Orthorexia: Eating Disorders Under the Guise of Health

When “Clean Eating” Morphs into an Eating Disorder

Orthorexia nervosa (ON) is a colloquial term used to describe an excessive preoccupation with “clean eating” or eating food that is healthy. The term orthorexia was introduced in 1997 by Dr. Steven Bratman as a proposed eating disorder for those whose dietary restrictions, intended to promote health, paradoxically lead to unhealthy consequences.

Orthorexia nervosa is not recognized as an eating disorder by the American Psychiatric Association and is not mentioned as an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is only a descriptor of a collection of disordered eating behaviors related to food quality and improving health.

For most of those living with orthorexia nervosa, it starts as an honest attempt to live healthier and only becomes disordered when a person starts restricting foods, cutting out entire food groups or becomes so rigid in their diet that they begin to eat a diminishing number of foods prepared in very specific ways. Paradoxically, the pursuit of health develops into an avoidance of foods necessary for health and wellbeing.

Orthorexia Nervosa as a Disorder

While exact rates remain uncertain due to the lack of standardized diagnostic criteria for ON, some studies indicate that orthorexia nervosa is becoming more prevalent, especially in Western societies with a strong emphasis on health and nutrition.

Risk factors associated with development of orthorexia nervosa can include:

• Perfectionism and neuroticism
• A history of dieting or body dissatisfaction
• Exposure to media promoting unrealistic body ideals and “clean eating” dieting trends
• Obsessive compulsive disease (OCD) or obsessive compulsive traits

Differentiating Orthorexia from Eating Disorder Diagnoses

Orthorexia is distinct from other eating disorders in the motivations behind the disordered eating behaviors. While anorexia nervosa, bulimia nervosa and binge eating disorder (BED) are primarily or partially characterized by disturbances in food quantity, orthorexia nervosa centers around food quality.

Orthorexia is also distinct from ARFID. Individuals with ON choose not to restrict their intake based on disinterest, sensory properties or aversive experiences with food, but because of a drive to be as healthy as possible. 

While orthorexia nervosa presents in ways unique from other eating disorders, there is still much overlap with other eating disorders, specifically anorexia nervosa. Just because someone has an existing diagnosis, it doesn’t exclude them from developing orthorexic disordered eating behaviors.

Signs & Symptoms of Orthorexia

A consensus definition and diagnostic criteria for ON using the Delphi process was recently proposed and includes:

• “A strong preoccupation with one’s eating behavior and with self-imposed rigid and inflexible rules which are strictly controlled and include spending an excessive amount of time for planning, obtaining, preparing and/or eating one’s food.”
• “The definition of ‘healthful eating’ or ‘pure eating’ includes a dietary theory or set of beliefs whose specific details may vary. Subjects with ON often refer to ‘healthy’ foods as pure, clean, organic, right, correct, natural, safe; ‘unhealthy’ food is often referred to as processed, with added ingredients, prepared, treated, toxic, contaminated such as to represent harmful consequences for the individual’s health. It might also include any other definition of healthy or unhealthy according to the affected individual (his/her background/culture/knowledge/moment in life) or to dietary trends and cultures.”
• “Individuals with ON experience emotional distress, anxiety (if they are confronted with food they believe to be unhealthy and they fear they might be impaired by eating them), problems concerning attention and concentration (if an individual thinks about healthy eating all day) and a feeling of guilt as a consequence of not being able to eat healthy.”
• “In ON, the adherence to self-imposed dietary rules has an undue influence on self-evaluation.”

Although orthorexia nervosa is not accepted as a formal diagnosis, the proposed diagnostic criteria can offer valuable insight into the clinical presentation of orthorexia nervosa. However, further research and consensus is needed to standardize, validate and understand orthorexia nervosa as a potential diagnosis.

Preoccupation with Optimum Health & Nutrition

Individuals with orthorexia nervosa have a preoccupation with achieving optimum health, which can also lead to an exaggerated fear of adverse health consequences. Patients may suffer from anxiety about their food choices, particularly around their diet not meeting their health goals. They may be extremely concerned about developing certain diseases, especially if they have a family health history of such diseases. Similar to those with anorexia nervosa and bulimia nervosa, an individual with orthorexia will spend an exceptional amount of time thinking about food. They might also ruminate about caloric information, health benefits, food processing and food preparation.

Obsession with Food Quality & Dietary Restriction

Those with orthorexia are more concerned with food quality than food quantity. They might be overly rigid in what they consider “good” food. Instead of being flexible when they don’t have access to food that meets their specifications, they rigidly adhere to their diet. They may refuse to eat or become anxious after eating when presented with food that doesn’t adhere to their requirements.

They may be overly concerned with certain “health foods” or terminology in absence of a food allergy or intolerance:

• Organic
• GMO-free
• Gluten-free
• Soy-free
• Whole grain
• Raw foods
• Unprocessed

Dietary restrictions can also escalate over time, leading to the exclusion of entire food groups, such as:

• Low/No Carb
• Low/No Sugar
• Low/No Fat

Those with orthorexia may frequently fast or “cleanse” (partial fast) to “purify” or “detox” from certain foods or additives. They might also use a large amount of or heavily rely on the use of food supplements.

Impact on Daily Life & Functioning

Similar to other eating disorders, like anorexia nervosa and bulimia nervosa, patients may build an identity around their disorder. For those with orthorexia, they base a large portion of their identity on the purity and perfection of their diet and tie their self-worth to adherence to their diet. An inability to adhere to strict dietary requirements may cause shame or anxiety. Many of those with ON will start devoting a large portion of their time to the pursuit of “clean eating” by researching nutrition, joining health food forums or participating in group fasting/detoxing. The pursuit of nutritional information, meal planning and meal preparation may take up an increasingly large portion of their day, impacting their ability to perform other tasks.

Those with orthorexia nervosa may notice their relationships with others begin to suffer as they:

• Have difficulty eating meals they did not prepare
• Feel uncomfortable eating at restaurants or unapproved establishments
• Spend an increasing amount of time planning meals, preparing meals or researching nutrition

Medical Complications of Orthorexia Nervosa

Despite pursuing a healthy diet, those with ON can experience medical complications, including malnutrition, nutrient and electrolyte deficiencies, osteoporosis, and food borne illness as a result.

Malnutrition

Prolonged adherence to restrictive diets, where certain foods or entire food groups are avoided, can compromise nutritional status. Prolonged food restriction often leads to malnutrition, which can cause a variety of medical complications across every organ system.

Nutritional Deficiencies

Prolonged malnutrition and dehydration can cause a deficit in electrolytes — including potassium, sodium, magnesium and phosphorus — and key vitamins and nutrients. These disturbances can lead to the development of a wide range of medical complications across the gastrointestinal, cardiovascular, musculoskeletal, renal (urinary) and nervous systems.

Refeeding Syndrome

Chronically malnourished patients are at risk of developing the potentially deadly complication, refeeding syndrome. Refeeding syndrome is comprised of the various clinical complications that develop due to a shift in fluids and electrolytes that occurs in significantly malnourished patients upon reintroduction of nutrition.

Osteoporosis (Low Bone Mineral Density)

Low weight, overexercising and hormonal changes from malnutrition can all contribute to low bone mineral density. Low bone mineral density is one of the few complications that may persist after medical stabilization.

Overexercising

Some individuals with orthorexia nervosa also participate in compulsive exercise. Exercising when malnourished or amenorrheic can have adverse effects on bone density despite its benefits when done appropriately at a healthy weight.

Hormonal Changes

There are numerous hormones that are affected by malnutrition and can have an adverse effect on bone mineral density, including:

• Gonadal hormones (i.e. testosterone, estrogen)
• Growth hormone
• Cortisol
• Adipokines and other gut hormones

Food Borne Illness

Some individuals with orthorexia nervosa adopt a raw diet, where they eat food that is raw and/or unprocessed (whole foods) which can increase their risk for food borne illness from raw or uncooked foods. They may also avoid preservatives in their foods. Foods without preservatives expire quicker, which can also lead to food borne illness with consumption of expired foods.

Treating Severe Orthorexia Nervosa

To date, there are no studies of treatment effectiveness for orthorexia nervosa, although there are suggested best practices. The ideal intervention involves a multidisciplinary team that includes physicians, psychotherapists and dieticians in an outpatient setting. For patients experiencing significant weight loss and malnutrition, inpatient medical stabilization and refeeding under the supervision of experienced physicians is required.

Treating Medical Complications

For those experience severe medical complications as a result of their eating disorder, medical stabilization, nutritional rehabilitation and serum electrolyte monitoring are essential for treatment.

Medical Stabilization

Medical stabilization is recommended for eating disorder patients who are severely low weight, are seriously medically compromised or are at risk for refeeding syndrome. Medical stabilization should be done under the supervision of those with experience normalizing vital signs, restoring cardiovascular and bowel function, resolving electrolyte and chemistry abnormalities and restoring levels of key electrolytes.

Nutritional Rehabilitation (Refeeding)

Nutritional rehabilitation for an eating disorder patient should be individualized and increasing caloric intake should be based on the expert opinion of a registered dietician and other clinical team members who have excellent knowledge of eating disorders. Weight gain early in the refeeding process can also be very slow as the body switches from a catabolic state to an anabolic state but caloric increases must still be done judiciously.

Monitoring Blood Values

It is important to monitor electrolytes, blood counts and glucose values closely during the refeeding process to prevent refeeding syndrome. Frequency of monitoring can be lowered as the patient becomes more medically stable. Monitoring phosphorous levels is particularly important since hypophosphatemia is a leading factor in the development of refeeding syndrome.

Other minerals, electrolytes and vitals to monitor during the early stages of refeeding include:

• Potassium
• Magnesium
• Glucose
• Hemoglobin
• Heart rate
• Blood pressure
• Oxygenation

Mental Health Treatment for Orthorexia Nervosa

While there is no consensus on the best modalities for orthorexia specifically, patients will likely see benefit from many of the existing treatment options for eating disorders, like psychoeducation, nutrition counseling and cognitive behavioral therapy (CBT).

Psychoeducation

Psychoeducation is foundational in eating disorder treatment. It providers patients with information about their condition, its underlying psychological factors and potential health consequences. Through psychoeducation, individuals are able to identify and address distorted beliefs and cognitive patterns about food and health.

Nutrition Counseling

Nutrition counseling is a vital intervention for those living with orthorexia nervosa. Patients should be given ample education on balanced nutrition as well as information about common misconceptions around food, health and nutrition. Healthcare and nutrition misinformation on social media may contribute to the development of orthorexia nervosa, so combatting these myths and working through a patient’s concerns can be an important tool in recovery.

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a first-line treatment for eating disorders. CBT is a form of psychotherapy focusing on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop effective coping mechanisms. CBT is not a singular therapeutic technique, and encompasses other treatments like Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT).

Enhanced Cognitive Behavioral Therapy (CBT-E) is a form of CBT especially designed for eating problems and disorders. It differs from standard CBT because it is based on and aims to address psychological and behavioral mechanisms specific to eating disorders.

While improving health is an admirable goal, for some it can develop into disordered eating, like in the case of those with orthorexia nervosa. While orthorexia nervosa is not a formal diagnosis, it is a common collection of disordered thoughts and behaviors that may require specific interventions.