Disclaimer: The following article discusses themes of eating disorders.

Nutritional meal plans, consistent workout routines, and an avoidance of unhealthy foods. What do all of these factors have in common? Although they might originate as healthy habits, extreme versions of these practices can all be symptoms of a chronic eating disorder: orthorexia nervosa.

First described by Dr. Steven Bratman in 1996, orthorexia nervosa is characterized by a pathological fixation on eating proper food. Individuals with orthorexia nervosa often fixate on specific foods that they perceive as healthy—like proteins and leafy greens—and vehemently abstain from foods that they consider unhealthy—like carbohydrates and fast food. Over 57 million people regularly engage in orthorexic behavior.

But how do clinicians distinguish between health-conscious eaters and people struggling with a disorder? Orthorexia nervosa becomes dangerous not because an individual wants to eat healthy but because regular deviations from their meal plans can lead to immense emotional distress, anxiety, and shame. To help make this distinction, we can consider three aspects of an individual’s behavior: pursuit, penalization, and perception. While these three aspects have not been clinically proven, within the scope of this article, they serve as a simplified method to draw a clearer line between healthy, positive diet changes and destructive, negative fixations on body stereotypes and diet culture.

Above: Symbolic depiction of orthorexia nervosa. Image courtesy of News Medical Life Sciences.

Pursuit (relaxed vs. stringent)

One way to characterize disordered vs. non-disordered eating is by examining how an individual specifically pursues their focus on eating healthy foods. For example, individuals with a relaxed pursuit might maintain a diary for meal planning and calorie tracking information or follow doctor-advised portion sizes. On the other hand, individuals with a stringent pursuit might follow unreasonable calorie restrictions and goals, exercise excessively, or fixate on precise calorie counting—even for negligible amounts of calories. In orthorexia nervosa, “healthy habits” become maladaptive when the individual’s fixation on their goals begins to disrupt or harm other aspects of their daily lives.

Above: Obsessive calorie tracking. Image courtesy of Lark.

Penalization (understanding vs. harsh)

A second way to identify disordered eating is by considering how a person self-modulates their eating habits. Those struggling with eating disorders often exhibit rash, immediate emotional or physical reactions when they deviate from their intended food behavior.

Generally, when people catch themselves eating fast food or a carb-heavy meal without planning, they take one of two approaches: while some reflect on what led them to deviate from their goals, accept this as a natural part of life, and change the unhealthy motivation that led to this outcome, others might shame and penalize themselves using negative self-talk, self-harm, and isolation or make a sudden change in expectations (like eating twice the amount of protein the next day) to “compensate.” Most people with orthorexia would more often take the latter approach despite its obvious potential to further damage their health and self-image.

Above: Artistic depiction of the isolating nature of obsessive eating habits, bodily stereotypes, and diet culture across demographics. Image courtesy of NPR.

Perception (adaptive vs. maladaptive)

In orthorexia nervosa, a shift in perception from adaptive to maladaptive can drive the progress from eating habits to an eating disorder. For example, someone might fixate on macronutrients because their dietician suggested limiting a specific food group for health-related reasons, whereas another might fixate on macronutrients because they believe a decrease in carbohydrates is the only way to lose weight and gain their family’s acceptance. The latter is a maladaptive perception that could have harmful consequences—such as skipping social events at public restaurants with their family. Moreover, Instagram celebrities and cosmetic bloggers often provide eating tips and tricks on new, trendy diets. These forms of modern marketing are a major source of maladaptive perceptions that can perpetuate harmful eating practices.

Above: Depiction of social isolation and mental disorders as they pertain to family. Image courtesy of Stand Alone Charity.

Legitimizing Orthorexia Nervosa

Despite its prevalence, orthorexia nervosa is absent from the DSM-5, the standardized psychological guide and reference book for all psychological and mental disorders. Orthorexia nervosa has not received its own DSM-5-TR diagnosis because many clinicians think it is encapsulated by several other diagnoses, including anorexia nervosa and avoidant/restrictive food intake disorder. Currently, researchers have offered a limited scientific basis to justify an entire criteria and standardized description, definition, and treatment method being built around orthorexia. Formal acknowledgment by the American Psychological Association would help legitimize orthorexia nervosa as a distinct, legitimate disorder that warrants further research and help develop lasting treatment strategies.