ORTHOREXIA NERVOSA: WHEN EATING HEALTHY BECOMES AN OBSESSION

Medically Reviewed by Dr. Sony Sherpa (MBBS) - December 30, 2022

An abnormal fixation with healthy food is a symptom of Orthorexia Nervosa, sometimes known as Orthorexia. The term ‘Orthorexia Nervosa’ was first coined by a Californian doctor, Steven Bratman, in 1997. This term is derived from the Greek word ortho, meaning correct, and orexis, meaning appetite, which refers to a fixation on righteous eating.

Incorporating quality food into the diet usually benefits general health and well-being. It does not mean that anyone who subscribes to a healthy eating plan or diet is suffering from orthorexia. However, people suffering from orthorexia seem to refine and restrict foods according to their understanding of ‘healthy’ and ‘pure’. As this belief about healthy foods can be subjective and vary person-to-person, such dietary restrictions intended to promote health can paradoxically lead to an array of unhealthy consequences.

Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)​ has not officially classified orthorexia as a separate eating disorder, it has been gaining increasing attention lately as a serious mental illness that can have a severe impact on an individual’s overall well-being.

What is Orthorexia?

Orthorexia is a proposed eating disorder characterized by excessive focus on eating healthy. A person suffering from orthorexia will avoid food that he or she believes to be impure or unhealthy.

Research has shown people with orthorexia, and other eating disorders, such as anorexia, bulimia, etc., share certain similarities in terms of identifying and regulating emotions. Orthorexia frequently coexists with anorexia nervosa and can result in malnutrition and weight loss. However, there are subtle differences between these illnesses, as unlike other eating disorders, people with orthorexia are preoccupied with the notion of quality, rather than quantity, of food to an excessive degree. The obsession with the quality of food is driven by their pride in eating ‘only healthy foods’ rather than body image insecurities associated with anorexia and bulimia. Since orthorexia is motivated by an obsession with achieving the ideal diet, some research has suggested a tight connection between obsessive compulsive disorder (OCD) and orthorexia.

Signs and Symptoms

The signs and symptoms of orthorexia go beyond a simple preference for a healthy diet. A person with orthorexia can exhibit the following behavioral, psychological, and physical signs and symptoms:

1. Concern over the quality of food: Individuals with orthorexic behavior are often obsessed over the quality and purity of food. Individuals with this condition often limit their food intake to organic, farm fresh, whole, raw, and/or vegan food. The quality of food always takes precedence over quantity.
2. Inflexible eating patterns: People with orthorexia are incredibly rigid with their diet. They will avoid unhealthy food (according to their understanding) at any cost, irrespective of circumstances.
3. Obsession with food research: Individuals with orthorexia might be compulsively checking ingredient lists and nutritional labels, researching all the ingredients, obsessively following food and ‘healthy lifestyle’ blogs on social media, and spending hours planning a meal.
4. Judgment about the eating habits of others: Individuals with orthorexia are usually very critical about others' food choices while they have no rational explanation of their own.
5. Cutting out entire food groups: Orthorexia-fueled rule-based diets can often lead to the elimination of an entire food group or more if it is perceived as unhealthy. Such food groups commonly include processed foods, sugar, meat, dairy products, carbohydrates, and/or gluten.
6. Emotional turmoil and anxiety: Individuals with orthorexia face severe anxiety, distress, shame, guilt, and/or depression if they ever fail to follow the rigid eating patterns and their strict self-prescribed exercise regimen.
7. A constant fear of sickness or disease: People with orthorexia are constantly labeling foods as ‘good’ and ‘bad’ and have a strict belief that they need to consume only the ‘good’ food to stay healthy. If ever they fail to comply with their own rules, they tend to believe that they will fall sick. Whenever they fall sick, they tend to blame the food they ate, even if there is no evidence of that food being unhealthy.
8. Anxiety being around certain foods that are perceived as unhealthy: Individuals with orthorexia usually have an intense urge to separate themselves from foods that are unhealthy, according to their rulebook. This could bring great discomfort if they are in the vicinity of such forbidden foods. 
9. Social Isolation: Avoiding going out and skipping social events in fear of the food not meeting their standard is a common issue for those with orthorexia. This, in turn, often leads to depression and intensified thought disturbances and behaviors.
10. Weight loss: Although typically not intentional, cutting out certain foods and limiting food variety to bring immense health benefits can vastly deplete nutrition. Such an unbalanced diet often results in malnutrition and eventual weight loss.

Causes

Although the exact cause of orthorexia is not known yet, the widespread fixation on ‘clean eating’ might have contributed to the development of this disorder. While the concept of ‘dieting’ has been around for centuries, the new obsession over ‘healthy eating’ sweeping the globe has legitimized orthorexic behaviors. This makes it easier for individuals to appear productive and healthy initially until it takes an obsessive turn and distorts their overall well-being.

Some typical causes and risk factors for orthorexia are listed below:

1. Psychological factors

• Low self-esteem
• Perfectionism
• Difficulties in controlling emotions
• A constant need to structure one’s life
• Appearance orientation
• History of an eating disorder
• Preoccupied with the thought of being overweight

2. Biological factors

• Close relatives with eating disorders, diabetes, etc.
• Parental feeding practices
• Parental history of dieting

3. Social/Cultural factors

• Being bullied, body-shamed, fat-shamed
• Buying into the idea of an ‘ideal’ body

Orthorexia diagnosis

A certified doctor, nutritionist, and mental health professional may be able to help with orthorexia.

There are no formal criteria for a medical diagnosis of orthorexia, and the National Eating Disorders Association has also not determined a treatment plan for individuals that exhibit the characteristic symptoms.

In 2016, Bratman and Thomas M. Dunn, Ph.D., a professor at the University of Northern Colorado, proposed two-part diagnostic criteria for orthorexia nervosa:

Criteria A states:

The individual will exhibit an obsessive focus on healthy eating according to their understanding of a healthy diet, along with exaggerated emotional distress concerning food choices perceived as unhealthy. Eventually, unintentional weight loss may ensue as a result of restrictive dietary choices. In addition:

• Individuals will compulsively follow and stay occupied with the notion of dietary practices that promote optimum health according to their understanding.
• If self-imposed dietary restrictions are broken, it results in heightened fear of illness and feelings of personal impurity, accompanied by anxiety and humiliation.
• Dietary restrictions escalate over time and may include the elimination of entire food groups and frequent and/or severe "cleanses" (partial fasts) for detoxification.
• Subsequently, this results in weight loss, although the desire to lose weight is non-existant, hidden, or secondary to healthy eating.

Criterion B states:

The compulsive behavior and mental preoccupation regarding food may lead to physical and psychological impairments:

• A restricted diet may result in malnutrition, severe weight loss, or other medical complications.
• Personal distress or impairment of social, academic, or occupational functioning due to beliefs or behaviors about a healthy diet.
• Strict adherence to the self-prescribed healthy eating behavior defines positive body image, self-worth, identity, and/or contentment.

Orthorexia Treatment

It is important to recognize that orthorexia can be as detrimental to health as any other eating disorder. It can cause irreparable harm to one's physical, psychological, and social well-being if left untreated. However, complete recovery from orthorexia is possible with the right support and a multi-disciplinary approach, including physicians, dieticians, and psychotherapists, while treating the problem.

Common methodologies used by doctors to treat orthorexia include:

• Cognitive Behavioral Therapy: CBT helps in recognizing that a person’s thoughts and beliefs directly affect their emotions and behaviors. Hence, by challenging their mental preoccupation and changing their negative beliefs about certain foods and body image, CBT can help restore their self-esteem and well-being.
• Dialectical Behavioral Therapy: DBT is a combination of cognitive therapy and meditation. DBT aims to help an individual to come to terms with their uncomfortable thoughts, feelings, behaviors, and insecurities rather than avoiding them.
• Exposure and response prevention: By gradually exposing the individual to situations and food that trigger them, the response can be controlled and restructured to normalcy.
• Nutritional Counseling: Without educating the patient about the dietary nutritional requirements to maintain good health, treatment for orthorexia will not be effective. This aspect of the treatment regimen can be assisted by a trained dietitian or nutritionist.
• Medication: Individuals with orthorexia are often found to be suffering from other eating disorders and mental illnesses. A physician or psychiatrist may prescribe anti-anxiety or antidepressant medication for any underlying mental health disorder and also address any accompanying eating disorder.
• Correcting nutritional deficiencies: Due to restrictions on many food groups, individuals with orthorexia can be deficient in multiple vitamins, minerals, and other nutrients. It is extremely important to restore these and other essential nutrients as a part of the treatment. In case of severe malnourishment and significantly underweight individuals, hospitalization may be necessary.

Coping with Orthorexia and Support

With the growing fixation on ‘clean eating’, it is much easier to fall prey to obsessive behaviors regarding food habits. This can make diagnosing an eating disorder like orthorexia much more difficult as well. Even after recognizing the problem, living with orthorexia can be challenging. However, with more studies and research on orthorexia and the rising media attention to this relatively new eating disorder, seeking help has never been easier. Currently, there are several things that a person can do to cope and find support which include:

1. Talking with a medical or mental health professional is an important first step. Their support is vital for proper guidance and direction to recover from orthorexia.
2. Sharing and confiding in a trusted friend or family member can be crucial for successful recovery.
3. Practicing self-acceptance and stress management techniques form the core of the coping mechanism. Although it may seem hard at the beginning, self-acceptance goes a long way in recovery.
4. It is crucial to stay away from crash diets, celebrity influencers, and nutritional advice from less-than-reliable sources in the age of social media and the global preoccupation around "clean eating".

There are various online support networks to help cope with such eating disorders, such as:

• National Eating Disorders Association
• National Association of Anorexia Nervosa and Associated Disorders

Individuals with orthorexia can get back to a balanced diet with the right assistance and treatment, free from baseless prejudice against any particular food group, and make informed choices on healthy eating.

Summary

Today, fad diets, savvy marketing, and social media trends propagate ever-changing images of what a healthy lifestyle should look like. It is easy to cave in under such pressure and follow perceived standards without knowing the truth. It is essential to make informed choices about nutrition but not at the cost of mental health. Being mindful of the food you eat and its impact on overall health can be beneficial. However, there’s a fine line between healthy eating and obsessing over food to the point of developing an eating disorder.

If anyone has experienced such symptoms or knows someone whose quest for the ‘perfect diet’ is significantly disrupting their social life and well-being, it could be a sign of orthorexia. It is an eating disorder that can have life-threatening consequences. Hence, immediate consultation with a qualified health professional such as a doctor, psychologist, or registered dietitian is strongly recommended.

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References:

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