The role of a wholesome, nutrient-rich diet in supporting health and wellbeing is inarguable. However, when preoccupation with one’s food quality, provenance or “purity” shifts from a priority to an all-out obsession, it can actually work against physical, mental and emotional health. This “pathological obsession with healthy eating” is called orthorexia nervosa, and it may be an unfortunate outcome of current messaging regarding healthy diets reaching those who are more susceptible than others to this kind of behavior.

We explored the issue of orthorexia nervosa (ON) in an article a few years back, but research conducted since then has revealed more about this condition that is worth looking at. Having a better understanding of who’s at increased risk and what some of the adverse consequences are can help medical and nutrition professionals identify patients and clients who may need counseling in this area.

Jennifer Mills, an associate professor in the Department of Psychology at Canada’s York University, was lead author on a study that attempted to determine who might be at increased risk for ON. Regarding ON in general, she said it succinctly: “When taken to the extreme, an obsession with clean eating can be a sign that the person is struggling to manage their mental health.”

Not surprisingly, the researchers found positive associations between ON and perfectionism, disordered eating, history of dieting or an eating disorder, poor body image, drive for thinness, obsessive-compulsive traits and psychopathology. It’s difficult to determine exact figures for prevalence of ON because there is no universally agreed upon definition. The authors of a paper in the journal Easting and Weight Disorders who looked for commonalities in definitions and diagnostic criteria noted that in multiple studies, primary diagnostic criteria included some of the following: obsessional or pathological preoccupation with healthy nutrition; emotional consequences of non-adherence to self-imposed nutritional rules (e.g., stress or anxiety); or psychosocial impairments in relevant areas of life as well as malnutrition and weight loss.

The authors provided a good general description of ON: “The pursuit of an ‘extreme dietary purity’ due to an exaggerated focus” on food generated by self-imposed dietary rules intended to promote health, but which may have detrimental consequences on health. Steven Bratman, MD, who coined the term orthorexia nervosa, also explained that extreme diets—initially intended for good, healthy reasons—can lead to malnutrition and/or impairment of daily functioning.

Bratman also wrote:

“Enthusiasm for healthy eating doesn’t become ‘orthorexia’ until a tipping point is reached and enthusiasm transforms into obsession. Orthorexia is an emotionally disturbed, self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable. A gradual constriction of many other dimensions of life occurs so that thinking about healthy food can becomes the central theme of almost every moment of the day, the sword and shield against every kind of anxiety, and the primary source of self-esteem, value and meaning. This may result in social isolation, psychological disturbance and even, possibly, physical harm. To put it another way, the search for healthy eating can become unhealthy.”

There might not be a universally accepted definition for the condition, but that doesn’t mean it’s impossible to identify in an “I know it when I see it” approach, particularly for medical and nutrition professionals who are in a good position to recognize when someone’s dedication to “healthy eating” has gotten to the point that it’s interfering with their daily life and may ultimately be causing worsened health—the opposite of the intended effect.

In the age of social media, it’s impossible to escape messages about food, both subliminal and overt. Respected institutions like the Mayo Clinic tell us about “clean eating,” and we’re told that fasting could “prevent aging.” (Imagine that—preventing aging! Who writes these headlines, anyway?) Other news outlets tell us “sugar is definitely toxic,” and while sugar certainly isn’t a health food, strawberries and cantaloupe are probably not the reasons why as much as 88% of US adults are metabolically unhealthy. “Natural” food has become a marker for piousness and purity, with people’s food choices connotating information about their morality in ways it didn’t in the past.

It would be difficult for anyone not to be affected by these messages in some way. It does seem, however, that some are more susceptible than others to reaching a point where obsession about food quality becomes a primary focus and driving motivation in their life, rather than their food being a means to the end of having a happy and healthy body, mind and spirit. And there’s a difference between orthorexia and simply being concerned about following a healthy diet. In an essay about the distinction, Dr. Bratman wrote, “Healthy diet turns into orthorexia when a boundary is crossed and a person’s relationship with food begins to impair various essential dimensions of human life.”

There are reasons why particular dietary approaches may be best for certain individuals to follow—for example, a low-carb or ketogenic diet for those with type 2 diabetes, or a low FODMAP diet for those with IBS. Beyond medical necessity, people quite reasonably may choose to follow any number of diets to support weight loss, athletic performance, or just overall good health, and none of these indicates someone has a mental health condition. Orthorexia is more of a concern when the physical morphs into the psychological, and self-imposed, arbitrary “food rules” create a prison-like atmosphere in one’s mind giving a false sense of control.

With the ever-growing focus on clean eating and the rise of “food shaming,” it’s important for healthcare professionals to be aware and remain vigilant for orthorexia among their patients. Some patients may not realize they’ve crossed a threshold into dangerous behavior and may need help.