What Is Orthorexia Nervosa?

What Is Orthorexia Nervosa?

The term “orthorexia nervosa” describes an obsession with healthy, "pure," or "clean" eating. It was coined as an analogy to anorexia nervosa: “ortho,” meaning right; “orexia,” meaning hunger; and “nervosa” meaning fixation or obsession.

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 he did not originally take the diagnosis seriously, he later discovered that people were experiencing serious health consequences as a result of the condition.

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.

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. These restrictions tend to lead to elimination of entire food groups and/or the addition of cleanses, fasts, and detoxes.
• 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 as well as anxiety.
• 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.

Diagnosis

In a 2016 paper in the journal Eating Behaviors, Dr. Bratman and his co-author, 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

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. Researchers are currently proposing the use of the diagnostic tool ORTO-R, which contains six items from ORTO-15 determined to be the best markers of orthorexia nervosa.

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 now 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.

Orthorexia may also, on occasion, 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).

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.

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.

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.

Treatment

Although treatments have not been specifically validated for orthorexia, clinicians have reported that treatments that challenge the dietary theory and build 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.

Counseling is the mainstay of treatment. Some treatment approaches that may be recommended include cognitive behavioral therapy and dialectical behavior therapy. Medications such as antidepressants and anti-anxiety medications may also be helpful.

If you don't have a doctor who specializes in eating disorders, speak with your primary healthcare professional first—they 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

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Often, people with eating disorders cannot recognize the power the condition has over them. In fact, people with orthorexia still believe what they are doing is to be healthy and don't see it as problematic. They may not even be inclined to speak with a doctor at all.

If your current thoughts and/or behaviors surrounding food is causing distress and/or impacting your daily functioning, then it is advised to seek professional help.

Coping

In addition to getting help from a qualified professional, there are also self-help strategies that you can use to help you manage daily life 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 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.