What is Orthorexia Nervosa?

Orthorexia nervosa (also known as orthorexia) is a proposed eating disorder characterised by an excessive preoccupation with eating healthy food.

The term was introduced in 1997 by American physician Steven Bratman, M.D. He suggested that some people’s dietary restrictions intended to promote health may paradoxically lead to unhealthy consequences, such as social isolation, anxiety, loss of ability to eat in a natural, intuitive manner, reduced interest in the full range of other healthy human activities, and, in rare cases, severe malnutrition or even death.

In 2009, Ursula Philpot, chair of the British Dietetic Association and senior lecturer at Leeds Metropolitan University, described people with orthorexia nervosa as being “solely concerned with the quality of the food they put in their bodies, refining and restricting their diets according to their personal understanding of which foods are truly ‘pure’.” This differs from other eating disorders, such as anorexia nervosa and bulimia nervosa, where those affected focus on the quantity of food eaten.

Orthorexia nervosa also differs from anorexia nervosa in that it does not disproportionally affect one gender. Studies have found that orthorexia nervosa is equally found in both men and women with no significant gender differences at all. Furthermore, research has found significant positive correlations between ON and both narcissism and perfectionism, but no significant correlation between ON and self esteem. This shows that high-ON individuals likely take pride over their healthy eating habits over others and that is the driving force behind their orthorexia as opposed to body image like anorexia.

Orthorexia nervosa is not recognised as an eating disorder by the American Psychiatric Association, and so is not mentioned as an official diagnosis in the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM).

Brief History

In a 1997 article in the magazine Yoga Journal, the American physician Steven Bratman coined the term “orthorexia nervosa” from the Greek ορθο- (ortho, “right” or “correct”), and όρεξις (orexis, “appetite”), literally meaning ‘correct appetite’, but in practice meaning ‘correct diet’. The term is modelled on anorexia, literally meaning “without appetite”, as used in the definition of the condition anorexia nervosa. (In both terms, “nervosa” indicates an unhealthy psychological state.) Bratman described orthorexia as an unhealthy fixation with what the individual considers to be healthy eating. Beliefs about what constitutes healthy eating commonly originate in one or another dietary theory such as raw foods veganism or macrobiotics, but are then taken to extremes, leading to disordered eating patterns and psychological and/or physical impairment. Bratman based this proposed condition on his personal experiences in the 1970s, as well as behaviours he observed among his patients in the 1990s. In 2000, Bratman, with David Knight, authored the book Health Food Junkies, which further expanded on the subject.

Following the publication of the book, in 2004 a team of Italian researchers from La Sapienza University of Rome, published the first empirical study attempting to develop a tool to measure the prevalence of orthorexia, known as the ORTO-15.

In 2015, responding to news articles in which the term orthorexia is applied to people who merely follow a non-mainstream theory of healthy eating, Bratman specified the following: “A theory may be conventional or unconventional, extreme or lax, sensible or totally wacky, but, regardless of the details, followers of the theory do not necessarily have orthorexia. They are simply adherents of a dietary theory. The term ‘orthorexia’ only applies when an eating disorder develops around that theory.” Bratman elsewhere clarifies that with a few exceptions, most common theories of healthy eating are followed safely by the majority of their adherents; however, “for some people, going down the path of a restrictive diet in search of health may escalate into dietary perfectionism.” Karin Kratina, PhD, writing for the National Eating Disorders Association, summarises this process as follows: “Eventually food choices become so restrictive, in both variety and calories, that health suffers – an ironic twist for a person so completely dedicated to healthy eating.”

Although orthorexia is not recognised as a mental disorder by the American Psychiatric Association, and it is not listed in the DSM-5, as of January 2016, four case reports and more than 40 other articles on the subject have been published in a variety of peer-reviewed journals internationally. According to a study published in 2011, two-thirds of a sample of 111 Dutch-speaking eating disorder specialists felt they had observed the syndrome in their clinical practice.

According to the Macmillan English Dictionary, the word is entering the English lexicon. The concept of orthorexia as a newly developing eating disorder has attracted significant media attention in the 21st century.

Signs and Symptoms

Symptoms of orthorexia nervosa include “obsessive focus on food choice, planning, purchase, preparation, and consumption; food regarded primarily as source of health rather than pleasure; distress or disgust when in proximity to prohibited foods; exaggerated faith that inclusion or elimination of particular kinds of food can prevent or cure disease or affect daily well-being; periodic shifts in dietary beliefs while other processes persist unchanged; moral judgment of others based on dietary choices; body image distortion around sense of physical “impurity” rather than weight; persistent belief that dietary practices are health-promoting despite evidence of malnutrition.”

Cause(s)

There has been no investigation into whether there may be a biological cause specific to orthorexia nervosa. It may be a food-centred manifestation of obsessive-compulsive disorder (OCD), which has a lot to do with control.

Diagnosis

In 2016, formal criteria for orthorexia were proposed in the peer-reviewed journal Eating Behaviours by Thom Dunn and Steven Bratman. These criteria are as follows:

  • Criterion A:
    • Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue, but this is conceptualised as an aspect of ideal health rather than as the primary goal.
    • As evidenced by the following:
      1. Compulsive behaviour and/or mental preoccupation regarding affirmative and restrictive dietary practices believed by the individual to promote optimum health. (Footnotes to this criteria add: Dietary practices may include use of concentrated “food supplements.” Exercise performance and/or fit body image may be regarded as an aspect or indicator of health.)
      2. Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.
      3. Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy food.
  • Criterion B:
    • The compulsive behaviour and mental preoccupation becomes clinically impairing by any of the following:
      1. Malnutrition, severe weight loss or other medical complications from restricted diet.
      2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviours about healthy diet.
      3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behaviour.

A diagnostic questionnaire has been developed for orthorexia sufferers, similar to questionnaires for other eating disorders, named the ORTO-15. However, Dunn and Bratman critique this survey tool as lacking appropriate internal and external validation.

Epidemiology

Results across scientific findings have yet to find a definitive conclusion to support whether nutrition students and professionals are at higher risk than other population subgroups, due to differing results in the research literature. There are only a few notable scientific works that, in an attempt to explore the breadth and depth of the still vaguely-understood illness, have tried to identify which groups in society are most vulnerable to its onset. This includes a 2008 German study, which based its research on the widespread suspicion that the most nutritionally-informed, such as university nutrition students, are a potential high-risk group for eating disorders, due to a substantial accumulation of knowledge on food and its relationship to health; the idea being that the more one knows about health, the more likely an unhealthy fixation about being healthy can develop. This study also inferred that orthorexic tendencies may even fuel a desire to study the science, indicating that many within this field might suffer from the disorder before commencing the course. However the results found that the students in the study, upon initial embarkation of their degree, did not have higher orthorexic values than other non-nutrition university students, and thus the report concluded that further research is needed to clarify the relationship between food-education and the onset of ON.

Similarly, in a Portuguese study on nutrition tertiary students, the participants’ orthorexic scores (according to the ORTO-15 diagnostic questionnaire) actually decreased as they progressed through their course, as well as the overall risk of developing an eating disorder being low at 4.2%. The participants also answered questionnaires to provide insight into their eating behaviours and attitudes, and despite this study finding that nutrition and health-science students tend to have more restrictive eating behaviours, these studies however found no evidence to support that these students have “more disturbed or disordered eating patterns than other students” These two aforementioned studies conclude that the more understanding of food one has is not necessarily a risk factor for ON, explaining that the data gathered suggests dietetics professionals are not at significant risk of it.

However, these epidemiologic studies have been critiqued as using a fundamentally flawed survey tool that inflates prevalence rates. Scholars have questioned both the reliability and validity of the ORTO-15.

Most scientific findings tend to agree, however, young adults and adolescents are extremely susceptible to developing eating disorders. One study found that there was no relationship between BOT score and college major, which may indicate the prevalence of mental health issues and eating disorders on college campuses and that health and science majors are no longer the only ones affected More studies have also been conducted on the link between increased Instagram use and Orthorexia nervosa. The social media based healthy community has recently grown in popularity especially on platforms such as Instagram. The hashtag #food is one of the top 25 most popular hashtags on Instagram. A study that investigated this relationship found that increased use of Instagram correlated between symptoms of ON with no other social media platform having the same effect. With young adults and adolescents making up the majority of social media users, exposure to this type of content can lead to developing unhealthy behaviour.

Book: Orthorexia – When Healthy Eating Goes Bad

Book Title:

Orthorexia – When Healthy Eating Goes Bad.

Author(s): Renee McGregor.

Year: 2017.

Edition: First (1st).

Publisher: Nourish Books.

Type(s): Paperback and Kindle.

Synopsis:

Can healthy eating become a dangerous obsession?

Orthorexia is an eating disorder that is hard to see. It is not about purging or cutting calories. But by excluding foods in pursuit of a “clean” or ideal diet, it can quickly turn into a compulsion with serious consequences for mental and physical health.

For the first time, dietician, nutritionist and eating disorder campaigner Renee McGregor reveals the true messages behind these dangerous diets. Packed with first-hand experiences and analysis, it provides the tools to guide sufferers back to a balanced, truly healthy way of eating.

Book: Cognitive Behaviour Therapy for Adolescents with Eating Disorders

Book Title:

Cognitive Behaviour Therapy for Adolescents with Eating Disorders.

Author(s): Riccardo Dalle Grave and Simona Calugi.

Year: 2020.

Edition: First (1st).

Publisher: Guildford Press.

Type(s): Hardcover and Kindle.

Synopsis:

This state-of-the-art guide provides a powerful transdiagnostic approach for treating adolescent eating disorders (anorexia nervosa, bulimia nervosa, binge-eating disorder, and others) in either outpatient or inpatient settings.

It describes how enhanced cognitive behaviour therapy (CBT-E) – the gold-standard treatment for adult eating disorders – has been systematically adapted and tested with younger patients.

With a strong motivational focus, CBT-E gives the adolescent a key role in decision making. The book presents session-by-session guidelines for assessing patients, determining whether CBT-E is appropriate, developing case conceptualisations, conducting individualised interventions, addressing medical issues, and involving parents.

User-friendly features include case vignettes and reproducible forms; purchasers get access to a Web page where they can download and print the reproducible materials in a convenient 8 1/2″ x 11″ size.

CBT-E is recognised as a best practice for the treatment of adolescent eating disorders by the UK’s National Institute for Health and Care Excellence (NICE).

Book: Cognitive Behaviour Therapy for Eating Disorders

Book Title:

Cognitive Behaviour Therapy for Eating Disorders.

Author(s): Glenn Waller, Helen Cordery, Emma Corstorphine, Hendrik Hinrichsen, Rachel Lawson, Victoria Mountford, and Katie Russell.

Year: 2007.

Edition: First (1st), Illustrated Edition.

Publisher: Cambridge University Press.

Type(s): Paperback and Kindle.

Synopsis:

This book describes the application of cognitive behavioural principles to patients with a wide range of eating disorders – it covers those with straightforward problems and those with more complex conditions or co-morbid states.

The book takes a highly pragmatic view. It is based on the published evidence, but stresses the importance of individualised, principle-based clinical work.

It describes the techniques within the widest clinical context, for use across the age range and from referral to discharge.

Throughout the text, the links between theory and practice are highlighted in order to stress the importance of the flexible application of skills to each new situation. Case studies and sample dialogs are employed to demonstrate the principles in action and the book concludes with a set of useful handouts for patients and other tools.

This book will be essential reading for all those working with eating-disordered patients including psychologists, psychiatrists, nurses, counsellors, dieticians, and occupational therapists.

Book: Cognitive Behaviour Therapy and Eating Disorders

Book Title:

Cognitive Behaviour Therapy and Eating Disorders.

Author(s): Christopher G. Fairburn.

Year: 2008.

Edition: First (1st).

Publisher: Guildford Press.

Type(s): Hardcover and Kindle.

Synopsis:

This book provides the first comprehensive guide to enhanced cognitive behaviour therapy (CBT-E), the leading empirically supported treatment for eating disorders in adults.

Written with the practitioner in mind, the book demonstrates how this transdiagnostic approach can be used with the full range of eating disorders seen in clinical practice.

Christopher Fairburn and colleagues describe in detail how to tailor CBT-E to the needs of individual patients, and how to adapt it for patients who require hospitalisation.

Also addressed are frequently encountered co-occurring disorders and how to manage them.

Reproducible appendices feature the Eating Disorder Examination interview and questionnaire.

Book: The Food Addict’s Meal Prep Manual

Book Title:

The Food Addict’s Meal Prep Manual: Save Yourself From Food Addiction In Only 2 Hours A Week.

Author(s): Dr. Joan Ifland (PhD).

Year: 2018.

Edition: First (1st).

Publisher: ?.

Type(s): Kindle.

Synopsis:

Research shows that addiction to processed foods explains why we overeat. Processed foods are everywhere which makes it very hard to break the food addiction cycle. It seems like people are pushing processed foods at every turn.

But you CAN break the cycle! Having your own beautiful meals is the secret! In The Food Addicts Meal Prep Manual, we’re going to show you step-by-step how to prepare all your meals in only 2 hours a week. Having meals at hand will give you a big advantage in regaining control over your food. This quick, easy guide shows you how to have fun and save lots of money by making all your food in two hours per week.

The guide lets you pick the foods you already love. You will be delighted at how beautiful and delicious these healthy meals are. Learn the surprising truth that ‘healthy’ can be scrumptious, inexpensive, and quick. This guide shows you how.

But you CAN break the cycle! In The Food Addicts Meal Prep Manual, we are going to show you step-by-step how to prepare healthy meals in only 2 hours a week, helping you to break the cycle of sugar, salt and processed foods, which are keeping you from having the body you want.

Go from feeling poor to having endless energy. Finally be able to lose weight and gain back that self-confidence. And most importantly, take back control in your life without the mindless eating and self-shaming that is keeping you locked in the cycle.

Book: Food Junkies: Recovery from Food Addiction

Book Title:

Food Junkies: Recovery from Food Addiction.

Author(s): Vera Tarman.

Year: 2019.

Edition: Second (2nd).

Publisher: Dundurn.

Type(s): Paperback, Audiobook, and Kindle.

Synopsis:

A fact-filled guide to coping with compulsive overeating problems by an experienced addictions doctor who draws on many patients’ stories of recovery.

Overeating, binge eating, obesity, anorexia, and bulimia – Food Junkies tackles the complex, poorly understood issue of food addiction from the perspective of a medical researcher and dozens of survivors. What exactly is food addiction? Is it possible to draw a hard line between indulging cravings for “comfort food” and engaging in substance abuse? For people struggling with food addictions, recognizing their condition remains a frustrating battle.

This revised second edition contains the latest research as well as practical strategies for people facing the complicated challenges of eating disorders and addictions, offering an affirming and manageable path to healthy and sustainable habits.

Book: Food Addiction: Treatment for Overeating

Book Title:

Food Addiction: Treatment for Overeating.

Author(s): Charlie Mason.

Year: 2019.

Edition: First (1st).

Publisher: Tilcan Group Limited.

Type(s): Paperback, Audiobook, and Kindle.

Synopsis:

Millions of people are struggling with their healthy eating and lifestyle to help manage their weight. But what most people do not notice is the link between emotional craving and eating and unwanted weight. A part of your brain tells you that you need to eat a healthy meal but your craving is telling you to reach for the comfort food instead.

Chances are, you end up with the comfort food, but it is not for a lack of willpower or motivation! Food addiction leads to various health-related problems including being over-weight and other eating disorders.

Food addiction is a mental and physical issue that requires mental and physical treatment. Unlike other addictions, you cannot eliminate food from your daily behaviours as you can with smoking or alcohol. You need food to survive. This means you need to find a way to stop your cravings and eat less in a realistic way.

As you navigate through the pages of this book, you will find tips and techniques to help you understand your cravings, how to stop them, and ways to treat your food addiction. Enjoy the simple and easy-to-follow tables, lists, and guides as you choose healthy meals over unhealthy and your wellbeing over cravings.

This book is designed to give you solutions to overeating in an inspiring and unique way!

It aims to reveal to you the common beliefs and thoughts about foods, untangle the addictive impulses programmed in your brain, and how to retrain your mind and body so you can live a healthier, happier, and balanced life with eating.

Using an approachable and factual delivery, Food Addiction: Treatment for Overeating offers you real solutions and simple steps so you can learn how to release the negative feelings entrapping you in your negative habits and the constant drudgery of failed diets and broken assurances.

Book: The Food Addiction Recovery Workbook

Book Title:

The Food Addiction Recovery Workbook: How to Manage Cravings, Reduce Stress, and Stop Hating Your Body.

Author(s): Carolyn Coker Ross (MD, MPH).

Year: 2017.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you are struggling with obesity or food addiction, you have probably been told that you must deprive yourself of certain foods in order to lose weight. You may have also been convinced-by the media and by our culture-that if you finally become thin your life will be better, you will be happier, and your suffering will come to an end.

The problem is – it is not all about the food. It is about how food is used to self-soothe, to numb ourselves against the pain of living or to cope with stress and unresolved emotions. Even as your waist whittles away, the problems that caused your food addiction won’t disappear.

The Anchor Programme™ approach detailed in this workbook is not about dieting. It is about being anchored to your true, authentic self. When you find your unique anchor, you will relate better to your body, you will know intuitively how to feed your body, and you will reach the weight that is right for you. Anyone who’s been on the diet treadmill-losing and regaining lost weight-will admit that losing weight does not instantly bring health or happiness. That is because losing weight is a red herring for the real issue, the misuse of food to solve a problem that has nothing to do with food.

This book offers a whole-person approach that blends practical information on managing stress and regulating emotions without relying on food. If you are ready to uncover the true cause of your food addiction, you will finally be able to embrace a balanced diet and reach the weight that is right for you.

Book: The Emotional Eating Workbook

Book Title:

The Emotional Eating Workbook – A Proven-Effective Step-By-Step Guide To End Your Battle With Food And Satisfy Your Soul.

Author(s): Carolyn Coker Ross (MD, MPH).

Year: 2016.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

For over fifty years, nutritional and medical scientists have dissected the problem of obesity. The result of this half-century of investigation has been a series of recommendations about what and how much to eat, and an unintended consequence is that we have been deprived of the joy of eating. From low-fat diets to the no-carb craze, the market has been continually flooded with one assortment of fad products and diets after another. So, when does it end?

If you are struggling with emotional overeating and are trying to lose weight, you should know that you do not need to deny yourself certain foods. In The Emotional Eating Workbook, you will learn about the real psychological needs that underlie your food cravings, how to meet those needs in positive ways, be mindful of your body, and find the deep satisfaction many overeaters seek in food.

It is not about food. It is about how food is used to self-soothe, numb ourselves against the pain of living, or self-medicate in coping with stress and unresolved emotions. The Anchor Programme™ approach detailed in this book is not about dieting. It is about being anchored to your true, authentic self. When you find your unique anchor, you will relate better to your body, you will know intuitively how to feed your body, and you will reach the weight that is right for you.