While a focus on healthy eating is often positive, it can become just as problematic as any other food-related obsessive behavior when taken to an extreme. When a person is obsessively focused on healthy eating, they may have an eating disorder known as Orthorexia Nervosa (ON).

What is Orthorexia Nervosa?

While other eating disorders, such as Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED), pertain to the volume of food consumed, Orthorexia relates to its quality.^[1] For an individual suffering with ON, weight loss is not the goal, but it can occur as a consequence.

A person struggling with ON may experience anxiety around their dietary habits, and the behaviors associated with ON are also linked to those of AN and Obsessive-Compulsive Disorder (OCD).

While it is normal and even productive to plan and strive to follow a healthy diet, a person struggling with Orthorexia will face strong feelings of guilt or shame following a failure to adhere to their strict guidelines for pure, healthy eating.^[2]

As a result of their obsession with healthy eating, a person may become reluctant to join friends or family for dinner, which can lead to social isolation and spending large amounts of time in a state of worry around what they should or should not eat.

Food Restriction as a Cultural Phenomenon

In contemporary society, it is common for people to follow a strict diet and avoid certain foods. According to Marcelo Campos, MD, of Harvard Health Publishing, this may be due to the following reasons^[3]:

• A modern, more hygienic approach to food
• An increase in the use of toxic or harmful chemicals in food production
• A societal view on genetically modified organisms (GMO)
• An increased awareness of the importance of eating healthy
• The influence of articles, blogs, and social media pages that strongly encourage cleaner eating.

Food Restriction as a Medical Necessity

It is sometimes medically necessary to follow a strict diet and avoid certain foods. For example, those with Irritable Bowel Syndrome (IBS) must avoid foods that  agitate their digestive system. However, when there is no medical reason to radically restrict one’s diet, it can have a negative impact on a person’s individual and social wellbeing.

Prevalence of Orthorexia Nervosa

It is difficult to estimate the percentage of people in the US who suffer from Orthorexia, partly because there are currently no unanimous diagnostic criteria.

Though data is limited, studies published in the Eating and Weight Disorders journal suggest that women are twice as likely as men to develop Orthorexia.^[4] A questionnaire-based study intended to identify the prevalence of Othorexia and assess its symptomatology found that 21 – 57.6% of the 177 participants identified with the symptoms of ON.

Further research on ON and its diagnostic criteria is needed before any solid, empirical data can be applied. Simply following a strict diet or exclusively eating healthy foods is not sufficient to justify a diagnosis. Such behavior must become obsessive and have a negative impact on one’s life in order to be labeled as ON.

A person struggling with ON should speak with a mental health care professional about how they are feeling and their relationship with food in general or with certain types of food.

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Symptoms

While individuals suffering with ON desire to “achieve optimum health,” according to a Neuropsychiatric Disease and Treatment article by Koven and Abry, 2015, the condition itself may lead to nutritional deficiencies, medical complications, strained relationships, and overall poor quality of life.^[5]

ON is characterized by a “restrictive diet, a focus on food preparation, and ritualized patterns of eating.” It has been found that symptoms of ON relate to those of AN, OCD, OCPD, Somatic Symptom Disorder, Illness Anxiety Disorder, and Psychiatric Spectrum Disorders.

Characteristic obsessions of ON include excessive scrutiny of:

• the origin of food’s source (e.g., exposure to pesticides, the use of supplementary hormones in the source animal, etc.)
• how the food was processed (retention of nutrients)
• the quality of the food’s packaging (plastic contamination, whether or not information on packaging is sufficient to make a judgement about the food)

This focus on food quality is driven by a strong desire to optimize one’s health and wellbeing, as opposed to being tied to dietary restrictions based on religious ideology, animal welfare, or sustainable agriculture.

Beyond the level of food intake, a person suffering with ON will spend much time cataloging, researching, weighing and measuring food, and planning future meals, which leads to intrusive, food-related thoughts. OD sufferers will show signs of emotional distress if food deemed sufficiently healthy by the affected individual is unavailable.

Diagnosis of Orthorexia Nervosa

While Orthorexia is not yet included in the DSM-V^[6], Moroze et al. proposed four diagnostic criteria for ON in a 2015 Psychosomatics journal article:

1. Obsession with healthy eating. Two or more of the following behaviors must occur for this criterion to be met^[7]:

• Consuming a nutritionally unbalanced diet due to preoccupying beliefs concerning food purity
• Worrying about eating impure or unhealthy food and the effect of food quality and composition on both physical and/or emotional health
• Strict avoidance of foods believed to be unhealthy, which may include foods containing any fat or preservatives, food additives, animal products, or other ingredients considered by the individual to be unhealthy
• For individuals who are not in a food-related profession, excessive amounts of time (e.g., 3 hours or more per day) spent reading about, acquiring, and preparing specific types of foods based on their perceived quality and composition
• Feeling guilty or worried after transgression in which “unhealthy” or “impure” foods are consumed
• Intolerance to others’ beliefs concerning food
• Spending excessive amounts of money relative to one’s income on foods because of their perceived quality and composition.

2. The obsession must lead to either or both of the following:

• Decline in physical health due to nutritional imbalances (e.g., developing malnutrition because of an unbalanced diet).
• Severe distress or impairment of social, academic, or vocational functioning, stemming from obsessive thoughts and behaviors that focus on patients’ beliefs about “healthy” eating.

3. The issue is not simply a result of the symptoms of another disorder, such as OCD, AN, or Schizophrenia.
4. The behavior cannot be more accurately explained by religious ideological restrictions, professionally diagnosed food allergies, or a special diet required by a presenting medical condition.^[8]

In Conclusion

Mindfulness around one’s dietary choices is an important feature of physical and mental health and wellbeing. However, once this mindfulness becomes a hyper-focus, whereby a person becomes obsessed with eating purely healthy foods, withdraws from social dining situations, and refuses to eat due to lack of food they deem healthy, it can  compromise their health and wellbeing.

 

Sources:

^[1] Varga, M., Dukay-Szabó, S., Túry, F. and van Furth Eric, F., 2013. Evidence and gaps in the literature on orthorexia nervosa. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 18(2), pp.103-111.

^[2] Campos, MD, M., 2018. Orthorexia: The Extreme Quest For A Healthy Diet. [Blog] Harvard Health Blog, Available at: <https://www.health.harvard.edu/blog/orthorexia-the-extreme-quest-for-a-healthy-diet-2018091214777> [Accessed 10 June 2020].

^[3] Koven, N. and Abry, A., 2015. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatric Disease and Treatment, p.385.

^[4] Ramacciotti, C., Perrone, P., Coli, E., Burgalassi, A., Conversano, C., Massimetti, G. and Dell’Osso, L., 2011. Orthorexia nervosa in the general population: A preliminary screening using a self-administered questionnaire (ORTO-15). Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 16(2), pp.e127-e130.

^[5]  Koven, N. and Abry, A., 2015. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatric Disease and Treatment, p.385.

^[6] Koven, N. and Abry, A., 2015. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatric Disease and Treatment, p.385.

^[7] Moroze, R., Dunn, T., Craig Holland, J., Yager, J. and Weintraub, P., 2015. Microthinking About Micronutrients: A Case of Transition From Obsessions About Healthy Eating to Near-Fatal “Orthorexia Nervosa” and Proposed Diagnostic Criteria. Psychosomatics, 56(4), pp.397-403.

^[8] Moroze, R., Dunn, T., Craig Holland, J., Yager, J. and Weintraub, P., 2015. Microthinking About Micronutrients: A Case of Transition From Obsessions About Healthy Eating to Near-Fatal “Orthorexia Nervosa” and Proposed Diagnostic Criteria. Psychosomatics, 56(4), pp.397-403.