Orthorexia Nervosa: When Healthy Eating Becomes Extreme

A History and Description of Orthorexia Nervosa

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What is Orthorexia?

Orthorexia is not recognized by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as an official eating disorder. It remains a proposed diagnosis that is attracting increased interest by researchers, treatment professionals, bloggers, and the public, especially as a desire for healthy food has become more mainstream.

Orthorexia is not merely veganism, a gluten-free diet, or a general appreciation for healthy eating.

According to Dr. Stephen Bratman, the doctor who coined the term in 1996 to describe the obsession with healthy eating he had seen in several of his patients, “People can adhere to just about any theory of healthy eating without having an eating disorder (with the only caveat that such a diet must provide adequate nutrients).”

Orthorexia commonly begins as an “exuberant” interest in healthy eating that escalates over time. What was originally a choice becomes a compulsion and the individual can no longer choose to relax their own rules. Eventually, the person’s restrictive eating starts to negatively impact both their health and social and occupational functioning; eating the right foods becomes increasingly important and squeezes out other pursuits. A person’s self-esteem becomes very closely tied to their adherence to their selected diet. Consequently, any deviation from the diet typically causes extreme feelings of guilt and shame.

Dr. Bratman observes the irony of the pursuit of healthy eating backfiring and becoming incredibly unhealthy.

History of Orthorexia

At the time he coined the term, Dr. Bratman was working in alternative medicine. Many “healthy” diets were touted as alternatives to medications, but Dr. Bratman began to notice significant costs to this approach.

These included an inability to share food with others; an inability to eat food one once enjoyed; an identity wrapped up in food; and guilt, shame, and fear associated with straying from the diet.

Dr. Bratman discerned that for some patients it would be more prudent to relax about their eating than to improve or further restrict their diet. As a form of “tease therapy,” Dr. Bratman decided to invent a disorder his patients could focus on being cured of. He hired a Greek scholar to help him choose the name. The term “orthorexia nervosa” was coined to mean an obsession with eating the right food; “ortho,” meaning right, “orexia,” meaning hunger, and “nervosa” meaning fixation/obsession. He was making an analogy to anorexia nervosa.

Dr. Bratman said he originally thought of orthorexia as a way to encourage his patients to loosen their own strictures, rather than a serious diagnosis. He published the term in 1997 Yoga Journal article – from there it was quickly taken up by popular magazines.

Dr. Bratman himself did not take it seriously. It was not until after the publication of a humorous book on the subject that he learned that he had “tapped into something bigger.” He learned that people were dying from the condition.

Proposed Risk Factors

Dr. Bratman (2016, IAEDP) described what he believes are several risk factors for orthorexia:

  • Adoption of a highly restrictive dietary theory
  • Parents who place undue importance on healthy food
  • Childhood illness involving diet and/or digestive issues
  • Medical problems that can’t be addressed by medical science
  • Traits of perfectionism, OCD, and extremism
  • Fear of disease

Development of Proposed Diagnostic Criteria

Orthorexia Nervosa was the subject of an Italian study in 2004, which gave further credibility to the condition. In 2014, Jordan Younger, a popular blogger discussed having suffered from orthorexia. At this point, Dr. Bratman decided to study and write about the condition he had first recognized. It is important to note that there are no reliable studies on how prevalent Orthorexia Nervosa is. There are, however, according to Bratman and Dunn, “convincing case studies and broad anecdotal evidence to conclude that sufficient evidence exists to pursue whether [Orthorexia Nervosa] is a distinct condition.”

In a 2016 paper in the journal Eating Behaviors , Dr. Bratman co-authored with Thom Dunn, Ph.D. they propose diagnostic criteria.

Criteria A

All of the following:

  1. Compulsive behavior and/or preoccupation with restrictive diet to promote optimum health
  2. Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity, and/or negative physical sensations, anxiety, and shame
  3. Dietary restriction increases over time and may come to include elimination of food groups and cleanses. Weight loss commonly occurs but the desire to lose weight is not the focus.

Criteria B

Any of the following:

  1. Malnutrition, severe weight loss, or other medical consequences from restricted diet
  2. Intrapersonal distress or impairment of social, academic or occupational functioning due to beliefs or behaviors about healthy diet
  3. Self worth, identity, and body image unduly dependent on compliance with “healthy” diet

Other features and medical risks

Dr. Bratman reported that the condition of orthorexia has already shown signs of evolution since he first conceived of it. He noted that exercise is more commonly a part of it than it was in the 1990s. He also reported that incorporating low-calorie foods has also become a bigger part of the healthy eating associated with orthorexia. In cases where individuals pursue both purity and thinness, there may be an overlap between anorexia nervosa and orthorexia nervosa. Orthorexia may also, on occasions, be a disguise for anorexia by individuals presenting a more socially acceptable way of staying thin. Orthorexia nervosa may also cross over with bulimia nervosa and Avoidant/Restrictive Food Intake Disorder (ARFID).

Although the behaviors (dietary restriction) and consequences (weight loss, malnutrition, bingeing and/or purging) associated with orthorexia nervosa may look similar to anorexia nervosa or bulimia nervosa, the main difference is in the content of the belief system. Patients with orthorexia primarily think about ideal health, physical purity, enhanced fitness and avoiding disease. They restrict foods perceived as unhealthy and embrace certain “superfoods” perceived as providing special health benefits according to their belief system about what constitutes healthy food. In contrast, patients with anorexia consciously focus on weight and restrict foods primarily based on calories. There are other differences as well.  People are usually ashamed of their anorexia and attempt to hide it, but persons with orthorexia may actively attempt to persuade others to follow the same health beliefs. Those with anorexia often forego meals; people with orthorexia typically do not (unless they are deliberately “cleansing”). Finally, when an anorexic person is in treatment, they have no particular objection to being fed with Ensure or Boost except regarding the calories, whereas a person with orthorexia would object to the chemicals in those supplements. These distinctions in beliefs may be important. Dr. Bratman observed that treatment professionals’ misunderstanding the concerns of someone with orthorexia may lead to treatment failure.

Because orthorexia is only a proposed diagnosis, there is a great deal we do not know. For example, we do not know its relationship to the existing eating disorders, such as anorexia nervosa, bulimia nervosa, binge eating disorder, and ARFID. Nor do we know its relationship to anxiety disorders. Research is needed to refine the diagnosis, determine prevalence rates, identify risk factors, and develop treatments. An important first step is developing an assessment tool; a 100-question survey is in development to assess and diagnose orthorexia.

One thing we do know is that, because it can cause malnutrition, orthorexia nervosa may produce any of the medical problems associated with anorexia nervosa including loss of menses, osteoporosis, and heart failure. Although treatments have not been specifically validated for orthorexia, clinicians, and Dr. Bratman reported that treatment that challenges the dietary theory and builds more flexible eating have been successful in the treatment for orthorexia.

If you or a loved one shows signs of orthorexia, please seek help from an eating disorder treatment professional. As with other eating disorders, early intervention increases the chance for a complete recovery and minimizes negative consequences.


Most of the information in this article was presented by Dr. Bratman and colleagues during the following session at the International Association for Eating Disorder Professionals (IAEDP) 2016 Symposium on February 20, 2016:

Orthorexia Comes of Age: Past, Present and Future of the Most Controversial Eating Disorder

Steven A. Bratman, MD, MPH, Jessica Setnick, MS, RD, CEDRD and Amanda Mellowspring, MS, RD, CEDRD

Additional sources consulted include:

Bratman, Steven (1997). Health Food Junkie.  Yoga Journal September/October:42-50..

Bratman, Steven (2014) What is Orthorexia?

Bratman, Steven (2015) Orthorexia:  Proposed Formal Criteria

Bratman, Steven (2015) Foreward to “Breaking Vegan

Bratman, Steven (2015) Orthorexia:  An Update

Bratman, Steven (2015) Orthorexia Nervosa (Mirror-Mirror Eating Disorder)

Dunn, Thomas, Bratman, Steven (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 11-17.

Moroze, R. M., Dunn, T. M., Holland, J. C., Yager, J., & Weintraub, P. (2015). Microthinking about micronutrients: A case of transition from obsessions about healthy eating to near-fatal “orthorexia nervosa” and proposed diagnostic criteria. Psychosomatics, 56(4), 397–403.

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