Orthorexia: A Unique and Complex Eating Disorder on the Rise

Orthorexia nervosa is an eating disorder that many people are unaware of and can be challenging to treat. A systematic review and meta-analysis featuring more than 30,000 people from 18 different countries published last year shows that the condition is on the rise and more common than you may think.

The analysis searched four databases from January 2005 to July 2023 and found that approximately three out of ten participants had symptoms of orthorexia. The key characteristic of orthorexia is an unhealthy obsession with healthy eating with a focus specifically on eating “clean and pure.” A 2022 review describes it as an unhealthy eating pattern that can start out health-promoting but then escalates. It includes an attitude of self-punishment that results in cleansing fasts and even tighter dietary restrictions. The patient can feel fearful of disease, anxiety, shame, and a sense of impurity.

“It may be difficult for practitioners to recognize their patient's behavior has dipped into the realm of disordered eating because, at face value, they may present as the perfect patient concerning diet and lifestyle,” explained naturopathic oncologist Marisa Soski, ND, FABNO. “This topic is especially important within the context of naturopathic medicine and integrative medicine as providers can inadvertently contribute to a patient’s stress and anxiety around food choices and can further push them down the spectrum of orthorexia.”

The authors of the most recent review explain that presently, there is no universally shared definition or diagnostic criteria, and orthorexia is not listed in the Diagnostic Statistical Manual of Mental Disorders.

Integrative Treatment

A patient's relationship with food can be complex, but Dr. Soski believes practitioners must delve deeply into this area with their patients.

"A patient's relationship with food is influenced by many factors, including cultural narratives about food, media marketing and messaging, our childhood experience with food, health status or various conditions, experience of trauma, access to nutrition education and food choices, energy levels, other life commitments, mental health status, and so much more,” said Dr. Soski who is adjunct faculty at San Francisco State University in the Holistic Health Department and the University of Western States in their Masters of Nutrition program. “The healthier our relationship with food is, the easier it is to make decisions that support our nutritional needs and therefore our physical, mental, and emotional health.”

A 2023 review identifies these factors linked to the development of orthorexia:

• Perfectionism, neuroticism, and/or a tendency towards obsessive-compulsive behavior.
• History of dietary and body dissatisfaction.
• The media’s portrayal of idealized body images and clean eating.
• Misinformation and unscientific health claims.
• High stress, anxiety, or dissatisfaction with other aspects of their lives.
• A fear of illness that develops into a consuming obsession.

In 1997, Steven Bratman, MD, a holistic medical physician, coined the term orthorexia. Dr. Bratman also created the Authorized Bratman Orthorexia Self-Test to help determine risk and assist with diagnosis.

Treatment of orthorexia can include cognitive behavioral therapy, nutritional counseling, and intuitive eating approaches.

“Ultimately, the treatment of orthorexia is very similar to other disordered eating patterns and involves a deep exploration into the patient’s relationship with food, mental health, and motivations for pursuing such an extreme approach to nutrition,” said Dr. Soski, who sees patients at Matrix Medicine in Boulder, CO, and also has a telemedicine practice. “It is imperative that practitioners are trained in the signs and symptoms of orthorexia so they can clinically identify it as well as understand how to make nutrition recommendations without contributing to the problem.”