1. Introduction
Disordered eating behaviors are a growing concern, capturing the attention of healthcare professionals and researchers globally. These behaviors span a wide range of unhealthy eating patterns and attitudes toward food, significantly impacting physical, psychological, and social well-being. While several eating disorders exist, including anorexia nervosa, bulimia nervosa, and binge eating disorder, each with distinct characteristics, it’s crucial to understand which diagnosis is primarily characterized by a distorted body image. Anorexia nervosa is the eating disorder most prominently recognized for this symptom, where individuals perceive themselves as overweight even when dangerously underweight. However, it is important to differentiate this from other eating disorders like orthorexia nervosa, which, while concerning, centers on an obsession with “healthy” or “pure” eating rather than body image distortion, though body image issues can be a comorbidity. This article will delve into orthorexia nervosa, exploring its unique features while acknowledging the central role of distorted body image in certain eating disorders and related conditions.
Orthorexia nervosa, often shortened to orthorexia, is an emerging eating disorder characterized by an excessive preoccupation with healthy eating. It involves an obsessive focus on food purity and a rigid pursuit of what is considered “clean” and “healthy” food. Individuals with orthorexia develop strict dietary rules, often eliminating entire food groups and obsessively concerning themselves with food sourcing, preparation, and nutritional content [1, 2]. While the pursuit of health is generally positive, in orthorexia nervosa, this focus becomes pathological, leading to significant distress and impairment in daily life. It’s important to note that while body image distortion is not the primary diagnostic criterion for orthorexia nervosa, dissatisfaction with body image can be a contributing factor in some individuals.
The rise of disordered eating behaviors is a significant public health issue, with conditions like anorexia nervosa, bulimia nervosa, and binge eating disorder posing severe health risks [3, 4]. Subclinical disordered eating, including orthorexia, is also increasingly prevalent. Societal pressures, media portrayals of unrealistic body standards, and the pervasive influence of social media contribute to these trends across various demographics [5]. This necessitates a thorough understanding of these behaviors to develop effective prevention, early intervention, and treatment strategies.
Research increasingly highlights the detrimental effects of disordered eating on both physical and mental health. Restrictive eating patterns can lead to nutritional deficiencies, metabolic disturbances, and other severe health issues [6]. Disordered eating is also linked to mental health conditions like depression, anxiety, and body dysmorphic disorder [7, 8]. Societal stigma further complicates these issues, preventing individuals from seeking help. Furthermore, these behaviors can impair social and occupational functioning, exacerbating isolation [9]. A comprehensive understanding is essential for healthcare professionals and policymakers to address these rising concerns and promote healthier relationships with food and body image.
The “clean eating” movement has significantly increased in popularity [2], reflecting a societal shift towards healthier lifestyles and mindful dietary choices. Clean eating emphasizes whole, unprocessed foods while minimizing refined and artificial ingredients. This trend is driven by desires for weight management, improved well-being, and increased energy [10]. However, it also raises concerns about rigid eating patterns, unrealistic body standards, and food stigmatization [2]. Balancing informed dietary choices with avoiding extreme restrictions remains an ongoing challenge.
Orthorexia nervosa has gained increased attention within disordered eating. Prevalence studies suggest rising rates, especially in Western societies focused on health and nutrition [11]. Risk factors include perfectionism, neuroticism, dieting history, body dissatisfaction, and exposure to media promoting unrealistic body ideals and clean eating [12]. Diagnosis and conceptualization are debated; orthorexia nervosa is not in the DSM-5 or ICD-10 [13, 14], but diagnostic tools exist. Treatment involves multidisciplinary approaches like CBT and nutritional counseling. Further research is needed to understand prevalence, risk factors, and effective treatments for these emerging eating disorders.
2. Historical Context and Emergence of Orthorexia and Orthorexia Nervosa
The emergence of orthorexia nervosa is rooted in the late 20th and early 21st centuries, aligning with increased societal focus on health and wellness. Dr. Steven Bratman coined “orthorexia” in 1997, observing excessive healthy eating preoccupation in his patients [15]. Initially informal, it described obsession with pure foods. As awareness grew, orthorexia was recognized as needing research. “Orthorexia nervosa” then described a severe form with anxiety and functional impairment from rigid “pure” diets [1]. Social media and the internet amplified dietary trends, glorifying certain eating patterns and potentially contributing to orthorexic behaviors through relentless clean eating promotion and unscientific health claims [16]. The history highlights the complex interaction of societal norms, technology, and the pursuit of health, emphasizing the need to understand and address orthorexia nervosa.
The distinction between orthorexia nervosa and other eating disorders lies in their primary focus. Anorexia nervosa, bulimia nervosa, and binge eating disorder are marked by disturbances in food quantity or eating patterns. In contrast, orthorexia nervosa centers on food quality and purity [17]. Orthorexia nervosa involves excessive preoccupation with “healthy” or “pure” foods, strict elimination of food groups, and intense fixation on nutritional content [2]. Anorexia nervosa involves caloric restriction and low body weight [18], while bulimia nervosa includes binge eating followed by compensatory behaviors [18]. Binge eating disorder involves recurrent binge episodes without compensatory behaviors [18]. Orthorexia nervosa is unique in its focus on perceived health benefits and lack of concern about body shape or weight, differentiating it from disorders characterized by distorted body image. Recognizing these distinctions is vital for accurate diagnosis and appropriate support.
Assessing prevalence of orthorexia nervosa is challenging due to its recent recognition and lack of standard diagnostic criteria, resulting in limited and inconclusive research. However, studies suggest rising concern, especially in Western societies with popular health and wellness trends [19]. Prevalence estimates vary widely, with some studies reporting up to 90.6% in specific populations [11, 20, 21]. Variability may stem from lack of diagnostic consensus and assessment tools. Orthorexia nervosa, the more severe form, is likely less prevalent than orthorexia but may share similar risk factors [11]. Standardized criteria and rigorous research are needed for accurate prevalence data on these emerging eating disorders.
3. Risk Factors and Associated Psychological and Sociocultural Influences
Risk factors for orthorexia nervosa involve complex psychological and sociocultural influences. Individual-level factors include personality traits [22]. Perfectionism, neuroticism, and obsessive-compulsive traits may increase vulnerability to rigid dietary behaviors [22]. Dieting history and body dissatisfaction can also contribute to disordered eating focused on food purity [23, 24]. Socioculturally, media portrayals of idealized bodies and clean eating trends pressure individuals to meet unrealistic health standards [25]. Social media disseminates these trends, promoting harmful dietary practices and social comparison [21]. Misinformation and unscientific health claims fuel fears about “toxic” foods, reinforcing restrictive diets. Societal norms prioritizing appearance and equating health with dietary purity can encourage orthorexia nervosa, necessitating targeted prevention and intervention [26].
Psychological and sociocultural influences on orthorexia nervosa are intertwined. Psychologically, individuals facing stress, anxiety, or life dissatisfaction may seek dietary control as a coping mechanism [27, 28]. Obsession with pure foods raises concerns about personal illness fears and extreme diets. Anxiety about unhealthy food can significantly impact well-being [1]. Genuine health concerns can evolve into unhealthy obsessions needing careful consideration within mental health and nutrition.
Pursuing clean eating and rigid rules can provide identity and purpose within health-conscious communities [10]. Sociocultural influences shape norms around food, body image, and health. Media glorification of certain diets and demonization of others can promote all-or-nothing approaches, reinforcing “pure” choices as the only acceptable ones [10]. Societal pressure and fear of judgment can escalate orthorexic behaviors. Understanding these intertwined influences is key for healthcare professionals and policymakers to develop effective strategies promoting balanced relationships with food.
4. Definition and Diagnostic Criteria
Orthorexia nervosa is recognized as an emerging eating disorder, prompting efforts to establish diagnostic criteria, though it’s not officially in DSM-5 or ICD-10 [13, 14]. Researchers and clinicians have proposed criteria based on observed characteristics [1, 16, 29]. These include intense preoccupation with food purity, excessive focus on nutritional content, rigid dietary rules, and significant life impact. For orthorexia nervosa, criteria may also include severe anxiety from dietary deviations, leading to psychological impairment and disruptions in social, occupational, or educational activities [29]. While these offer insights, standardized, validated criteria are needed for better diagnosis and treatment. Donini et al. (2022) recently attempted to build consensus on future directions [30].
Diagnosing orthorexia nervosa is challenging due to its recent recognition and lack of standardized criteria. Differentiation from other eating disorders is a primary challenge. Symptoms overlap with anorexia nervosa, both involving rigid dietary rules [17]. However, orthorexia nervosa lacks the body image distortion and fear of weight gain characteristic of anorexia. Distinguishing orthorexia nervosa from OCD and generalized anxiety disorder is also complex due to overlapping symptoms related to health and cleanliness obsessions [2].
The lack of universally accepted criteria for orthorexia nervosa leads to inconsistent assessments and diagnoses. This also hinders accurate prevalence estimation. Addressing these diagnostic challenges and clarifying distinctions from other disorders is crucial for improved clinical recognition, early intervention, and evidence-based treatments. Recent efforts aim to achieve consensus on conceptualization and diagnosis [30], providing new directions requiring further research. Distinguishing between healthy orthorexia and orthorexia nervosa is also essential to avoid over-diagnosis and stigmatizing healthy eating habits [31, 32, 33, 30].
5. Psychological and Physical Consequences
The psychological impact of orthorexia nervosa is significant and multifaceted. Individuals experience considerable distress and anxiety related to food choices, leading to a preoccupation with dietary purity [2]. This focus can cause social isolation and functional impairment as food dominates thoughts and behaviors. Guilt, shame, and failure may arise from dietary deviations, increasing anxiety and reinforcing obsessive cycles [34]. Enjoyment of social gatherings is diminished due to food-related stress, leading to social withdrawal and alienation. Distorted beliefs about diet and health can develop, causing rigid thinking and impaired cognitive flexibility [35]. The psychological burden of orthorexia nervosa significantly impacts emotional well-being, relationships, and quality of life, necessitating early intervention [36].
Orthorexia, with its obsessive focus on “pure” and “healthy” foods, can lead to nutritional deficiencies and health issues. Restrictive diets eliminate food groups or limit choices based on purity criteria, resulting in imbalances and deficiencies in proteins, fats, vitamins, and minerals [37]. Prolonged restriction can compromise nutritional status, causing malnutrition, osteoporosis, and weakened immunity [38, 39]. Fixation on raw or unprocessed foods can increase risk of foodborne illnesses. Fear of “impure” foods heightens anxiety and stress around eating, exacerbating psychological impacts [40]. Healthcare professionals must recognize these nutritional consequences and provide support for both physical and psychological aspects, emphasizing early intervention for long-term well-being.
The impact of orthorexia nervosa on quality of life and social functioning is substantial. Preoccupation with food purity and rigid rules can dominate thoughts and behaviors, reducing engagement in social activities and enjoyment of communal meals [26]. Anxiety and stress in food-related social situations lead to avoidance of gatherings and events [41]. Social isolation negatively affects relationships and connections. Obsession with clean eating can strain relationships with family and friends who don’t adhere to the same principles. This impact contributes to loneliness, depression, and reduced well-being [36]. Dietary rules may become prioritized over personal and professional pursuits, compromising overall quality of life. Understanding this social impact is crucial for effective interventions addressing both psychological and social aspects to improve well-being and social connectedness.
Impaired social functioning is a key feature of orthorexia nervosa [32, 35]. Rigid dietary rules often lead to social isolation [1]. Avoidance of social gatherings involving food, dining out, or shared meals becomes common [33]. Anxiety about food quality can distance individuals from those not sharing dietary restrictions, causing alienation [2, 12, 26]. Rigid mindset and time-consuming behaviors hinder spontaneous social activities, further compromising connections. Impaired social functioning highlights the need for comprehensive approaches addressing both physical and psychological aspects to help individuals regain healthy relationships with food and social interactions.
6. Personality and Sociocultural Influences
Psychological factors are central to orthorexia nervosa. Individuals at risk often exhibit perfectionism, obsessive-compulsive tendencies, and high neuroticism [22]. The need for control and orderliness can manifest in strict dietary adherence and fixation on food purity [22]. Low self-esteem or body dissatisfaction may drive individuals to seek identity through an idealized “healthy” lifestyle, using food for validation [5]. Anxiety or fear of health consequences may lead to restrictive diets to protect well-being, exacerbating obsessive behaviors [42]. Stress and life transitions can trigger or escalate these disorders, intensifying the perceived need for dietary control [43]. Understanding these psychological factors is critical for early recognition, prevention, and tailored treatment.
Sociocultural influences and media significantly shape disordered eating, including orthorexia nervosa. Modern societies emphasize appearance, equating health and beauty with thinness and specific body ideals. Media portrayals of unrealistic body images reinforce these norms [44]. Individuals, especially young adults, internalize these ideals and engage in extreme dieting to conform [45]. Social media platforms disseminate dietary trends and promote “clean eating” cultures. Exposure to curated images of “perfect” bodies and “healthy” eating normalizes extreme dieting, reinforcing strict rules as key to health and success [5, 25, 44]. Public health campaigns are needed to promote body positivity, challenge unrealistic ideals, and foster balanced nutrition.
Personality traits and obsessive-compulsive tendencies significantly contribute to psychological conditions, including orthorexia nervosa. Research links these disorders to specific personality traits [22, 23, 41]. Perfectionism is prominent in orthorexia nervosa, driving individuals to seek flawless health and nutrition [23]. This manifests as rigid dietary rules and relentless pursuit of unattainable dietary ideals. Obsessive-compulsive tendencies intensify fixation on food purity, leading to repetitive thoughts and behaviors [17]. The need for control drives meticulous meal planning. Perfectionism and obsessive-compulsive traits create vulnerability to orthorexia nervosa, emphasizing the importance of addressing these traits in therapy for a balanced approach to food.
7. Assessment and Diagnosis
Identifying orthorexia nervosa is challenging due to the lack of standardized diagnostic criteria in systems like DSM-5 and ICD-10 [13, 14]. As a new concept, clear clinical recognition guidelines are lacking. Boundaries between orthorexia, other eating disorders, and conditions like OCD or anxiety disorder are blurry, complicating diagnosis [17, 29, 36, 42]. Overlapping symptoms necessitate comprehensive assessments considering context and motivations. Reliance on self-report measures introduces biases. Standardized diagnostic tools are still developing. Further research and collaboration are needed to establish a comprehensive framework for identifying orthorexia nervosa, improving diagnostic accuracy and guiding treatment.
Efforts to assess orthorexia nervosa have led to questionnaires and tools. The Bratman Orthorexia Test (BOT) is widely used [46]. BOT has 10 items assessing preoccupation with healthy eating, life impact, and anxiety related to dietary deviations. The Dusseldorf Orthorexia Scale (DOS) measures orthorexic behaviors on a 10-point scale [47]. The Teruel Orthorexia Scale (TOS) assesses obsessive food thoughts and time spent on dietary habits [48]. Clinical interviews provide deeper understanding. These tools offer insights, but ongoing research is needed to refine and validate them for accurate identification and treatment guidance.
Differential diagnosis of orthorexia nervosa requires careful consideration of overlapping symptoms with other eating disorders and mental health conditions. Orthorexia nervosa shares similarities with anorexia nervosa, particularly in restrictive eating [49]. Differentiation relies on the absence of body image distortion and primary focus on food purity in orthorexia nervosa [29]. Distinguishing orthorexia nervosa from bulimia nervosa and binge eating disorder involves evaluating compensatory behaviors typically absent in orthorexia nervosa [50]. Comorbidity is relevant; orthorexia nervosa may co-occur with anxiety disorder, OCD, or depression [2, 12, 16, 26, 29, 36, 50]. These comorbidities complicate diagnosis and require comprehensive assessment to differentiate the primary impact of orthorexia nervosa. Accurate differential diagnosis and comorbidity assessment are crucial for effective treatment planning.
The distinction between “orthorexia” and “orthorexia nervosa” is complex and debated. Lack of clear distinctions in diagnostic tools poses challenges for assessment and treatment. “Orthorexia” generally refers to obsession with healthy eating and pure foods [15], while “orthorexia nervosa” suggests a more severe form with distress and impairment [1]. However, absence of standardized criteria makes differentiation difficult in practice. Orthorexia nervosa is not formally recognized in DSM-5, complicating matters further. Clinicians and researchers are working to refine criteria, but lack of consensus remains a hurdle.
8. Treatment Approaches
Psychoeducation and cognitive-behavioral therapy (CBT) are key treatments for orthorexia nervosa [2]. Psychoeducation informs individuals about orthorexia nervosa, its consequences, and underlying psychological factors [2]. This empowers them to challenge distorted beliefs about food and health. CBT is an evidence-based intervention targeting maladaptive thoughts and behaviors. It helps individuals identify and reframe rigid thoughts about food, nutrition, and body image, and develop coping strategies for anxiety related to dietary deviations.
CBT also helps develop a balanced approach to eating, gradually reintegrating avoided foods [51]. Regular monitoring of diet and emotions is crucial in CBT, increasing awareness of triggers. Combining psychoeducation and CBT provides tools to modify maladaptive behaviors and beliefs, fostering positive dietary changes and psychological well-being in orthorexia nervosa treatment.
Nutritional counseling and intuitive eating are valuable in treating orthorexia nervosa. Nutritional counseling involves dietitians specializing in eating disorders, providing personalized support for a healthy relationship with food [52]. It addresses nutritional deficiencies from restrictive diets and promotes flexible food choices. Dietitians help create meal plans meeting nutritional needs, encouraging variety. Intuitive eating emphasizes internal hunger and satiety cues, reconnecting individuals with their body’s signals for nourishment. It helps overcome rigid rules and promotes mindful, non-judgmental eating, self-compassion, and body acceptance [53]. Integrating nutritional counseling and intuitive eating helps individuals trust their bodies, develop positive food relationships, and cultivate sustainable, balanced eating habits supporting physical and psychological well-being. Promoting positive body image is also beneficial in eating disorder treatment [54].
Mindfulness and acceptance-based treatments are promising for orthorexia nervosa [55]. Mindfulness cultivates present moment awareness and non-judgmental acceptance of thoughts and emotions, allowing individuals to observe obsessive thoughts about food without impulsive reactions. It increases insight into triggers and motivations. Acceptance-based strategies encourage embracing vulnerabilities without self-criticism, fostering self-compassion and reducing dietary perfectionism. Integrating mindfulness and acceptance helps develop balanced food relationships and psychological resilience. Individuals embark on healing journeys by developing self-awareness and self-compassion, overcoming orthorexia nervosa and cultivating healthier lives [56]. Further research is needed to explore the efficacy of these treatments for orthorexia nervosa.
Family and social support are crucial in orthorexia nervosa recovery [57]. Family involvement significantly influences treatment adherence and outcomes. A nurturing environment reduces isolation and stigma, creating a safe space for sharing struggles. Family therapy facilitates communication and addresses dysfunctional dynamics. It educates family members on supporting recovery. Social support from peers and support groups is also invaluable [58]. Connecting with others facing similar challenges fosters empathy and shared growth. Support groups allow experience sharing and encouragement. Combined family and social support creates a robust network, bolstering resilience and commitment to recovery, providing a foundation for sustained progress and improved well-being.
9. Future Directions and Research Needs
Longitudinal studies on the course and outcomes of orthorexia nervosa are essential to improve understanding and interventions. Current research is limited by cross-sectional studies. Longitudinal studies can provide insights into the natural trajectory of these disorders, including stability, progression, and remission. Following individuals over time allows researchers to explore factors influencing development and exacerbation, and identify protective factors for recovery. Longitudinal studies can also assess intervention effectiveness and long-term consequences on physical and mental health, including nutritional deficiencies and social functioning. Overall, these studies are crucial for deepening understanding and guiding targeted interventions.
Cross-cultural studies are needed for a global understanding of orthorexia nervosa prevalence to recognize cultural influences. The concept of “healthy” eating varies across cultures, affecting orthorexia nervosa presentation. Cross-cultural studies can explore how cultural norms influence attitudes toward food and health, revealing unique risk and protective factors. Understanding global prevalence is crucial for public health. Given digital media’s spread of health trends, orthorexia nervosa likely transcends borders. Examining prevalence across regions helps identify high-risk populations and allocate resources for prevention. Global understanding through cross-cultural studies will contribute to culturally sensitive diagnostic criteria and public health strategies, advancing global recognition and management.
Developing consensus on diagnostic criteria and assessment tools for orthorexia nervosa is critical to advance research, clinical recognition, and treatment outcomes. Lack of standardized criteria hinders accurate diagnosis and comparability across studies. Absence of agreed-upon assessment tools complicates capturing the full spectrum of orthorexic behaviors. Comprehensive, validated diagnostic criteria and assessment measures are crucial to differentiate orthorexia nervosa from other disorders and enable tailored treatments. Consensus will enhance diagnostic accuracy, promote early intervention, and provide a foundation for advancing research and understanding.
10. Conclusions
This review comprehensively examined orthorexia and orthorexia nervosa, covering prevalence, risk factors, diagnosis, and treatment. By reviewing literature and data, it highlights growing concerns about these emerging eating disorders. The paper emphasizes diagnostic complexities due to lacking standardized criteria and the need for better assessment tools. While a recent consensus paper by Donini et al. [30] has advanced understanding of diagnosis, unified diagnostic criteria are urgently needed for accurate identification, research, and effective treatment. Personality traits, sociocultural influences, and psychological factors are identified as significant risk factors. Sharing and accumulating data should better define these disorders and provide valuable insights for healthcare professionals, researchers, and policymakers in addressing orthorexia nervosa.
Author Contributions
Conceptualization, O.H. and M.A.; Writing—Original Draft Preparation, O.H.; Writing—Review and Editing, O.H. and M.A. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
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Conflicts of Interest
The authors declare no conflict of interest.
Funding Statement
This research received no external funding.
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References
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