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What is Orthorexia?

Those social media influencers you love, who give off the “beacon of health” impression, might be inspiring. You might think “I’d like to be as healthy as them”.

But ask yourself this question…

Under the surface, are they really all that healthy?

Is being consumed by an extreme healthy-eating fixation, involving rigid food rules, fear, anxiety, and, most likely, malnutrition, a healthy and happy way to live?

More of a good thing, is not always better, and this is certainly the case when an interest in healthy eating is taken too far.

Orthorexia Nervosa is a relatively new health-concern that describes an extreme fixation with healthy eating that can become anything but “healthy”. Orthorexia can result in significant mental distress and physical harm.

Orthorexia involves ritualistic eating and food preparation patterns, extreme food rules around “attaining diet purity”, rigid avoidance of arbitrarily defined “unhealthy” foods/food groups and eating only from a list of acceptable foods that is subject to individual variation (Bhattacharya et al., 2022; Cena et al., 2019; Niedzielski and Kazmierczak-Wojitas, 2021).

Is Orthorexia an eating disorder?

Technically Orthorexia is not considered a diagnosable eating disorder or mental disorder. However, this is not because Orthoerxia isn’t a severe issue, but rather because it’s a relatively new phenomenon. As research, and validated measures emerge,, this will likely change.

Orthorexia has been described in 2 phases. The first, being still relatively healthy where Orthorexia-like behaviours act as a coping strategy for anxiety and other psychological issues. The tipping point where a healthy eating interest transitions to phase 2, becoming obsessive, disordered and therefore harmful has not been identified (Niedzielski and Kazmierczak-Wojitas, 2021; Vanente et al., 2021).

Whilst most individuals who have self-diagnosed as having Orthorexia recognise it as a health concern, some do not think Orthorexia is problematic at all, and rather think of Orthorexia as a salvation from chronic disease. One survey respondent in a 2020 study even called it a “made-up condition” that only discourages healthy eating (Valente et al., 2020).

Despite what those who self-diagnose with Orthorexia perceive, Orthorexia shares many traits and negative outcomes with recognised eating disorders and other psychological disorders such as obsessive-compulsive disorder (OCD) (Zagaria et al., 2021). One of these eating disorders is Anorexia Nervosa which is loosely characterized as the restriction of Calorie intake relative to requirements, intense fear of weight gain and distorted body image.

Those suffering from Anorexia tend to fixate on food quantity out of a fear of weight gain, driven by appearance. By comparison, those experiencing symptoms of Orthorexia tend to place greater focus on food quality to attain optimal health (Dunn and Bratman, 2016). However, this does not mean those with symptoms of Orthorexia are not conscious of and affected by appearance and body weight.

In fact, those who self-diagnose with Orthorexia describe a similar fear of weight gain or fat-phobia and can experience unhealthy extreme low body weight similarly to Anorexia sufferers. However, this fear is derived from health-seeking values as excessive weight results in various poor health outcomes, instead of being primarily driven by superficial appearance (Valente et al., 2020).

How is Orthorexia diagnosed?

Currently Orthorexia cannot be formally diagnosed which is a severe limitation to existing research around potential causes and prevalence. However, numerous signs and symptoms have been identified and they include:

anxiety (especially around food choices),
social isolation (given the role of food in social interactions),
excessive guilt following ‘slip ups’, mood swings,
depression and using food behaviours as a primary regulator of self-esteem (Valente et al., 2020).

Who is affected by Orthorexia and what causes it?

Anyone can be affected by Orthorexia.

However, those with obsessive-compulsive traits, anxiety, exercise addiction, negative body image, a perceived vulnerability to disease, a fear of losing control, a desire for thinness, perfectionistic traits, past eating disorders, an immersion in western culture, and a health related life event, or change, that prompts greater interest in health and the desire to seek control, might be more susceptible (Valente et al., 2020).

The effect of western health and beauty ideals appears to trigger the over-valuing of physical appearance and health, promoting excessive dietary restriction. This is perhaps magnified by social media (Valente et al., 2020).

Findings from a 2020 study in young adult women suggest social media is not correlated with Orthorexia, but rather an indirect link via negative body consciousness may be at play (Gann, 2020).

Given this, it’s plausible that those who already have poor body image, or health interests might use social media to gain #inspo, which can trigger fixations with healthy-eating and body image to become more extreme.

Exercise addiction has also been linked with Orthorexia, however, , it cannot be firmly said what causes what (Strahler et al., 2021).

A major life event or change, such as a health complication, awareness of a concerning family medical history, or even something relatively minor such as food allergy may prompt health seeking eating interests to become extreme (Valente et al., 2021).

Pre-existing obsessive-compulsive traits such as food checking (eg; repeated, precise food weighing and precise macro tracking), planning, and thinking about food might also increase risk (Niedzielski and Kazmierczak-Wojitas, 2021).

Is Orthorexia harmful?

A myriad of negative physical, mental, and social health outcomes can occur as a product of Orthorexia. These include:

immense guilt,
obsessive behaviours,
anxiety,
malnutrition,
impaired daily function,
unhealthy low body weight,
poor body image,
low self-esteem and
social isolation (Dunn and Bratman, 2016).

Orthorexia can also be self perpetuated, like a vicious cycle. For example, feelings of anxiety and guilt following the consumption of a “banned food” or deviation from self-imposed food rules may further drive restriction in a bid to regain control (Dunn and Bratman, 2016).

Despite an obsessive interest in optimising physical health being the crux of Orthorexia, indeed, the negative effects include physical health too. Orthorexia is not just a mental health concern.

Those suffering from symptoms of Orthorexia tend to eliminate certain foods, and food groups and eat exclusively from a list of acceptable foods, which can lead to malnutrition (Niedzielski and Kazmierczak-Wojitas, 2021). If certain food groups/types are omitted from the diet and food selection becomes rather narrow, a skewed intake of vitamins, minerals, and macronutrients (protein, carbs, fats), as well as insufficient total Calories (insufficient Calories to sustain proper human function), may result. This can create gaps in diet adequacy leading to malnourishment and nutrient deficiencies.

In a cohort of 134 women, 79.5% reported their menstrual cycle was irregular or stopped altogether during Orthorexia, bolstering other indications that Orthorexia can result in low energy availability and/or micronutrient malnutrition (vitamin, mineral deficiencies), due to the desire to lose weight for health, and limited food diversity.

Obsessive levels of food focus and food rules are traits of known eating disorders. Orthorexia can have indirect effects on social, and even financial health.

You might be a beacon of physical health, but remember, total health is limited by its weakest link. If you have no money because you can’t do your job properly (because your mind is debilitated by food-related thoughts) and you spend your money on expensive health-foods, your total financial situation might not be so great.

Similarly, if you have no social life because attending a social occasion might not align with your food rules, practices and list of accepted foods, your social health might not be ideal. Indeed, impaired social function, unhealthy relationships and social isolation were described as the most distressing aspect of Orthorexia (Valente et al., 2020).

Why “clean/pure eating” approaches are not needed to achieve a healthy diet and changes to body weight or shape?

Your body weight, as well your health, is not influenced by the presence of “perfection”. Principles, not perfection, are what underpins these things.

If you’re looking to manage or manipulate your body weight the single principle that fundamentally drives change is energy balance. Whilst it does get a bit more complicated with moving targets, human behaviour etc, fundamentally weight change is as simple as Calories in versus Calories out when you peel it all back.

In the case of health, we’re really looking at whether the diet provides sufficient energy and nutrients to promote and support function. Yes, consuming excessive energy (Calories) will result in a positive energy balance (Calorie surplus), which over a longer period of time will yield notable weight gain and poor health effects. So we want to avoid that, but practically speaking, it doesn’t need to be complicated any further.

A health-seeking diet can and should include indulgences. Indulgences won’t harm physical health assuming the formerly mentioned principles are present; in fact, if anything indulgences will enhance total health.

Indulgences play a key role in a health-seeking lifestyle largely due to their positive influence on social and emotional health. No part of the Australian Dietary Guidelines states you must eliminate indulgences or “treats”, rather the guides just advise moderating your intake. Specified serving sizes of discretionary foods equal roughly 150 Calories which equates to.

2 scoops (75g) regular ice cream
50-60g (about two slices) processed meats, salami, mettwurst
1 ½ thick or 2 thinner higher fat/salt sausages
30g salty crackers (a small individual serve packet)
2-3 sweet biscuits
1 (40 g) doughnut
1 slice (40 g) plain cake or small cake-type muffin
40g sugar confectionery (about 5-6 small lollies)
60g jam/honey (about 1 tablespoon)
1/2 small bar (25 g) chocolate
2 tablespoons (40 g) cream
1 tablespoon (20 g) butter or hard margarine
200 mL wine (2 standard drinks (note this is often 1 glass for many Australian wines)
60 mL spirits (2 standard drinks)
600 mL light beer (1½ standard drinks)
400 mL regular beer (1½ standard drinks)
1 can (375 mL) soft drink
1/3 (60 g) commercial meat pie or pastie
12 (60 g) fried hot chips

(NHMRC, 2017).

A diverse balanced whole food-focused (not whole food only) diet that includes indulgences in moderation, can adhere to health-eating and weight management principles perfectly well.

Worrying about minute details such as whether your food is organic, or weighed to the nearest gram, and stressing about having a few hot chips and a drink on a Friday night with your friends, is simply a complete waste of time insofar as it relates to health. In fact, it’s doing your health harm, if anything.

How to recover from Orthorexia?

A set of recovery steps specific to Orthorexia has not been established and discussing this is both beyond the scope of this blog and my own scope of practice as a sports nutritionist. If you’re experiencing symptoms and effects of Orthorexia seek professional help. The Butterfly Foundation referral database can help you find a legitimate dietitian and psychologist who is experienced in eating disorders.

In those who self-diagnose with Orthorexia, recovery was viewed as a continual learning process of managing symptoms because Orthorexia will always be lingering in the background (Valente et al., 2020). Working alongside a dietitian and psychologist who specialise in eating disorders will help you identify root causes and learn how to eat in line with your values instead.

Interestingly, despite social media’s role in potentially driving the onset of Orthorexia, those who are self-diagnosed with Orthorexia view social media as a powerful recovery tool giving social media a dual purpose in Orthorexia. Following, and interacting with online communities that challenge Westernised health and beauty ideals, promoting body positivity and intuitive eating (which by definition rejects the idea of foods being good or bad, healthy or unhealthy), appears to be very helpful (Valente et al., 2020).

Conclusion

Just like anything ‘good’, a healthy eating interest can become damaging when it’s taken too far. The ‘beacon of health’ persona you envisage, inspired by your favourite health influencers, might seem appealing on the surface.

But, in reality, behind the pretty smoothie bowls, toned abs, and glowing skin, there may be food obsession, food fear, food anxiety, OCD, malnutrition, and social isolation that debilitate the attainment of a fulfilling, happy existence.

…Is that the way you want to live life?

…Is that really what you call “health”?

Health is not about “perfection”, and your goals don’t care about “perfection” either. The “perfect diet” is probably one that promotes total health and happiness.

If you feel like you’re becoming preoccupied or obsessed with “healthy” eating and it’s affecting your social health, you’re stressed about what and where you eat, or even breaking your bank, it might be time to consider if it’s all worth it.

If you can relate to some of the things that have been mentioned in this blog, then reach out to one of our team or head to the Butterfly Foundation.

A damaging obsession with an arbitrary, and misleading definition of “the perfect diet” can do your health anything but good. Your health does not care about perfection.

Orthorexia Nervosa is a relatively new health concern that shares many traits and negative outcomes with eating disorders. It describes an extreme obsession with healthy eating and food purity that can result in social isolation, malnutrition, poor physical health and severe psychological distress.

At this stage, a universally agreed definition and diagnostic criteria have not been established, so more questions including causes, prevalence and recovery remain.

Interpersonal factors such as OCD, anxiety, and life-changing events (eg; illness) may also contribute to and trigger the development of Orthorexia.

Orthorexia is a serious and seemingly rising issue that requires the help of a legitimate medical professional.

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