment professional. As with other eating disorders, early intervention increases the chance of a complete recovery and minimizes negative consequences.

If you don't have a doctor who specializes in eating disorders, speak with your primary healthcare professional first—he/she can most likely refer you to a specialized doctor. Be sure to discuss behaviors, day-to-day issues, and anything else related to your eating and well-being with your doctor.

Orthorexia Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Mind Doc Guide

Oftentimes, people with eating disorders cannot recognize the power the condition has over them—they may not even be inclined to speak with a doctor at all. If this is the case for you or a loved one, a doctor's visit (and hopefully a discussion with a doctor) is a great first step. From there, hopefully, intervention in the form of realistic treatment options can progress.

Coping

In addition to getting help from a qualified professional, there are also self-help strategies that you can use to help you cope with daily living with your condition. Some of these include:

  • Join a support group: Look online for support groups specifically for people who have symptoms of orthorexia. It can be helpful to connect with people who have had similar experiences. You can also find advice and tips on how to deal with the symptoms of the condition.
  • Set limits: If you find that working out, planning meals, or shopping for healthy foods are eating up most of your time, set a limit on how much time you can devote to such habits each day. Sticking to your limits can be difficult at first, but you may find that you are able to improve with time and practice.
  • Start slow: Orthorexia often involves very restrictive eating patterns, so work on very slowly breaking out of these habits. Try to incorporate new foods into your diet. Trying new recipes or restaurants can be a fun way to incorporate different nutritious foods into your eating plan.
  • Talk to a dietitian: It can be helpful to talk to someone with specific training to help you create a stick to a healthy eating plan. Talk about your past eating habits, come up with a nutritious plan that is less restrictive, and make regular appointments to keep track of your progress.

A Word From Verywell

Since orthorexia is only a proposed diagnosis, there is a great deal we do not know. For example, we do not know its relationship to the existing eating disorders, such as anorexia nervosa, bulimia nervosa, binge eating disorder, and ARFID. Nor do we know its relationship to anxiety disorders.

Research is needed to refine the diagnosis, determine prevalence rates, identify risk factors, and develop treatments. An important first step is developing an assessment tool; a 100-question survey is in development to assess and diagnose orthorexia.

One thing we do know is that, because it can cause malnutrition, orthorexia nervosa may produce any of the medical problems associated with anorexia nervosa including loss of menses, osteoporosis, and heart failure.

If you or a loved one are struggling with orthorexia nervosa, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database.

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Article Sources
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