What is Orthorexia?

Orthorexia was defined in 1997 by Dr. Steven Bratman, MD, and Renee published her book on the subject in 2017. It is not currently recognised in a clinical setting as a separate eating disorder, so someone who visited the doctor with the symptoms would not be officially diagnosed with “orthorexia”, although the term may be brought up when discussing their illness.

As well as psychological, it can cause physical problems, because someone’s beliefs about what is healthy may lead to them cutting out essential nutrients or whole food groups. All eating disorders are serious mental illnesses, and should be treated as quickly as possible to give the sufferer the best chance of fully recovering.

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).

What causes Orthorexia?

Orthorexia is about obsessive self-improvement, rather than necessarily doggedly trying to reach a perfect weight, as in the more well-known eating disorders such as anorexia and bulimia. The aim is to improve the self through improved quality in diet and lifestyle, rather than to reduce, restrict or burn calories. That said, there are clear commonalities in the triggers for obsessive, extreme behaviours between all three eating disorders. We might say that these are the fundamental underlying factors – “causes” is probably too limiting a word – of orthorexia (and of anorexia and bulimia). 

Feelings of being out of control

We can’t control how anyone else looks or feels. Nor can we control everything that happens to us over the course of a day, week, year or life. Dissatisfaction with life and the self, and feeling impotent to put it right or to have influence, means that a vulnerable person may turn to food intake as something he or she can control to try to find order in everything else that feels out of kilter or unmanageable. We see this in small children all the time – think of the toddler who copes day in, day out with being told what to do and how to behave, probably even what to wear. Then, it comes to trap me and he or she flatly refuses to eat a carrot, or a piece of broccoli, or a piece of chicken. Why? Because when so much feels out of control, what we put into our bodies is something over which we can have the final word. 

It’s the feelings of being out of control that lead to obsessive, predictable patterns of behaviour – whether that manifests as a strict diet or a particular order for completing a certain task. It’s not surprising that those with an eating disorder also often show other obsessive compulsive tendencies too. 

Low self-esteem or lack of spiritual fulfillment

Purging the body in order to rid it of feelings of inadequacy or incompleteness manifests in anorexics as abstinence, in bulimics as regurgitation and in orthorexics as eating purely, according to the strict rules of a chosen diet. Of course, nothing about low self-esteem is as simple as all that. Feelings of not being good enough often have deep roots, embedded in years of perceived failure, or perhaps trauma or anxiety and stress. Nonetheless, a set of food rules, closely followed at all times, provides a sense of success and fulfillment – “If I can adopt these rules and live by them at all times, I must be good enough because I have succeeded.” 

A need to be perfect

One study, published in Eating and Weight Disorders (EWD) Journal in April 2016, investigated what causes there were for orthorexia. The researchers asked 220 individuals to complete a questionnaire investigating attitudes to perfectionism, body image, relationships and self-esteem. The results found that, as well as a previous history of eating disorder, there were higher orthorexic tendencies in those showing higher scores in dissatisfaction with body image and a need for perfection. Of course, this makes sense – the logic goes that through the perfect and precise following of rules comes a perfect person. 

Lack of self-compassion

I have found that one of the most striking and recurring themes that comes up during my work with individuals who have disordered-eating issues, such as orthorexia, is lack of self-compassion, the inability to be kind to the self. When we are healthy, we know that there is no such thing as perfect – there isn’t the perfect journey, the perfect meal, the perfect cup of coffee, let alone the perfect body. We forgive life for its anomalies and imperfections and we even appreciate and welcome them as the flecks of colour in every otherwise ordinary day. For a person with orthorexia, however, as we’ve seen there is a need to be perfect. When perfect doesn’t come, instead of a quick shrug of the shoulders, there is guilt, remorse, self-loathing. Someone with orthorexia keeps pushing, even if the body screams to stop (in pain or hunger or because of some other physical need); there’s a sense that we are not worthy of our own kindness, because we aren’t yet good enough – perfect enough – to deserve it. 

These triggers are by no means exhaustive. Just as every individual has different dietary needs, so every individual has different psychological pushes and pulls, triggers and touchpoints. I couldn’t pretend to have covered them all, nor even to have discovered them all – but these are the triggers that I see so frequently in the clients who come to my clinic. 

The Symptoms of Orthorexia

For a person suffering from an eating disorder, it is virtually impossible to notice that something is wrong – decisions to limit, restrict or in another way control food intake seem perfectly rational and logical and in the case of orthorexia, even healthy. That’s why it’s so important that we are all aware of the signs and symptoms – so that even if we can’t see the dangers in our own behaviour, we can notice them in those we love. The following are some of the common signs in the behaviour of those with orthorexic tendencies. 

Citing undiagnosed food allergies as rationale for avoiding certain foods

Individuals struggling not just with orthorexia but with any eating disorder may use this as an excuse to limit or control what they eat. In some individuals there is a categorical belief that a particular food or food group causes illness. However, others present it as an excuse – a means of sidestepping questions about what he or she is choosing to eat and not eat. For example, if I told you I was gluten-intolerant, you would be far less likely to question why I refuse a bowl of pasta or avoid eating the bread roll with the soup you’ve served me. Fabricating an allergy or intolerance enables sufferers to persist with the rules of their eating disorder even when they are with other people. 

In orthorexia, there’s a banned list that might include all or some of the following: 

Fat, sugar or salt 

Animal or dairy products 

Foods containing any artificial colours, flavours or preservatives 

Foods treated with pesticides or having undergone genetic modification 

Showing signs of co-occurring disorders, such as obsessive compulsive disorder (OCD)

As we’ve already seen, the need to take control over life is a key trigger for eating disorders. This can manifest in food choices and also in other ways. Individuals who have OCD and an eating disorder often have set rules relating to food preparation (the way in which vegetables are chopped, the order in which ingredients are added, or the precise weighing of ingredients, for example), as well as obsessive addiction to cleaning routines and even constant checking to ensure that they’ve done what they think they’ve done (a checking and rechecking that you’ve locked the door, or folded the washing, or turned off the oven, for example). The routines of the disorder evoke a sense of control and calm. Any deviation from those routines causes anxiety and stress. 

Performing elaborate rituals relating to food

It is not uncommon for individuals with eating disorders to demonstrate extreme behaviour relating to food storage and (as I mentioned above) preparation. In addition, an individual with an eating disorder may create delicious and elaborate meals for other people, without eating a morsel themselves. On the one hand, this is a means to show compassion toward others to fulfill a need to demonstrate kindness that the sufferer finds it impossible to show to him- or herself. On the other hand it also gives the sufferer a sense of self-worth; or a feeling of somehow being superior to all those who can’t resist the food that’s put in front of them and don’t follow those strict rules. 

Evident discomfort eating food cooked by someone else

Remember how needing to take control is a trigger for orthorexia? Well, this manifests frequently in obvious signs that a meal cooked by someone else is somehow unpalatable or inedible. You might find that a sufferer will push food around his or her plate; or he or she may have hovered awkwardly in the kitchen while you’re preparing the meal, watching every move. 

Turning down social invitations that involve eating

Whether it’s the birthday cake at a family gathering, or a three-course meal at a dinner party, those who suffer from eating disorders will avoid at all costs social situations that might involve the need to eat outside of their rules. 

Healthy individuals often associate going out for dinner with friends as a means of bringing a sense of fulfillment to life. But, what makes that occasion a happy one? Is it the food? Probably not – it’s the interactivity, the sociability, the human connection and the feeling of being part of a pack, of belonging. The great irony is that sufferers of orthorexia remove themselves from social situations, especially those involving food, because it’s much harder to follow the food rules when someone else is cooking or when other people are watching or perhaps questioning. The resulting sense of isolation goes on to create a vicious cycle of low self-esteem and feelings of lack of self-worth.

Expressing guilt about breaking rules – and trying to put things right

Remember that orthorexia is all about rule-following, so if any rule is broken the sense of guilt in the sufferer can be overwhelming. As a result he or she may show a particularly manic episode of exercise or food restriction somehow to redress the balance, purge and purify. If a friend says to you, “I can’t come for a coffee because I have to go for a run/ am fasting that day because I really overindulged yesterday”, beware.