Orthorexia and anorexia‘Perfectionism is a self-destructive and addictive belief system that fuels this primary thought: If I look perfect, and do everything perfectly, I can avoid or minimise the painful feelings of shame, judgement, and blame.’
BRENE BROWN
The pursuit of healthy eating is always seen as a good thing. But what happens when it gets taken too far?
Orthorexia nervosa is an obsession with healthy eating that’s taken to the point where it is psychologically, socially and even physically damaging. It is still relatively unknown and misunderstood, but that’s gradually starting to change. One of the biggest misconceptions about orthorexia is that it is simply a case of trying to be healthier, and what’s wrong with that? Hopefully by the end of this chapter you’ll understand why this condition is so much more than that, and why it’s of growing concern.
The term ‘orthorexia’ is derived from the Greek ‘ortho’ (‘correct’) and ‘orexis’ (appetite). It was coined by the American physician Steven Bratman back in 1997 in response to a growing obsession with healthy eating that he noticed, particularly among yogis. Orthorexia is unusual in this respect, as the term first appeared outside scientific journals, and only gradually gained credibility among health professionals and scientists over time.
Orthorexia is characterised by an obsessive focus on healthy eating, food anxieties and non-medical dietary restrictions. It is not officially recognised as an eating disorder, but it has all the attributes of one.
The symptoms of orthorexia include making healthier food choices such as eating more fruits and vegetables, eating fewer refined white grains, and shopping in health food stores. It is also associated with other positive lifestyle habits such as exercise, not smoking and not binge-drinking. Individuals with orthorexia are also likely to share details about their way of eating and recommend it to friends and family.68 This is one of the important differences between orthorexia and other eating disorders. One key characteristic of most eating disorders is that they are secretive and drive individuals to hide their thoughts and behaviours around food from the world. In orthorexia, the opposite seems to be true, and people are happy to be loud and proud about their dietary choices.
So far, all of these symptoms sound quite positive. But orthorexia is also associated with significant dietary restrictions, malnutrition and social isolation.
Currently, orthorexia does not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM)*, as official diagnostic criteria are still being established and we still need more research to convince enough people that this is a real, distinct condition that deserves to be in the DSM.
The proposed diagnostic criteria for orthorexia include obsessive focus on healthy eating, food anxiety and dietary restrictions, with these behaviours causing clinical impairments.69,70
The primary criterion for orthorexia is an obsession with healthy eating or following a rigid dietary pattern in the pursuit of health. This can include the following ideas:
• Removal and avoidance of foods deemed to be ‘unhealthy’. Dietary restrictions can be sudden, but usually escalate over time. Starts with elimination of specific foods, then entire food groups, and may lead to the point where someone is relying on ‘cleanses’ or fasts to ‘purify’ the body. These foods are removed without medical reason such as a diagnosed allergy or intolerance, and are not based on the instruction of a trained medical professional. Situations such as following a low FODMAP diet for IBS (under the guidance of a dietitian) or removing gluten from the diet following testing positive for coeliac disease would not fall under this, nor would removing pork from the diet for religious reasons.
• Worry about eating foods that are deemed ‘unclean’ or ‘unhealthy’, including worry about how this may affect the person’s physical and mental health. In particular, worrying about increasing risk of disease, exacerbating disease, feeling ‘dirty’ or producing negative physical symptoms.
• Spending excessive amounts of time seeking out specific foods that are deemed ‘safe’, reading about food and health, and preparing these foods, including spending time weighing out exact quantities of foods allowed. Also spending a large amount of money on these foods, which can include things like superfood powders or organic/biodynamic food.
• Feelings of guilt, shame and anxiety after consuming ‘unclean’ or ‘unhealthy foods’, often producing severe distress, and often with compensatory behaviours afterwards. For example, if someone eats a food they deem to be ‘unhealthy’ (accidently or deliberately), they may compensate by being more restrictive the next day, perhaps by doing a juice cleanse or cutting out another food.
• Intolerance of others’ food beliefs, and a firm belief that their way is the best and only way to eat for health. The only exception to this might be someone who is following a similar dietary pattern, only slightly more restrictive. For example, someone who is mostly raw vegan might see someone who is 100 per cent raw vegan as even healthier and look up to their eating habits.
The second main criterion is that these preoccupations and obsessive ideas around food impair the person’s health in some way. This is important, as it differentiates between someone passionately pursuing a healthier lifestyle and it becoming a clinical obsession. There is a scale ranging from disordered eating to fully clinical anorexia nervosa, and the same applies to orthorexia: there is a scale from simply picking up some obsessive ideas about food and having mild orthorexic tendencies to having more severe, clinical orthorexia. Diagnosis does require a cut-off somewhere on that scale.
In the case of orthorexia, these obsessions are clinical when the person’s physical health or mental health suffers. Physical health can be affected because of nutritional deficiencies that can occur due to eating an unbalanced, restrictive diet, or unintended weight loss, again as a result of severe restriction of food groups. In orthorexia, weight loss is not deemed to be the primary goal, whereas pursuing health is. It can also be disruptive to someone’s social life, affect academic or work performance as a result of the time spent thinking about food as well as potentially avoiding work situations involving food, and cause mental distress. This can especially be the case if body image and self-worth is mostly or totally dependent on compliance with what the person defines as ‘healthy’ eating behaviour. For me, one of the easiest ways to spot if someone has orthorexic tendencies or issues with food is by asking them how they would feel if their friends spontaneously asked them to go out for pizza tonight. If making this decision sparks anxiety, or a long and drawn-out thought process as to whether it’s a good idea (ignoring any financial issues) and whether they can allow themselves to go, then their relationship with food isn’t healthy.
Other traits that aren’t considered to be essential to making a diagnosis but can also be helpful to identify can include obsessively focusing on planning food choices, buying food, preparing food and eating it. I’ve seen orthorexic clients who spend hours in a supermarket, obsessively checking the label on every single food item before discarding it. Food is often seen primarily as a source of health rather than a source of pleasure, and being near forbidden foods can be distressing, including watching others eat them. Body dissatisfaction doesn’t tend to be centred around weight, but instead is focused on looking ‘healthy’ and ‘well’. Even if their way of eating ends up leading to deficiencies and malnutrition, there is still a reluctance to give up this way of eating, instead focusing on what to eliminate next.
Orthorexia is still quite new and unknown, and so I want to offer some examples of how it can manifest. Hopefully this will help increase your understanding of how it presents and how it differs from other eating disorders.
Client A was an overachiever who had a bit of a health scare and turned to Dr Google. They decided to cut out animal products from their diet, then when that didn’t feel like enough they also removed gluten and ‘refined sugar’. Over time this led to a fear of processed foods, so everything had to be made from scratch at home, including foods like hummus. They started doing the occasional juice cleanse to rid their body of any ‘toxins’ that might be contributing to their health. After a year of this they ended up in a situation where they had some vitamin deficiencies and severe anxiety about eating food that they hadn’t prepared themselves, which meant they couldn’t go out and enjoy a meal with friends, and their social life suffered. Their weight hadn’t really changed significantly – the same clothes still fit – but they were miserable and so confused about what to eat.
Client B had a history of low self-esteem and poor body image, including being teased as a child. They joined a gym in order to fit more with the ideal body type, and decided to reduce their carbohydrate intake in order to speed up their progress. This was successful in the short term but then every time they went out and had a beer or ate a pizza with friends, they would feel bloated and wouldn’t be able to perform well at the gym the next day. Worried that this was hindering their progress, they decided to stop drinking, track their carbohydrate intake, and consume protein powders. They also stopped going out with friends. The result was some intentional weight gain, low mood, and anxiety around eating too many carbohydrates and not enough protein. Despite all this, their parents still commented that they looked ‘weird and tired’ the next time they saw them, which left them confused and disheartened that their routine wasn’t working.
When client C’s mother died of cancer, they became incredibly worried about whether they would end up getting it too. They started reading everything they could find about cancer, and were horrified at all the things they were told could cause it. Gradually, they started cutting out various foods, started scanning every food item for the ingredients list, and established food rules such as making sure to eat 10 different vegetables every day, with only one portion of each allowed to avoid repetition. All packaged foods were off limits, and they ended up with unintentional weight loss, vitamin deficiencies, and huge amounts of anxiety about eating anything that wasn’t a vegetable, bean or pulse.
As you can see, in all three of these cases weight was not the focus, but health and avoiding disease was a common theme, as was anxiety. In this way, orthorexia can take up too much mind space with food and health, to the detriment of mental health and a social life.
Orthorexia and anorexiaThe term ‘orthorexia’ was deliberately intended to have parallels with anorexia. The two definitely have some similarities. Anorexia and orthorexia share characteristics such as perfectionism, anxiety, a need for control, and self-discipline. Both also share the negative feelings of guilt and anxiety when deviating from the set food ‘rules’. However, while people with anorexia are preoccupied with the quantity of food, those with orthorexia are more concerned with the quality of food. The result of this in both groups can be elimination of food groups, which often leads to weight loss. But whereas with anorexia this weight loss is intentional and desired, with orthorexia weight is not the focus, and weight loss is not the ultimate goal. It is usually either not desired or comes secondary to the focus on health. As previously mentioned, one of the key differences is that those with anorexia tend to hide their eating habits, whereas those with orthorexia are happy to proclaim them to friends, family and even complete strangers on social media.
In addition to sharing traits with anorexia, there are also some similarities with obsessive compulsive disorder (OCD). These occur in the form of taking the time to carefully weigh and measure out portions of food, meal planning, and intrusive thoughts of food throughout the day, including away from meal times. The main difference is that in OCD, thoughts and obsessions are seen as being in conflict with the person’s ideal self-image and cause distress to the sufferer, whereas the obsession with healthy eating in orthorexia is seen as normal, desirable even. Despite these similarities, orthorexia is still considered to be a separate condition, rather than a subtype of anorexia.
A common trend that’s now being observed is that patients with anorexia are turning towards orthorexia during their recovery.71 This may be a compromise by which patients continue to exercise control over their food intake, but in a more socially acceptable way. In patients with anorexia, those who have higher orthorexic symptoms seem to be closer to recovery. The orthorexic tendencies seem to allow them to feel more autonomous and able to learn to eat more ‘normally’, suggesting that orthorexic tendencies may be a coping strategy during recovery.72 It’s important to note, though, that I’m not saying those with orthorexic tendencies are recovered, as their eating behaviours are just as disordered as those of anorexic patients without orthorexia, which shows that the relationship with food isn’t healthy and ideal.
CausesWho is at risk of developing orthorexia? Current estimates suggest that it affects around 1 per cent of the general population,73 similar to other eating disorders. But those especially at risk seem to be people who either have a keen interest in health and nutrition or are under pressure to look a certain way or be healthy for their job. This includes yoga instructors, dietitians, nutrition students, young athletes and exercise students.
Establishing the cause of any eating disorder is complicated, and orthorexia is no different. Trying to pinpoint an exact cause is difficult, as although there may be a clear trigger, it’s likely there are also several underlying issues. Based on the research available (and there isn’t that much) as well as my own experiences in my clinic, there are a few potential triggers and causes I’ve identified.
Similar to other eating disorders, control can play a big role in the development of orthorexia. If someone is experiencing difficulties in life that feel out of their control – whether it is parents going through a divorce, experiencing a break-up, abuse, or getting a scary diagnosis or a health scare (as with client A on pages 104–5) – food can be one thing that you can control. That level of control offers comfort and reassurance. It can manifest itself in the form of an eating disorder such as anorexia, or in trying to be the healthiest person you possibly can be, leading to orthorexia.
Although orthorexia is not associated with a desire to be thin, the pursuit of health can still be a highly aesthetic goal, encouraged by a societal promotion of the ‘thin ideal’ or ‘lean ideal’ (see the example of client B on pages 104–5).74 Ask someone what they imagine a ‘healthy’ person looks like and most likely they will describe a woman who is fairly thin (but not too thin), with curves but a fairly flat stomach, glossy hair and glowing skin. Basically, pretty much every famous wellness blogger. A ‘healthy’ man would be someone fairly lean, with visible muscles, smooth skin and a visible jawline.
Look at the Love Island contestants and this becomes blatantly obvious: everyone falls into these categories. They all fit the thin or lean ideal, which is why they’re all considered to be attractive and desirable. If you haven’t seen Love Island (either the UK or Australian versions), then think of shows like The Bachelor or Are You The One in the US. When someone doesn’t fit these ideals, it’s beyond understandable that this can lead to low self-esteem and body image issues.
The media is often blamed for eating disorders in general, but this is definitely an oversimplification that doesn’t do the complexity of eating disorders justice. Societal ideals of beauty are linked to eating disorders through the images of beauty we see in the media, but whether an individual develops an eating disorder depends more on whether they internalise those images and compare themselves with the people who are shown as being beautiful. Because these images are often airbrushed and Photoshopped, the comparison doesn’t end favourably and they feel like they don’t match up to what they should look like. If someone sees these images and doesn’t engage in this comparison, they are far less likely to develop an eating disorder.
In addition to pervasive beauty ideals, there has been an increasing moralisation of health, to the point where seeking good health is now seen as a moral obligation. By engaging in health behaviours (albeit to an extreme level), people are praised and seen as being good members of society, and not being a ‘burden’ on the healthcare system. Despite it being arguably quite selfish, it’s seen as a selfless pursuit.
The feeling of not being good enough is a really horrible, unpleasant state that can lead to unhealthy coping mechanisms. Particularly among adolescents and young adults, there is enormous pressure to find a partner, fit in with peers, find a job and get accepted to a university, and the rejection that can follow is crushing to self-esteem. If you’ve been told (explicitly or implied) that you’re not good enough, it’s understandable that this can lead to eating issues, because one of the easiest and most obvious ways you can change is through your appearance (as client B did). Getting a ‘revenge body’ is now a commonly known phenomenon. The post-break-up haircut is even older. The idea of ‘reinventing yourself’ when you change jobs or go to university is focused almost purely on appearance. Making these changes is assumed to lead to improved self-esteem and self-confidence.
Individuals with orthorexia tend to be less satisfied with their bodies and have poor body image. There is a clear relationship between orthorexic symptoms and an unhealthy relationship with the body.75 But changing your appearance to improve self-esteem is placing a plaster over the problem rather than addressing it directly.
Following a strict set of rules and being praised for following them, as well as receiving praise for trying to be healthier, only serves to increase the dependency of self-esteem on appearance and orthorexic tendencies.
Low self-esteem and perfectionism are related, but I’ve listed them separately as I still feel they are distinct issues. While self-esteem is more about making up for perceived shortcomings by improving appearance, perfectionism is more about the need to be the best version possible in all aspects of life, including appearance. The pursuit of perfection is relentless and consuming, as perfection arguably doesn’t exist. While you may be able to achieve 100 per cent in test scores, health and appearance is more nuanced, and can lead someone down the path of engaging in ever more extreme behaviours in order to achieve ‘perfect’ health.74 Following a strict set of rules about what you can and cannot eat, to the letter and without any deviation, could be seen by the individual as a way of achieving perfection in this area.
A big trigger I often see in clinic is some sort of health scare, affecting either the individual or a close friend or family member. This health scare could be a parent being diagnosed with diabetes, a surprising blood test result, or suddenly experiencing severe bloating. What follows is usually a visit to Dr Google, where the ratio of accurate to inaccurate information is shocking at best. Overblown claims, fad diets and dubious bloggers with no health qualifications … it’s a minefield. For every ailment, there (almost definitely) exists a site on page one of Google that advocates elimination of certain foods or food groups. When an individual is in a vulnerable position, they are far more likely to accept these ideas about restriction and elimination of foods without questioning, which can set them down the path of orthorexia – particularly if the elimination helps them to feel better within a few days or weeks, as is often the case. Usually the foods suggested for elimination tend to be things like sugar, high-carbohydrate foods or processed foods, which tends to result in higher consumption of vegetables, an overall increase in nutrients and feeling healthier. There is also often a strong desire to feel better, because of the high cost involved, and that in itself can produce a placebo effect in the short term, before the increased restriction and anxiety leaves them feeling worse.
Although the focus of orthorexia doesn’t tend to be weight and weight loss, that doesn’t mean that diets don’t play a role. Diets may have gone a little out of fashion, but rather than disappear they have simply been rebranded as ‘lifestyles’. Call it what you want, it’s still a diet. The best example of this is ‘clean eating’. The clean-eating movement is not a diet, it’s a lifestyle, with a focus on health, although weight loss is usually offered as an added bonus. Clean eating has been hugely blamed in the media for the rise in orthorexia. I would argue it has been rightly demonised for the harm it has done, but it would be an oversimplification to suggest that it is the sole cause of orthorexia. The very use of the word ‘clean’ is an issue in itself (go back to Chapter 4 for a more detailed explanation of why the term itself is so hugely problematic), but it’s the myriad of interpretations and variety of restrictions clean eating suggested that has made it particularly insidious, combined with its overwhelmingly successful use of social media. You could get into clean eating by removing all processed foods, then see another blogger tell you to avoid soy, so you do that too, then a number of posts show up that say how awful refined sugar is, so you also eliminate that. And so it goes on, until the list of acceptable foods is so small you end up with deficiencies and malnutrition.
When underlying issues such as low self-esteem or trigger events such as rejection or health scares are combined with the huge wealth of health misinformation online (particularly on social media), it provides the perfect storm for orthorexia to develop. By no means am I suggesting that social media is the cause of orthorexia, but having access to such volumes of information makes it far easier for orthorexia to develop and exacerbate.
Social media seems to be the biggest enabler of orthorexic tendencies. It’s no coincidence that the whole ‘clean eating’ movement owes its success to social media such as Instagram – so much so that a dramatic link has been established between spending more than an hour a day looking at food and health accounts on Instagram and increased risk of developing orthorexia.76
TreatmentAs orthorexia isn’t currently in the DSM, there is no clear official treatment pathway in the same way that there is for other eating disorders. This also makes it much harder for people to access free treatment on the NHS, other than joining a long waiting list for counselling.
Based on my experience with orthorexia, as well as helping those who come to see me in clinic, the following pages list some of the methods I use to help improve people’s relationship with food and themselves.
Often the ideas clients have about food are, through no fault of their own, based on misinformation. My clinic space is a complete no-judgement zone. Everyone falls for nutrition myths in life, and judging people for falling for misinformation is not helpful. What is helpful is understanding what ideas someone has about food and where those ideas have come from. Sometimes a client will be able to pinpoint the exact person on social media who scared them out of eating a food. Once these ideas and their origins have been established, we can begin to unravel these ideas and counter them with evidence-based advice.
The kinds of foods people are most likely to have misconceptions about are animal products (especially dairy), carbohydrates, sugar and increasingly more specific concerns such as soy products or lectins in beans.
Embedded within these ideas about specific foods is a general misunderstanding about what actually constitutes a healthy diet. The absolute black-and-white thinking around these foods and the imposed rules do not allow for any deviation. So sensible public health messages about reducing added sugar intake are translated into ‘avoid added sugar’ instead. Along with correcting false ideas about specific foods, there needs to be re-education on the importance of balance and moderation in eating, and the enjoyment of eating, instead of focusing on the tiny details. Moderation looks different for everyone, but in general it means eating a wide variety of foods without overeating any one in particular. It means eating lots of fruit and vegetables, but not feeling guilty about picking up a ready meal one day when you’re coming home late from work and are too exhausted to cook. It means thinking about long-term patterns, not focusing on the details of every meal.
One of the first things I do with any client who has orthorexic tendencies is find out about their forbidden foods and food rules. This involves creating a list of foods considered ‘forbidden’ or ‘unhealthy’ as well as a list of ‘allowed’ or ‘healthy’ foods. In some cases it’s also useful to create a list of foods that are sometimes ‘allowed’ but induce feelings of guilt, as this is a feeling we want to dissociate from food. In addition, we also create a list of food rules, which is particularly challenging, as many things won’t feel like rules until you’re asked to break them.
Once these lists have been created, I usually ask clients to rank foods according to the level of anxiety or guilt they produce: low-, medium- and high-anxiety foods. During every session we then discuss which food to tackle for their homework – usually starting with low-anxiety foods – and how best to go about this. I ask clients to make sure they are comfortable and relaxed before, enjoy the food slowly and savour it during, and afterwards think of three positive things about the experience. This is to help counter any negative thoughts around the food. Usually this results in one of two outcomes: either eating the food is a wonderful experience and they feel glad they could enjoy it, or they realise they actually don’t enjoy that food as much as they thought, and it no longer has the same power as before. This process is slowly repeated with as many foods as needed, and it is always a collaborative decision. Later down the line we then tackle food in social situations that can be challenging, such as buffets, which seem to be anxiety-inducing for many people.
A lot of misconceptions about food come from social media, particularly from Instagram. If, after going through a client’s list of food anxieties, it appears that many of them come from bloggers and Instagrammers, I will take the time to go through their social media feeds with them. I’ll identify potentially problematic individuals, ask them why they follow certain people and (most importantly) ask them how they feel after viewing the content they post. If they say they feel worse afterwards, I will hit the unfollow button for them. As someone who spends a lot of time on social media myself, I know how hard it can be to hit ‘unfollow’, as you feel bad for doing it, especially if you’ve been following someone for a while. So I do it for my clients to ease that process. Nine times out of ten they don’t even notice that person is missing from their feed.
If someone spends a large amount of time on social media, particularly Instagram, then it can also be beneficial to actively try to reduce that time, at the very least to under an hour per day. I generally find that as I talk to a client about social media, after a while they realise themselves what a negative influence it can be and implement changes on their own, such as spending less time scrolling, or following more fluffy animals on Instagram – you can’t feel bad about yourself while looking at pictures of cute puppies!
I’m not a psychologist, so if someone has severe self-esteem and body-image issues, I will always recommend they see a psychologist or counsellor as well as seeing me. But improving people’s relationship with food goes hand in hand with improving their relationship with themselves and their body, and working on both at the same time has a wonderful cumulative effect that’s really encouraging for both me and them.
A lot of self-compassion and self-acceptance exercises can seem really awkward and hippyish, and that’s a difficult hurdle for some people to overcome. But I have found them to be honestly helpful. When we engage in daily negative self-talk, those ideas about ourselves are constantly reinforced to the point where those thoughts can become automatic. Think about all the times you’ve looked at yourself in the mirror and automatically thought ‘Ugh’ or immediately picked up on something that’s wrong with your reflection. To fight back against those automatic thoughts takes time and conscious effort. If you imagine an old-fashioned set of scales, like the Libra star sign, if you’re adding negative thoughts daily to one side, your self-perception is massively skewed in the negative direction. It takes more than just one positive thought to counter all that; it takes continuously adding more and more positive thoughts to the other side of the scales before you even get to a point where you’re in neutral. The point being that you won’t magically wake up one day and fall in love with yourself – it takes work.
In order to counter negative thoughts, you first have to be aware of their existence, which is easier said than done when the thoughts are automatic. I’ll usually start off by asking clients to make a note of every time they have a negative thought about their body, usually in the form of a tally (some people like to use emojis and code them according to the nature of the thought). Doing this over a couple of days will usually do the trick, and help make them aware of just how often they think negative thoughts about their body. Most of the time, people are shocked at how often they think these thoughts. It takes writing them down and seeing it visually represented to really appreciate this. That’s the first step. After that, the next challenge is to counter each of the negative thoughts with something that’s positive or neutral. Let’s be honest, countering ‘I hate my thighs’ with ‘I love my thighs’ is pointless – you’re not going to believe it. But countering it with ‘My thighs allowed me to walk to work / do my workout / climb the stairs to my flat’ is neutral yet far more effective. I arm my clients with a few examples and ask them to try this for a few days. It requires deliberate conscious effort at first, but the idea is that after a while the negative thoughts slowly become fewer and the positive/neutral ones feel more natural and believable.
As well as engaging in more positive self-talk, I also do self-compassion exercises with clients. Examples of this include making a list of 50 things you like about yourself (so hard to do), writing a letter to yourself as if you were a friend, or simply taking some time out in the day to consciously do something nice for yourself.
A lot of these techniques aren’t just applicable to those with orthorexia; I see a great many people in clinic who are on the spectrum of disordered eating from years of failed dieting or reading fearmongering messages about food in the media, in books and on social media. If even one or two of these is helpful, then that’s at least a great starting point.
Although there are some things you can do yourself to help with any orthorexic tendencies you may have, such as unfollowing people on social media and implementing some self-care practices, I would always recommend seeking out a health professional to guide you. The difficulty is that not many healthcare professionals have heard of orthorexia, let alone have experience in helping individuals who suffer from it. When people come to see me in clinic, it’s usually because I’m the only person they know who recognises and understands what they’re going through.
When seeking out a nutrition professional, look out for the letters RNutr, ANutr, or RD after their name. These letters are a sign that this person has studied nutrition at university as a science. Although there are many great nutritional therapists, I am always hesitant to recommend their services, as there is a very vocal and dangerous subgroup who promote pseudoscience, and so the title is no guarantee of evidence-based practice. With a registered nutritionist or dietitian, you can at least be sure they are held to a strict code of ethics. Many nutritionists or dietitians (myself included) offer people the chance to have a quick call before committing to a full session, just to ask any questions and see if they’re the right person for you. If someone doesn’t offer this, email them and ask what experience they have in orthorexia.
Please answer the following questions. If you have diagnosed food allergies or foods you avoid for medical reasons, don’t include those in your decision-making. For example, if you have a peanut allergy but never avoid any other foods apart from peanuts, you might answer the question ‘Do you avoid certain foods for health reasons?’ with ‘Never.’
|
|
ALWAYS |
OFTEN |
SOMETIMES |
NEVER |
Do you avoid certain foods for health reasons? |
4 |
3 |
2 |
1 |
Do you read nutrition labels? |
4 |
3 |
2 |
1 |
Do you avoid foods with certain ingredients? |
4 |
3 |
2 |
1 |
Are your food choices affected by worry about your health? |
4 |
3 |
2 |
1 |
Is the nutritional value of food more important than the taste? |
4 |
3 |
2 |
1 |
Do you have food rules? |
4 |
3 |
2 |
1 |
Do you stick to your rules rigidly? |
4 |
3 |
2 |
1 |
Do you think about food more than three hours a day?* |
4 |
3 |
2 |
1 |
Do you seek out nutrition articles online? |
4 |
3 |
2 |
1 |
Does eating healthy foods increase your self-esteem? |
4 |
3 |
2 |
1 |
Do you spend a lot of money in health food shops? |
4 |
3 |
2 |
1 |
Do you feel guilty about eating something unhealthy? |
4 |
3 |
2 |
1 |
Do you find eating out in restaurants stressful? |
4 |
3 |
2 |
1 |
Do you prefer to eat alone? |
4 |
3 |
2 |
1 |
Have you recently cancelled dinner plans because you can’t find anything for you on the menu? |
4 |
3 |
2 |
1 |
* If you work in food, focus on food thoughts that aren’t related to your work.
The usual tool used to assess risk of orthorexia in research uses language that isn’t particularly user-friendly, so these questions are based on my own assessments I might use in clinic. Please note this is NOT a diagnostic tool, but can provide a guideline to see where your relationship with food is at.
• If you scored below 30: your relationship with food is most likely very good.
• If you scored between 31 and 45: You seem to have some anxieties around food, and it may be worth addressing these in case they become more severe over time.
• If you scored 45 or higher: You may be at risk of orthorexia, and I would recommend seeking professional guidance to help you get to a happier place with food.
* The DSM is the standard classification of mental health disorders used by professionals to diagnose mental health conditions.