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The evolution of eating disorders

Diet Mental health
Meet the orthorexics: smart, health-conscious professionals eating themselves ill. Alex Turnbull reports

The post-Christmas period is boom time for healthy habits. Gym memberships spike, dry January empties pubs, and the contents of fridges are warily assessed.

A minority will stick to their regime, and we should applaud them. But for a minority of this minority, healthy living can become an unhealthy obsession. This is the world of orthorexia.

The condition, so-named in 19971 by US doctor Steven Bratman, is a pathological obsession with ‘healthy eating’, which sees sufferers cut out any food that they consider damaging to their health. While this might sound harmless and even desirable, the consequences can be dire when taken too far.

‘Most often, orthorexia merely creates psychological distress and impairs various life dimensions,’ says Dr Bratman. ‘However, emaciation is common among followers of certain diet plans, such as raw foodism, and this can at times reach the extremes seen in anorexia nervosa.’

The condition is a cocktail of both mental and physical risks. Orthorexia can lead to people cutting whole food groups out of their diet, which has led to reports of otherwise healthy patients presenting with malnutrition. Additionally, if the sufferer accidentally consumes a food they consider unhealthy, it can provoke extreme feelings of anxiety and disturbance, which causes huge levels of stress. In extreme situations, the consequences of orthorexia can be fatal.

‘I tried doing a one or two-day fast and then a few days of raw foods. It didn’t cure my problems but I felt better. Eating in this way brought about a light, euphoric feeling, and I felt clearer,’ wrote Kate Finn, a massage therapist in California who documented her experience of orthorexia, and later died of orthorexia-induced starvation that led to heart failure.

A primary care nurse is unlikely to see a patient refer to him or herself as having orthorexia, but it is important to be aware that a patient who enthusiastically takes up a new diet may display the symptoms. While anorexia is a well-known, widely publicised condition, the knowledge surrounding orthorexia is murkier.

Many patients will consider themselves to be healthy and doing the right thing, without realising they are slipping into a potentially dangerous cycle. As orthorexia is a fixation on being healthy, manifested through a new diet with behaviour classically deemed positive in health terms, many patients displaying orthorexic behaviour patterns may not recognise they are be harming themselves.

‘Nurses must have the wisdom and knowledge to discern between a diet that is healthy and a state where it dominates the patient’s eating, and the extent to which their feelings are affected by their choices when eating,’ says Deanne Jade, the founder of the National Centre for Eating Disorders.

Evidence suggests that certain groups are particularly vulnerable to developing the condition, and they are very different to the stereotype of the troubled teenage girl with anorexia. The new face of eating disorders is more likely to be the same confident professional never missing a gym session, logging their runs on social media or shunning the carbs at dinner.

A review of 11 studies on the condition2 in the US found that while 6.9% of the general population displayed orthorexic tendencies, this figure rose to 35% in healthcare professionals, and to 57.8% for people working in the arts. Other risk factors include high socioeconomic status, obsessive compulsive traits and history of other problematic behaviour
with food.

While there is no data on the condition for the UK, Ms Jade said that she encounters orthorexic behavior ‘all the time’ and not just in patients she sees as part of her work, but in friends and acquaintances as well.

She says that ‘huge numbers of people’ in the UK are walking around showing patterns of orthorexic behaviour, and that many people are ‘cutting out foods without any scientific basis’ but more an ‘emotional bias against certain food groups’.

‘Many professionals who have experienced working with patients with eating disorders would call othorexia “an escape from anorexia”,’ says Ms Jade. ‘People with orthorexia have very similar character traits to those displaying anorexia, but they cannot just starve in the way that people with anorexia do.’

‘There is a view that it may be more closely connected to OCD due to the nature of the illness, although it does also have similarities with anorexia nervosa,’ says a spokesperson for Beat, a charity for people experiencing eating disorders.

It turns out that it’s not such a massive jump from the obsessive food measuring of anorexia, to the rituals of the orthorexia. ‘People develop rules about how much to eat, the timing and location of eating meals, avoiding specific foods due to misguided beliefs on what they perceive as healthy. It’s a behaviour that can have insidious and far-reaching effects beyond the physical,’ says Emer Delaney, a specialist dietitian and spokesperson for the British Association of Dieticians.

‘What starts as a genuine intention to become healthier, develops into a diet that becomes so restrictive in both calories and variety, that health suffers [due to the small amount of nutritional value in many foods considered healthy.] People slowly begin to eliminate entire food groups such as dairy, grains and meat and food choices become extremely limited.’

While there is no concrete evidence surrounding how and why orthorexia has developed, the condition seems to have mirrored the rise of both social media and the new breed of cult diets. With a flurry of platforms such as Instagram and Twitter, idealised bodies are quickly becoming the latest status symbol. The link between self-image and eating disorders is well-known but some have suggested that the focus is switching from a thin body, to an athletic body. Celebrity body transformations – whether it’s an actor bulking up for an action movie, or a reality TV star exhaustively and lucratively sharing pictures of her bikini body – are catnip for the media, and emulated by fans. Ms Jade cited astheticism and perfectionism as common character traits in people who display signs of orthorexia.

‘The increasing emphasis on body muscle and tone over and above size and shape may well be affecting incidence of orthorexia, along with more imagery available on social media and the increase in marketed products for “fit” bodies,’ says the Beat spokesperson.

Another possible trigger is the rise of novel diets that call for cutting out entire food groups, often with little or no scientific basis. Experts see these as often going beyond the pale(o). ‘The behaviour is very personal. It has nothing to do with science [the decision to cut out certain food groups],’ says Ms Jade. ‘People who display this type of behaviour often get confirmation of their bias against foods from the media.’

The challenge for the health professional is to identify a condition with potentially few external symptoms which has yet to be fully understood.

The condition is currently thought of as an Other Specified Feeding and Eating Disorder, a term used to describe conditions that do not yet have agreed clinical definition, but differ from anorexia and bulimia. This is why there are no reliable figures on the number of people with the condition, as it currently cannot be diagnosed. However, recently, the first criteria for diagnosis of the condition were proposed in the journal Eating Behaviors.3 These are:

Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices believed by the individual to promote optimum health.

Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.

Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe ‘cleanses’ (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy food.

Ms Delaney says that it is essential for nurses and other clinicians to discourage foods from being labeled as good’ or bad, ‘as this can help eliminate any guilt associated with “treat” foods, allowing room for their inclusion as part of a healthy, balanced diet’.

Ms Jade also said it was important to be aware that many people falsely consider themselves to be allergic to products such as dairy and wheat, and that any adverse reactions they’ve experienced when eating these products could be a psychosomatic reaction. ‘If someone is highly conscious about what they eat, some of the symptoms they’ll experience are a result of this anxiety. If someone thinks that they are allergic to something, there is only one way to find that out. That is by seeing someone medically trained who can figure out whether that is or is not the case.’

But how can a clinician discern between a patient who has a new focus on eating healthily and someone who may have orthorexia? According to Beat, research has identified orthorexia as ‘being more than just an obsession with healthy eating; it extends to the person having a specific attitude to food, preparing food in a certain way, deeming certain foods harmful and avoiding them, and placing more importance on the quality of foods consumed than key areas of their lives such as their career and relationships’.

In these times of rising obesity, it is a vital part of a nurse’s job to explain to patients how healthy eating could save their life. But as the healthy eating message becomes prevalent, it also risks becoming distorted, with some patients swinging to the other extreme. When a patient claims they’re eating clean they may be hiding a dirty little secret.

Other Specified Feeding and Eating Disorders (OSFED)
OSFED is the term used to describe eating disorders which do not fall in line with the clinical parameters of a diagnosis of anorexia or bulimia. According to Beat, approximately half of all eating disorders diagnosed in the UK in 2013 were classified as OSFEDs.4 Some examples of these conditions include:
  • Atypical anorexia nervosa: This is where anorexic behaviour is observed, but the patient’s weight is not below normal.
  • Atypical bulimia nervosa: When symptoms of bulimia are shown, but the behaviour associated with the condition is less frequent.
  • Atypical binge-eating disorder: Where patients feel compelled to eat large quantities but not as regularly as those with a fully-fledged binge eating disorder.
  • Purging disorder: Patients will use laxatives, diuretics, or enemas to control weight or shape.
  • Night eating syndrome: The patient feels the need to eat large quantities of food at nighttime.


1. Original orthorexia essay. Bratman S. 1997.

2. Evidence and gaps in the literature on orthorexia nervosa. Dukay-Szabo S et al. 2013.

3. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Bratman S et al. 2016.

4. Beat. Types of eating disorder.