Orthorexia: When healthy eating becomes dangerous

Orthorexia nervosa is an eating disorder based on an unhealthy obsession with nutrition – so what are the signs and how can it be treated?

Eating healthily is good, right? Well, no, not always. Even the supposedly healthy trend for so-called clean eating has a potential dark side. Extreme practitioners are at risk of an eating disorder known as orthorexia nervosa, says Renee McGregor, a registered dietitian and author of Orthorexia: When Healthy Eating Goes Bad.
Clean eating is a diet characterised by eating whole, natural foods and avoiding those that are processed and refined. While, in theory, clean eating has a positive impact on your health, it can become problematic.
Victoria Taylor, a dietitian at the British Heart Foundation, says, “There are extreme versions of clean eating and these don’t have a sound basis.” She cites the example of people excluding dairy and wheat from their diets, even if they don’t have an intolerance or allergy. 
However, it’s not just those who follow a clean eating diet too obsessively that are at risk. George Mycock, the founder of MyoMinds (a mental health organisation that works to research and raise awareness of eating, exercise and body image concerns in exercisers), found that his pursuit of muscle growth led him to adopt orthorexic behaviours. 
George says, “The symptoms of orthorexia I experienced tied together with my compulsive and dependent pursuit of muscle. I would spend hours researching optimal nutrition for muscle growth and would rigidly weigh and track every gram of food I ate.”
He adds, “These behaviours are commonplace for many gym goers these days. I think most people have categories of ‘good’ and ‘bad’ foods somewhere in their mind, and it’s not always something that would be described as disordered behaviour.”
So could you or someone you know be at risk?
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The term orthorexia nervosa was coined by Steven Bratman, an American physician, in 1997. The origins of the word are Greek with ortho meaning correct and orexi meaning appetite. 
The basis for Bratman’s coining of the term came from his observations about his “overly diet-obsessed patients”. He says that for those with orthorexia “eating healthily has become an extreme, obsessive, psychologically limiting and sometimes physically dangerous disorder”.
McGregor defines orthorexia as an “obsession with eating purely and eating correctly” from a health perspective. 
Marian* has suffered with orthorexia for nearly a decade. “Once my brain and body learnt to fixate on certain rules and arbitrary dichotomies between “healthy” or “unhealthy” food, it became a self-imposed trap that felt impossible to break from, even if I know that I am underweight. It was less about the body and more about control,” she says.
Symptoms will of course vary from person to person, but there are some common signs that you can look out for.
Physical symptoms usually manifest because those with orthorexic behaviours are cutting out entire food groups. These symptoms can include:
Behavioural signs include:
Psychological signs:
Although there is little research into the causes of orthorexia, especially in terms of physical and biological factors, there are certain behaviours that may increase one’s risk of developing the disorder. 
There is a strong link between those with OCD and those who develop orthorexia, McGregor observes. She notes that those with OCD traits or behaviours are more likely to think through an orthorexic lens. This could mean, for example, that they obsessively study menus or avoid going out to eat.
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Marian experiences a consistent need for control in her eating. “At any point in my life when I feel that I lack control, such as during the pandemic, I cling to my eating disorder.”
“I have cancelled holidays, dates and even career paths because of how they may interfere with my eating routine.”
She adds that she will “meticulously analyse menus or packaging before consuming food” and always seeks out “the stereotypically ‘healthy’ foods such as fruits, vegetables and anything wrapped in green packaging with a natural aesthetic”.
McGregor suggests that social media use may be a risk factor for orthorexia because of people sharing their lives and seeing how they stack up against others, as evidenced in the widespread trend for sharing pictures of food and comparing eating habits. Moreover, 24/7 access to social media can mean “we’re constantly exposed to other people’s opinions about food,” says McGregor.
Kerri Fleming, a representative for eating disorder charity BEAT, confirms that it can have an impact on someone already struggling or inclined to struggle.  She says social media can be harmful “to someone who’s already vulnerable, or someone who may be exposed to the factors that could lead to an eating disorder developing.”
Marian agrees with this in terms of her own experience, with social media often fuelling her orthorexic behaviours. “At one point, my social media feeds were flooded with celebrities’ manipulated waistlines and recipes that swapped spaghetti for courgettes. Seeing a virtual ideal that is impossible to obtain motivates an orthorexia mindset,” she says.
There is currently no formal diagnosis for orthorexia, but at the end of 2022, a consensus statement about orthorexia was published. The document, with input from 47 eating disorder researchers, defined orthorexia and suggested a diagnostic criteria. 
The biggest difference between orthorexia and anorexia is that whilst body image is a “rooting factor” of anorexia, those with orthorexia are not necessarily concerned with how their body looks. While those with orthorexia may think about their body image, their main concern is “keeping their body as healthy as possible and putting in only what they consider [to be] healthy foods into their body”. 
Bratman says the main distinction between anorexia and orthorexia is that anorexics seek weight loss, whereas orthorexics are focused on eating purely, with weight loss being a side effect or sometimes not being an issue at all. He also suggests that sometimes individuals recovering from anorexia may “graduate to orthorexia, keeping their disordered eating habits and moving the focus from weight to purity”.
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As with any eating disorder, orthorexia can have a detrimental impact on both a person’s physical and mental health.
In terms of physical side effects, McGregor states that orthorexia can have a negative impact on hormonal health, regardless of gender. This is because disordered eating can lead to “a downregulation of production of either oestrogen or testosterone” if a person isn’t getting all the nutrients their body needs.
McGregor adds that vitamin deficiencies can also be an indicator of orthorexic behaviour as these can suggest that someone is cutting out whole food groups. For example, if someone is cutting out dairy products, they may become deficient in calcium. 
Marian agrees that there have been adverse physical side effects during her battle with orthorexia. She says: “Losing weight was the catalyst for my orthorexia probably because, in a fatphobic society, a slim body equates to health and desirability.
“Perceived or real weight gain does trigger my orthorexia but I feel that it has merged into something beyond merely weight loss. Fixating on routine for diet and exercise is about control – and a different kind than just losing weight as the end goal, which is the root of anorexia.” 
She adds, “For nearly a decade, I have been officially underweight – had a highly irregular period. As well as experiencing a persistent state of feeling painfully cold, my nails are brittle and my skin isn’t clear.”
Besides physical effects, orthorexia can also have an impact on one’s mental health and their relationships with others. Fleming notes that those with orthorexia can be quite “critical” of other people’s food choices and eating habits. This “can cause a lot of tension in relationships and ruin some of those relationships,” she says. Zara, 24, notes that her orthorexia in school and Sixth Form led her to “borderline judging other people for making ‘unhealthy’ food choices”. 
McGregor also recognises that orthorexia can be very isolating. “Any sort of disordered eating will 100% cause more social isolation, and the more socially isolated we are – as we know from Covid – the more dominant negative thoughts become.” She adds, “What people don’t realise is that the most important thing for our well-being as humans is social connection. And a lot of social connection revolves around sitting around and eating and drinking.”
For George, the mental health effects were severe. “I felt horrendous and eventually suicidal as I constantly chased a feeling of worthiness,” he says.
As with most eating disorders, the first step in treatment for orthorexia is acknowledging the disorder and the negative effects it is having. Given that those who have orthorexia aim to keep their body “as healthy as possible”, recognising the detrimental impact of their behaviours can be particularly difficult.
Fleming states that there is currently no guidance on treatment due to the relative newness of the condition. However, she states that “psychological work” such as therapy is likely needed for treatment to figure out the root cause of the person’s disordered eating. 
McGregor also supports the use of therapy to identify the “purpose” behind a patient’s behaviour. “When you can help someone to understand [their purpose], then you can start working around the psychology of where it’s coming from and work through how you help someone with that. 
“At the same time, you will look at their food beliefs and their food rules, and you’ll start to give them ways of trying to challenge their food habits.” For example, she states that “a lot of people with orthorexia will absolutely need to weigh everything” and so a first step for them would be to start having the same breakfast – but without weighing it.
For Marian, getting treatment for orthorexia has been an arduous process – she remains on a long waiting list for therapy.
She says, “No medical professional ever instigated further support for my orthorexia. Once I had graduated, I tried to obtain this myself. Now, I have been on an NHS waiting list for eating disorder therapy for nearly a year.”
In terms of prevention, Fleming says it’s similar to that of other more recognized eating disorders.
“It’s just having kind of more normal conversations around food, not villainising any food groups or food types, and working on eating everything in moderation,” she says.
“I think we just need to make sure that as a family, as an education system and as a society, we are normalising all food groups in moderation, rather than the extreme diets that people with orthorexia are choosing.”
Marian thinks that “professionals and loved ones should look out for an obsessive, restrictive approach to diet and fitness, specifically in the demographic of high-achieving young women”.
If you think you may struggle with disordered eating or have been affected by the contents of this article you can contact BEAT’s helpline for support here.
*Names have been changed