What is Orthorexia?

Do you know someone who strictly eats healthy food all of the time? This dedication may seem like an admirable trait, but when taken to the extreme can do more harm than good. It’s a blurry line, but there are certainly differences between enjoying healthy foods and obsessing over them.

In the early 2000’s, after watching the documentary Supersize Me (a 2004 documentary about the fast food industry) and reading the Omnivore’s Dilemma (which famously encouraged us to avoid eating anything that our great grandmothers wouldn’t have recognized as food), I was inspired to go back to school to become a dietitian and help others “see the light” so to speak.

Though difficult for me to admit, this career choice was likely rooted in some overly obsessive behaviors around food. I encouraged friends and family to eat as I was eating and I felt superior when I made “healthier” choices than others. I judged people for their weight gain and patted myself on the back for staying slim.

The more applause I received for my healthy choices and lean appearance, the more righteous I felt in my decisions. At the time it felt like I was eating to optimize my health, but in hindsight, my preoccupation with food was negatively impacting my life in ways I didn’t even realize.

I stand back now and can see this behavior aligns in many ways with orthorexia.

What is orthorexia?
The word ortho is Greek for “correct” and orexi means “appetite”.

This term applies to those who are highly nutrition-conscious, aiming for perfection in all that they eat. Oftentimes, this militant attitude towards food is positively reinforced by diet culture and media, so someone with orthorexia may not see these qualities as problematic. But they certainly can be.

In orthorexia, healthy eating turns extreme and includes obsessive thoughts, self-punishment for breaking food rules such as exercise or fasting, restrictive eating behaviors, and a belief that one’s self-esteem and identity are wrapped up in dietary choices.

Orthorexia differs from the more well-known eating disorders, which are centered around body image and a desire for thinness. For example, someone with orthorexia may eat beef but only if it’s from local butcher and refuse it if sourced elsewhere. Or, if faced with the choice of eating fast food on a road trip, or not eating for 8 hours, they would choose to go hungry.

Is this the same as “clean eating”?
Clean eating does not have a specific definition but is characterized by eating whole foods that are minimally processed. There is nothing inherently disordered about the concept of clean eating but those with orthorexia may obsess over clean eating choices to the point where it does become disordered and/or harmful.

When did orthorexia become a popular term?
Orthorexia Nervosa (ON) was originally coined in 1997 by Steven Bratman MD and explained in his book Health Food Junkies. After coaching his patients on how to lose weight, he discovered they sometimes became so obsessed with food that it was negatively impacting their other relationships. He connected ON to other disordered eating behaviors like obsession/compulsion, exhaustive food research, and constant food worry.

Is orthorexia an official diagnosis?
At this time, ON is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) like other eating disorders, such as Anorexia Nervosa. It is often looped into the DSM-5 diagnosis called Other Specified Feeding or Eating Disorder (OSFED) or other mental illness such as Obsessive Compulsive Disorder (OCD).

Diagnostic criteria have been proposed for ON. Here is one example from the Dunn & Bratman review paper: “an obsessional preoccupation with healthy foods paired with impairment of physical or mental health because of the obsession, and the lack of a different mental illness, an established medical problem, or religious belief leading to the behaviors.”

Has there been research on ON?
Research on the topic has been inconclusive, partly because there isn’t an established definition. Also the concept of orthorexia has changed over the past 20 years as there seems to be more more overlap with weight and appearance as well as allergies or self-imposed restrictive diets related to medical conditions.

There also haven’t been widely accepted or validated tools that clearly identify orthorexia or at least differentiate it from non-harmful healthy eating habits. The “TON-17” is the most updated questionnaire at the time this article is published.

Interestingly, a 2017 study revealed 50% of registered dietitians were at risk for ON. Though the study had many limitations, including a now invalidated questionnaire, it does underscore my curiosity to self-diagnose my 20-something self. Hindsight is 20/20!

Curious about some of those validated assessment questions? Here are a few examples directly from the TON-17:

• Do you trust food prepared by another person?
• Do you often talk about healthy foods to convince others to change their diet?
• Are you concerned about too much unhealthy food being available?
• Do you think people who eat junk food are putting their lives at risk?
• Do you plan each meal in detail?
• Does your diet make you feel lonely?
• Do you push your hobbies or interests to the background to engage in a healthy lifestyle?
• Do you prefer to eat a healthy meal alone to going out with friends or family to eat something out?
• Do food quality thoughts torment you for most of the day?

Treatment Options
If you answered ‘yes’ to many of these questions, you may be feeling like a preoccupation with healthy eating is negatively impacting your life.

Orthorexia is typically treated in similar ways to eating disorders or other disordered or obsessive eating behaviors. You can find a dietitian who specializes in treating eating disorders in your area. Or contact me and I may be able to refer you to someone who can best meet your needs.

KEY TAKEAWAYS
Orthorexia is not an official diagnosis but is often included under the umbrella of OSFED. It is characterized by an obsessional preoccupation with healthy foods that can negatively impact daily life. One of the most up-to-date tools to assess for orthorexia is the TON-17.

As always, I welcome your questions about orthorexia behaviors and/or treatment options and look forward to hearing from you.