Orthorexia nervosa is an eating disorder that involves a fixation on healthy eating. A person with the disorder may focus so much on optimal nutrition that it impacts other aspects of their life.
Healthy eating can lead to major improvements in health and well-being.
However, for some people, focusing on healthy eating can become obsessive and develop into an eating disorder called orthorexia or orthorexia nervosa.
Like other eating disorders, orthorexia can have severe consequences. People with orthorexia become so fixated on healthy eating that it negatively affects their well-being.
Orthorexia is complex and not fully understood. In some cases, orthorexia can be linked to other conditions, such as obsessive-compulsive disorder (OCD) and other eating disorders.
However, some argue that orthorexia should have its own diagnostic criteria and treatment plan.
This article explains everything you need to know about orthorexia, including its signs and symptoms, the negative health effects it may promote, and the treatments currently available.
What is orthorexia nervosa?
Orthorexia, or orthorexia nervosa, is an eating disorder that involves an unhealthy obsession with healthy eating.
American physician Steve Bratman first coined the term “orthorexia” in 1997. The term is derived from the Greek words “orthos,” which means “right,” and “orexis,” which means “appetite.” However, it’s better translated as “correct diet.”
Unlike other eating disorders, orthorexia mostly revolves around food quality, not quantity. Unlike those with anorexia nervosa or bulimia nervosa, people with orthorexia mostly focus on the perceived healthfulness of food rather than on losing weight or being thin.
They have an extreme fixation on the “purity” or “cleanliness” of their foods and an obsession with the benefits of healthy eating.
The medical community is beginning to recognize orthorexia. However, neither the American Psychiatric Association nor the current edition of the industry standard “Diagnostic and Statistical Manual of Mental Disorders” has officially defined it as an eating disorder.
Summary: Orthorexia nervosa is an eating disorder that involves an unhealthy obsession with optimal nutrition. People with this disorder become so preoccupied with the perceived healthfulness of food that it adversely affects their health and daily activities.
Signs and symptoms of orthorexia nervosa
Although orthorexia does not have official diagnostic criteria, it does have common signs and symptoms, including:
- experiencing intense fear of “unhealthy” foods and avoiding those foods
- having an obsession or preoccupation with healthy foods, nutrition, and eating
- being unable to deviate from a specific eating style or dietary regimen without feeling extreme anxiety
- obsessively checking ingredient lists and nutrition labels
- cutting out large groups of food despite having no medical, religious, cultural, or ethical reason for doing so (e.g., gluten, sugar, all carbs, all fats, animal products)
- spending unusually large amounts of time planning, buying, and preparing meals they perceive as healthy, to the point that it interferes with other areas of life
- having an unusual interest in or excessively critical view of other people’s eating habits
- spending an unusual amount of time reviewing menus or thinking about the foods served at events
- avoiding social events and foods prepared by other people
- bringing premade meals to events as a result of the belief that other people’s food will not meet their standards of “healthy”
- experiencing unintentional malnutrition or weight loss as a result of severe food restrictions
- fixating on preventing or curing disease with food or “clean eating”
For people with orthorexia, violating the healthy eating “rules”, they set for themselves or “caving” to cravings for foods they perceive as unhealthy leads to severe emotional distress and a decreased sense of self-worth.
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Often, people with orthorexia feel that their self-worth depends on their ability to meticulously follow a lifestyle that they consider healthy.
The most common sign of orthorexia is an obsession with healthy eating that negatively affects your life.
Summary: Eating healthy becomes unhealthy when an obsession affects daily life. People with orthorexia feel that their self-worth depends on following a healthy diet, and they experience extreme anxiety when this feels out of their control.
Trying to “do it right” regarding nutrition may feel tempting, but it can backfire. If you are preoccupied with food or weight, feel guilt surrounding your food choices, or routinely engage in restrictive diets, consider reaching out for support. These behaviors may indicate a disordered relationship with food or an eating disorder.
Disordered eating and eating disorders can affect anyone, regardless of gender identity, race, age, socioeconomic status, or other identities.
They can be caused by biological, social, cultural, and environmental factors — not just by exposure to diet culture.
Feel empowered to talk with a qualified healthcare professional, such as a registered dietitian, if you’re struggling.
What causes orthorexia?
Although you may begin a diet simply intending to improve your health, this focus can become more extreme. Over time, good intentions and an interest in supporting your health via food choices can develop into orthorexia.
Although researchers aren’t sure exactly what causes orthorexia, many factors seem to play a role in its development.
Risk factors for developing orthorexia
Research on the precise causes of orthorexia is sparse, but obsessive-compulsive tendencies and past or current eating disorders are known risk factors. In some cases, orthorexia may manifest as a more “socially acceptable” way to restrict food.
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Other individual risk factors include tendencies toward perfectionism, high anxiety, and a need for control.
Social factors such as nutrition knowledge, higher income, access to “clean” foods (e.g., organic produce), use of social media, and weight stigma or bias are also associated with orthorexia-related behaviors.
In university settings, students in health-related majors (such as nutrition and dietetics, biology, and kinesiology) may be more likely to demonstrate orthorexia symptoms than those in other majors — although orthorexia can affect any student, regardless of their major.
Further, the rapid increase in promoting “clean eating” lifestyles on social media may also play a role in developing orthorexia.
Proponents of clean eating promote whole, minimally processed foods, which are healthy. But the phrase “clean eating” moralizes food by painting other foods as “dirty” or undesirable. Moralization stigmatizes some foods, contributing to eating disorders such as orthorexia.
However, there is no official diagnostic tool for orthorexia, so it’s difficult to ascertain what puts a person at a higher risk. Therefore, more research is needed.
Summary: The exact causes of orthorexia are unknown. However, certain personality and social risk factors, such as high anxiety, a history of disordered eating, social media exposure, and interest in health and wellness, have been identified.
How common is orthorexia?
Sometimes, it can be hard to differentiate between orthorexia and an interest in healthy eating.
Also, because orthorexia has no universally agreed-upon diagnostic criteria, different studies use different criteria for diagnosing it.
Studies focusing on groups of people more likely to have orthorexia — such as university students, vegans, and healthcare workers — will likely result in higher incident rates than studies of the general public.
For example, one review found that the prevalence of orthorexia ranged from 6.9% in the general Italian population to 88.7% among Brazilian nutrition students.
Also, vegans and vegetarians seem to have higher rates of orthorexia. However, for these populations, choosing to be vegan or vegetarian is a symptom of orthorexia rather than a cause.
Moreover, some criteria for orthorexia don’t assess whether orthorexia-based behaviors negatively affect the person’s social, physical, or mental health, even though evaluating distress is a crucial part of defining orthorexia as a disorder.
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Enthusiasm for healthy eating transforms into orthorexia only when it becomes an obsession that negatively affects everyday life, such as an extreme fear of eating certain foods or a refusal to eat out with friends.
For this reason, it’s hard to determine how common orthorexia is.
However, when these negative effects are considered, orthorexia rates drop to less than 1% of the population, which is more aligned with the rates of other eating disorders.
Summary: The rate of orthorexia among the general public seems to be around 1%. However, it appears higher in certain groups, such as university students in health-related majors, healthcare workers, and vegetarians and vegans.
How is orthorexia diagnosed?
Because orthorexia has no formal diagnostic criteria, it’s unclear whether orthorexia is a unique eating disorder, a part of another eating disorder such as anorexia nervosa, or a subtype of OCD.
That said, healthcare professionals may use many proposed diagnostic tools to diagnose orthorexia. These include:
- ORTO-15. This is a 15-question screening tool used to identify symptoms and behaviors related to orthorexia. A score of 40 is the cutoff for diagnosis. However, this tool has been criticized for its inability to differentiate between pathological eating behaviors and eating-related values (e.g., ethical veganism and religious beliefs).
- ORTO-R. This newer version of ORTO-15 includes the six most relevant questions related to orthorexia symptoms and behaviors.
- Bratman Orthorexia Test (BOT). This is a 10-question screening tool consisting of “Yes/No” responses. The questions are based on obsessive thinking about food, beliefs about nutrition and health, restriction, and other factors. However, it’s not commonly used.
- Eating Habits Questionnaire (EHQ). This 21-item questionnaire measures knowledge, positive vs. negative feelings, and problematic behaviors related to healthy eating. However, studies have suggested that it needs improvement before it can be a valid diagnostic tool for orthorexia.
Bratman and Dunn (2016) proposed the two diagnostic criteria: an obsessive focus on healthy eating and behavior that disrupts daily life to make the distinction between healthy eating and orthorexia clearer.
1. An obsessive focus on healthy eating
The first part is an obsessive focus on healthy eating that involves exaggerated emotional distress related to food choices. This can include:
- Behaviors or thoughts. The person experiences compulsive behaviors or mental preoccupations with dietary choices that they believe will promote optimal health.
- Self-imposed anxiety: Breaking self-imposed dietary rules causes anxiety, shame, fear of disease, a sense of impurity, or negative physical sensations.
- Severe restrictions. Dietary restrictions escalate over time and can include eliminating entire food groups, adding dangerous cleanses or fasts, or both.
2. Behavior that disrupts daily life
The second part is a compulsive behavior that prevents typical daily functioning. This can happen in any of the following ways:
- Medical issues. Malnutrition, severe weight loss, or other medical complications are health conditions that can result from this compulsive behavior.
- Lifestyle disruption. Personal distress or difficulty with social or academic functioning due to beliefs or behaviors related to healthy eating can cause lifestyle disruptions.
- Emotional dependence. Body image, self-worth, identity, or satisfaction can be excessively dependent on complying with self-imposed dietary rules.
More research into orthorexia will help establish better methods for diagnosis.
Summary: There is no official diagnostic tool for orthorexia. A few diagnostic tools exist, such as ORTO-15, ORTO-R, the Bratman Orthorexia Test, and the Eating Habits Questionnaire, but all have limitations.
Negative health effects of orthorexia
The negative health effects linked to orthorexia generally fall into one of the following three categories:
1. Physical effects
Although studies on orthorexia are limited, this condition will likely lead to many of the same medical complications as other eating disorders.
For instance, a shortage of essential nutrients caused by restrictive eating can result in malnutrition, anemia, or an abnormally slow heart rate.
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Severe malnutrition may lead to digestion problems, electrolyte and hormonal imbalances, metabolic acidosis, general weakness, and a weakened immune system.
These physical complications can be life-threatening and shouldn’t be underestimated.
2. Psychological effects
People with orthorexia can experience intense frustration when their food-related habits are disrupted.
Moreover, breaking self-imposed dietary rules will likely cause guilt, self-loathing, or a compulsion toward “purification” through dangerous cleanses or fasts.
In addition, people with orthorexia spend a lot of time scrutinizing whether certain foods are “clean” or “pure” enough. This can include concerns about vegetables’ exposure to pesticides, hormones used in dairy production, and artificial flavors or preservatives.
They may spend extra time researching, cataloging, weighing, and measuring food or planning future meals outside of meals.
This preoccupation with diet may compromise their ability to function daily, leading to decreased productivity, social activity, and enjoyment.
3. Social effects
People with orthorexia feel anxious or threatened when considering giving up their perceived control around food.
They often follow strict, self-imposed rules dictating which foods can be combined in a sitting or eaten at particular moments during the day.
Such rigid eating patterns can make it challenging to participate in social activities revolving around food, such as dinner parties or eating out.
Intrusive food-related thoughts and the tendency to feel that their food habits are superior to others may further complicate social interactions.
These effects can lead to social isolation, which seems to be common among people diagnosed with orthorexia.
Summary: The rigid eating patterns, intrusive food-related thoughts, and feelings of moral superiority associated with orthorexia may have many negative physical, psychological, and social effects.
How orthorexia is treated
The health effects of orthorexia can be just as severe as those of other eating disorders. If left untreated, orthorexia can result in irreversible damage to a person’s health.
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The first step toward overcoming orthorexia is identifying its presence.
Acknowledging the problem can be challenging because people with this disorder are less likely to recognize its negative effects on their health, well-being, or social function. Many may believe their behaviors are promoting health rather than harming it.
Once an individual can recognize these negative effects, it’s recommended that they seek help from a multidisciplinary team that includes a doctor, a psychologist, and a registered dietitian.
In some cases, eating disorder experts will treat orthorexia as a variety of anorexia and/or of OCD and will discuss treatments such as:
- psychotherapy to treat underlying disorders such as anxiety, depression, or OCD
- gradual exposure and reintroduction to trigger foods
- behavior modification
- cognitive reframing or restructuring
- various forms of relation training (e.g., meditation, yoga, tai chi, guided imagery, breathing exercises)
- weight restoration, as needed
However, the effectiveness of these treatments for orthorexia hasn’t been scientifically confirmed.
Also, it’s important to note that orthorexia — like any other eating disorder — can occur in people of all body shapes and sizes. Therefore, being underweight is not a diagnostic factor, and weight restoration won’t be part of everyone’s recovery journey.
Finally, education on evidence-backed nutrition information may help people living with orthorexia to understand, limit, and eventually eliminate false food beliefs.
Summary: There are several ways to treat orthorexia. Seeking help from a multidisciplinary healthcare team is strongly recommended.
Being mindful of the foods you eat and how they affect your health is generally considered good.
However, there’s a fine line for some people between healthy eating and developing an eating disorder.
If you feel that your current healthy diet negatively affects your health, psychological well-being, or social life, it’s possible that your focus on health has transformed into orthorexia.
Like all other eating disorders, this disorder can have life-threatening consequences and shouldn’t be taken lightly.
Please know that help is available, and eating disorders can be treated. Talking with a qualified health professional such as a doctor, psychologist, or registered dietitian is strongly recommended.