Can healthy eating actually become unhealthy? It’s a question many of us probably haven’t spent a day, let alone 5 minutes, thinking about because it sounds so counterintuitive. Since the 2000s, researchers have been interested in orthorexia nervosa (ON) — an eating disorder characterized by the obsession of healthy eating to the point where one’s day is consumed by worrying about the purity of foods with the goal to maximize health. Rather than simply eating a balanced diet, the premise of ON is founded on deeper social-cultural and psychological factors. The symptoms include pursuing idealized body images propagated by Western beauty standards and social environment, disordered eating, perfectionism, anxiety, and feelings of moral superiority for eating pure foods coupled with guilt for breaking ritualized “food rules” [1,2]. In addition, ON can lead to consequences that are biological in nature such as nutritional deficiencies, medical complications, and poor quality of life [3].
The original concept of ON is universally attributed to Dr. Steven Bratman (MD), who explains how he overcame his long-standing obsession with eating pure and healthy foods in his article, the “Health Food Junkie” (1997) [4]. Soon thereafter, the term “orthorexia”, originating from orthos meaning correct and orexis meaing appetite, began to spread rapidly within health-related websites and eventually was taken up as an area of research by predominantly European scholars [1]. Dr. Lorenzo M. Donini (MD/PHD), one of the forefront leaders in ON clinical studies, developed the current “gold standard” diagnostic tool for ON called ORTO-15: a self-report questionnaire which asks patients to answer questions about common ON symptoms on a scale of “always to never” [1]. Some of the questions include: “In the last three months, did the thought of food worry you?”, “Do you think that the conviction to eat only healthy foods increases self-esteem?”, and “Do you think that eating healthy foods changes your lifestyle (frequency of eating out, friends, …)?” [5].
At first, there was a lot of backlash against orthorexia, and it was called “a made-up word” used to “shame those trying to achieve a healthy lifestyle.” However, the presence of ON in social media began to expand in 2014, when popular Instagrammer and blogger Jordan Younger (known as “The Blonde Vegan”) revealed that she was orthorexic [1]. The #orthorexia community on Instagram, although relatively small (186K), is important to note because this community gives people who struggle with ON to have a safe, shared space to talk about ON, learn from/support one another, and keep each other accountable on recovery efforts. One interviewee in a Valente et al. study stated, “As a society, this is not something we talk about or are aware of, so when I am able to read [ON-related content] I realize I am not the only one that feels that way” [6].
However, social media can also play a heavy hand in forming body image insecurities and causing disordered eating patterns. This finding was supported by a study that discovered a positive correlation between Instagram usage and prevalence of ON [7]. It is important, though, to distinguish the two kinds of users that account for opposite outcomes of Instagram usage. Users willing to recover from ON have feeds filled with inspirational ON content, whereas users who are sucked into the toxicity of society’s standards have feeds filled with dangerously influential and healthy eating “celebrities” [7].
The novelty of ON in research explains why there is still not much consensus on whether this disease is a new, separate disorder, or just a variant of already established ones. Currently, it is not officially recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [2]. Therefore, to gain a better understanding of ON, a new diagnostic tool needs to be developed to replace ORTO-15. Initially created for an Italian population, the translation of diagnostic questions to English is poor, leading to unreliable results [1]. ORTO-15 is also unable to effectively distinguish between healthy eating and pathological eating, as the assessed prevalence was at 6% while actual studies’ reports found a prevalence closer to 50% [5]. Currently, the Orthorexia Nervosa Task Force is in the process of developing a better version of ORTO-15 called ORTO-R, which addresses the limitations mentioned above along with a few others. In general, additional studies should diversify their target population outside of Europeans and broaden the age group of focus to young adults, where ON seems to be the most prevalent.
As social media plays an influential role in decreased body image satisfaction and higher prevalence of ON, large social media companies should focus on better management, restructuring, and accountability. One possible method includes removing ON-sensitive content and replacing it with resources to help those struggling to recover. Although it is unreasonable to take down celebrities’ posts that might act as an inspiration for healthy lifestyles, social companies should regulate posts that get the most traction and reduce how often it pops up on recommended feeds. As socially-aware messaging is an important factor to stop misinformation from spreading, which is terrifyingly easy to do on social media, social media companies should make a greater effort to push for messages that remind its users that not everything seen on social media is realistic. Hopefully, through these methods and the spread of more awareness, the prevalence of ON can be reduced in future generations.
References:
Hanganu-Bresch, C. (2019). Orthorexia: Eating right in the context of healthism. Medical Humanities, 46 (3), 311-322. https://doi.org/10.1136/medhum-2019-011681
Cheshire, A., Berry, M., & Fixsen, A. (2020). What are the key features of orthorexia nervosa and influences on its development? A qualitative investigation. Appetite, 155, 104798. https://doi.org/10.1016/j.appet.2020.104798
Koven, N., & Abry, A. (2015). The clinical basis of orthorexia nervosa: Emerging perspectives. Neuropsychiatric Disease and Treatment, 11, 385–394. https://doi.org/10.2147/ndt.s61665
Bratman, S. (1997). Health Food Junkie: Obsession with dietary perfection can sometimes do more harm than good, says one who has been there. Health Food Junkie--Orthorexia Nervosa, the new eating disorder. Retrieved November 30, 2021, from https://www.beyondveg.com/bratman-s/hfj/hf-junkie-1a.shtml.
Rogoza, R., & Donini, L. M. (2020). Introducing Orto-R: A revision of Orto-15. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 26(3), 887–895. https://doi.org/10.1007/s40519-020-00924-5
Valente, M., Renckens, S., Bunders-Aelen, J., & Syurina, E. V. (2021). The #orthorexia community on Instagram. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. https://doi.org/10.1007/s40519-021-01157-w
Turner, P. G., & Lefevre, C. E. (2017). Instagram use is linked to increased symptoms of orthorexia nervosa. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 22 (2), 277-284. https://doi.org/10.1007/s40519-017-0364-2
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