When healthy eating becomes unhealthy: Orthorexia

How is the clean eating movement on social media partly responsible?

What does a healthy relationship with food look like? This is something I often explore with my clients during the first few sessions. On a physiological level, our bodies need food for fuel and nourishment - but there appears to be a consensus that food is so much more than this. Food builds connections, it’s a way people show love and share experiences, there’s a huge emotional component which should ideally be free from shame or guilt.

Our relationship with food is one of the most important relationships in our life, and like any relationship it requires attention, and work to stay healthy. It’s normal to go through phases where we neglect it; life becomes stressful and we skip meals, or we tend to our emotional needs with occasional bouts of overeating. Our bodies are smart and when we’re not attending to it, they will find a way to let us know something isn’t right, and trigger signals to encourage us to establish homeostasis.

After working within sport and exercise settings I began to recognise that the pursuit of being the healthiest version of ourselves can become unhealthy too. Orthorexia is a relatively new term and one that received closer attention when #cleaningeating #fitspo began to trend on social platforms. Orthorexia nervosa (ON) is defined as an obsession with healthy food, healthy eating, or health-conscious eating behaviors (Pontillo et al., 2022).

The term was first coined by Steven Bratman in 1997 and is derived from the Greek term ortho, meaning correct, and orexi, meaning appetite.

Namely, our pursuit for “perfection” when it comes to our eating habits begins to cause ongoing, excessive anxiety and may coincide with preoccupation with strict food rules and avoidance. With regards to ON it is common to hear clients report that foods may be excluded because they are considered “impure” (reasons may include the presence of pesticides or artificial substances; Pontillo et al., 2022), which is different from cutting out certain food groups for general health reasons, or because you feel better when you avoid them. An individual’s identity may be predominantly determined by the perfection of their diet, instead of their interests, hobbies, work and friends. An excessive amount of time may be spent planning and prepping meals, instead of doing the things they enjoy with the people they value. ON has been reported to have a detrimental impact on health, relationships, and quality of life (Scarff, 2017).

Orthorexia is classified as an unspecified feeding and eating disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5).

Simply being more mindful about your food choices or adopting a specific lifestyle or diet for whatever reason, doesn’t equate to someone having orthorexia. With most eating disorders, it’s never about the food. It’s more to do with how we think and feel about food and what’s going on at a much deeper emotional level. We may feel like something isn’t quite right, or perhaps we want to regain a sense of control over an aspect of our life because we feel we have little to no control over anything else - generally we’re searching for something to make us feel better.

On reflection, orthorexia appears to share characteristics with both eating disorders (EDs) and obsessive-compulsive disorder (OCD; Pontillo et al., 2022). Orthorexia may involve restrictive eating habits, but it differs in many ways from anorexia, Bratman (2017) shared a few key insights: “People with anorexia skip meals; people with orthorexia do not (unless they are fasting). Those with anorexia focus only on avoiding foods, while those with orthorexia both avoid foods, they think are bad and embrace foods they think are super-healthy”. Some argue recent health scares may also be a risk factor for orthorexic tendencies - rigid food rules and a preoccupation with food may occur in an attempt to negate real or perceived illness. This makes sense - but it’s important to be curious about our efforts to maintain good health and identify if they may be having a detrimental effect.

The role of social media

Social media use may also be a risk factor, and our usage has increased significantly over the years. Social media has been found to have negative effects on depression, social comparisons, body image and disordered eating. Granted, it’s not all negative, and has a lot more to do with how you use the platform and who you choose to engage with. There are a lot of health practitioners sharing evidence based content to shed light on the misinformation.

The pandemic was psychologically testing for most. We were cooped up at home, in isolation and spending more time online. Some researchers argued that those with ON tendencies may have had a hard time ignoring weight-based content on social media or even sought it out more than usual during lockdown, as a result of the body dissatisfaction (Gobin, Mills & McComb,2021).

Good questions to ask ourselves as we’re scrolling through the highlight reel may include:

• How did that post make me feel about myself?
• How did that post make me feel about the food I generally eat?
• What emotions came up for me when I saw that post? e.g., did I feel motivated and inspired, or was I experiencing guilt and shame?
• Is this coming from a reputable source? (Although this is important, I think it’s also key to note that there may be less qualified individuals online who are doing a fantastic job to promote healthy messages and may be undergoing further training and/or have mentors who are qualified).

What are some of the warning signs of orthorexia?

• Preoccupation with food and eating habits
• Extreme dietary rules that may lead to malnutrition
• Cutting out an increasing number of food groups (e.g., sugar, carbohydrates, dairy, animal products)
• Good Vs Bad food labels
• Frequent, somewhat excessive engagement following of food-related posts and ‘healthy lifestyle’ bloggers on social platforms
• Changes in mood and emotional distress over meal planning, food preparation and eating
• Food fixation that affects social interactions

I think one of the key points to consider when it comes to creating awareness around orthorexia is our pursuit for perfection and rigidity. A healthy relationship with food involves relieving yourself of the pressure of trying to eat ‘perfectly’ - instead it’s balanced, experimental and mindful. It’s forgiving and respectful. We acknowledge food is neither good nor bad - instead some food is more dense in nutrients and others are less. If our eating habits are unsustainable, stressful, obsessive or wrapped in morality, they’re no longer healthy.

Treatment

First, recognising that you may have taken your diet too far is no small feat. If you have been experiencing symptoms of ON and anxiety, low mood or distress, reach out to a health professional.

Orthorexia is still a relatively new term that practitioners and researchers are working hard to better understand, diagnose and treat. Regardless of the lack of consensus, therapy could be a good place to start. Cognitive behavioural techniques may be helpful to gently challenge rigid beliefs, improve daily habits, increase the variety of foods eaten and exposure to anxiety-provoking feared foods - as well as weight restoration if needed. Self-regulation and relaxation techniques could be helpful to relieve anxiety surrounding meal times. Experts recommend a multidisciplinary team approach that includes a GP, psychologist, and dietitian (Koven and Abry, 2015).

Resources

www.butterfly.org.au Support for Eating Disorders and Body Image Issues

www.eatingdisordersqueensland.org.au Services for Eating Disorders and NDIS Support

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References

Barnes, M.A. & Caltabiano, M,L. (2017). The interrelationship between orthorexia nervosa, perfectionism, body image and attachment style. Eat Weight Disord, 22(1), 177–184.

Bratman, S. (2017). Orthorexia: an update. [Accessed April 18, 2017].http://www.orthorexia.com/orthorexia-an-update. Updated October 5, 2015.

Dunn, T.M. & Bratman, S. (2016). On orthorexia nervosa: a review of the literature and proposed diagnostic criteria, Eating Behaviour, 21, 11–17.

Koven, N.S. & Abry, A,W. (2015). The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatr Dis Treat, 11, 385–394.

Pontillo, M., Zanna, V., Demaria, F., Averna, R., Di Vincenzo, C., De Biase, M., Di Luzio, M.,Foti, B., Tata, M.C. & Vicari, S. (2022). Orthorexia Nervosa, Eating Disorders, and Obsessive-Compulsive Disorder: A Selective Review of the Last Seven Years. Journal of Clinical Medicine, 11, 6134, doi: 10.3390/jcm11206134.