What is Orthorexia?
Orthorexia, Orthorexia Nervosa, or sometimes named the “clean eating disorder” is a term describing a collection of eating behaviours and attitudes that are often prevalent in certain populations e.g., wellness bloggers, crash dieters, and those with difficult relationships to food.
Orthorexia is an “unrecognised” eating disorder, which means it isn’t a clinical diagnosis as of yet like Anorexia Nervosa, Binge Eating Disorder, etc., are. But that doesn’t mean people with Orthorexia aren't deserving or in need of support.
Orthorexia and Orthorexic behaviours/mentality could be described as a collection of disordered behaviours, and it moves to a “disorder” when the behaviours/mentality really interfere with a person's life. I have a whole article about the difference between disordered eating and eating disorders.
Orthorexia has picked up traction in the past few years, and is a pretty commonly discussed condition on social media, especially after the backlash of the “Clean Eating Movement” of the mid-2010s.
Since Orthorexia is often spoken about in the media, there’s more awareness than 10 years ago. However, it also means I get asked quite a lot about it as a disordered eating and eating disorder nutritionist. My hope is the article answers any questions you have about Orthorexia, and that it’s in a context that’s really simple to understand. I will outline prevalence, diagnosis, and treatment - then in a future article I will write more in depth about Orthorexia recovery.
Signs of Orthorexia
Currently, Orthorexia is not a formal diagnosis in the Diagnostic Statistical Manual (DSM-V) and is defined as an Unspecified Feeding or Eating Disorder (UFED.) Also in this category is Body Dysmorphic Disorder. UFED are relationships to food/body that cause distress to the person, impairments in social, work, and other areas of life - food/body actions and thoughts often dominate a person’s mind.
However, they do not meet the “full” criteria for other eating disorders, therefore the term Unspecified is used aka UFED. It’s not uncommon for people experiencing Orthorexia to have similar symptoms to Anorexia Nervosa and Bulimia Nervosa.
There are two proposed criteria for Orthorexia; criteria A and B. These may one day appear in the DSM-5, and are currently used in emergency care settings to make a diagnosis for the best course of treatment. Criteria A Orthorexia is characterised by mental distress and food preoccupation, and Criteria B Orthorexia includes Criteria A plus clinical impairments e.g. medical or nutrition consequences.
Criteria A - Marked by significant emotional distress in your relationship to food. Food choices are made on what’s seen as healthy, with distress and discomfort towards perceived unhealthy foods. Weight loss may occur from low food intake, limited range of foods, intake of low calorie “healthy” foods - but this is not the primary goal in Orthorexia. Full criteria includes:
Mental preoccupation and compulsive behaviours that affirm and further restrict dietary intake, e.g. educating oneself on the food industry, ingredients in foods, food production, etc. This is to achieve “optimum health” but eventually leads to fear of foods, worry about ingredients in everyday food products, and a very restrictive diet.
Self-imposed food rules and beliefs lead to a fear of disease or illness, negative physical sensations and symptoms from certain foods, and anxiety and shame if off-limits foods are consumed.
Key is that dietary restrictions escalate over time, which leads to even further restrictions. Sometimes cleanses or detoxes are needed to further “purify” the individual.
Often not overly concerned with weight loss, and the “goal” in Orthorexia is to be as healthy as possible. If a fear of weight gain is present, this would suggest another eating disorder.
Criteria B - The behaviours and thoughts about food from Criteria A lead to clinical outcomes, including:
Malnutrition, weight loss, and other medical complications from restrictive diets.
Personal distress or impairment of social and work functioning. Beliefs of food outweigh life tasks and enjoyment e.g., cooking meals and taking them to restaurants instead of ordering food.
Positive body image, self-worth, identity, and life satisfaction are dependent on compliance with “healthy” behaviours.
Additional traits associated with Orthorexia include:
Extreme focus on food choice, planning food, preparing food in the “perfect” way or most effective way.
Food is only for fuel, health, and nutrition, and not about pleasure or taste.
Some experience distress when around off-limits or unhealthy or impure foods.
Belief and faith that including or eliminating certain foods will cure or prevent disease.
Moral judgement towards others based on their food choices.
Belief that dietary practices are health-promoting, even when there are outcomes such as malnutrition, extreme weight loss, and poor health.
A summary of the signs of Orthorexia
I outlined the diagnostic criteria of Orthorexia above, but it's also helpful to clearly see how this might "look" in real life. Relationships to food differ between people, so no two people with Orthorexia have exactly the same behaviours, thoughts, or experience. Some signs of Orthorexia include:
Eliminating food groups or foods (often carbohydrates, sugar, fat, gluten, dairy, or going completely vegan), in an attempt to be healthy. This usually starts off with a few foods, and turns into a big list of foods the person doesn't eat.
The way of eating interferes of other aspects of life, like relationships with others, spending time with people, work performance, leaving the house, eating out of the house, being able to find suitable food at others houses or in food places.
Food shopping trips, planning food shopping, and menu planning takes a long time (sometimes 2-3 hours in the grocery shop) due to distress or indecisions over food purchases, or analysing food labels.
Avoiding social events where off-limits foods will be present.
Feelings of guilt, anxiety, anger, low food, especially if food isn't "perfect" or healthy enough.
Watching many recipe videos, what I eat in a day vlogs on Youtube or Tik Tok. Hobbies and free time is taken up by food related things e.g. learning about new diets, watching health documentaries.
Ridged exercise routines, that usually are rule-based (e.g. have to exercise 4-5 times a week) and are followed by guilt if they can't be completed for any reason.
Low energy levels, poor concentration, recurrent colds, prolonged muscle soreness after exercise, loss of menstrual cycle, weight loss, malnutrition, vitamin and mineral deficiencies, digestive problems.
How to get support for Orthorexia
If you suspect you have Orthorexia, or any type of disordered relationship to food, the first step is to book an appointment with your GP. In the UK, this is the first step to receiving support. After this, you may be referred to an NHS eating disorder clinic where they can assess, diagnose, and potentially offer you treatment. If treatment is unavailable, as sadly it often is, you may be put onto a waiting list for therapy or NHS Dietetic support. You can also opt for private support from eating disorder Registered Nutritionists and Dietitians, and an eating disorder counsellor/therapist.
Treatment for Orthorexia
I would like to give more space to how to recover from Orthorexia, as just like recovering from any disordered eating, there’s a lot of information to write about. So I am going to write a separate article all about treatment - which I will link to right here when it’s available.
Treatment for Orthorexia is similar to other eating disorders, where the first goal is medical and nutrition stabilisation. This follows the structure of the RAVES approach, which I have summarised in the linked article.
Treatment for Orthorexia requires additional support, such as overcoming food fears and guilt, understanding where views about nutrition, health, and food come from, exposure to “unhealthy” or impure foods (when it feels safe to do so), and ultimately working towards food and eating not need to be “perfect” anymore.
I hope this article was helpful, and if you feel like you might be struggling with Orthorexia; please arrange a free chat with me to hear how I might be able to support you, or help you figure out your next steps.