Update on Orthorexia

I recently attended the iaedp conference in Florida.  What an amazing few days of education, networking, connecting with colleagues, and WARM weather!

While there, I had the honor of attending a talk on Orthorexia Nervosa: Past, Present & Future of the most Controversial Eating Disorder by Steven Bratman, MD, MPH, Amanda Mellowspring, MS, RDN, CEDRD, and Jessica Setnick, MS, RD, CEDRD.

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Orthorexia usually begins as an exuberant interest in healthy food.  This itself is not an eating disorder, but in susceptible individuals can transform into disordered eating.  Certain risk factors may be: adoption of a highly restrictive diet, a parent that has a high interest in “healthfoodism”, childhood illness involving diet and/or digestive issues, medical problems that can’t be addressed by medical science, traits of perfectionism, OCD, extremism, and fear of disease.  This style of eating can turn problematic when certain foods are idealized as semi-magical foods while others are demonized as evil (aka sugar! I hear that all the time…) Someone can start to develop a decreased food variety, as well as cut out entire food groups (aka vegan or paleo).  Eventually breaking some of these diet “rules” can lead to fear of disease and sense of impurity accompanied by anxiety and shame.  Basically, food becomes a primarily source of self-worth, happiness, and meaning.  Dr. Bratman has developed criteria to be published soon in the Eating Behaviors journal with Tom Dunn, PhD.


Proposed Diagnostic Criteria for Orthorexia Nervosa:

Criterion A. Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue, but this is conceptualized as an aspect of ideal health rather than as the primary goal.  As evidenced by all the following:

  1. Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices* believed by the individual 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, accompanied by anxiety and shame.
  3. Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to idealization about healthy food.

*Dietary practices may include use of concentrated “food supplements.”

**Exercise performance and/or fit body image may be regarded as an aspect or indicator of health.

Criterion B. The compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:

  1. Malnutrition, severe weight loss or other medical complications from restricted diet
  2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviors about healthy diet.
  3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior


In addition to these criteria, the published article also includes the following paragraph:

Other traits are commonly associated with ON in the literature. While the authors feel that these are not essential to making the diagnosis, they may help confirm it. These include obsessive focus on food choice, planning, purchase, preparation, and consumption; food regarded primarily as source of health rather than pleasure; distress or disgust when in proximity to prohibited foods; exaggerated faith that inclusion or elimination of particular kinds of food can prevent or cure disease or affect daily well-being; periodic shifts in dietary beliefs while other processes persist unchanged; moral judgment of others based on dietary choices; body image distortion around sense of physical “impurity” rather than weight; persistent belief that dietary practices are health-promoting despite evidence of malnutrition.

Cite as: Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17.


Is this you?  Amanda and Jessica both talked about ways to counsel these clients that may be a little different from typical eating disorder treatment.  We also discussed ethical issues relating to this treatment.

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Bottom line, if any disordered eating is getting in the way of you living your life to the fullest, treatment can help.