Orthorexia Nervosa—The Extreme Form of Clean Eating

Healthy Eating vs Obsession

Eating healthy and getting in shape are goals many people share. However, some people take these aims to such an unhealthy extreme that it becomes a destructive obsession called orthorexia nervosa or simply orthorexia.

Overview

Orthorexia is an emerging eating disorder. Its key feature is an extreme fixation on proper nutrition or healthful eating characterized by a restrictive diet, ritual eating patterns, and a consuming avoidance of all foods believed to be impure. While not yet officially listed in the Diagnostic and Statistical Manual, recognition of this disorder is growing among eating disorder experts.

The term orthorexia nervosa, which was first coined in 1998, comes from the Greek ortho, meaning correct, and orexi, meaning appetite. Orthorexia nervosa falls under the category of an unspecified feeding and eating disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5).

Currently, orthorexia does not have an officially recognized diagnostic criterion or treatment protocol—and there is critical debate over whether ON should be considered a standalone disorder or simply a variation of other mental health conditions (such as anorexia nervosa or obsessive-compulsive disorder).

Below, we explore what is known about this condition, including its risks, causes, symptoms, typical progression, and treatment. Additionally, we look at comorbid mental health conditions that are associated with ON.

What Causes Orthorexia?

Woman looking her meal.

B. BOISSONNET / BSIP / Getty Images

We are blanketed with headlines about the (often unfounded or exaggerated) healing effects of various "superfoods" and fad diets. Social media feeds overflow with extensive lists of "clean" foods to eat (and what to avoid), as well as claims about the damaging effects of consuming processed food, genetically modified organisms (GMOs), and non-organic produce. 

This bombardment of information can be helpful, but often much of it is inaccurate, overwhelming, and contradictory—and sometimes encourages addictive or unsafe behaviors and feelings, particularly for people with eating disorders. Occasionally, this focus on "ultra-healthy" and "clean" eating can be taken to an unhealthy extreme.  

Orthorexia often begins as a genuine desire to adopt a healthy lifestyle through better food choices. However, this positive intention becomes an eating disorder when a person's interest in food quality and purity becomes an obsession. 

Signs and Symptoms

According to the National Eating Disorders Organization (NEDA), those who develop an unhealthy obsession with eating a healthy diet may be suffering from orthorexia nervosa. Orthorexia Nervosa is defined as having an extreme focus on righteous eating that interferes with a person's wellbeing and sense of self. An iron-clad will is often needed to maintain this rigid eating style.

Typical Symptoms

The hallmarks of orthorexia nervosa include the following symptoms:

  • A consuming obsession with meal planning and preparation
  • A preoccupation with the idea that some foods are good while others are extremely bad, shameful, or toxic to consume
  • Linking self-worth with what you eat
  • Obsessively thinking about food
  • Progressive elimination of many types of food
  • Severe limitations on food intake
  • Compulsive checking of ingredient lists and nutritional labels with an increased concern about the health of ingredients
  • Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, or all animal products)
  • An inability to eat anything but a narrow group of foods that are deemed ‘healthy’ or ‘pure’

Causes

Orthorexia often starts out as an innocent attempt to eat more healthfully, but sufferers develop an extreme focus on food quality and purity. They become consumed with what and how much to eat, and how to deal with slip-ups. They may see each day as a chance to eat right, make "pure" choices, and rise above others in dietary prowess.

Maintaining self-esteem relating to food often becomes paramount for people with orthorexia who may begin to link feeling good about themselves with adherence to their strict eating plan. While those with anorexia often feel ashamed of their food habits, people with orthorexia often feel virtuous or empowered by their ability to control the purity of their food intake.

If temptation wins, the need to self-punish through stricter eating, fasts, and exercise often takes over, creating an unhealthy cycle of increasingly rigid and controlled eating. 

Progression and Comorbidities

Research on the prevalence, impact, and natural history of ON is early. However, initial studies shows that orthorexia symptoms seem to show an overlap with disorders such as anorexia nervosa, obsessive-compulsive disorder (OCD), and anxiety. 

Anorexia Nervosa

Anorexia and orthorexia are similar in that they are food restrictive but their fears surrounding food are different. Orthorexia sufferers do not necessarily fear gaining weight or obsess over how their body looks—although they may value thinness and appearance. Instead, they are phobic over foods they do not believe are pure or "good" enough to consume. 

Obsessive-Compulsive Disorder (OCD)

The fixations and obsessive thinking common in OCD are also present in ON. For this reason, some experts argue that orthorexia should be seen as a type of OCD. Other experts believe ON should be classified as a unique disorder. The two conditions differ in that with ON the focus is entirely on controlling diet and intertwining self-worth with which foods are consumed.

Typical Progression

Food intake is usually limited to certified organic and whole foods. Foods not measuring up to orthorexia “clean” standards are typically shunned, thought of as "bad," and removed from the diet.

This disorder is not only obsessive but progressive in nature, as people with orthorexia tend to increase the intensity and restrictiveness of the dietary limits they follow as the condition continues.

Entire food groups like meat, dairy, or grain are often eliminated one-by-one in search of the “perfect” clean diet. Eliminating essential nutrients from the diet can spiral into malnourishment and severe nutrient deficiencies in extreme orthorexia cases. People with orthorexia often fail to understand that their obsession with having exacting control over their food intake has replaced eating healthy. 

Orthorexia Is Isolating

A person with orthorexia will often begin isolating themselves from social functions and family meals. Anxiety surrounding only being able to eat pure foods becomes stronger than wanting to spend time with other people. According to the Academy of Nutrition and Dietetics, people with orthorexia don’t enjoy food in the same way that someone with a healthy relationship to food does.  

People with ON would often rather be alone than face questions and judgments from those who don't understand their philosophies about food.

An individual who has a positive relationship with food enjoys and sees food as fuel and nourishing for their body. They may eat healthy most of the time, but it's not an obsession for them. Those with orthorexia typically feel virtuous and "successful" when they eat foods considered to be good or safe. If they deviate from their self-imposed extreme diet restrictions, it causes anxiety and self-loathing.

Clean Eating Is Accepted

Because clean eating diet trends have become more popular, there is more interest in this subject by clinicians and researchers. 

One impediment to helping people with this disorder is that society has accepted obsessive healthy eating and extreme leanness as commonplace and admirable. Behaviors of people with orthorexia are often misinterpreted and even favorably looked upon by those wanting to achieve the same goals. 

People with orthorexia may feel empowered by praise, while hiding behind the idea that they're eating right and healthy. Because of this dilemma, many people with this condition (and their loved ones) are unaware of just how problematic the symptoms of orthorexia can become. 

Clean Eating Is Also Stigmatized

Clean eating has become a popular diet pattern but it also carries some hurtful social stigmas. While some individuals have improved their health and fitness using this type of restrictive eating, not everyone is a fan of these plans.

People who follow extreme clean eating can experience both positive and negative judgment for these habits. Critiques of their eating can cause feelings of isolation—and push them deeper into their obsession.

According to research, people may be judged, often inaccurately, for their eating behaviors. For limited studies have suggested that individuals eating low-fat diets may be considered more attractive, positive, and mindful than those consuming a high-fat diet. Alternatively, people eating low-fat diets may be viewed as high-strung, unhappy, anti-social, or self-centered.

Studies indicate a damaging potential for negative social repercussions for clean eating behaviors. Also, there is evidence of negative bias against individuals with eating disorders. These negative perceptions of clean eating and orthorexia symptoms may encourage some people to keep quiet when they are struggling with this condition. 

Social Perceptions

One study examining social perceptions asked 149 participants to read brief descriptions of a fictional woman that outlined her lifestyle and eating habits. One vignette described her as a clean eater, another as having an eating disorder, and a third didn't detail her eating patterns at all. The volunteers were asked to rate how they felt about the woman in each case. 

The results indicated less positive attitudes toward those with clean diet patterns compared to the control group. The participants also indicated they were less interested in being social with the women described as eating clean. Interestingly, those with more established eating disorders (such as anorexia or bulimia) were rated less negatively than those exhibiting orthorexia symptoms. 

People with orthorexia may feel that their eating habits are correct but that others don't understand or have the willpower to adhere to them.

Those committed to extreme clean eating often end up feeling the need to hide their obsessions. Developing a better understanding of prevalent stigmas about disordered eating is an important step in helping those suffering from these conditions to get the help and support they need.

Treatment

Orthorexia nervosa is a serious condition that can have devastating mental and physical side effects, as well as isolating social ramifications. Compounding these issues is the problem that many orthorexia sufferers remain in denial about their behaviors—and may even feel righteous or proud of them.

Diving into the mental and emotional side of food behaviors is necessary to overcome orthorexia. This is best done with a professional skilled in treating eating disorders and/or anxiety disorders, particularly those that specialize in anorexia nervosa and/or obsessive-compulsive disorder.

Exposure therapy is widely used to treat those with orthorexia to increase the variety of foods eaten and increase exposure to the feared or "bad" foods. Other potentially beneficial therapies include:

  • Dialectical behavior therapy
  • Cognitive behavioral therapy
  • Medications, including anti-anxiety medications and antidepressants

Recovery usually requires those with orthorexia to take the steps necessary to change. This includes adopting more realistic and healthy views of food intake and eliminating the perception of food as either good or bad.

According to the National Eating Disorders Association, individuals in recovery can still aim to eat healthfully, but with a less rigid focus and understanding of what healthy eating is.

A few of the recovery steps, new views, and healing mantras on food that can help include:

  • Food intake or abstinence doesn’t make you a better person.
  • Food is important, but only one small aspect of life.
  • Self-esteem should not be based on the quality of your diet.
  • You can shift your identity away from the food you eat.
  • You can gain a broader definition of who you are and develop other interests rather than primarily focusing on what you eat (or don't eat).
  • Your life includes other important things—work, fun, and relationships.

A Word From Verywell

It's often difficult to admit having a problem with food obsessions, especially when you suspect people may judge you harshly. But if the description of orthorexia sounds familiar to you and you are wondering if your relationship to food could be problematic, it can't hurt to speak to a professional. You'll usually be treated with more kindness and support than you expect.

Understanding and acknowledging that you have a problem and sharing your concerns with loved ones and medical professionals are the first steps toward recovery—and healing your relationship with food.

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Article Sources
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  2. Barker ME, Tandy M, Stookey JD. How are consumers of low-fat and high-fat diets perceived by those with lower and higher fat intakeAppetite. 1999;33(3):309-317.

  3. Nevin SM, Vartanian LR. The stigma of clean dieting and orthorexia nervosaJ Eat Disord. 2017;5:37. doi:10.1186/s40337-017-0168-9

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