Orthorexia: what it is, signs, risks and how to get help

The term orthorexia nervosa comes from the Greek words for proper and appetite and was proposed by Steven Bratman in 1997. The British Dietetic Association (BDA) describes it as a pathological fixation on healthy eating, aptly dubbed a disease disguised as a virtue. People with orthorexia develop an unhealthy fixation on eating pure or clean foods.

Paying attention to what you eat is not a problem in itself. The BDA says it is when this becomes entangled with rigid, obsessive thinking, compulsive and ritualistic behaviour and self-punishment that there are red flags. The difference is between choice and compulsion: for most people healthy eating is flexible, whereas in orthorexia there is little or no room for flexibility.

It is not recognised as a separate diagnosis in the main classification systems, so you will not usually be given the label by a doctor. In practice a clinician is likely to look at the eating behaviour and its effects on health. The NHS describes other specified feeding or eating disorder (OSFED) as a category used when someone's symptoms do not exactly fit the expected symptoms of a specific eating disorder.

There is no validated official list, but the BDA article draws together common themes: worry and preoccupation about eating impure or unhealthy foods and their effect on the body, spending excessive time thinking, researching, writing or talking about food, excessive time preparing or acquiring food, which can lead to financial difficulties, inflexibility or intolerance towards other people's diets and beliefs, and guilt and shame when food perceived as unhealthy is eaten.

• Rigid rules about which foods are allowed, with whole categories removed because they are processed, unnatural or impure.

• Time spent researching and planning meals that interferes with work, study or social life.

• Avoiding eating with other people or at restaurants.

• A feeling of superiority over people who eat differently, or judgement of their food choices.

• Intense guilt or compensatory behaviour after breaking a self-imposed rule.

• A belief, described by the BDA as magical thinking, that a strict diet can cure anything from vague unease to allergies or cancer.

The BDA says treatment of orthorexia typically requires a multidisciplinary team that includes some combination of psychiatrists, psychologists, GPs and dietitians. The dietitian's role is to work with the person to reduce food fears and help create eating patterns that feel good and provide adequate nutrition, and incorporating mindfulness and intuitive eating principles can be especially helpful, alongside motivational interviewing to look at the cost of restrictive behaviour on the person's values and life.

The BDA also cautions that if a dietitian misinterprets anxiety about eating as enthusiasm for healthy eating, nutrition education can contribute to unhealthy obsessions and fears. A person with these concerns should say plainly how food rules are affecting them, rather than asking for a stricter plan.

The BDA says that these behaviours can lead to malnutrition because of the imbalance of the diet and to difficulties with education, socialising or work. Paradoxically, they are often at the expense of the person's overall mental and physical wellbeing, including their nutritional status.

Because the bar is always moving, people may feel it is their own fault for not adhering strictly enough, and then try again while becoming more restricted. Weight loss can occur, although it is not the aim.

The NHS lists physical signs of eating disorders in general that apply here too: feeling cold, tired or dizzy, a racing heart or fainting, problems with digestion, and a weight that is very low for age and height.

It is debated whether orthorexia is a unique disorder or a precursor to, or variant of, anorexia or obsessive-compulsive disorder (OCD), the BDA says. Anorexia and orthorexia share preoccupation with food, restrictive eating, rituals and anxiety, and both can provide a sense of control. People with orthorexia, anorexia and OCD all share rigid and perfectionistic traits.

A second BDA article says anorexia differs because people with it are preoccupied with body weight and shape, whereas people with orthorexia do not share that body dissatisfaction and instead manipulate the diet because of an obsessive compulsion to achieve the perfect healthy diet. It adds that those who present with orthorexia in eating disorder services are most commonly diagnosed with avoidant or restrictive food intake disorder (ARFID) rather than anorexia or bulimia, and that orthorexic behaviours can also be present alongside other eating disorders.

The BDA says prevalence has been found to be between less than 1% and 6.9% in the general population, though current screening tools are considered flawed. Higher prevalence, up to as much as 50%, has been suggested in groups including dietitians, nutrition, nursing and medical students, yoga instructors, exercise students and people working in the performing arts. A second BDA article reports that use of Instagram has been associated with increased reports of orthorexic behaviours in research, perhaps because of exposure to images that normalise behaviours that are not healthy.

Bratman is quoted by the BDA as saying the condition often begins innocently as a desire to overcome chronic illness or improve general health. Anyone with an illness for which they have been told diet might matter can be drawn into increasingly strict rules.

The NHS names factors that make eating disorders more likely in general, which may also be relevant here: a family history of eating disorders, depression or alcohol or drug misuse; being criticised for eating habits, body shape or weight; pressure to be slim from society or a job such as ballet dancing, modelling or athletics; anxiety, low self-esteem, an obsessive personality or perfectionism; and sexual abuse.

The NHS says that if you think you may have an eating disorder you should see a GP as soon as you can. The GP will ask about your eating habits and how you are feeling, check your overall health and weight, and may refer you to an eating disorder specialist or team of specialists. It can be very hard to admit to a problem, and bringing a friend or loved one with you may make it easier.

You can also talk in confidence to an adviser from the eating disorders charity Beat, which has a helpline and information. If you are worried about someone else, the NHS advises letting them know you are worried and encouraging them to see a GP, and offering to go along with them.

The NHS lists feeling cold, tired or dizzy, a racing heart, fainting or feeling faint, digestion problems and a weight that is very low or very high for someone’s age and height among the physical signs of eating disorders. If someone collapses or is very unwell, call 999 or go to A&E.

The BDA stresses that paying attention to a healthful diet is not inherently a problem. The BDA article distinguishes choice from compulsion: for most people healthy eating is flexible, whereas in orthorexia there is little or no room for flexibility, and food rules are enforced with guilt, anxiety or self-punishment.

The BDA warns that if a dietitian misinterprets anxiety about eating as enthusiasm for healthy eating, nutrition education can contribute to unhealthy obsessions and fears. So if you think this applies to you, tell the professional plainly how food rules are affecting your life, rather than asking for a stricter plan.

On the NHS the route is through a GP, who may refer you to an eating disorder specialist or team. The NHS says treatment depends on the type of eating disorder and usually includes talking therapy, and that for other specified feeding or eating disorder (OSFED) it depends on the type your symptoms are most like.

The BDA says treatment of orthorexia typically requires a multidisciplinary team including some combination of psychiatrists, psychologists, GPs and dietitians. Some people also choose a private psychologist or dietitian with eating disorder experience; whoever you see should understand that the aim is to loosen food rules rather than tighten them.