What is orthorexia, particularly in young adults with a history of anxiety or obsessive-compulsive disorder (OCD)?

What is Orthorexia?

Orthorexia nervosa (ON) is an obsessive-compulsive eating pattern characterized by an extreme preoccupation with consuming only "pure" or "healthy" foods, leading to rigid dietary rules, severe food restrictions, and significant psychosocial impairment or malnutrition. 1, 2

Core Clinical Features

Orthorexia involves the following key characteristics:

• Obsessive focus on food quality (not quantity), with fixation on eating only foods perceived as healthy, pure, or "clean" 1, 2
• Rigid dietary rules that progressively eliminate entire food groups, avoiding anything with artificial colors, flavors, preservatives, pesticides, GMOs, unhealthy fats, excess salt, or sugar 3
• Ritualistic behaviors extending beyond food selection to include obsessive concerns about food preparation methods and kitchenware used 3
• Time-consuming preoccupations with thoughts, worries, and planning around food choices 4
• Social isolation as a consequence of the restrictive eating patterns and inability to eat in social settings 2, 3
• Malnutrition and physical health consequences resulting from the severely restrictive diet 1, 2

Relationship to Anxiety and OCD in Young Adults

In young adults with anxiety or OCD history, orthorexia shares substantial overlap with obsessive-compulsive patterns but appears more closely related to eating disorder pathology than to OCD itself. 1

Key Distinctions from OCD:

• Orthorexia measures show poor to moderate ability to detect OCD symptoms and obsessional thinking, suggesting it is not primarily an OCD-spectrum disorder 1
• The obsessive thoughts in orthorexia center specifically on food purity and health, rather than the contamination fears, harm obsessions, or symmetry concerns typical of OCD 5
• Unlike OCD compulsions that aim to neutralize anxiety from intrusive thoughts, orthorexic behaviors are driven by pursuit of perceived health perfection 1, 4

Overlap with Eating Disorders:

• Orthorexia demonstrates strong predictive ability for detecting eating disorder symptoms and anorexia nervosa, suggesting it may represent a subtype of eating disorders or anorexia nervosa 1, 6
• Orthorexia is consistently related to restrictive eating patterns and weight control motivations characteristic of anorexia nervosa 6
• However, orthorexia shows less consistent relationship with body dissatisfaction, shape/weight concerns, binge eating, or emotional eating that characterize other eating disorders 6

High-Risk Populations

Young adults at elevated risk include:

• Adolescents and young adults, as eating disorders are more prevalent in this age group 2
• Females, who show higher rates of orthorexic behaviors 3
• Those with history of anorexia nervosa, as orthorexics often share features with anorexic patients including excessive need for self-care, perfectionism, and rigidity 3
• Athletes, particularly those in bodybuilding or aesthetic sports 3
• Individuals with pre-existing anxiety or OCD, as obsessive-compulsive thoughts and symptoms have a direct effect on orthorexia development 4

Clinical Significance and Impairment

The condition causes substantial functional impairment through:

• Severe dietary restrictions leading to nutritional deficiencies and malnutrition 1, 2
• Social relationship deterioration due to inability to participate in normal eating situations 2, 3
• Mental health complications, including worsening of underlying anxiety or obsessive-compulsive symptoms 2, 4
• Progressive isolation as compensation for the rigid dietary requirements 3

Clinical Assessment Approach

When evaluating suspected orthorexia in young adults with anxiety or OCD:

• Assess the focus of obsessive thoughts: Are they centered on food purity and health (orthorexia) versus contamination, harm, or symmetry (OCD)? 5, 1
• Evaluate dietary restriction patterns: Look for progressive elimination of food groups based on perceived "impurity" rather than weight/shape concerns 3, 6
• Examine social functioning: Determine if social isolation results from inability to maintain dietary rules in social settings 2, 3
• Screen for eating disorder symptoms: Use validated measures like the EAT-26, as orthorexia shows strong overlap with eating disorder pathology 1, 4
• Differentiate from body dysmorphic disorder: Unlike BDD, orthorexia is not driven by appearance-based preoccupations but by health/purity obsessions 5

Treatment Implications

Treatment approaches developed for eating disorders, particularly anorexia nervosa, are likely most appropriate for orthorexia rather than OCD-focused interventions. 1

• Multidisciplinary team involving physicians, psychotherapists, and dietitians is required 3
• Cognitive-behavioral therapy adapted from eating disorder protocols should be the primary psychological intervention 1
• Serotonergic medications (SSRIs) may be considered as adjunctive treatment in some cases 3
• Address underlying anxiety or OCD as comorbid conditions, recognizing that obsessive-compulsive thoughts contribute to orthorexia development through food preoccupation 4

Important Clinical Pitfalls

• Do not dismiss orthorexia as simply "healthy eating taken too far"—it causes genuine malnutrition and psychosocial impairment 1, 2
• Avoid treating as primary OCD when the presentation is actually an eating disorder variant 1
• Recognize that food preoccupation mediates the relationship between both dieting behaviors and obsessive-compulsive symptoms with orthorexia 4
• Screen for progression to anorexia nervosa, as orthorexia may represent an early or variant presentation 1, 6