A healthy diet is certainly important for the proper functioning of the body. In modern conditions, one can find many factors that somehow negatively affect the body and the state of human health. Adequate nutrition ensures quality of life, including the level of health and the body’s ability to cope with physical, mental, and psycho-emotional stress. Thus, irresponsible attitude to nutrition issues is unacceptable. However, recently, more attention is being paid to the opposite problem of an increasingly excessive concern with the quality of one’s nutrition, the so-called “orthorexia nervosa.”
It is interesting to note that the term “eating behavior” has come into use due to numerous diseases associated with abnormal nutrition for medicinal purposes. The striving for “proper” nutrition has led many overly ardent advocates of a healthy lifestyle to the emergence of such a disorder when the desire for health through food develops into a real mania. Experts designate this disorder under the term ‘orthorexia nervosa,’ in other words – healthy eating psychosis.
Orthorexia nervosa is characterized by fixation on eating the ‘right’ or healthy food, as well as an overemphasis on avoiding foods perceived as unhealthy. The negative consequences for the physical condition of a person suffering from orthorexia nervosa are due to the strict dietary restrictions that he/she follows. The choice in favor of one or another product or type of products is made on the basis of a conclusion about the usefulness, which can be either scientifically justified or represent the result of one’s own inference or taken from an unreliable source (Avşar 11). At the same time, such patients are categorical in relation to their beliefs regarding food. Own taste preferences are not taken into account when choosing a meal. A dichotomous classification of food is characteristic, and all products are divided into useful and harmful (Strahler et al. 7-8). Healthy foods are allowed to be consumed in large quantities, and the use of the “harmful” ones is strictly prohibited.
People with orthorexia completely avoid foods of unnatural colors, flavors, and preservatives; they do not accept pesticides or genetic modifications; fat, sugar or salt; animals or dairy products, or other ingredients that are considered unhealthy. Such a behavior when a person is attentive to the mentioned above factors, and tries to reduce the consumption of harmful substances in products is considered to be normal. However, if the situation goes to an extreme, it begins to impede life. For example, refusing to have dinner with friends due to the presence of “the wrong food” can be a sign of orthorexia.
Some of the behavioral changes that might indicate orthorexia can be summarized as follows:
- The obsession that there is always a relationship between food choices and health problems such as asthma, digestive problems, bad moods, anxiety, or allergies;
- Increased interest and an overwhelming need to explore the ingredients of healthy foods (Zickgraf et al. 41-43).
Thus, people suffering from orthorexia can refrain from consuming specific food groups, which can lead to a deficiency of nutrients and trace elements consumed. In severe cases, strict exclusion of any food groups from the diet can lead to exhaustion. Excessive consumption of certain foods can also be harmful to health.
Psychologically, with orthorexia nervosa, maintaining a strict diet forces the individual to make significant volitional efforts in order not to violate the established rules, which allows a person to feel good, worthy, deserving his own respect. In the event of a ‘breakdown,’ when a person with an appropriate attitude to food, for any reason, uses foods ‘forbidden’ for him by his own belief, a feeling of intense anxiety and guilt follows, which can often be accompanied by a kind of punishment in the form of more severe self-restraint or starvation.
Some people with orthorexia nervosa describe that maintaining a strict diet allows them to feel superior (Dunn and Hawkins para. 9-12). The desire to eat in accordance with own beliefs sometimes forces a person to spend a significant part of time planning, organizing, purchasing, preparing food, and even growing it. Peoples with orthorexia nervosa describe that the obsessive desire for a sense of cleanliness and health, initially dependent only on the quality of the food consumed, gradually begins to affect other areas of life (Brytek-Matera 57-58). On the social plane, the consequence of orthorexia nervosa can be social isolation as a result of lifestyle and value differences. Such people may feel the need to bring their own food with them or refuse to eat together with people who do not share their beliefs about proper nutrition. They may feel their moral superiority in relation to selectivity and their “correctness,” and may also begin to promote their own beliefs in their environment.
The term “orthorexia nervosa” (or simply orthorexia) was first suggested in 1997 by Steven Bratman, MD, to describe the excessive desire of some people to eat exceptionally healthy foods. At present, a general description of the phenomenon of orthorexia nervosa is provided only by Bratman; a formal working definition with the corresponding psychological diagnostic criteria has not been proposed. In addition, there are currently no reliable empirical studies which support that orthorexia nervosa can worsen a person’s condition. Bratman, based on his own experience, argues that orthorexia nervosa has the right to be considered a mental disorder, since it can have negative consequences for an individual in physical, psychological, and social terms. In particular, this is due to the fact that with orthorexia, fears and restrictions apply not only to the products themselves, but also to the methods of their preparation. All this can lead to difficulties in communicating with family and friends: people with orthorexia find it difficult to eat at guests, restaurants, and cafes.
As a result of the assumption of the negative impact of orthorexia nervosa on an individual’s quality of life, Bratman believes that this style of eating is a separate mental disorder (Bratman and Knight 17). However, scientific research in the field of orthorexia nervosa is relatively recent, and a thorough study is currently needed in order to deepen the understanding of orthorexia nervosa and its possible relationship with existing mental disorders. Orthorexia involves a focus on food quality as opposed to quantity. Social and cultural conditions contribute to the spread of certain styles and forms of nutrition, which inevitably turns into pathology in people with a genetic predisposition to eating disorders.
In the early days of orthorexia nervosa, Bratman argued that the disorder was a unique form of eating disorder. Over time, as more research was carried out, it became necessary to determine whether orthorexia nervosa is a separate nosological form or a variant of the course of an already known disorder, such as an eating disorder or anxiety disorder.
There is a version that this is a type of anorexia nervosa, since both anorexia and orthorexia are characterized by anxiety, perfectionism, and the desire to control their lives. However, people who have an obsessive desire to eat right do not always strive for thinness. Some researchers regard this behavior as a ritual typical of obsessive-compulsive states, or as a manifestation of hypochondria (Strahler et al. 3). Finally, there is a hypothesis that orthorexia is not a disease, but a social tendency, the over-adherence to which can lead to other eating disorders (Strahler et al. 1-14.).
Patients with orthorexia and those diagnosed with anorexia have similar symptoms: perfectionism; increased anxiety; high need for control; potential for significant weight loss. Adherence to diet serves as a marker of self-discipline, and giving up on it is perceived as a loss of self-control. Patients are also characterized by a limited understanding of their condition and denial of functional impairments associated with the disorder (Dunn para. 5-6). However, there are some differences between orthorexia and anorexia, primarily about motivation. Those who are struggling with anorexia are fearful of obesity and are more often concerned about restricting certain foods to achieve a definite weight. They are more concerned with body appearance than food quality or purity. Those with orthorexia tend to be more natural and cleaner. Another key difference is that people with anorexia tend to hide their disorder, while those with orthorexia tend to flaunt their habits.
As the disease progresses, some of the long-term health risks of orthorexia can mimic the symptoms of anorexia associated with tight restrictions. Ultimately, food choices become so limited in types, quantities, and calories that malnutrition begins to deteriorate health. This type of malnutrition affects the body and can lead to nutritional deficiencies, osteoporosis, heart disease, and endocrine dysfunction as a result of a lack of essential nutrients (Cena et al. 228). In addition to physical health problems, as the disease progresses, there are some long-term risks to mental health. Feelings of anxiety, obsession, or depression may occur, which intensify as the person becomes more isolated (Cena et al. 230).
Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) still does not use the term ‘orthorexia’ as a name for an eating disorder, the disease has many characteristics that make it one of them. People with anorexia or bulimia nervosa are overly concerned with calories, weight, and shape. However, such an obsession is only an external manifestation of the patient’s need for change, control, overcoming internal anxiety and disharmony associated with a distorted self-perception. In other words, these eating disorders are mental and not physiological diseases. The table below shows the similarities and differences between orthorexia and the much better understood eating disorders anorexia and bulimia, and helps to assess the place of orthorexia in the spectrum of these diseases. In addition, these diseases often go hand in hand with the tendencies to develop obsessive-compulsive disorder.
Table 1. Similarities and Differences Between Orthorexia and Studied Eating Disorders – Anorexia and Bulimia
The main personality traits and behavioral features that determine a person’s predisposition to these diseases are especially similar. Orthorexics do not always see a distorted image of their body in the mirror and seek to bring their figure back to normal with the help of strict nutritional control. Most often, they see in proper nutrition a tool for achieving harmony with themselves, which requires physical purity. In some cases, the trigger is namely a disease – a person thinks: “If to completely eliminate sugar, then I will be cured of this” or “If I give up carbohydrates, then I will stop suffering from this.” In turn, the improvement in well-being prompts the fanatical adherence to a “clean” diet.
Orthorexia nervosa is likely to occupy an intermediate position between anorexia nervosa and avoidant restrictive food intake disorder (ARFID) presented in the DSM-V. However, pathological selective eating behavior does not reflect the complexity of motivational and behavioral disturbances in people with orthorexia nervosa. Although orthorexia is often misdiagnosed as anorexia, these patients often take pride in their eating habits instead of hiding it, especially on Instagram. The researchers also emphasize that this condition is often comorbid with obsessive-compulsive personality disorder and somatoform disorders (Brytek-Matera 40-42).
Some authors believe that orthorexia is a type of anorexia nervosa. It has been noted that individuals with anorexia nervosa and those prone to orthorexia have similar personality traits: perfectionism, high levels of anxiety, and the need to control their lives (Strahler et al. 6). Nevertheless, the difference between anorexia and orthorexia lies in the fact that in the first case, a person is concerned mainly with the amount of food and its calorie content, and in the second, with its quality, that is, the composition and method of preparation. In addition, people with a history of orthorexia do not always strive for weight loss (unlike those with anorexia). Although in some cases weight loss has a certain meaning for them, the main goal in orthorexia is to maintain and improve physical health, as well as a sense of bodily “purity” (Avşar 12). Others suggest that orthorexia is a form of obsessive-compulsive disorder rather than an eating disorder such as anorexia and bulimia (Strahler et al. 11-12). However, it should be noted that obsessive-compulsive individuals are aware of the irrationality and futility of their behavior, while those who show signs of orthorexia are convinced that dietary adherence improves their health.
The term “orthorexia” has been proposed as a widely used term, but has not received medical acceptance. Despite this, it belongs to the family of eating disorders, but in fact it is closer to a phobia than to eating disorder. In this regard, it seems rational and necessary to include this disorder in the DSM. However, further research is needed on the development and course of orthorexia, its epidemiology and diagnosis, in order to determine the correct classification within the DSM.
Works Cited
Avşar, Orçun. “Orthorexia Nervosa As an Eating Disorder.” Edelweiss Psychiatry Open Access, vol. 1, no. 1, 2017, pp. 11-13.
Bratman, Steven, and Davis Knight. Health Food Junkies. Broadway Books, 2000.
Brytek-Matera, A. “Orthorexia nervosa – an Eating Disorder, Obsessive-Compulsive Disorder or Disturbed Eating Habit?” Archives of Psychiatry and Psychotherapy, vol. 1, 2012, pp. 55-60.
Cena, Hellas et al. “Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature.” Eating and Weight Disorders, vol. 24, no. 2, 2019, pp. 209-246.
Dunn, Thomas, and Nicole Hawkins. “Orthorexia Nervosa.” Psychiatric Times, 2020, Web.
Strahler, Jana et al. “Orthorexia Nervosa: A Behavioral Complex or a Psychological Condition?” Journal of Behavioral Addictions, vol. 7, no. 3, 2018, pp. 1-14.
Zickgraf, Hana et al. “Disentangling orthorexia nervosa from healthy eating and other eating disorder symptoms: Relationships with clinical impairment, comorbidity, and self-reported food choices.” Appetite, vol. 1, no. 134, 2018, pp. 40-49.