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ORTHOREXIA: AN EATING DISORDER OF THE MODERN AGE? The increasing trend for ‘eating clean’ can bring with it ‘unhealthy’ behaviours that in turn can lead to orthorexia nervosa, an eating disorder that is worryingly on the rise. Alice Fletcher Registered Dietitian within the NHS Countess of Chester NHS Foundation Trust (Community Dietitian) Alice has been a registered dietitian for four years working within NHS Community based teams. She is passionate about evidencebased nutrition and dispelling diet myths. Alice blogs about food and nutrition in her spare time at nutritionin

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This article has been reviewed by Paul Jones, Specialist Dietitian, West Cheshire and Wirral CAMHS Eating Disorder Services and Eloise du Luart, a professional triathlete who has recovered from orthorexia.


Is there any greater pleasure than biting into some hot salty buttered toast, or indulging in a warm scone with sumptuous clotted cream and strawberry jam with friends, knowing that it won’t harm you in the short term and such taste sensations are all part of a balanced diet? Does the thought of this fill you with horror? Does a green smoothie with a list as long as your arm of organic exotic ingredients like bee pollen sound much more inviting? It is a disproportionate view of the power of foods that can become an issue with orthorexia. We know that the occasional scone isn’t going to give us cancer, turn our blood to acid or make our gut ‘leak’, but those displaying symptoms of orthorexia no longer have a sense of proportion and can become so obsessed with food for health that they become paradoxically less healthy. Orthorexia has 137,000 tagged posts on Instagram, many from people recognising that their quest for health has become unhealthy. This number has doubled in three years since I last took note of it. But what exactly is orthorexia?

was first defined in 1997 by Californian doctor Steven Bratman (read more about it on his comprehensive website: Orthorexia refers to an unhealthy obsession with eating ‘pure’ food. Food considered ‘pure’ or ‘impure’ can vary from person to person. This doesn’t mean that anyone who subscribes to a healthy eating plan or diet is suffering from orthorexia. As with other eating disorders, the eating behaviour involved (‘healthy’ or ‘clean’ eating in this case) is used to cope with negative thoughts and feelings, or to feel in control. Someone using food in this way might feel extremely anxious or guilty if they eat food that they feel is unhealthy. It can also cause physical problems, because someone’s beliefs about what is healthy may lead to them cutting out essential nutrients or whole food groups. Another thing of note is that unlike other eating disorders, those displaying orthorexic tendencies may flaunt these beliefs publicly, social media (particularly Instagram) may be used for this purpose.


Diagnosis Although not formally recognised in the Diagnostic and Statistical Manual,

Orthorexia nervosa misleadingly translates to ‘correct/right [eating]’. It Table 1: Orthorexia buzzwords Clean






Chemical free

Dairy free




Gluten free


Innocent February 2019 - Issue 141

This material is for healthcare professionals only.



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Reference: 1. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i

CONDITIONS & DISORDERS Table 2: The Bratman Orthorexia Self-Test1 If you are a healthy-diet enthusiast and you answer “yes” to any of the following questions, you may be developing orthorexia nervosa: (1) I spend so much of my life thinking about, choosing and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work and school. (2) When I eat any food that I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods. (3) My personal sense of peace, happiness, joy, safety and self-esteem is excessively dependent on the purity and rightness of what I eat. (4) Sometimes I would like to relax my self-imposed ‘good food’ rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make ANY exception to your diet, then this item does not apply). (5) Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own. (6) Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me or has caused other signs of malnutrition such as hair loss, loss of menstruation or skin problems.

awareness about orthorexia is on the rise.4 Work has been carried out to develop a validated screening tool for the disorder (ORTHO-15), but this is not being used at present in the UK.2 However, it soon may come under the diagnosis bracket of ‘eating disorder not otherwise specified (EDNOS)’.3 Incidence The exact incidence of orthorexia remains difficult to quantify due to it not being a recognised standalone diagnosis, but its behavioural pattern is frequently observed by eating disorder specialists.3 Orthorexia may also go hand in hand with compulsive over exercising/exercise addiction, although evidence showing this is varied. As with anorexia, orthorexia is thought to be more common in women, but men may also be affected.1 Dr Bratman has developed a self-test to quickly see whether an individual’s healthy eating routine could have crossed the line into the realm of disordered eating, available on his website1 (see Table 2). FURTHER SIGNS, SYMPTOMS AND WARNING SIGNS OF ORTHOREXIA

It can be difficult to pinpoint when concern over the healthfulness of someone’s diet and behaviour has truly become a problem. This list is not exhaustive, but gives further insight into 24 February 2019 - Issue 141

behavioural, physiological and psychological symptoms: • An increase in concern about the health of ingredients. • Spending considerable time scrutinising the source of foods, for example: - Have vegetables been exposed to pesticides? - Has nutritional content been lost during cooking? - Have artificial flavourings or preservatives been added? - Does food contain plastic-derived carcinogenic compounds? - Do the labels provide enough information to judge the quality of specific ingredients? • Cutting out an increasing number of food groups (all sugar, all carbs, dairy, meat, then all animal products); this fixation is primarily prompted by a desire to maximise physical health and wellbeing, rather than religious beliefs, concerns for sustainable agriculture, environmental protection, or animal welfare. • An inability to eat anything, but a narrow group of foods that are deemed ‘healthy’ or ‘pure’. • An unusual interest in the health of what others are eating. • Spending a considerable amount of time thinking about what food might be served at upcoming events and feeling anxious about it.

CASE STUDY EXAMPLE Unlike the eating disorder anorexia nervosa, where a sufferer may concern themselves with amounts of foods, orthorexia is about the health properties of foods. In February this year, Eloise du Luart (a professional triathlete who has recovered from both anorexia and orthorexia) spoke with the BBC about her experiences of orthorexia during her adult life.5 Eloise was diagnosed with anorexia as a teenager, but when she went to University, she thought that ‘clean eating’ had saved her. Eloise cut out major food groups and bought into (often expensive) foods that offered health-giving properties. Her breakfast would consist of ‘proats’ (protein oats), something we see all over Instagram, the contents of which included the addition of eight further ‘health’ ingredients: vegan protein powder, maca powder, bee pollen, baobab powder, chia seeds, raw cacao, almond butter and sugar-free chocolate. This would be presented beautifully and Eloise admits would often be cold by the time she ate it after taking photos of it for Instagram. She recognised that her lifestyle had become more of a problem than a cure when she fractured her back and was told that her bones had become brittle from malnutrition and overtraining. She sought help and has since recovered with professional support, including from the Performance and Eating Disorder Specialist Dietitian Renee McGregor (Twitter handle: @mcgregor_renee). When Eloise looks back on her experience with orthorexia, she reflects that she can “see the control and the obsession”. She reports that at the time she thought she was ‘detoxing’ her body.

• Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available. • Obsessive following of food and ‘healthy lifestyle’ blogs on Twitter and Instagram. • Not attending social events with friends and family due to concerns over what foods will be available (though this concern may be hidden). • Compensative behaviour (most commonly excessive exercise) if eating something considered to be ‘unclean’ may occur. • Body image concerns may or may not be present. • Micronutrient deficiencies, lack of menstruation in women and an underweight body mass index may or may not be present. ORTHOREXIA VERSUS CLEAN EATING

People who have suffered from orthorexia have reported the use of a restrictive diet to aid recovery from another diagnosed (or self diagnosed) illness (such as chronic fatigue syndrome), as having triggered orthorexia.1 The health blogger and café owner Ella Woodward (aka ‘Deliciously Ella’) does not herself have orthorexia, but she has famously documented her recovery from postural orthostatic tachycardia syndrome (POTS) through a diet free from grain (and gluten), dairy, refined sugar and additives. Whilst Ella has received much media attention,6

she has been faced with a backlash for promoting the ‘clean eating’ movement, which she refuted in an interview with Dr Giles Yeo on BBC TV’s Horizon, which aired in January 2017, titled Clean Eating - The Dirty Truth.7 Ella has since distanced herself from clean eating, instead focusing on a plant-based dietary approach for health. Adopting healthy eating patterns like Ella’s, is not orthorexia. An idea of ‘healthy eating’ may be conventional or unconventional, extreme, sensible, or completely bizarre, but regardless of this, that person does not necessarily have orthorexia. They are simply adhering to a style of diet. The term ‘orthorexia’ only applies when an eating disorder develops around that diet theory and it begins seriously affecting quality of life. Dr Bratman notes that the more restrictive a diet, the more likely it is to set off the psychological factors that lead to an eating disorder. ‘Clean eating’, which at its core involves wholefoods in their most natural state and avoiding processed foods such as refined sugar, is unlikely to lead to orthorexia. He notes that ‘raw foods veganism’ is on the other extreme and has a high orthorexic potential. This is a challenging diet to manage safely, and many people who will ultimately develop orthorexia have followed a raw vegan diet. Nonetheless, there are many people who adopt the raw-food vegan lifestyle and do not become orthorexic, so they are not intrinsically linked.1 February 2019 - Issue 141


CONDITIONS & DISORDERS Figure 1: Unique and shared features of orthorexia, anorexia and obsessive-compulsive disorder3 Orthorexia • Focus on food quality • Unrealistic food beliefs • Desire to maximise health • Flaunt behaviours

• Limited insight • Intrusive thoughts • Guilt over food • Ritualised food transgressions preparation • Perfectionism • Ego-syntonic • Focus on • Cognitive rigidity thoughts contamination • Trait anxiety • Impaired working memory • Impaired functioning OCD Anorexia • Poor external • Obsessions and • Focus on food quality monitoring compulsions may • Fear of obesity; extend beyond food disturbed body image • Secretive about • Realises that behaviours • Drive for thinness; behaviours are excessive/ excessive exercising • Depressed mood unreasonable • Ego-dystonic thoughts


Orthorexia bears some similarities to anorexia and someone who has symptoms of orthorexia might be diagnosed with anorexia if they fit with those symptoms as well. Eating disorders that can’t be diagnosed as anorexia, bulimia, or binge eating disorder might be diagnosed as ‘other specified feeding or eating disorder’ (OSFED). The Venn diagram (Figure 1) shows how they are linked. SOCIAL MEDIA: IS IT A CONTRIBUTORY FACTOR?

‘Dieting’ is out and ‘wellness’ is in. Language around weight, body image and health is changing. Social media is packed with people declaring they are “strong”, not skinny, that they are “getting lean, eating clean” and turning to plant-based foods. Instagram is filled with tanned, lean, beautiful people eating sumptuous, exquisite plates of foods akin to works of art. Such people often manage to cram in and document two hours of exercise each day (without breaking a sweat, or instead 26 February 2019 - Issue 141

sweating glitter), make three meals worth of organic gluten-free, dairy-free, grain-free, raw, vegan, (pleasure-free?) food for their equally beautiful family, work full-time and fly to the moon and back on a unicorn (well maybe not that part). Could the sheer volume of such influential seemingly perfect people, often recommending ‘detox’ products and special powders and pastes be increasing the incidence of those adopting very restrictive diets under the guise of health? That question is a tricky one to answer and, as mentioned earlier, following an extreme diet does not immediately mean that you develop orthorexia. Photographing beautiful food does not mean you necessarily have an eating disorder. However, the sheer volume of perfect gorgeous plates of food cooked by perfect bodies available to us at the touch of a button is certainly a huge change to the social landscape comparative to only 10 years ago. Whether social media could be defined as a causative factor, or simply enables orthorexic behaviour, is something tricky to detangle.

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Issue 141 Orthorexia  

Issue 141 Orthorexia