Understanding Orthorexia

We are constantly encouraged to live a healthy lifestyle, eat a healthy diet, and look aesthetically pleasing. Popular and social media bombard us with images and videos of exercise techniques, the ‘perfect’ plate, and new ‘on trend’ beauty techniques and surgeries. These images and videos can be overpowering and, for some, can lead to unrealistic expectations of ourselves. Attempts at trying to achieve such expectations have consequences. One concern is that these attempts are contributing to a rise of orthorexia, which is recognised as obsessional healthy eating.

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What is orthorexia?

Orthorexia is broadly considered to be an obsessional fixation with ‘correct’ nutrition. It is characterised by rigid and inflexible dietary rules that include spending excessive amounts of time planning, preparing, and eating food.

Strict rules are coupled with strong beliefs about healthy food types. These beliefs vary from person-to-person but can include only eating ‘clean’, organic, or unprocessed food that will not be harmful to an individual’s health. Those who suffer from orthorexia may also be heavily influenced by popular dietary trends such as paleo, fruitarianism (only eating fruits, nuts and seeds), and intermittent fasting.

Proposed diagnostic criteria for the disorder are mainly based on existing research and case studies. The criteria include 1) being mentally preoccupied with and partaking in compulsive eating behaviours that are thought to promote flawless health, 2) emotional and physical reactions to not eating a perfectly healthy diet (e.g., fear, anxiety), and 3) restrictive eating patterns that change from disordered eating behaviours to clinical eating disorder pathology (e.g., anorexia). Impairments associated with pursuing perfect eating can also be used to diagnose orthorexia, such as malnutrition, severe weight loss, and interference in social, academic, and work domains of life.

What is orthorexia associated with?

The onset of orthorexia has been linked to a number of risk factors, including having a history of eating or mental disorders, depressive symptoms, and anxiety. However, lifestyle factors can also contribute to the disorder, such as participating in competitive sports, high levels of exercise, and being vegan or vegetarian. Researchers are currently debating whether orthorexia precedes, exists at the same time as, or follows other feeding and eating disorders (e.g., anorexia and bulimia). Some researchers have suggested that the disorder may lead to anorexia, or that it may be the result of recovering from anorexia.

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New consensus

There has been past disagreement about the extent to which orthorexia is similar or dissimilar to other disorders, namely anorexia, avoidant restrictive food intake disorder (ARFID), and obsessive-compulsive disorder (OCD). In addition, it is not currently recognised as a distinct clinical eating disorder in either the Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-5-TR) or International Classification of Diseases (ICD-11). However, international multidisciplinary specialists and researchers have carried out recent work on consensus of the definition and diagnostic criteria for orthorexia. The outcome of this work suggests that orthorexia is likely a distinct feeding and eating disorder. This position is justified by reasons outlined below.

Differences from anorexia

First, distinct differences between orthorexia and anorexia have been highlighted. For example, in anorexia, the primary goal is to lose weight or maintain a current low weight, whereas the goal in orthorexia is to reach optimal health. In addition, body dissatisfaction and explicit search for thinness drive dietary restraint in anorexia, while, in orthorexia, appearance concerns are not a central focus and there is no aware search for thinness. A further difference is that anorexic individuals self-evaluate based on their weight and shape, but self-evaluation for orthorexic individuals is centered around the ability to follow strict dietary rules to improve the status of their health. If an individual with orthorexia experiences weight or shape phobia, it will typically be unconscious and present as an implicit attitude.

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Differences from ARFID

Second, differences between orthorexia and ARFID have also been noted. ARFID manifests as a persistent failure to meet energy and/or nutritional needs. There is an overlap of symptoms as a result of orthorexia and ARFID (e.g., significant weight loss, interference with social and mental functioning, and nutritional deficiencies), however, in ARFID, these symptoms form diagnostic criteria. For example, malnutrition and psychosocial impairment associated with conditioned negative responses to food (e.g., choking), a lack of interest in food, and selective intake based on sensory properties of food (e.g., texture) are the basis of ARFID diagnoses. However, in orthorexia, malnutrition and impaired functioning are consequences of food restriction based on worries about how pure and healthy food is. A further difference is an acute focus on the short-term effects of eating in ARFID, where in orthorexia, fear of long-term consequences of food and eating (e.g., diabetes, cancer) are at the forefront.

Differences from OCD

Third, there have been proposed differences between orthorexia and OCD. OCD is made up of two parts - obsessions and compulsions. Obsessions in OCD are unwelcome thoughts, images, or worries that repeatedly occur and cause significant anxiety. Compulsions manifest as repetitive behaviours that are used to reduce anxiety caused by the obsession. Orthorexia has commonly been described as a subtype of OCD. However, the disorders differ in two key ways. First, individuals with OCD suffer from ego-dystonic obsessions (unwanted and distressing), whereas obsessions in orthorexia are ego-syntonic. These ego-syntonic obsessions are considered appropriate thoughts and behaviours that will aid optimal health status. In addition, there is tentative evidence that obsessional thoughts in orthorexia may be reflected onto others with the expectation of those around them also striving for ideal health (i.e., orthorexia by proxy). This is not the case in OCD, however, there have been some reports of a by proxy nature of compulsive rituals.

Moving forward

Notably, there is a need to clarify where orthorexia fits on the eating disorder spectrum. Additional research is required to understand whether the disorder could be considered as a distinct fourth subtype of ARFID, or whether it could be included as a third subtype of ARFID in the DSM-5-TR. In addition, using a transdiagnostic model, further work is needed to explore the role of the body and body image distortion in orthorexia. This work should include body dissatisfaction, body and muscle dysmorphia, and body dysphoria. It should also be extended to negative body image, self-evaluation based on weight and shape, and societal influences (e.g., diet culture).

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With the consensus paper in mind, we now have a first standard definition of orthorexia and collective proposed diagnostic criteria. Practically, we can begin to better validate and assess the reliability of existing measuring instruments, expand the accuracy of prevalence rates of the disorder, and identify evidence-based treatment protocols. Doing so, will allow individuals suffering from orthorexia to access the support that they need to start to recognise and challenge distorted ways of thinking, feeling, and behaving.