Orthorexia Nervosa: When “Clean Eating” Morphs into an Eating Disorder

Orthorexia nervosa is an emerging form of disordered eating defined by a fixation on “clean” or “healthy” eating that leads to physical or mental health concerns. Though not officially recognized in the DSM, orthorexia nervosa shares features with anorexia nervosa and ARFID, and can result in malnutrition, health complications and impaired functioning. A multidisciplinary treatment approach can support recovery.

What is Orthorexia Nervosa?

Orthorexia nervosa is a term used to describe a preoccupation with “clean eating” or eating food that is perceived as healthy, that paradoxically negatively impacts health, often leading to health issues like malnutrition.

Orthorexia 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 describes a collection of disordered eating behaviors related to food quality and health improvement.

Proposed Diagnostic Criteria

There is support for orthorexia nervosa to be added to the DSM as an eating disorder. A consensus definition and diagnostic criteria for orthorexia nervosa using the Delphi process was recently proposed, including two lists of criterion for presentation and consequences.¹

Although orthorexia is not accepted as a formal eating disorder 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 as a diagnosis.

Presentation

The criterion proposed for definition, clinical aspects and duration includes:¹

• 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. It might also include any other definition of healthy or unhealthy according to the affected individual or to dietary trends and cultures
• Experience emotional distress, anxiety, problems concerning attention and concentration and a feeling of guilt as a consequence of not being able to eat healthy 
• Adherence to self-imposed dietary rules has an undue influence on self-evaluation
• Symptoms should are present for at least the last six months (unless there is a severe impairment of health or psychosocial functioning, the diagnosis can be given after only three months)

Consequences

The criterion proposed for consequences on health status, cognition and relationships:¹

• Involves disturbances of eating habits that lead to a nutritionally unbalanced diet that negatively affects health status (both physical and mental health), and quality of life
• Includes emotional, cognitive and/or social consequences, that have a negative effect on the individual’s educational, work or social life
• Has a negative impact on other important areas of psychosocial and personal functioning
• Food selectivity can contribute to cause nutritional deficiencies and hormonal disturbances
• May result in low body weight that corresponds to sociocultural ideals of healthiness or may overlap greatly with thin and muscular ideals.
• Low weight may be better conceived as a side effect or a consequence of orthorexia instead of as the result of body dissatisfaction

Orthorexia versus other eating disorder diagnoses

Just because someone has an existing diagnosis, it doesn’t exclude them from developing orthorexia-type disordered eating behaviors. However, there are some ways that orthorexia differs from other eating disorders.

Food quantity

What differentiates orthorexia and other eating disorders like anorexia nervosa, bulimia nervosa and binge eating disorder (BED) are the motivations behind the disordered eating behaviors. "While other eating disorders are primarily or partially characterized by disturbances in food quantity, orthorexia nervosa centers around food quality," explains Leah Puckett, MD, MPH, hospitalist at ACUTE.

Health

Orthorexia also differs from avoidant restrictive food intake disorder (ARFID). Individuals with orthorexia 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. 

Orthorexia Risk Factors

Anorexia nervosa

Orthorexia and anorexia nervosa share traits like perfectionism, anxiety and a strong need for control.² They also share traits of achievement orientation, viewing adherence to their diet as a sign of self-discipline and seeing deviation from the diet as a failure of self-control.³

Both also have limited insight into their condition and often deny the functional impairments linked to their disorder.

Obsessive-compulsive traits

There is overlap between OCD and orthorexia. Those with orthorexia nervosa often have certain obsessive-compulsive traits:^3,4

• Recurrent, intrusive thoughts about food and health at inappropriate times
• Inflated concern over contamination and impurity
• A strong need to arrange food and eat in a ritualized manner.

Similar to those with OCD, individuals with orthorexia have little time for other activities because following a strict eating style disrupts normal routines.

Career & athletics

Athletes, performers and those whose careers focus on nutrition and health for performance may be at risk for orthorexia.⁵ These individuals are likely to be especially sensitive to health and nutrition issues, may feel pressure to serve as health role models and often exhibit tendencies toward perfectionism.⁵ This includes:

• Healthcare providers
• Actors and performers
• Models
• Influencers

What Makes Orthorexia Nervosa Different from Healthy Eating?

Orthorexia nervosa is not just a passion for health or being mindful about what one eats. Healthy eating is additive; it nourishes both the body and the soul. It helps individuals meet their nutritional needs and provides the energy to stay active, maintain relationships and participate in daily activities.

Conversely, orthorexia is restrictive and limiting. It often turns into an obsession that takes over many people’s lives and ultimately results in malnutrition, social impairment and a decrease in overall health.⁶

Signs & Symptoms of Orthorexia Nervosa

Health anxiety

Individuals with orthorexia nervosa often experience health anxiety, which may present as a preoccupation with achieving optimal health or an excessive fear of health problems. Patients might worry about their food choices or be overly concerned about developing certain diseases, especially if there is a family history of those illnesses. 

Preoccupation with optimum health & nutrition

Someone with orthorexia will spend a significant amount of time thinking about food. They might also ruminate on macronutrients and micronutrients, health benefits, food processing or food preparation.

Obsession with food quality

People with orthorexia are likely to be more concerned with food quality than quantity.⁷ They can be excessively strict about what they label as “good” food. They may also be preoccupied with certain “health foods” or terminology even when they don't have a food allergy or intoleranc:

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

Dietary restriction

Someone with orthorexia nervosa might refuse to eat entirely if food that meets their quality standards isn’t available. Dietary restrictions can also worsen over time, leading to the exclusion of entire food groups, such as:

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

Frequent fasting or “detoxing”

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

Meal planning takes over their life

For many individuals with orthorexia nervosa, meal planning can take over their life. They 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. This can take up an increasingly large portion of their time at the expense of other areas of life, including their relationships.⁷

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

Diet defines self-worth

Like anorexia nervosa and bulimia nervosa, patients with orthorexia may develop an identity centered on their condition. They often base much of their self-image on the purity and perfection of their diet and tie their self-worth to strict adherence to it.⁷

Medical Complications of Orthorexia Nervosa

Malnutrition

Prolonged adherence to restrictive diets, where specific foods or entire food groups are avoided, can compromise nutritional status.² 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 lead to deficiencies in electrolytes — including potassium, sodium, magnesium, and phosphorus — as well as essential 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 includes various clinical problems caused by fluid and electrolyte shifts that happen in severely malnourished patients when nutrition is restarted.

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

Numerous hormones 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, a diet consisting mostly of raw and 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, which expire faster and can cause foodborne illnesses.

Medical Treatment for Orthorexia Nervosa

To date, there are no studies of treatment effectiveness for ON, although there are suggested best practices.

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 in these areas:

• Normalizing vital signs
• Restoring cardiovascular and bowel function
• Resolving electrolyte and chemistry abnormalities and restoring levels of key electrolytes

Nutritional rehabilitation

Nutritional rehabilitation for an eating disorder patient should be individualized. 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

Psychological Treatment for Orthorexia Nervosa

Psychoeducation

Psychoeducation is essential in treating eating disorders. It gives patients information about their condition, including psychological factors and potential health risks. By providing psychoeducation, individuals can recognize and challenge distorted beliefs and patterns related to food and health.

Nutrition counseling

Nutrition counseling is crucial for individuals with ON. Patients need thorough education on balanced eating and should be informed about common misconceptions related to food, health and nutrition. Misinformation on social media about healthcare and nutrition can contribute to orthorexia, so debunking these myths and addressing patient concerns are key steps in recovery.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a first-line treatment for eating disorders. CBT is a type of psychotherapy that focuses on challenging and changing cognitive distortions and their related behaviors to enhance emotional regulation and develop effective coping skills. CBT is not a single technique; it includes other approaches like acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT).

Enhanced cognitive behavioral therapy

Enhanced cognitive behavioral therapy (CBT-E) is a type of CBT specifically designed for eating problems and disorders. It differs from traditional CBT because it focuses on and aims to treat the psychological and behavioral mechanisms unique to eating disorders.

How Common is Orthorexia?

Existing estimates of orthorexia range from 7-57% in the general population, with rates as high as 82% in specific groups.⁵

However, studies vary on whether orthorexia is more common among women or men.⁵ There are also no consistent findings on the prevalence of orthorexia based on age, education level, body mass index, smoking status and alcohol consumption.⁵ This likely results from the lack of agreement on the definition and diagnostic criteria for orthorexia.

Find Help for Orthorexia Nervosa

If orthorexia is causing serious medical complications, getting support isn’t just helpful, it’s essential for your health. Medical stabilization and nutritional rehabilitation can address many of the complications of an eating disorder and help your body start healing. With the right specialized treatment, recovery from any eating disorder is possible.

Start now with a free assessment.

References

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2. Bosi, A. T. B., Çamur, D., & Güler, Ç. (2007). Prevalence of orthorexia nervosa in resident medical doctors in the faculty of medicine (Ankara, Turkey). Appetite, 49(3), 661–666. https://doi.org/10.1016/j.appet.2007.04.007
3. Bratman S, Knight D. Health Food Junkies: Orthorexia Nervosa– Overcoming the Obsession With Healthful Eating. New York, NY: Broadway; 2000.
4. Kinzl, J. F., Hauer, K., Traweger, C., & Kiefer, I. (2006). Orthorexia nervosa in dieticians. Psychotherapy and Psychosomatics, 75(6), 395–396. https://doi.org/10.1159/000095447
5. Koven N, Abry A. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatr Dis Treat. 2015;11:385-394 https://doi.org/10.2147/NDT.S61665
6. Dunn, T. M., & Bratman, S. (2015). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11–17. https://doi.org/10.1016/j.eatbeh.2015.12.006
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