Orthorexia Nervosa: A Primer
Nutrition: Is it possible for healthful eating to become unhealthy?
The term orthorexia nervosa (ON), referring to an obsession with dietary virtue, has become increasingly common since it was coined just over 10 years ago. Steven Bratman, MD, initially introduced the term in an article in the October 1997 issue of Yoga Journal, as a somewhat “tongue in cheek” way of describing an unhealthy obsession with healthful eating (Bratman 1997; Mathieu 2005).
In a society so focused on the “rising costs of health care,” the “obesity epidemic” and the “green movement,” it is hard to imagine that being health-conscious could be considered unhealthy. The challenge in determining when healthy eating or exercise crosses the line into unhealthy obsession is that, for the average American, there is seemingly no framework in our society for conceptualizing this idea.
With orthorexia, the quality of the foods consumed is more important than personal values, interpersonal relations, career plans and social relationships (Bosi, Camur & Güler 2007). Displacement of interpersonal relationships by food quality is evidenced by Bratman himself, as he describes one aspect of the leap from health to obsession in referencing a trip to his mother’s home during his own struggle with ON: “I found myself criticizing the preservatives in the dressing, the mushrooms in the salad (considered “rotten” by the diet followed at the time), and the artificially flavored fruit drink in the cups, combining the superiority of an orthorexic with . . . insulting manners” (Bratman & Knight 2001). In an article for BBC News, David McCandless (2005), also a self-proclaimed “orthorexic,” writes that most orthorexic individuals resort to “an iron self-discipline bolstered by a hefty dose of superiority over those who eat junk food.”
Orthorexic individuals tend to follow diets that are tied to a philosophy or theory. The more restrictive and complicated the diet, the more the person is likely to be attracted to it (Mathieu 2005; Bratman & Knight 2001). Adherence to one’s own interpretation of a strict dietary philosophy generates the potential to leave out major food components. For these reasons, individuals with orthorexia often have insufficient and unbalanced staple diets.
The restrictive behavior gives rise to a shortage of essential nutrients, modification of social and personal relationships and a change in general psychophysical condition, as described by Bosi, Camur & Güler (2007), who note that “a number of orthorexic individuals would rather starve than consume any foodstuff which they deem to be impure or unnatural.” Sticking to their regimen is thought to take strong willpower, hence allowing orthorexic individuals to feel self-righteous and superior to people whom they consider lacking in such self-control (medicalnewstoday.com 2004).
In many cases, those with orthorexia have in common a spiritual or religious belief that a perfect diet will help them achieve purity. The motivation is not to lose weight but to achieve this feeling of perfection or purity (Mathieu 2005). Bratman and Knight (2001) state, “As orthorexia progresses, a day filled with wheatgrass juice, tofu and quinoa biscuits may come to feel as holy as one spent serving the destitute and homeless.” In the full-blown stage, “within the orthorexic is a grim sense of self-righteousness that begins to consume all other sources of joy and meaning.”
As interest has mounted around the validation and incidence of ON, the number of related studies has increased. In 2007, Bosi, Camur and Güler released a study on the prevalence of ON among resident medical doctors and determined that 45.5% of the doctors involved in the research had orthorexia or “highly sensitive behavior” related to eating (Bosi, Camur & Güler 2007; Donini et al. 2004). The dominant research on orthorexia has taken place in Europe. The focus there has generally been on recognizing ON as problematic, but organizations like the Swiss Society for Nutrition (www.sge-ssn.ch/) have gone further, stressing the dangers of the condition and how widespread it has become. In 2005, Zamora et al. estimated the incidence of ON in Spain at 0.5%–1%, affecting both genders equally. Recognition of the condition within the U.S. has increased primarily in avenues of popular culture, such as book reviews, websites and informal journal discussions. The Macmillan English Dictionary (2008) notes that the word is entering the English lexicon.
Although the condition is not listed in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994), some practitioners who have documented its damaging results in their practices do use it as a diagnosis (Strand 2004; American Psychiatric Association 2000). The manual covers all recognized mental health disorders in children and adults.
Self-proclaimed “orthorexics,” including McCandless and Kate Finn—noted names within the community of people who recognize ON—have contributed personal stories online and in print. Finn’s diary, available online through the Beyond Vegetarianism website, follows her personal struggle with ON, which eventually led to her death in 2003 (Finn 1999).
One dramatic difference between ON and diagnostic eating disorders is that it affects males equally and potentially more often than females. In the initial study by Donini et al. (2005), researchers noted that the physiological characteristics, sociocultural factors and psychological behaviors that characterized subjects suffering from ON showed a higher prevalence in men. In the original research on medical doctors done by Bosi, Camur and Güler (2007), no statistical difference was noted in the incidence of “highly sensitive behavior on healthy nutrition” among males and females.
Given this trend in the (albeit limited) research, recognition of ON as a separate eating disorder within the accepted standards has this poignant and painful individual characteristic—it is the only eating disorder with a tendency for equal or higher incidence among males.
While ON primarily pinpoints the obsession with healthy eating, the parallel seen in the fitness industry is undeniable. A society so focused on ideal health, longevity and eternal youth certainly equates exercise with fitness. But just as fixating on healthy eating does not equate to health, fixating on exercise does not equate to fitness.
Whereas the dietitian’s role is to help individuals understand how food choices can support health, it is the fitness professional’s role to support individuals in understanding how exercise can support fitness. It is not only what we eat, but how we eat and how we feel about eating that influence our nutritional health. Likewise, it is not only what exercise we do, but how we exercise and how we feel about exercise that influence our physical fitness.
Parallels between how we interact with food and exercise run deep. In 2007, the School of Social & Health Sciences at Halmstad University in Sweden compared results from questionnaires on social physique anxiety and on sociocultural attitudes toward appearance with results from an orthorexia test developed by Bratman (Eriksson et al. 2007). The researchers concluded that physical appearance and anxiety regarding physique were so closely related to food behaviors that those scales would be acceptable in determining a diagnosis of orthorexia nervosa in lieu of questionnaires focused solely on food behaviors.
Outside of the discussion as to whether ON warrants its own diagnosis, many professionals agree on one thing: labeling this internal struggle with food as a formal diagnosis is not as important as providing solutions for the person struggling with the condition (Mathieu 2005).
As with most aspects of diet and exercise, moderation is the key. Changes in food choices and exercise should be made gradually and in a way that fits the person’s tastes and lifestyle. Eating more healthily and changing one’s approach to fitness should have a positive effect on health without reducing enjoyment of life or affecting relationships with others.
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- Know your scope of practice. Recognize when to work in coordination with a treatment team and when to refer out.
- Be cautious to avoid validating orthorexic traits, beliefs and behaviors. Avoid labeling the behaviors or the person as “orthorexic,” as labeling can perpetuate the individual’s need to be identified through these behaviors.
- Avoid battling over philosophy. If concerned, help the client or colleague by noting how quality of life is being affected.
- Always maintain professional relationships with health providers (e.g., dietitians, therapists, physicians) whom you can use as referrals.
- Make connections with alternative health providers (e.g., naturopathic physicians, acupuncturists). These providers can also be valuable referrals for this population, which may resist conventional health referrals.
- Always encourage and model a healthful balance with food and fitness choices.
The fundamental difference between ON and anorexia nervosa (AN) or bulimia nervosa (BN) is that in orthorexia there is no fear of gaining weight or obsession with the quantity of food intake; instead the obsession is with the quality of food and includes aversions to certain foods considered impure or toxic (Zamora 2005; Bosi, Camur & Güler 2007).
Despite the strong arguments made for the differences between ON and diagnostic eating disorders, they share many characteristics. The chart below notes the differences and parallels.
American Psychiatric Association. 1994, 2000 (paperback). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (4th ed.). Arlington, VA: APA.
Bosi, A.T.B., Camur, D., & Güler, C. 2007. Prevalence of orthorexia nervosa in resident medical doctors in the faculty of medicine (Ankara, Turkey). Appetite, 49 (3) 661–66.
Bratman S. 1997. The healthy food eating disorder. www.orthorexia.com/index.php?page=essay; retrieved Apr. 15, 2008.
Bratman, S., & Knight D. 2001. Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating. New York: Broadway Books.
Donini, L.M., et al. 2004. Orthorexia nervosa: A preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eating and Weight Disorders, 9 (2), 151–57.
Donini, L.M., et al. 2005. Orthorexia nervosa: Validation of a diagnosis questionnaire. Eating and Weight Disorders, 10 (2), e28–32.
Eriksson, L., et al. 2007. Social physique anxiety and sociocultural attitudes toward appearance impact on orthorexia test in fitness participants. Scandinavian Journal of Medicine & Science in Sports, 18 (3), 389–94.
Finn, K. 1999. Finding the balance between the extremes of denial and indulgence. www.beyondveg.com/finn-k/bio/finn-k-bio-1a.shtml; retrieved April 12, 2008.
Macmillan English Dictionary. 2008. Word of the week archive. Orthorexia. www.macmillandictionary.com/New-Words/040103-orthorexia.htm; retrieved April 12, 2008.
Mathieu, J. 2005. What is orthorexia? Journal of the American Dietetic Association, 105, (10), 1510–12.
McCandless, D. 2005. I am an orthorexic. http://news.bbc.co.uk/go/pr/fr/-/1/hi/magazine/4389849.stm; retrieved July 29, 2010.
Medicalnewstoday.com. September 20, 2004. Orthorexia nervosa—obsessed with eating to improve your health. www.medicalnewstoday.com/articles/13695.php; retrieved Aug. 3, 2010.
Strand, E. 2004. Orthorexia: Too healthy? http://psychologytoday.com/articles/index.php?term=pto-20041202-000004.html.
Zamora, M.L.C., et al. 2005. Orthorexia nervosa. A new eating behavior disorder? Actas Espanolas de Psiquiatria, 33, (1), 66–68.
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