Orthorexia
Many people strive to eat foods that are wholesome and nourishing. But some people go to extreme lengths to “eat clean” at all times. This may lead to a disordered eating pattern known as orthorexia nervosa (or, simply, orthorexia).
What is orthorexia?
Orthorexia occurs when a person’s obsession with eating only “clean” or “healthy” foods negatively affects their physical health, mental health or personal relationships [1]. People with orthorexia seek dietary perfection or purity. This quest includes consuming only the “right” or “pure” foods, vitamins and supplements [2].
Orthorexia nervosa meaning
Orthorexia stems from the Greek words for “right” and “appetite.” The term means “correct appetite.” Orthorexia nervosa refers to a disordered eating pattern where people obsessively focus on eating “pure” or “clean” foods to achieve optimal health [1].
Orthorexia definition
When it comes to orthorexia, there is currently no clinical definition of the condition. Experts do agree that individuals with orthorexia-type disordered eating often experience several key symptoms:
- An obsessive focus on achieving optimal health through eating the “right” foods
- Preoccupation with food, inflexible food rules and compulsive behaviors related to food
- Clinically significant medical, mental or physical health consequences [1]
Currently, there is no official definition of orthorexia nervosa, but studies are ongoing to develop a clear definition [3].
Orthorexia vs. common eating disorders
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Orthorexia nervosa
People with orthorexia seek out “clean” or “pure” foods. They may or may not want to change their body weight or size. Orthorexia is associated with restricting certain types of foods. Over time, restriction and a fixation with food purity negatively affects one’s physical health, mental health and personal relationships.
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Orthorexia vs. anorexia and bulimia
People with anorexia and bulimia change their food intake and other behaviors to change their body weight or size. They may or may not develop orthorexia-type fixations to consume only “clean” or “pure” foods. Symptoms of restricting, bingeing or purging with anorexia and bulimia can cause serious mental and physical health complications.
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Orthorexia vs. binge eating disorder
Binge eating disorder (BED) symptoms include binge eating on a regular basis and feeling a lack of control with how much one eats. People with BED may or may not want to change their body weight or size. BED is often associated with feelings of guilt, shame and distress.
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Orthorexia vs. ARFID
Avoidant/restrictive food intake disorder (ARFID) symptoms include restricting food due to sensory features, worrying about choking or vomiting, or having no interest in food. As with orthorexia, people with ARFID may experience specific food-related beliefs or have a tendency toward obsessive-compulsive disorder (OCD). With ARFID, the obsession with eating “clean” or “pure” foods is not commonly seen or observed.
Orthorexia and food restriction
Restricting one’s diet in any way can lead to eating disorders, malnutrition, and mental and physical health concerns. While orthorexia is not officially recognized as an eating disorder, many eating disorder experts believe that orthorexia symptoms are clinically significant and can be addressed in an eating disorder treatment program.
What causes orthorexia?
Dieting is one of the main gateways leading to disordered eating and eating disorders. A person with a history of dieting who starts to eat more “clean” or “healthy” may develop orthorexia if their “clean eating” goes to an extreme.
Factors Increasing the Risk of Orthorexia [4-6]
- History of eating disorder thoughts and behaviors
- Perfectionism
- Rigid thinking and inflexibility
- Focus on health and well-being
- Being an athlete or fitness practitioner
Clean eating vs. orthorexia
A worldwide trend has emerged in recent years whereby people pursue a quest for clean eating. With a goal of making healthy lifestyle changes, they may try to avoid processed foods, artificial coloring or artificial flavoring. They may try to consume organic whole foods in their natural state as much as possible. Many people cite "clean eating" as helping them overcome mental and physical health challenges. However, a quest for clean eating can lead to food restriction and rigid food choices that can potentially cause nutritional deficiencies and/or malnutrition.
One of the challenges in trying to eat “clean” and “pure” is that we can never fully control what we consume. We can’t always control where our food comes from, how it is transported, how it is prepared and how it is consumed. This lack of control combined with the quest for perfection in eating can cause a great deal of suffering for individuals.
Who is at risk for orthorexia?
Researchers have found certain personality traits and factors to increase the risk of developing orthorexia:
- Perfectionism
- Neuroticism
- Obsessive and compulsive tendencies (a desire for control and order)
- History of dieting
- Poor body image or body dysmorphia
- Seeing unrealistic body images portrayed in the media (especially social media)
- Family history of eating disorders
Reading or listening to misinformation about food safety and false health claims may also increase the risk of orthorexia [7].
Orthorexia symptoms
Orthorexia includes obsessive thoughts about food quality, cleanliness or purity.
- A person with orthorexia may choose to only eat food items they consider to be clean, healthy, pure, or holy.
- They may limit or restrict specific foods or entire food groups.
- They may spend a lot of time shopping for, preparing and cooking foods.
As an example, some people with orthorexia choose to eat only raw foods because they believe those are the most healthy or pure foods. This fixation can cause stress and anxiety in social gatherings when the preferred food is not present. The time spent shopping and preparing food can cut into time spent at school, at work, on hobbies and in relationships.
Orthorexia signs to watch for
- An obsession with food’s health value, cleanliness or purity
- A constant pursuit of wellness
- Refusal to eat foods that are not organic or locally grown
- Refusal to eat foods if they don’t know the source (farm, factory) of the food
- Extreme food restrictions (cutting out entire food groups because they are “toxic”)
- Anxiety when the person must eat foods off their “banned foods” list
- Complete avoidance of “junk” foods or foods considered unhealthy
- Extreme concern about possible chemicals or toxins in food, whether they have been proven to be harmful or not
- Frequently posting pictures of perfectly healthy meals
- Taking an extreme amount of time to order, shop for and prepare foods (may visit multiple grocery stores to buy only foods that are organic and locally grown/produced)
- Fixation on clean, pure, or holy foods vs. toxic or dirty foods
- Rigid thinking and distorted beliefs about food
- Being preoccupied with food, including persistent, uneasy or disturbing thoughts about food
Orthorexia social behaviors
In many cultures, food is central to social gatherings and celebrations. This means that orthorexia can affect a person’s social life. If a person has near-impossible standards of what they can eat, they may struggle to eat at restaurants, at the homes of friends or in other social settings. This may show up as:
- Only eating with people who make the same food choices
- Eating before or after social gatherings
- Skipping or avoiding meeting friends at restaurants or for coffee
- Avoiding work events that serve food
- Avoiding gatherings at school or college that revolve around food
- Avoiding holiday parties
If you know someone with orthorexia, they may frequently comment on the type of food you buy. They may ask, “how can you eat things that are so terrible for you?” As a result of their thoughts and behaviors, people with orthorexia may end up isolated.
Orthorexia complications
The symptoms of orthorexia (rigid food rules, restrictive food choices and compulsions about food) are associated with distress and difficulty functioning.
Physical complications of orthorexia
- Nutritional deficiencies (protein, fat, vitamins, minerals) or malnutrition
- Osteoporosis
- A weakened immune system
- Gastrointestinal issues
- Impact on organ function
- Hormone changes
Mental health consequences of orthorexia
- Anxiety and depression
- Social isolation and withdrawal
- Feelings of shame and guilt
- Feeling like a failure
- Relationship challenges and struggles
Orthorexia treatment
We have worked with many individuals in our treatment centers with signs of orthorexia. These individuals have come to us because they are malnourished and experiencing serious mental and physical health issues. In treatment, we help individuals recover from orthorexia by offering:
- Evidence-based eating disorder therapies
- Nutritional counseling and education
- Psychoeducation and social support
- Treatment for medical issues and co-occurring mental health conditions
Since no two people will have the same orthorexia symptoms, treatment looks different for each individual and is highly personalized. Nutritional deficiencies and imbalances are all addressed in treatment [7].
Therapy for orthorexia
Therapy for orthorexia is similar to treatment for other eating disorders. Therapy for orthorexia may also look like therapy for obsessive-compulsive disorder (OCD). Therapists work with each patient on an individual basis and within a group setting to help them identify coping skills to manage their fixations, obsessions and compulsions. Values work is often incorporated into therapy as well. At Eating Recovery Center, we use a variety of evidence-based therapies to help people overcome orthorexia.
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CBT for orthorexia
Cognitive behavioral therapy can be particularly helpful for orthorexia as the individual challenges distorted beliefs and eating patterns. Rigid thoughts and behaviors are challenged in a structured way while coping skills are taught to reduce anxiety and stress related to eating food that is not considered “pure.”
Psychoeducation and social support
Psychoeducation is an important component of orthorexia treatment. Providers offer education on orthorexia symptoms, explore the risk of mental and physical health concerns, and discuss psychological issues related to orthorexia. Along with medical management, therapy and nutritional counseling, support from family, friends and peers is extremely helpful when a person is recovering from an eating disorder. Family therapy and group therapy are both integrated into eating disorder treatment.
Nutritional counseling for orthorexia
Nutritional counseling for orthorexia involves working with a registered dietitian to receive counseling, education, meal planning, meal support and more. Using an individualized orthorexia treatment plan, we do the following:
- We support people in developing more normalized eating patterns: eating several meals and snacks a day containing a variety of nutrients.
- Depending on one’s symptoms and the severity of their illness, we may work to help them eat more of their “safe” foods first. Safe foods are the foods that an individual with orthorexia believes to be pure or clean.
- Over time, we will incorporate more challenging foods into the individual’s meal plan. These are often referred to as “fear” foods.
- We may create a fear food hierarchy, identifying foods that are most feared and rank them with foods that are least feared (safe).
- People with orthorexia are often fixated with controlling everything they eat. In treatment, that control is challenged. Treatment naturally evolves as the individual no longer can control where their food comes from, how it is prepared and what is in each individual meal.
As the individual makes progress, they start to go on outings to eat in restaurants and other settings. This can be challenging at first, but the treatment team supports them through the entire process.
Orthorexia origins [8]
The doctor who coined the term orthorexia nervosa wrote that orthorexia nervosa refers to a pathological fixation on eating proper food. He also referenced the pseudo-spiritual nature of eating pure food that may lead one to perform numerous acts of penitence and ever-stricter diets and fasts.
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Orthorexia FAQ
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How is orthorexia connected to diet culture?
Diet culture preaches extreme messages and can inspire extreme eating disorder thoughts and behaviors because the underlying message is “you are not good enough as you are.” If diet culture did not exist, eating disorders like orthorexia might not exist. Some of the conflicting messages of diet culture that may lead to orthorexia include:
- “Carbs are bad.”
- “Organic food is good.”
- “Factory farming and GMOs are bad.”
- “Only eat local.”
- “You must lose weight no matter the cost.”
(Please note, the above list refers to messages promoted in diet culture. These statements are not supported or endorsed by Eating Recovery Center.)
The consequences of diet culture include feelings of guilt, shame and regret, low self-esteem, body image issues and a cycle of restricting, binge eating or purging the food we eat.
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How is orthorexia different from anorexia?
People with orthorexia are primarily focused on whether a food is “clean,” “pure” or “healthy” whereas those with anorexia are primarily focused on their body size, weight and shape. When it comes to eating disorder diagnosis, anorexia is a well-researched eating disorder that is included in the DSM-5. Orthorexia is not a distinct diagnosis in the DSM-5, although people with anorexia and other eating disorders may have symptoms of orthorexia. Get more facts about anorexia here.
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Is orthorexia related to OCD?
People with OCD may face higher risks of having orthorexia than others. Some people with OCD may hyperfocus on food rituals. Orthorexia may be seen as a food ritual taken to the extreme. Shopping, preparing and cooking food is seen as part of the ritual to help the person feel “safe,” “clean” or “holy.” As orthorexia obsessions and compulsions become more frequent, and as foods are restricted more and more, the individual can become malnourished. In malnourished individuals, mental health begins to deteriorate. The brain of someone who is malnourished will focus even more on obsessions and compulsions.
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Do food allergies cause orthorexia?
Cutting out any food or group of foods can increase the risk for developing an eating disorder like orthorexia. When people stop consuming dairy products due to a milk allergy, or cut out gluten-containing products for celiac disease, they may develop more generalized fears and anxieties around food. This can lead to extreme or obsessive thoughts and behaviors related to eating. However, many people with food allergies and intolerance do not develop eating disorders.
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Can following a vegan or vegetarian diet lead to orthorexia?
Since people eating a vegan or vegetarian diet are choosing to eliminate specific foods or entire food groups, they face an increased risk of developing eating disorders like orthorexia. Some people choose to go vegan or vegetarian because they believe it is a socially acceptable way to restrict the foods they eat. However, many people who eat vegan or vegetarian diets do not develop eating disorder thoughts and behaviors.
Sources
- Cena, H., Barthels, F., Cuzzolaro, M., et al. (2019). Definition and diagnostic criteria for orthorexia nervosa: A narrative review of the literature. Eating and Weight Disorders, 24, 209-246. https://doi.org/10.1007/s40519-018-0606-y.
- Mehler, P.S., & Andersen, A.E. (2022). Eating disorders: A comprehensive guide to medical care and complications (4th ed.). Johns Hopkins University Press.
- Donini, L,M., Barrada, J.R., Barthels F., et al. (2022). A consensus document on definition and diagnostic criteria for orthorexia nervosa. Eating and Weight Disorders, 27(8), 3695-3711. doi: 10.1007/s40519-022-01512-5.
- Novara, C., Pardini, S., Maggio, E., et al. (2021). Orthorexia nervosa: Over concern or obsession about healthy food? Eating and Weight Disorders, 26, 2577-2588. https://link.springer.com/article/10.1007/s40519-021-01110-x.
- Messer, M., Liu, C., McClure, Z., Mond, J., Tiffin, C., & Linardon, J. (2022). Negative body image components as risk factors for orthorexia nervosa: Prospective findings, Appetite, 178. https://doi.org/10.1016/j.appet.2022.106280.
- López-Gil, J.F., Tárraga-López, P.J., Soledad Hershey, M., López-Bueno, R., Gutiérrez-Espinoza, H., Soler-Marín, A., Fernández-Montero, A., & Victoria-Montesinos, D. (2023). Overall proportion of orthorexia nervosa symptoms: A systematic review and meta-analysis including 30 476 individuals from 18 countries. Journal of Global Health, 13. https://doi: 10.7189/jogh.13.04087.
- Horovitz, O., & Argyrides, M. (2023). Orthorexia and orthorexia nervosa: A comprehensive examination of prevalence, risk factors, diagnosis, and treatment. Nutrients, 15(17), 3851. doi: 10.3390/nu15173851.
- Bratman, S. (1997). The health food eating disorder. Yoga Journal
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