When does healthy become unhealthy?
by Sophie Bertrand BSc, MSc and Dr Alison Colville MbCHb, MRCGP, LFHom (med)
Having completed an MSc in Nutriton and eating disorders, I am very family with the research surrounding the topics of anorexia, bulimia and binge eating disorder. However, we are now being faced with the rise of a condition named ‘orthorexia’ which describes an individual that will avoid all foods that they consider to be ‘unhealthy’ thus becoming extremely restricitive in regards to their eating habits. Being that this condition is not yet listed in the Diagnostic and Statistical Manual of Mential Disorders (DSM-5) it can be somewhat difficult to diagnose. Being that my ethos is centred around encouraging idividuals to have a healthy relationship with food, I wanted to ask for General Pracitoners perspective and her understanding of orhorexia to help educate individuals who find it difficult to separate the idea of being healthy and having a good relationship with food from only eating ‘healthy foods’. Myself and GP Alison Colville (also known as ‘The Wholehealth Doctor’) have teamed up to hopefully clear up and answer any questions surrounding this topic.
When does healthy become unhealthy?
Is it when we start choosing organic over non-organic? Is it when we turn down dinner with a friend because you know they won’t have dairy free options? Or perhaps it’s when you spend your day planning your meals for the following day? The truth is, it is very hard to tell. Individually, these can be health conscious behaviours to have but when they start to negatively impact your mental state, relationships or day-to-day life then perhaps things have gone too far.
What is Orthorexia Nervosa?
ORTHOREXIA NERVOSA was first described in 1997 by a man called Bratman who found his behaviour around food and health becoming obsessive whilst running a health retreat. 
‘After a year or so of this self-imposed regime, I felt light, clear headed, energetic, strong and self-righteous. I regarded the wretched, debauched souls about me downing their chocolate chip cookies and fries as mere animals reduced to satisfying gustatory lusts. But I wasn’t complacent in my virtue. Feeling an obligation to enlighten my weaker brethren, I continuously lectured friends and family on the evils of refined, processed food and the dangers of pesticides and artificial fertilizers.’
Does this sound familiar?! You can read the rest of his story at www.orthorexia.com/original-orthorexia-essay/
Although not currently recognised as a disease by Psychiatric diagnostic guidelines, Orthorexia is a condition which is becoming increasingly diagnosed. There are differing views as to whether it is a ‘disorder’, a ‘behavioural addiction’ or an ‘extreme dietary habit’. Particularly amongst those with a history of mental illness or in recovery from other eating disorders. Essentially, the condition is characterised by obsessive behaviour surrounding the perfect diet and other healthy actions such as excessive exercising, use of supplements, and extending into ritualistic selfcare practices.
As I wrote this article, I realised that in my GP practice I have never diagnosed this condition, or in fact, come across it all. Does that mean perhaps it doesn’t exist? Well, the evidence suggests the otherwise, so clearly, we are not aware of its existence, both the individual and the healthcare professionals. When we are eating ‘healthily’ and striving to improve our health or fitness we think we’re far from having a problem and so this is not something that we would seek help about. Interestingly, Orthorexia is a condition where the individual talks freely about their food habits, quite the opposite to those suffering with Anorexia Nervosa.
How do I know if I have it?
The ORTO-15 is a questionnaire which has been developed to identify those who may have Orthorexia. It clearly has it’s limitations, namely in it’s lack of standardisation and also cultural variations. However, it is a useful tool to make a general assessment of someone’s attitude towards their food and health. As a practitioner of lifestyle medicine and promoter of health, some of the questions I believe to be health conscious behaviour rather than specifically destructive e.g. ‘Are you willing to spend more money to have healthier food’ but see how you score….
|When eating, do you pay attention to the calories in the food?||⃝||⃝||⃝||⃝|
|When you go in a food shop do you feel confused?||⃝||⃝||⃝||⃝|
|In the last 3 months, did the thought of food worry you?||⃝||⃝||⃝||⃝|
|Are your eating choices conditioned by your worry about your health status?||⃝||⃝||⃝||⃝|
|Is the taste of food more important than the quality when you evaluate food?||⃝||⃝||⃝||⃝|
|Are you willing to spend more money to have healthier food?||⃝||⃝||⃝||⃝|
|Does the thought of food worry you for more than 3 hours a day?||⃝||⃝||⃝||⃝|
|Do you allow yourself any eating transgressions?||⃝||⃝||⃝||⃝|
|Do you think your mood affects your eating behaviour?||⃝||⃝||⃝||⃝|
|Do you think that the conviction to eat only healthy food increases self-esteem?||⃝||⃝||⃝||⃝|
|Do you think that eating healthy food changes your lifestyle? (frequency of eating out, friends…’?||⃝||⃝||⃝||⃝|
|Do you think that eating healthy food may improve your appearance?||⃝||⃝||⃝||⃝|
|Do you feel guilty when transgressing?||⃝||⃝||⃝||⃝|
|Do you think that on the market there is also unhealthy food?||⃝||⃝||⃝||⃝|
|At present, are you alone when having meals?||⃝||⃝||⃝||⃝|
L.M. Donini, D. Marsili, M.P. Graziani, et al. Eating Weight Disord. 10: e28-e32, 2005
|2 – 5 – 8 – 9||4||3||2||1|
|3 – 4 – 6 – 7 – 10 – 11 – 12 – 14 – 15||1||2||3||4|
|1 – 13||2||4||3||1|
The impact of social media
Probably the most shocking research I discovered was a study done by Turner et al who used the ORTO-15 questionnaire on 680 social media ‘health food’ account followers and found that a staggering 49% of them fit the criteria for Orthorexia. A similar study was done on random members of the public and found only 1% to fit the criteria. Interestingly, these figures are only linked to Instagram and not to other social media platforms. A further Austrian study by Kinzyl et al found that up to 55% of the dieticians they examined also exhibit behaviour consistent with Orthorexia.
Anyone on social media promoting food, wellness or any other practice of healthy lifestyle is potentially feeding into this. So, this begs the question… Are we feeding into this? As a doctor my goal is clearly to make people BETTER or restore their health and certainly not to drive an eating disorder. Ultimately, we need to be aware that this condition does exist and promote self-reflection in our eating/health habits to ensure that we don’t slide into more unhealthy habits. It is so important to have balance in all aspects of life and practicing mindfulness, meditation and journaling are fantastic ways to help us see through our actions and become more self-aware.
How to keep a healthy mindset
Try to go easy on yourself from time to time. You don’t have to be perfect, because perfection never ends. If you forget to meditate one day, or you’re invited to eat at a friend’s house, or even if you just need to sleep and have a bath rather than exercise, forgive yourself and move on. The 80:20 rule is a very useful rule to stick to: eat well, exercise, 80% of the time, and allow some flexibility for the other 20% of the time.
What we have to remember is that good food makes us happy, and being incredibly restrictive around food will ultimately leave you feeling unhappy. Food is to be enjoyed, it is fuel, it is energy, and cutting out food groups such as diary, is not going to have any positive impact on your health unless of course you are intolerant to it. Variety is key, and the more colours and varitey of foods you have in your diet, the better your gut health will be thus the healthier you will be. So try not to stick to such a restricted way of eating because the truth is, it is not healthier!
If you feel that your behaviour around food is becoming destructive to your life then please seek help from your GP, even if it’s just to talk things through. Some other supportive resources include:
Co- Written by Sophie Bertrand MSc and The Wholehealth Doctor
Dr Alison Colville MbCHb, MRCGP, LFHom (med)
Public speaker and GP with a specialist interest in lifestyle medicine and wellness
 Orthorexia nervosa and self-attitudinal aspects of body image in female and male university students / Donini et al / Journal of Eating Disorders 20153:2 / January 2015
 The stigma of clean dieting and orthorexia nervosa / Nevin et al / Journal of Eating Disorders20175:37 / July 2017
 The interrelationship between orthorexia nervosa, perfectionism, body image and attachment style / Barnes et al / Eating and weight disorders – studies on anorexia, bulimia and obesity / Vol 22 Issue 1 pp 117-184 / March 2017
 Orthorexia nervosa in dieticians / Kinzyl et al / Psychother Psychosom 2006;75:395–396 / October 2006
 Instagram use is linked to increased symptoms of orthorexia nervosa / Turner et al / Eating and weight disorders – studies on anorexia, bulimia and obesity / Vol 22 Issue 2 pp 227-284 / June 2017
 On orthorexia nervosa: A review of the literature and proposed diagnostic criteria / Bratman et al / Eating Behaviours Vol 21 pp 11-17 / April 2016