Orthorexia: Proposed Formal Criteria

Although the concept of orthorexia nervosa has been the subject of a great deal of media attention and is in wide use by eating disorder professionals, it has never been given a satisfactory formal definition. This omission has now been remedied in a newly published article in the journal Eating Behaviors I coauthored with Thom Dunn, Ph.D.

These criteria are intended as a starting point; we anticipate that they will be refined and modified over time. In particular, the references to weight loss remain provisional, pending research into the evolving relationship between orthorexia and anorexia.

Proposed Diagnostic Criteria for Orthorexia Nervosa:

Criterion A. Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue, but this is conceptualized as an aspect of ideal health rather than as the primary goal.  As evidenced by the following:

  1. Compulsive behavior and/or mental preoccupation regarding affirmative and             restrictive dietary practices* believed by the individual to promote optimum health.**
  2. 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. 
  3. 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.

*Dietary practices may include use of concentrated “food supplements.”

**Exercise performance and/or fit body image may be regarded as an aspect or indicator of health.

Criterion B. The compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:

  1. Malnutrition, severe weight loss or other medical complications from restricted diet
  2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviors about healthy diet.
  3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior

 

In addition to these criteria, the published article also includes the following paragraph:

Other traits are commonly associated with ON in the literature. While the authors feel that these are not essential to making the diagnosis, they may help confirm it. These include obsessive focus on food choice, planning, purchase, preparation, and consumption; food regarded primarily as source of health rather than pleasure; distress or disgust when in proximity to prohibited foods; exaggerated faith that inclusion or elimination of particular kinds of food can prevent or cure disease or affect daily well-being; periodic shifts in dietary beliefs while other processes persist unchanged; moral judgment of others based on dietary choices; body image distortion around sense of physical “impurity” rather than weight; persistent belief that dietary practices are health-promoting despite evidence of malnutrition.

Cite as: Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17.

17 thoughts on “Orthorexia: Proposed Formal Criteria

  1. Hi Dr. Steven,

    Your description of orthorexia fits my boyfriend to a tee. He most often avoids carbs and sugars. Very small amounts of carbs a day, less than 20g. He was about 235 lbs at his heaviest and wanted to get in shape for a career in law enforcement. It started in March 2016 with a ketogenic lifestyle focusing on fats and proteins and limiting carb intake. After a few months, it developed into something more serious. He would go to the gym 6 days a week with cardio and weightlifting. He would track calorie intake on a fitness app. Then he started weighing his food on a food scale, and refused to eat anything that wasn’t meal prepped. The worst instance was in September 2016 while attending a friend’s wedding, he brought a cooler of his own food items to eat instead of the meal prepared. He ate it in the car and left the reception early due to irritability. Since then, he has admitted to having a problem, an eating disorder. He meets with a dietician, but does not follow her advice. Most meals consist of grilled chicken or pork loin, raw broccoli, celery and bell peppers. He is not willing to get therapy. I am struggling to help him and would be interested in any advice you could offer. Thank you

  2. I think I am the poster child for this. I am 5’6″ and weigh 102. Very few foods I can eat. I’m a dance teacher. What can be done for this. I KNOW I need to eat more, but I love the feeling of being hungry.

  3. As someone who has recovered from an Ed 25 years ago, and then relapsed 10 years ago becausexI got suckered into the clean eating movement, I can say that it is important at least for me to practice health at every size which includes intuitive eating.
    We are in info overload and in a society which is full of fear mongering by media about everything it is no wonder we are not all insane about food or any issue really.
    It takes a lot of awareness to see where our thinking is skewed and addictive.
    It is understandable to want to find a magic bullet to fix our ills. But there is no diet or anything that will save us from just being human and dealing with life as it is, said for becoming more conscious and compassionate.

  4. I’ve read your whole article about these proposed diagnostic criteria but I have a question. Isn’t there any time limit? How long must de symptoms occure to actually speak of a disorder, is it 1 week or 2 weeks? Or maybe a month? I know that you’ve said before that the obsessive thoughts en compulsive behaviour has to take place for about 3 hours of the day, but I am interested in for how long this must occure.

    1. As the criteria describe a process of escalation, this implies a period of several months or years. But there is no exact time period in the proposed criteria

  5. I suppose the fact that there’s a term isn’t the problem, but more-so the use of the term by people to cast some sort of shame upon those who don’t want to eat like crap.

    Why do you all (society) care so much about people who adhere to exercise routines and strive to eat healthy? Are you mentally retarded?

  6. This is my mother. Even at 40 she still imposes her ideologies of the evils of certain foods on me. A common comment heard from her is “I can’t have that”. Thank you for giving it a name, it will help me heal my unhealthy relationship with food.

  7. This scares me, for a long time I have known a friend who I believed used her experiences as a teenage bulimic to get her attention in later life. Now this article reads like her to a tee. However what worries me most is she has a child who has recently been diagnosed with a syndrome. Suddenly my friend sees this as an opportunity to ban everything she considers unhealthy from their diet. She is obsessed with clean eating, all dairy products are banned, all sugars are banned to name a few. She excercises everyday and gets distressed if she can’t. She is doing courses on food, she plans her food obsessively worrying about fat content etc. Nobody questions her because she appears to know everything related to food, she is constantly giving her advice about how to clean eat and eat healthily yet will attend an excercise class and suddenly feel faint because she hasn’t eaten that day…cue lots of panic around her. She claims her daughter is allergic to milk (her husband told me it is so trace its barely noticeable) she has an ulcer so she cannot eat any fats. She has already eaten, we were once at a bbq and she left as the food was served to go home and do a bit of work, then came back when we had eaten claiming she had something at home. She is obsessed with her looks claiming she stays thin because her husband only compliments her when she is at her thinnest (not true) I have realised if she is not cooking it, or knows the cafe she is going to so she knows the menu she wil not eat out. Yet she constantly talks about drinking coffee, eating peanut butter and going out for cake? But what scares me most is she is solely in charge of what her daughter eats. No one dare say anything as she plays the victim so well.

  8. Read this with great interest; am acquainted with some of your other writings so knew that this would be where I could find good information.
    I belong to a thriving online diet support group and have noticed that some are very preoccupied with following the most restrictive part of the plan, which does not require adhering absolutely to those parts but allows a fair amount of flexibility. I read one posting today where that poster seemed terrified of going beyond those restrictions for fear of overeating if she didn’t. Some are all preoccupied with the “rules”. Black and white thinking? Seems like this would fall into that overlapping area described above.
    You know how much conflict there is out there about supposedly scientific dietary advice. My fear of getting any sicker (type 2 diabetes with neuropathy and very stubborn high blood pressure that improved very little with a 50 lb weight loss) had led me to a very low fat plan supposedly based on many years of peer reviewed research. Due to other research I decided to include a whole egg in my breakfast, only to realize that I was very close to a full-blown anxiety attack (which I get very rarely) over the damned egg yolk. Sat down next to two books I have by Dr-35-yrs-of-research and contemplated what he would probably say–relax and eat it but don’t eat another one tomorrow–based on the most current version of his plan. LOTS of anxiety out there about not following the trusted plans of those we consider wiser than us while not trusting ourselves. So, I made myself relax and ate the eggs but tomorrow is another day.

  9. This diagnosis fits my best friend to a T. I’m not sure how to approach her with this information without her; A. Denying, B.not getting the help she needs. She hasn’t had a period in two years. She’s 33. Her doctor told her she “isn’t TOO thin” . When I meet her she was healthy and about 136 lbs. She now weighs 103 and is a self clarified Vegan. She obsesses about anything that she ingests. Is obsessed with buying vegan cookbooks (what a joke) and cataloging each and every ingredient into a caloric/carb/protein/fat category. She works out six days a week. Always has a comment or recites an article about how horrible it is to eat meat, dairy and fish. The world would be a better place if we all followed her way.

    1. Mary,

      The aspects of this post that involve being judgmental of veganism are not helpful. There are a great many vegans who don’t have orthorexia. It may seem to be a peculiar lifestyle choice, but the same is true of many lifestyle choices to those who don’t share in them. Veganism itself is neutral; it’s something people get involved with for a number of valid reasons, including environmental concerns, ethical concerns, or health beliefs. (And, yes, there is actually tasty vegan food!) Your friend is vegan, and you are not, and while that may be a source of conflict, it’s not (in itself) a pathology.

      However, veganism can also be a cover for, a gateway to an eating disorder. See this article: http://www.theveganrd.com/2015/12/vegan-diets-and-orthorexia-how-should-activists-respond.html

      So, try to set your judgments aside! If your friend has an eating disorder, the best approach is to educate yourself on eating disorders, and then, with that knowledge, try to gauge how to best approach her.

    2. You have described my daughter……they can recover from what I’ve heard, but it is quite distressing to see this happening right in front of you. I’m so tired of the snide remarks about so-called unhealthy food…. Orthorexia is a serious illness…

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