Orthorexia Nervosa: Not Quite The “Healthy” Eating Disorder

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Orthorexia Nervosa is a term that’s been thrown around in health- and eating disorder-related fields quite a bit lately. 

Yet, despite heaps of discussion of this, there hasn’t been all that much scientific research devoted towards studying these phenomena. 

I expect much more work to be done on orthorexia in the coming years. 

But, now we’ve got some idea on what orthorexia actually is, and I want to touch on its definition and underlying symptoms, prevalence and incidence rates of orthorexia, and its impact on mental and physical health.

Clarifying Some Misconceptions

Before getting stuck into the definition and symptoms of Orthorexia Nervosa, I first want to clarify a couple of things.

First, orthorexia isn’t an officially recognised eating disorder. 

Some people will assume it is, but the reason it isn’t is that it’s not officially recognised in the DSM-5.

This isn’t to say that it’s not an important condition that’s severely impacting people, of course. 

But more on that in a moment.

Second, orthorexia isn’t a “healthy” eating disorder, contrary to some people’s opinions. 

This will become very clear why once I clarify the symptoms and their impact on functioning.  

What is Orthorexia Nervosa? 

Broadly speaking, the definition of Orthorexia Nervosa reflects a pathological obsession around healthy eating, with the aim of maintaining or improving health. 

Those with orthorexia feel anguish when they don’t eat “healthy” or “pure” foods, are obsessed with planning and preparing healthy meals, and experience a sense of superiority over others when they adhere to their strict diet ¹Brytek-Matera, A. (2012). Orthorexia nervosa–an eating disorder, obsessive-compulsive disorder or disturbed eating habit. Archives of Psychiatry and psychotherapy, 1(1), 55-60. 

Interestingly, it wasn’t until 2015 that a proposed formal criteria for Orthorexia Nervosa was put forth ²Moroze, R. M., Dunn, T. M., Holland, J. C., Yager, J., & 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), 397–403.

Let’s take a look at the signs, symptoms, and criteria for Orthorexia Nervosa. 

Criteria for Orthorexia Nervosa 

Criterion A: Obsessional preoccupation with eating “healthy foods,” focusing on concerns regarding the quality and composition of meals, as evidence by two or more of the following:  

1. Consuming a nutritionally unbalanced diet due to preoccupying beliefs about food “purity”
2. Preoccupation and worries about eating impure or unhealthy foods, and on the impact of food quality and composition on physical and/or emotional health.
3. Rigid avoidance of foods believed by the person to be “unhealthy,” which may include foods containing any fat, preservatives, food-additives, animal products, or other ingredients considered by to be unhealthy
4. For individuals who are not food professionals, excessive amounts of time (e.g. three or more hours per day) spent reading about, acquiring and/or preparing specific types of foods based on their perceived quality and composition
5. Guilty feelings and worries after transgressions in which “unhealthy” or “impure” foods are consumed.
6. Intolerance of others’ food beliefs
7. Spending excessive amounts of money relative to one’s income on foods because of their perceived quality and composition

Criterion B: The obsessional preoccupation becomes impairing by either of the following:

1. Impairment of physical health due to nutritional imbalances (e.g., developing malnutrition due to unbalanced diet).
2. Severe distress or impairment of social, academic or vocational functioning due to obsessional thoughts and behaviors focusing on the person’s beliefs about “healthy” eating.

Criterion C: The disturbance is not merely an exacerbation of the symptoms of another disorder, like obsessive compulsive disorder, schizophrenia, or other psychotic disorder.

Criterion D: The behavior is not better accounted for by the exclusive observation of organized orthodox religious food observance, or when concerns with specialized food requirements are in relation to professionally diagnosed food allergies or medical conditions requiring a specific diet.

Similarities and Differences with Other Eating Disorders

Now that you’re aware of the defining features of orthorexia, you should notice some obvious similarities and differences with the other eating disorders. 

Let’s bullet point some of these differences and similarities. 

Similarities with other eating disorders 

• Both have an obsessive focus on controlling eating habits which then lead to an unbalanced life
• Both have similar genetic predisposition for perfectionism, anxiety, and the need to control the environment
• Both have comparable levels of eating restraint, rigid diet rules that govern eating behaviour, and a sense of accomplishment when such rules are followed
• Both orthorexia and anorexia nervosa can result in severe malnutrition and weight loss. 

Differences with other eating disorders

• People with orthorexia, unlike anorexia and bulimia nervosa, are believed to be obsessed with food quality rather than quantity.
• The focus in orthorexia is not on striving for a thin physique; rather, it’s the behaviour of eating that’s most important to these individuals. 
• The prevalence of various compensatory behaviours (e.g., self-induced vomiting, laxative misuse) is much lower in orthorexia than most other eating disorders

Statistics and Facts

Let’s dive into some key stats and facts about orthorexia

How many people have orthorexia? 

This question is a little difficult to answer for a number of reasons, but let’s take a look at what some studies have found with respect to prevalence rates. The following statistics are presented in a recent review of orthorexia ³Dunn, T. M., & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating behaviors, 21, 11-17.

Prevalence Rates

• In Italian populations, the prevalence of people meeting criteria for orthorexia ranges from 5%-57%
• In Turkish populations, prevalence rates range from 40-60%
• In Polish populations, prevalence rates range from 43-68%
• Less than 10% of Australian students exhibit orthorexia. 
• People with an eating disorder are 10 times more likely to receive an orthorexia classification than people without an eating disorder. 

Risk Factors

Understanding what factors put people at risk for any condition is extremely important.

This is because if we know what the risk factors of something are, then we can devote a lot of effort towards addressing or targeting them. Therefore, in the long-run, if we are able to eliminate these risk factors, then we should be able to prevent the onset of a condition like orthorexia. 

Let’s take a look at some key risk factors, as identified in a recent review paper ⁴McComb, S. E., & Mills, J. S. (2019). Orthorexia nervosa: A review of psychosocial risk factors. Appetite, 140, 50-75. 

• Perfectionistic tendencies
• Obsessive-compulsive traits
• General psychiatric distress
• History of an eating disorder
• High levels of eating restraint
• Poor body image
• Drive for thinness 
• Belonging or working in a health-related field 
• Drug use
• Smoking 
• Social media use 

Consequences 

We need to take orthorexia pretty seriously because it’s been shown to be associated with a several poor health outcomes ⁵Cena, H., Barthels, F., Cuzzolaro, M., Bratman, S., Brytek-Matera, A., Dunn, T., … & Donini, L. M. (2019). Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 24(2), 209-246.

These poor health outcomes include:

• Eating disorders
• Low self-esteem
• Poorer quality of life
• Psychosocial impairment 
• Malnutrition and severe weight loss
• Electrolyte imbalance 
• Psychological distress

I hope that you’ve gained a lot more of an understanding of orthorexia and its underlying symptoms, prevalence, and consequences. 

We’ve only scratched the surface of this condition, meaning that there’s a heap more work we need to do to better understand it. This is, of course, unsurprising given that research on orthorexia has only just started to take off within the past few years.  

It’ll be interesting to see if it gets included as a formal diagnosis, or if particular treatments are constructed specifically for the condition. 

Watch this space.