What is Orthorexia: Symptoms, Complications and Causes

Orthorexia nervosa, while not an officially designated mental health diagnosis, is an increasingly concerning disorder. Evolving out of diet culture and the societal emphasis on “clean” and “healthy” food, orthorexic tendencies are viewed as socially acceptable due to a lack of understanding of the disorder and the dangers it presents.

Orthorexia Definition

The term orthorexia was coined in the 1990s by Steven Bratman, a practitioner of alternative medicine, and referred to “an almost pathological fixation on and obsession for healthy eating [1].” Individuals that struggle with orthorexia are typically focused on the quality as opposed to the quantity of food.

Orthorexia Nervosa DSM-5 Definition

It is important to clarify that Orthorexia Nervosa is not an official mental health diagnosis that is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Classification of Disease (ICD-10).

Steven Bratman proposed possible criteria for Orthorexia Nervosa diagnosis in 2016 including:

  1. An obsessive focus on “healthy” eating and avoidance of “unhealthy” foods,
  2. Mental preoccupation regarding dietary practices, and
  3. Very rigid dietary rules with violations causing exaggerated emotional distress (fear of disease, anxiety, shame, and negative physical sensations) [1].

Many debate whether Orthorexia is a lifestyle phenomenon or a disease, however, “reports of physical (malnutrition and weight loss), psychological (fatigue and emotional instability), and social consequences (social isolation, diminished quality of life, and stigma) comply with current concepts of mental disorders [1].”

Even so, Orthorexia is more a term used to describe specific disordered eating tendencies and pathology but cannot be considered an independent mental disorder or official diagnosis.

Facts About Orthorexia

Despite the lack of diagnostic classification, orthorexia is still being widely studied and researched and the following statistics have been determined related to orthorexic prevalence:

  • An estimated 21% to 57.6% of the general population engage in orthorexic behaviors [2].
  • Rates of orthorexia may be twice as high in women as in men [2].
  • Approximately 1% of college students struggle with orthorexic behaviors [3].
  • An estimated 10% of the population is at risk for orthorexia development [3].

healthy eating

Related Reading

Signs of Orthorexia Nervosa

Orthorexia Nervosa behaviors can become severe diagnostic concerns and cause problematic long-term effects if not recognized and treated early. Below are warning signs that an individual’s eating behaviors may have become disordered.

Physical

Physical warning signs of orthorexic behaviors are more challenging to spot than other eating disorder diagnoses, however, there are a few indications:

  • Weight fluctuations.
  • Reduced concentration.
  • Difficulty sleeping.
  • Vital/lab fluctuations.
  • Constipation.
  • Dehydration.
  • Malnourishment symptoms due to food rules reducing the amount of food being consumed.
  • Fine soft hair growth.
  • Thinning hair due.

Behavioral/Emotional

Possible orthorexia nervosa behaviors can be more clear when considering the following behavioral and emotional symptoms:

  • Obsession with the origin of foods (where/how prepared).
  • Obsessive concerns regarding food and possible medical or health concerns.
  • Rigid food rules.
  • Increased supplement usage.
  • Reduced consumption of food based on food rules centered on beliefs of “health.”
  • Concern about food preparation and techniques and control over these things.
  • Unwillingness to eat food not prepared by the individual themselves or whose preparation was not supervised by the individual.
  • Judgment of those that do not adhere to their food rules.
  • Linking self-esteem or self-view to adherence to food rules.
  • Obsessively checking nutrition labels.
  • Daily life revolves around food preparation or rules.
  • Withdrawing from others.

supplements

Dangers of Orthorexia

Many begin orthorexic behaviors to be more aware of what they are consuming and attempt to live “healthier” lives. Our societal beliefs and the impacts of diet culture and the wellness industry encourage many of the values held in Orthorexia Nervosa such as a focus on “purity” of food content and origin and “clean” eating. Emphasis on these aspects often becomes an obsession and results in food rules and rigidity that severely limit what an individual is comfortable consuming. Ultimately, what began as well-intentioned and socially accepted behaviors becomes disordered.

Long-Term Side Effects of Orthorexia Nervosa

Orthorexia Nervosa behaviors are often misperceived by society as “healthy” and “good” and, therefore, can go undetected or untreated. Without intervention, individuals become severely malnourished and can result in serious medical complications such as:

  • Malnourishment.
  • Reduced cognitive functioning.
  • Impaired immune system.
  • Increased emotional dysregulation (IE: depression, anxiety, etc).
  • Increased suicidal ideation and self-harming behaviors.
  • Organ failure.
  • Kidney issues.
  • Alteration in menstrual cycle and function.
  • Fertility issues.
  • Cardiovascular and heart issues/heart disease.
  • Isolation.
  • Job performance impairment.
  • Lowered bone density/osteoporosis.

Click on Image to Enlarge

Orthorexia infographic

Thank you to Jessica Setnick, MS, RD, CEDRD-S @ Understanding Nutrition

What Causes Orthorexia?

Like other eating disorders, there are various biological, psychological, and social aspects that contribute to development. Unlike other eating disorders, orthorexia can not only develop with approval from others based on social beliefs about food and the body, it can be perpetuated for the same reasons.

Biological Factors

Many of the biological factors that fuel anorexic beliefs and behaviors also fuel orthorexia, such as perfectionist tendencies. In other ways, orthorexia nervosa has similar neurological aspects to obsessive-compulsive disorder (OCD) such as obsessive fixations. Biological factors that contribute to orthorexia include:

  • Family history of eating disorder behaviors.
  • Perfectionistic and rigid personality traits.
  • Obsessive personality traits.
  • Childhood illness is related to diet or digestive issues.
  • Medical problems that one believes can be cured through “pure” eating.

counting calories

Psychological Factors

A large part of what contributes to orthorexia nervosa lies in psychology, as the disorder itself results from a cognitive fixation on the idea of “purity,” “cleanliness” and “health” in eating. Other psychological factors that contribute to orthorexia development include:

  • Low self-esteem/self-worth.
  • History of past trauma.
  • Co-occurring mental health diagnosis, particularly of OCD or Generalized Anxiety Disorder.
  • History of dieting.
  • Core beliefs are related to purity, cleanliness, and health as well as core beliefs related to food and self-worth, value, or morality.
  • Disordered familial beliefs surrounding food “purity” and “health.”
  • Tendency toward extremism and obsessiveness.
  • Reportedly feeling pressure to be perfect or achieve perfection/success.
  • Need for control.

Environmental Factors: Orthorexia & Social Media

As mentioned above, there is no doubt that, while society may not cause Orthorexic tendencies, the messages perpetuated about the body, food, and exercise via television and social media do not help. For example, one study learned that those following the “healthy eating” community on Instagram had a high prevalence of orthorexic tendencies [4]. Aspects of diet culture, the wellness and beauty industry, and social media that contribute to orthorexic beliefs are:

  • Emphasis on eurocentric beauty standards and the “thin ideal.”
  • Photoshopping and filters that alter the appearance without consumer’s awareness.
  • Messaging that appearance is connected to empowerment/worth/fulfillment/etc.
  • Lack of regulation around what is posted regarding laxatives/diuretics.
  • Disguising laxatives and diuretics as lollipops and shakes that are “weight loss supplements.”
  • Perpetuation of concepts that there are “quick fixes” to alter one’s body entirely from its biological predisposition.
  • Lack of awareness of reality versus highly-curated social media.
  • Reduced consumer consciousness.
  • Increased feelings of unworthiness or lack of value or “measuring up” to false portrayals of life and “highlight reels” via social media.

How to Treat Orthorexia Nervosa

Treatment for orthorexia nervosa differs somewhat from the treatment of other eating disorders, namely because it is not yet a formal diagnosis. As such, those that struggle with Orthorexia Nervosa might be misdiagnosed with Anorexia Nervosa or diagnosed with Other Specified Feeding and Eating Disorder (OSFED) in order to receive insurance coverage for any treatment. While this does allow individuals to be treated, it often leads to miscommunication regarding their symptoms. Even so, the clinical community has not yet decided whether Orhotrexia is not a type of Anorexia Nervosa.

As researchers and treatment professionals figure this out, those struggling do not need to wait to receive support. The evidence-based treatment recommended for most eating disorders, such as Cognitive Behavioral Therapy (CBT), Family-Based Treatment, or Dialectical Behavior Therapy (DBT) is showing promise in also treating Orthorexia Nervosa.

If you or a loved one are currently struggling with the Orthorexic tendencies mentioned above, do not minimize or judge your struggles. Instead, acknowledge that you are feeling challenged and give yourself permission to care for yourself enough to seek help.

Resources

[1] Strahler, J., et al. (2018). Orthorexia nervosa: a behavioral complex or a psychological condition. Journal of Behavioral Addictions, 7:4, 1143 – 1156.
[2] Ramacciotti, C.E., et al. (2011). Orthorexia Nervosa in the general population: a preliminary screening using a self-administered questionnaire (ORTO-15). Eating and Weight Disorders, 16.2.
[3] Dunn, T.M., et al. (2017). Prevalence of orthorexia is less than 1%: data from a US sample. Eating and Weight Disorders, 22:1.
[4] Turner, P.G., Lefevre, C. E. (2017). Instagram use is linked to increased symptoms of orthorexia nervosa. Eating and Weight Disorders, 22:2, 277-284.

Author: Margot Rittenhouse, MS, LPC, NCC
Page Last Reviewed and Updated By: Jacquelyn Ekern, MS, LPC on August 16, 2021

Orthorexia, Excessive Exercise, & Nutrition Articles

  • Anorexia, bulimia, and binge eating are not the only eating disorders with which people struggle. There are other eating disorders that are not as well known but just as dangerous. One of these “other” eating disorders is Orthorexia. It is lesser known and a bit more deceptive. It can often begin as a new lifestyle of eating healthier and cleaner, but it can become an obsession. The fixation on the types of food and “purity” of food can eventually lead to the suffer’s health becoming compromised. Although Orthorexia is not listed as an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders it is can still be a debilitating disease.
  • Having fundamental tools at your disposal while in recovery can be invaluable in creating favorable outcomes in the fight against an eating disorder. An important facet of eating disorder recovery is the nutritional component, and having adequate support in this area can serve as relapse prevention. Equipping oneself with helpful resources, such as a food planner or meal tracker, can empower you with the knowledge needed to propel you through your recovery journey. Learn more about the nutrition tools provided by Choose My Plate.
  • Eating disorders such as bulimia, anorexia, and binge eating have serious psychological and physical effects on those suffering from them. While many men and women have an understanding of caloric intake (“counting calories” being a common practice), it is critical to understand the importance of proper nutrition, and specifically to learn what your own body needs to maintain its health. When in recovery from an eating disorders, you should have a proper nutrition plan. Read more about the necessity of nutrition planning for the treatment of eating disorders.
  • The incessant need to persistently be moving, or engaged in extreme activities, such as working out three to five times daily in a gym, can be characteristics of excessive exercise. Commonly, eating disorders are coupled with a component of excessive exercising, as this method is commonly used to offset the effects of food consumption or utilized as a form of weight loss. Management for this overlooked factor of eating disorders can be integrated within an all-inclusive treatment plan. Read more about the diagnosis and evaluation of excessive exercise.
  • Have you ever experienced feelings of guilt for missing a workout? Do you push yourself to exercise, even if you are ill or injured? Evaluating the answers to these questions can help determine if exercise has been excessive and extreme. The hazards resulting from immoderate exercise can prove dangerous to one’s well-being, endangering health with such consequences as low heart rate or osteoporosis. Read more about properly assessing these scenarios is helpful for detection of compulsive exercise.
  • Statistics have revealed that those who struggle with an eating disorder have an increased likelihood of dealing with excessive exercising. The doubling effects of these destructive disorders can be deadly and include heart difficulties, reproductive complications, and stress fractures. While part of creating a healthy lifestyle includes engagement in moderate activity, exercise does not have to be extreme to be beneficial. Choosing moderation over extreme forms of activity can make all the difference. Read more about avoiding the negative effects of compulsive or extreme exercise.
  • Exercise is typically perceived as beneficial and advantageous and not usually viewed in a harmful light. However, even exercise can prove dangerous and detrimental when engaged in excessively, having repercussions that are far from beneficial, such as heart failure or fractured bones. With the added pressures evoked from social media to achieve body perfection, compulsive exercise is becoming more customary, though less understood. The moderation principle could also be applied to exercising, keeping the focus on the nurture-not destroy-your amazing body! Read more about excessive exercise as addiction in this article.
  • In a society that is continually inflicted with an artificial and unrealistic standard of beauty and body image, dieting has a commonplace role in the lives of countless men and women. Unfortunately, dieting is also associated with endless cycles of disappointment and failures, feelings of false hope, and restraints from living an enjoyable life. Can you imagine living a life where diets don’t exist? Visualize yourself freely experiencing self-acceptance, normalized eating, and physical activity-all meant to enhance every aspect of your being. Read more about how you can begin to free yourself from the burden of dieting.
  • While a healthy will to excel or have high-performance standards and expectations reflect a desirable personality trait, the perfectionist takes the will to excel to an extreme and irrational level. Read more about how perfectionism can lead to problems and possibly an eating disorder.
  • For far too many females, the fitness craze has more to do with the fanatic pursuit of thinness than it does with health or fitness. According to one recent study, 48% of survey participants identified weight and shape (versus health improvement) as the primary motivator for exercise.
  • Eating healthy food is an advisable, even laudable, pursuit in today’s world of fast food dining and the highly touted obesity epidemic. But, just as most people know that one alcoholic drink may be fine, but ten are too many, behavioral health professionals also recognize that healthy eating, when done to an extreme, can be very dangerous, even lethal.
  • Two other food-related disorders are also somewhat common to the college experience: exercise bulimia and drunkorexia. Although less is known about these disorders, each is a complex and dangerous disease.