Post by Carly Poynter, MA, previous staff therapist
What is Orthorexia?
Orthorexia is an eating disorder in which an individual is fixated on the quality of food and avoidance—in the pursuit of health—of foods labeled as “unhealthy” or “bad”. The person continues to pursue “health” despite experiencing considerable negative health consequences and an impact on psychological well-being.
Individuals typically begin to eat foods that they believe are “healthy” based on various characteristics such as the quality, preparation process, and benefits of the food. The individual then becomes increasingly focused on this “healthiness”. They eliminate foods or food groups based on judgments regarding what is “good” and what is “bad”. Over time, this focus becomes an obsession. What begins as an effort to control health becomes—ironically—a complete absence of control. And the “health” they were pursuing becomes unattainable due to the numerous physical and mental consequences of the dietary restriction.
Orthorexia is not a recognized DSM-5TR diagnosis. It’s not clear whether it is a variant of the other eating disorders or is its own unique disorder. However, the majority of clinicians believe that orthorexia should be its own distinct eating disorder, warranting further research and treatment designed specifically for its unique symptom presentation (Reynolds & McMahon, 2020).
Symptoms of Orthorexia
Orthorexia is not a recognized mental health disorder. Nevertheless, researchers have developed possible criteria based on the most frequent symptoms observed in patients presenting with the condition. Some of the most frequently cited symptoms include the following: (Donini et al, 2022)
- Preoccupation with one’s eating behavior. This may encompass rigid rules about food and spending a significant amount of time planning, researching, obtaining, preparing, and eating foods according to the rules determined by the individual.
- Need for control over food intake. Individuals may eliminate certain types of foods or whole foods groups.
- Fixation on “whole”, “pure”, or “clean” foods. People may obsessively check ingredients, limit foods that have multiple ingredients, and avoid foods that are not organic
- Focus on the health quality of foods. People may categorize and label foods as “good” and “bad” based on how the food is made, the number of ingredients, and the supposed benefits of the food.
- Extreme interest in social media, blogs, and websites that focus on “health” and “healthy lifestyles.”
- Emotional distress such as guilt or shame when “unhealthy” or “bad” foods are consumed.
- Perception of low self-worth is based on the individual’s inability to adhere to the rules identified by the individual.
- Rigid eating behaviors that result in a nutritionally unbalanced diet that impacts physical and mental well-being and causes impairment socially, educationally, or occupationally.
Relationship to Other Eating Disorders
Symptoms similar to anorexia nervosa may or may not be present such as fear of gaining weight, concerns with body image, preoccupation with food, or restriction of caloric intake. The primary difference between orthorexia and anorexia or bulimia is that people with orthorexia restrict their diets because of rigid health beliefs. Patients with anorexia and bulimia—by contrast—restrict their intake for reasons related to shape and weight. Exercise may be a symptom of orthorexia, used in the pursuit of health.
Medical Consequences of Orthorexia
The medical consequences of orthorexia vary depending on the type and quantity of nutritional intake. Some of the possible health consequences of malnutrition include the following: vitamin and mineral deficiencies such as anemia, depletion of immune system functioning, reduction of muscle mass, impaired temperature regulation, unplanned weight loss, hair loss, digestive system issues, electrolyte and hormone imbalances, loss of menses, bone mineral loss, and overall reduced energy and functioning.
How Do I Know If I Have Orthorexia?
In addition to excessive rules about food, you may feel guilty if any of your rules are broken. You may seek health advice from self-proclaimed “health gurus” on social media and strive for health and dietary perfection. It is also common for individuals to notice the health impact of malnutrition such as feeling tired and lightheaded.
If any of the information above resonates with you, seek medical attention and see the resources at the bottom of the page. Unfortunately, people with orthorexia may often believe what they are doing is healthy and don’t see it as a problem. A recent tragic example is Zhanna Samsonova, a social media influencer, who died after subsisting only on raw fruits.
Two self-report measures assess the symptomology of orthorexia:
- The Düsseldorf Orthorexie Scale (DOS) is a 10-item self-report measure of orthorexic eating behaviors (Barthels, Meyer & Pietrowsky, 2015).
- The ORTO-15 is a 15-item self-report measure designed to assess for characteristics of orthorexia (Donini et al, 2005).
What Causes Orthorexia And How Does It Develop?
Like all eating disorders, orthorexia likely develops from an interaction of genetic and environmental factors. In one case series, several individuals developed symptoms of orthorexia after a prior diagnosis with another mental health disorder such as obsessive-compulsive disorder, illness anxiety disorder, or bulimia nervosa. It appears that orthorexia behavior develops over time and there seem to be two broad stages in its development.
The first stage presents as a seemingly harmless choice to pursue a healthy diet. Some of the most popular diets individuals with orthorexia follow are clean eating, vegan, whole 30, raw foods, paleo, and elimination-based diets. While some of these diets can be followed safely, they may trigger more restrictive food rules and may escalate into a pathological need for dietary and health perfectionism. Others of these diets are dangerously imbalanced by design and can cause malnutrition.
In the second stage, this dietary restriction evolves into an unhealthy, pathological obsession with the previously adopted ideal. This stage involves further elimination of foods or food groups based on the perceived purity and health benefits or consequences of the food. The rigid rule-following and expansion of rules become more and more time-consuming. Due to the preoccupation associated with following these rules, the individual becomes emotionally distressed when they fail to follow the rules. They also start to base their self-worth on their ability to follow these rules. The rigidity makes it challenging to remain social and eat with others. These more rigid rules will also result in imbalanced nutrition that may result in malnutrition and subsequent medical consequences.
Who is Most at Risk for Orthorexia?
Individuals previously diagnosed with an eating disorder, obsessive-compulsive disorder, anxiety disorder, and other mental health conditions that influence the perceived ability to control health outcomes seem to be most at risk.
Professional athletes are also at great risk for the development of orthorexia. This may be due to the influence of dietary advice aimed at improving their performance. Individuals who participate in dieting are also at increased. This can be due to the misinformation about nutrition received. In addition, dieters ofte experience guilt based on their ability to follow the rules of a diet and the pressure to alter one’s body.
Treatment for Orthorexia
Since orthorexia is not a recognized DSM diagnosis, no treatment specifically designed to treat orthorexia exists. However, clinicians have used variations of treatments designed to treat other eating disorders and obsessive-compulsive disorder. A medical professional should assess patients presenting for outpatient treatment to ensure medical stability.
Ideally, a multidisciplinary treatment team–including a physician, dietitian, and psychotherapist who are knowledgeable about eating disorders or certified eating disorder specialists–should deliver coordinated care.
Because weight suppression often increases the potential for increased obsessive-compulsive behavior, if weight is suppressed, weight gain is often advisable.
Exposure and Response Prevention, Family-Based Treatment (FBT), and Enhanced Cognitive Behavioral Therapy (CBT-E) have all been applied to orthorexia. A common element of all of these treatments is exposure—the systematic reintroduction of avoided foods and eating situations. These treatments also include response prevention to eliminate compensatory behaviors including purging and excessive exercise. Exercise should also be monitored to ensure it is not excessive in relation to daily nutrition. The goal of treatment is to build more flexible eating habits and reduce the physical and psychological impact of the restricted diet.
Get Help for Orthorexia in California
Barthels, F., Meyer, F., & Pietrowsky, R. (2015). Die Düsseldorfer Orthorexie Skala—Konstruktion und Evaluation eines Fragebogens zur Erfassung orthorektischen Ernährungsverhaltens [Duesseldorf orthorexia scale—Construction and evaluation of a questionnaire measuring orthorexic eating behavior]. Zeitschrift für Klinische Psychologie und Psychotherapie: Forschung und Praxis, 44(2), 97–105.
Donini et al. 2005. Orthorexia nervosa: Validation of a diagnosis questionnaire. Eating and Weight Disorders.
Donini et al. 2022. A consensus document of definition and diagnostic criteria for orthorexia nervosa. Eating and Weight Disorders
Douma, E, Valente, M, & Syurina, E. 2021. Developmental pathway of orthorexia nervosa: Factors contributing to progression from healthy eating to excessive preoccupation with healthy eating. Experiences of Dutch health professionals. Appetite, 158.
Rania et al. 2021. Pathways to orthorexia nervosa: a case series discussion. Eating and Weight Disorders.
Reynolds, R. & McMahon, S. 2020. Views of health professionals on the clinical recognition of orthorexia nervosa: a pilot study. Eating and Weight Disorders
Zickgraf, H. 2020. Treatment of pathologic healthy eating (orthorexia nervosa), chapter in Editor(s): Eric A. Storch, Dean McKay, Jonathan S. Abramowitz, Advanced Casebook of Obsessive-Compulsive and Related Disorders, 21-40. Academic Press.