"Healthy" Orthorexia vs Orthorexia Nervosa?

Orthorexia nervosa (ON) is an eating disorder for which the primary symptom is an obsession with healthy eating.^1,2,3 Signs that someone might have ON include excessive meal planning, avoiding foods that are perceived as "impure," and restricting essential foods and nutrients from one's diet.

People with ON have similar personality traits as people with anorexia nervosa (AN), an eating disorder of restrictive eating, fear of weight gain, and extreme weight loss.^1,2,3 These personality similarities include perfectionism, anxiety, and obsessive-compulsive behaviors. People with ON, however, are usually less focused on their body weight and shape compared to people with other eating disorder types (e.g., AN).

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An obsession with healthy eating might seem unconcerning. However, ON is a serious condition with severe health detriments if left untreated. Specifically, ON can contribute to malnutrition, which can lead to immune dysfunction, as well as changes in how every bodily organ functions (e.g., brain, muscles, cardiac, gastrointestinal).⁴ ON can also reduce life quality for people with this disorder (e.g., lost relationships, depression, anxiety, and reduced productivity).

Risk Factors for Orthorexia Nervosa

Hypochondria, or health anxiety, is a risk factor for developing ON.⁵ People with health anxiety obsessively worry that they currently have a severe health condition or that they will develop a severe health condition. People with health anxiety might, therefore, eat as cleanly as possible to avoid poor health outcomes. Unsurprisingly, people with a vast knowledge of nutrition, health, and human biology (e.g., students and health professionals in medicine, nutrition, and dietetics), are at elevated risk for developing ON.⁶

Having a disorder of the gut–brain interaction (DGBI) is another risk factor for developing ON.⁶ DGBIs, such as irritable bowel syndrome (IBS), are complex disorders involving dysfunctions in how the gut and brain communicate.⁷ Symptoms of DGBIs vary across individuals and often include abdominal pain, diarrhea, constipation, bloating, fullness, nausea, and/or vomiting.

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While 40 percent of people globally have a DGBI, the underlying pathology of these disorders remains unclear—most patients seeking treatment for a DGBI show no structural abnormalities that can explain their symptoms.⁷ Consequently, health professionals often recommend dietary interventions for patients with a DGBI. However, research shows that individuals with digestive issues and food intolerances are at elevated risk for developing ON, possibly because of dietary restrictions in treatment.⁶

People with ON also process information in ways that are biased toward the self—this means that these individuals are chiefly concerned with achieving what they perceive to be personal health purity, often at the expense of other basic needs (e.g., nutritional requirements).² People with ON also struggle to think flexibly—this means that these individuals might find it difficult to direct their attention away from managing their personal health. These biases are similar to those observed in individuals with AN and obsessive-compulsive disorder (OCD).²

Diagnosing Orthorexia Nervosa

Currently, there are no strict criteria for diagnosing someone with ON. Nonetheless, there are questionnaires clinicians can use to help determine if a patient might have ON. These questionnaires include the ORTO-15,⁸ the Teruel Orthorexia Scale (TOS),⁹ The Eating Habits Questionnaire (EHQ),¹⁰ and the Düsseldorf Orthorexia Scale (DOS).¹¹

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There is, however, no optimal survey for diagnosing ON.^1,5 The lack of structure in defining and diagnosing ON is problematic because several ON behaviors, including restrictive eating and avoidance of "impure" foods, have been normalized in public and health circles.¹² Many health professionals readily prescribe dietary preventions, such as avoiding sugars or specific foods, to protect against certain medical conditions (e.g., diabetes). While some individuals might adjust to these suggestions without issue, individuals with risk factors for ON might take these dietary suggestions to extremes. And, with the normalization of restrictive and "pure" eating in Western cultures, it is uncertain whether a health professional would recognize if a patient crossed from "healthy" eating into ON territory.

The blurred lines between nonpathological healthy eating and ON are blurred even further by the term "healthy" orthorexia.^3,5,13,14

Healthy Orthorexia?

Like ON, healthy orthorexia isn't clearly defined.^3,5,13,14 Broadly, people with healthy orthorexia are thought to have an interest in, but not an obsession with, healthy eating and maintaining a healthy lifestyle. Ways of distinguishing ON from healthy orthorexia are still under investigation, which leaves ample room to justify ON behavior as healthy.

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One distinguishing factor between ON and healthy orthorexia might be how an individual with either condition feels about their lifestyle habits. In a recent study by Barthels et al. (2019), individuals who scored high on healthy orthorexia behaviors reported more positive affect toward their eating and lifestyle habits compared with individuals who scored high on self-reported ON behaviors. In contrast, individuals who scored high on ON behaviors reported more negative affect toward their eating and lifestyle habits compared with individuals who scored high on reported healthy orthorexia behaviors.

Another distinguishing factor between ON and healthy orthorexia is that people with ON tend to take their behaviors to an extreme, such as excluding foods that are vital for health—these individuals also fixate on the perceived health quality of foods, often to the detriment of their own life quality.^3,5,13,14 In contrast, people with healthy orthorexia report having more flexibility in their diets and less fixation on eating foods of a certain health quality. Finally, Depa et al. (2019) found that people with ON focused more on weight management than people with healthy orthorexia.

Nonetheless, additional research suggests that ON and healthy orthorexia can co-occur, with some individuals frequently sliding between each condition.¹⁵ Consequently, it is difficult to definitively differentiate ON from health orthorexia.

Conclusions: Removing the Term "Healthy" From Orthorexia

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The term "healthy" is weakly defined in public and health spheres.¹⁶ Broadly, a person is often described as healthy if they show no signs of disease. A person could also be described as healthy if they are in a state of optimal mental and physical well-being. People generally perceive "healthy" as a positive concept, despite the ambiguity of the word.

Given the ambiguity of ON and the term healthy, we need to consider whether healthy orthorexia is an appropriate way to describe a lifestyle that many health professionals and lifestyle enthusiasts advocate. Words carry great weight in medicine and can influence how patients think about a condition. Health professionals usually take great care when describing medical conditions to patients, caregivers, and the public.

However, associating a pathological condition (orthorexia) with a positive concept (healthy) invites opportunities for people with ON and health professionals to justify and overlook the severity of ON. Individuals with an eating disorder often deny the severity of their illness, and the term healthy orthorexia makes it too easy for this denial to continue. People should, therefore, not use the term orthorexia when describing eating habits that are perceived positively. It might also be time to retire the practice of giving nonpathological eating habits (e.g., healthy eating) a label altogether.