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‘Clean eating’: orthorexia nervosa - Medical Observer

Medical & health articles | Medical Observer 13 Feb 2018
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In the latest 'Talking Women' article for Medical Observer, Gillian Needleman, discusses orthorexia nervosa.

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Jean Hailes is proud to provide a monthly column in the medical newspaper, Medical Observer. Designed to give GPs and health professionals a short informative summary of important women's health topics and conditions, these articles provide practical information to inform and enhance clinical practice.

By Gillian Needleman
BA, Post Grad Dip, M.A
Clinical Psychologist, Jean Hailes for Women's Health

Orthorexia nervosa is a term used to describe people who become obsessive about healthy eating. Literally meaning 'correct appetite' in Greek, the disorder orthorexia nervosa was named in 1997 by American doctor Steven Bratman to describe an obsessive focus on 'clean eating', which is a diet that is highly restrictive or completely devoid of certain food groups.

Orthorexia fits in to the 'Other Specified Feeding or Eating Disorder' (OSFED) category, recognised in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A person with OSFED may present with some of the symptoms of eating disorders such as anorexia nervosa, but will not meet the full criteria. OSFED nonetheless includes genuine eating disorders, accounting for 30% of people who seek treatment for eating disorders, and is a serious mental illness that can occur in adults, adolescents and children.

Orthorexia can often co-exist with other anxiety disorders and is more common in young women.


Orthorexia has become more prominent due to the culture of 'clean eating' over the past decade. Due in part to people's disillusionment and confusion in changing health advice from official sources, the rise of orthorexia also corresponds with the advent of social media, and the popular trend of people posting pictures of their food.

Social media platforms have enabled many unqualified individuals to become hugely successful influencers of their own health messages. The resulting environment is a minefield for people trying to seek health information.

Orthorexia sufferers may be vulnerable to the inaccurate or exaggerated messages pushed by some influencers. They are also vulnerable to the distortion of accurate health messages. So, even if the person starts out with correct information, it is the dysfunctional and often anxiety-based connection to the beliefs that fuels the risk of health information distortion.


From a psychology perspective, orthorexia can negatively affect a person's life in many ways. For example, a person may not go out to dinner because they 'can't eat anything' on the menu. They will deliberately minimise attendance at social events as they prefer to eat – and be in control of – their own meals at home. The preoccupation can also be time consuming (planning, preparing, sourcing foods and information) and expensive. Alongside, there can be a sense of feeling 'righteous' and elements of perfectionism are applied to food behaviours and selection.

Beneath the impression of healthiness that is presented to others, there is often underlying anxiety that is managed through the careful nature of food choices and behaviours. The anxiety often manifests if there is some interruption to the individual's capacity to adhere to their regime.

Being healthy is about maintaining physical as well as emotional health. While people suffering from orthorexia may appear healthy because they are following a 'clean' diet, the associated anxiety from undertaking such a restrictive regime bears an emotional cost.

Orthorexia can be treated by a psychologist through cognitive behavioural therapy (CBT) and other mindfulness strategies. Intervention from a dietitian is also recommended, as accurate nutritional information from a credible source is essential.

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Diagnosis and treatment

Although orthorexia may be difficult to detect, there are subtle warning signs. During the course of a consultation, it may become apparent that a patient could be suffering from orthorexia.

Physical indicators of orthorexia could include weight loss, lowered immune system (eg, persistent cold), problems with cognition, nutritional deficiencies, and osteoporosis.

Emotional indicators may include high anxiety, conversational alerts that show hypervigilance around clean eating (eg, admission that a whole food group has been eliminated), and negative talk relating to eating (eg, "I have been eating badly", "I have not been good" etc).

If this is the case, the GP could ask some general questions about health and wellness and the patient's eating and exercise patterns. Due to the secrecy and emotional loading often inherent with this issue, the GP would aim to build trust through a general discussion around encouraging a healthy mind as well as a healthy body.

Questions a GP may wish to ask a patient:

"Firstly, is it OK if I talk to you a bit about your eating patterns? It's an area people can often find stressful and there's so much information out there."
"Can you give me an idea of what you've eaten today/ last couple of days?"

Make some emotional enquiries to try to ascertain whether the belief system is rigid to the point where the patient has withdrawn from social activities. If orthorexia is suspected, but the patient doesn't seem anxious and there are no other health concerns or nutritional deficits, aim to have a follow-up appointment to manage and monitor. Treat through psychoeducation and guidance – aim to help patient work towards a healthy body and mind.

If the patient is highly anxious and the answers point to orthorexia, the GP may encourage participation in an anxiety test, then offer to make a referral to a psychologist. Through treatment with CBT and other mindfulness strategies, the sessions will help to challenge the thinking by exploring the belief systems that have been negatively affecting the patient, and help with goal/ limit setting, and emotional regulation.

Practice points:

  • Orthorexia can be difficult to detect. However, there are subtle warning signs
  • Physical warning signs can include weight loss, lowered immune function, problems with cognition, nutritional deficiencies, and osteoporosis
  • Emotional warning signs can include high anxiety, hypervigilance with clean eating, withdrawal from social events
  • Patients with orthorexia can be secretive about their condition. Developing rapport with the patient is important
  • Gather information by asking general questions about lifestyle and eating patterns
  • If orthorexia is suspected, but patient doesn't seem anxious and there are no other health concerns or nutritional deficits, aim to have a follow-up appointment to manage and monitor. Treat through psychoeducation and guidance
  • If patient is very anxious, refer to psychologist for treatment. Treatment will include cognitive behavioural therapy (CBT) and other mindfulness strategies
  • Intervention from a dietitian is also recommended as accurate nutritional information from a credible source is essential.

Patient resources:

About the author

Gillian Needleman is a psychologist with Jean Hailes for Women's Health. Her areas of interest include women's health, sexual health, trauma and couple therapy.

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