Eating is an important factor in maintaining physical and mental well-being. However, a focus on “healthy eating” and nutrition can lead to a fixation on food choices, potentially developing into an eating disorder. Orthorexia nervosa is an eating disorder involving an obsession with “healthy eating.” Orthorexia nervosa is complex and can seem counterintuitive, but is a manageable and treatable condition. This article will help you better understand this often confusing eating disorder. 

What is Orthorexia Nervosa? 

Orthorexia nervosa is an eating disorder characterized by an exaggerated focus on healthy eating. It was first described by Dr. Steven Bratman in the late 1990s after seeing many patients exhibiting obsessions with healthy eating. Since then, the condition’s informal diagnostic criteria have been defined to include not only an obsession with nutrition, but also negative impacts on mental health (such as anxiety and depression) and daily functioning, and malnutrition in more severe cases. With other eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorder, patients tend to focus on their weight and body image. Orthorexia nervosa differs in that the primary fixation is not on body image, but rather on the “purity” or “healthiness” of food. Although orthorexia nervosa is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is still a serious eating disorder that must be addressed by a medical and/or mental health professional.

Symptoms of orthorexia nervosa

The symptoms and warning signs of orthorexia nervosa are diverse and often overlap with other eating disorders. It is important to know these symptoms to understand better how a focus on healthy eating can counterintuitively become an unhealthy obsession. Symptoms include:

• Obsession with the quality of food, including the source of the food item, how it was processed, and how its packaging might affect the nutrition of the food item
• Intense fear of eating “unhealthy” or “impure” foods
• Intense fixation on “clean eating”, dieting, and nutrition
• Elimination of entire food groups (such as all fats, gluten, all carbs, all meat) without medical, cultural, or religious reasoning to do so
• Stringent or ritualized eating patterns
• Avoidance of eating in social groups or dining out and social isolation 
• Critical opinions of other people’s eating habits
• Sudden or extreme weight loss
• Inadvertent malnutrition

Someone struggling with orthorexia nervosa may experience these symptoms coupled with mental health conditions, such as anxiety and depression. Oftentimes, someone with orthorexia nervosa will exhibit emotional distress when their particular rules around healthy eating are broken. This may result in a devaluation of self-esteem, negative impacts on socialization, and a general decline in their wellness. Orthorexia nervosa can be a serious and potentially severe eating disorder. It is important to know and recognize these symptoms to better understand how to navigate this complex condition.

Risk Factors 

Disordered eating can affect anyone regardless of health history, cultural background, or socioeconomic status. Though eating disorders are deeply rooted in personal experience, there are many well-known risk factors that can lead to orthorexia nervosa. 

The primary risk factor of developing orthorexia nervosa is having a close family member who has struggled with this disorder or other eating disorders. Additionally, a medical history of type 1 diabetes or a history of dieting is also common biological factors that can lead to the development of orthorexia nervosa. Psychological risk factors include a tendency for obsessive-compulsive behaviors, perfectionism, controlling behaviors, or a history of anxiety. Social factors also can play a role in developing orthorexia nervosa. Experiencing bullying (especially around weight or body image), access to detailed nutrition information, and a social experience focused on diet culture can all have an impact on developing an eating disorder such as orthorexia nervosa. 

Some research has shown that a tendency to practice vegetarianism or veganism can be related to orthorexia nervosa. Access to more expensive foods marketed as “clean” or “healthier” can also play a role, as can engaging with social media or marketing practices that promote “clean eating” or an exaggerated focus on healthy eating. Those who have studied nutrition or related topics in university settings are also prone to a higher risk of developing orthorexia nervosa. 

It is important to remember that a focus on eating in itself is not problematic. Maintaining a lifestyle whereby one feels healthy and happy is good for general well-being. However, if a focus on “healthy eating” becomes obsessive or symptoms of orthorexia nervosa develop, it is critical to seek assistance from a medical and/or mental health professional.

Diagnosis

Because orthorexia nervosa is not formally accepted as its own formal diagnosis, it can be complicated and challenging to know when disordered eating is orthorexia nervosa. Oftentimes it falls under the diagnosis of other eating disorders, such as anorexia nervosa, or is categorized as a subtype of conditions like obsessive-compulsive disorder (OCD). Nevertheless, there are several diagnostic tools that medical professionals can use to help diagnose orthorexia nervosa. These tests include:

• ORTO-15: This survey can be used to identify symptoms associated with orthorexia nervosa. There are professional criticisms of this questionnaire due to the confounding results it provides. This screening tool is often unable to provide differentiation between disordered eating and culturally related specific eating behaviors (such as ethical veganism or religiously motivated eating habits).
• ORTO-R: This updated version of the ORTO-15 provides additional specified questions to assess symptoms and eating behaviors related to orthorexia nervosa. 
• Bratman Orthorexia Test (BOT): Developed by Dr. Steven Bratman who first named orthorexia nervosa as a condition, the BOT is a binary (yes/no) survey that analyzes beliefs, thought patterns, and behaviors around healthy eating and nutrition. This test is not used as commonly as the ORTO-R.
• Eating Habits Questionnaire (EHQ): In this 21-question examination, providers can measure positive and negative feelings around healthy eating as well as the amount of nutrition-specific knowledge the patient exhibits. Though this test provides healthcare professionals with a general basis of their patients’ habits and associations, improvements to the test must be made to reliably diagnose orthorexia nervosa.

As medical researchers and mental health professionals continue to learn more about orthorexia nervosa, better diagnostic tools will arise. Though there are drawbacks to some of these tools, it is important to communicate symptoms to your doctor so that they can develop proper treatment plans that will lead the path to recovery.

Treatment

Struggling with orthorexia nervosa may be overwhelming and recovery may seem daunting, but there is help and support  for this eating disorder. Identifying your symptoms as a problem and seeking help can be an  important first step toward recovery from  orthorexia nervosa. Psychiatric care and psychotherapy can be critical in addressing co-occuring mental health conditions like anxiety or obsessive-compulsive disorder. This may take the form of group therapy, individual therapy, or medications. Behavioral therapies, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT), take varying routes to successfully address disordered thoughts and behaviors. Exposure therapy can also be very beneficial in treating orthorexia nervosa. In a controlled environment with a mental health provider, patients are exposed to different foods and eating habits that provoke fear or anxiety. Over time, patients learn to manage these negative emotional responses, leading to a decrease in avoidance and disordered eating behaviors. 

Orthorexia nervosa is a real condition with potentially severe effects on health and well-being. With proper intervention and access to eating disorder care, those struggling with orthorexia nervosa can manage their eating disorder and work toward recovery. 

Seek Help

If you or a loved one is experiencing orthorexia nervosa or any of the signs and symptoms listed above, you are not alone. Recovery is possible and help is available with the National Alliance for Eating Disorders.