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Orthorexia Nervosa: When “Clean Eating” Becomes an Overlooked Eating Disorder

5th January 2026 / Written by Harbor London

In recent years, orthorexia nervosa has gained attention within clinical, nutritional, and psychiatric literature as a distinct pattern of disordered eating. However, it remains potentially underdiagnosed, inconsistently defined, and largely misunderstood.

Unlike other eating disorders, orthorexia is rarely recognised through overt markers of physical decline¹. Rather, it often presents through behaviours that tend to be socially rewarded: discipline, dietary “purity,” and a visible commitment to health, for example¹.

Epidemiological estimates can vary widely, in part due to the absence of formal diagnostic criteria². Studies suggest prevalence rates ranging from low single digits in the general population, to significantly higher figures within specific subgroups^3-4. What remains consistent across clinical literature is not prevalence itself, but patterns of under-recognition: with some research suggesting a particular occurrence among individuals who might appear outwardly functional, successful, or physically “well.⁵”

Public narratives surrounding clean eating and wellness optimisation tend to frame dietary control as a marker of self-mastery, or even of moral virtue⁶. Within these frameworks, restriction can often be recast as intentionality, and rigidity as commitment⁶. Clinically, however, the same behaviours may reflect escalating anxiety, compulsive rule adherence, and a narrowing of psychological flexibility⁷. What begins as an adaptive interest in health can, over time, harden into a rigid system that governs identity, self-worth, and emotional regulation^6-7.

This paradox – where behaviours that appear beneficial may simultaneously be impairing – sits at the core of orthorexia nervosa¹. The experience is not necessarily defined by what an individual eats, but by the degree to which food-related rules may become inflexible, anxiety-driven, and psychologically distressing⁸.

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What is orthorexia?

The term “orthorexia nervosa” was first introduced in the late 1990s to describe a potentially unhealthy fixation on eating foods which are perceived as pure, clean, or optimally healthy⁹. Since then, clinical understanding has evolved, though consensus remains incomplete^1-2. Orthorexia is not currently recognised as a formal diagnosis in the DSM-5 or ICD-11, reflecting an ongoing debate regarding its nosological boundaries and overlap with existing eating and obsessive–compulsive spectrum disorders^1,10.

Despite this, there is growing agreement within psychiatric and psychological research that orthorexia represents a clinically meaningful pattern of disordered eating, characterised by quality-focused dietary restriction, heightened anxiety around food choice, and progressive functional impairment⁸. Unlike other eating disorders, such as anorexia nervosa, bulimia nervosa, or binge eating disorder, weight loss is not the primary driver or reinforcer¹¹. Instead, restriction is organised around perceived food “purity” – ingredients, sourcing, preparation methods, and avoidance of foods deemed harmful, artificial, or morally “wrong.^1,8”

Importantly, orthorexia is defined not by health-conscious behaviour itself, but more by rigidity and consequence¹². When dietary rules become non-negotiable, deviations provoke disproportionate distress in individuals, and eating behaviour can begin to dominate emotional life, social functioning, and self-perception¹³.

Why orthorexia may be missed

Contextually, the early features of orthorexia nervosa may be socially endorsed rather than interpreted as a potential cause for concern⁶. Dietary restriction framed as discipline or optimisation is frequently rewarded within wellness-oriented cultures, performance-driven environments, and potentially even in clinical settings^14-15. Behaviours that might otherwise raise clinical concern (such as strict elimination diets, escalating food rules, or intolerance of deviation) may be easily misinterpreted as a strong commitment to personal health¹⁴.

Preventative health messaging, bio-optimisation narratives, and algorithm-driven dietary advice often emphasise control, elimination, and self-surveillance, with limited attention to psychological cost¹⁶. In this context, psychological or physical distress may be interpreted as evidence of insufficient discipline rather than a signal of clinical dysregulation^14-16.

Orthorexia is unlikely to present with physical markers that can traditionally trigger intervention; weight stability, muscularity, or outward fitness can obscure significant internal distress, delaying both self-recognition and clinical response⁸. Individuals may not perceive themselves as “unwell”, particularly where their eating behaviours are closely tied to identity, values, or professional credibility^2-5.

Furthermore, reluctance to disclose may be common^8-13. For many individuals, the investment in a health-oriented identity can be profound, and the suggestion that these behaviours may be harmful can feel destabilising or shaming^17-18. Some research suggests that orthorexic traits are more frequently observed in certain populations, including high-level business leaders or elite sportspeople; not because vulnerability is exclusive to these groups, but because contextual reinforcement and functional camouflage can allow symptoms to persist longer without detection^2-4.

A fine line: health-conscious eating vs disordered restriction

Health-conscious eating, when psychologically adaptive, is characterised by flexibility, proportionality, and responsiveness to context¹⁹. Food choices may be intentional, but they remain adjustable in response to social situations, physiological needs, cultural practices, and life demands²⁰. Eating remains a source of nourishment and, at times, pleasure, rather than a site of moral evaluation²⁰.

Orthorexic patterns can emerge when this flexibility is replaced by rigid rule systems organised around fear rather than preference; for example, foods might become categorised not simply as more or less nutritious, but as “acceptable” or “unacceptable”, or “safe” or “contaminating^8,13”. Deviation from these rules may be accompanied by guilt, shame, or anxiety that is disproportionate to any objective health risk, and is frequently followed by compensatory restriction or intensified control^1,8.

As orthorexia progresses, spontaneity may diminish, social participation might narrow, and the cognitive and emotional load associated with eating increases⁸. What was once framed as self-care becomes a source of ongoing vigilance and distress, eroding quality of life even as outward markers of “healthy living” remain intact²¹.

Psychological and biological consequences

Psychologically, orthorexia is typically associated with escalating anxiety and preoccupation, often accompanied by obsessive-compulsive features such as intrusive thoughts, checking behaviours, and ritualised food preparation^1,8. Rather than reducing distress, dietary restriction frequently intensifies it, creating a self-reinforcing cycle in which control temporarily alleviates anxiety while simultaneously deepening dependence on rigid rules²¹.

Biologically, individuals may develop nutritional deficiencies, despite consuming diets perceived as “optimal”^13,22. Excessive elimination of food groups, combined with limited dietary variety, can compromise micronutrient intake and metabolic resilience, even in the absence of significant weight change²². These effects can often be overlooked because outward health markers may initially appear stable^{6, 14-18}.

Socially, the cumulative impact is often described as a progressive narrowing of quality of life^13,21. Meals may become sources of tension rather than connection or enjoyment, and avoidance of social situations involving food contributes to isolation and reduced mental wellbeing²³.

From a physiological perspective, fear-based restriction is associated with chronic stress activation, with sustained engagement of stress pathways that undermine both psychological regulation and physical health over time^1,24.

Assessment and early clinical signals

Throughout medical literature, orthorexia is rarely identified through overt complaint; more often, it emerges gradually within clinical encounters as patterns of rigidity, subtle distress, and preoccupation that may initially appear congruent with health-oriented values^7,21. Early signals may frequently manifest acutely, potentially more apparent to clinicians and trusted advisors than to an individual themselves, particularly when behaviours remain socially sanctioned or professionally rewarded^6-7,24.

Such fiduciary connections may notice distinctive language patterns that suggest moralisation of food rather than nutritional reasoning²⁵. References to “allowed” or “forbidden” foods, concerns about “toxicity,” “contamination,” or “purity” (itself a notably commonly-used word in the recounting of individual experiences), and expressions of self-reproach following dietary deviation can indicate that eating behaviour has become anxiety-driven rather than preference-based^1,8,21. Behaviourally, increasing inflexibility, avoidance of shared meals, and disproportionate distress when routines are disrupted may often precede more visible impairment¹³.

Assessment, therefore, requires particular care²⁶. Confrontational or reductive approaches risk entrenching defensive identification with health-conscious behaviours²⁶. Instead, nuanced exploration of motivation, emotional consequence, and functional impact is likely to be more meaningful²⁷. The clinical focus best-trained not on challenging dietary choices per se, but on understanding:

The psychological load required to sustain them
The degree of distress associated with deviation
The broader effects on mood, identity, and social functioning²⁸

Beyond “clean eating”: pathways toward sustainable health

Orthorexia presents a particular challenge to conventional treatment pathways precisely because it sits at the intersection of health behaviour and psychological distress1. Fragmented models of care, in which nutritional guidance, psychological support, and medical oversight are delivered in isolation, often fail to address the coherence of the condition29. Without integration, dietary rigidity may be inadvertently reinforced while underlying anxiety, perfectionism, or identity dynamics remain potentially unaddressed30.

Clinically effective intervention typically requires coordination across psychiatry, psychotherapy, and specialist nutritional care26-28. For instance, truly curated treatment would likely focus not only on restoring dietary flexibility, but equally, on addressing the emotional drivers that sustain restriction, including fear-based control, intolerance of uncertainty, and the use of food as a stabilising structure31. In tandem, psychological work may centre on reducing moral valuation of eating behaviour, and expanding identity beyond health performance32-33.

For some individuals, especially those with high-functioning lifestyles and/or significant investment in discretion, one-to-one, curated, and whole-person treatment pathways are likely to be drastically more appropriate and effective than standard or traditional models26-27. Continuity of care, privacy, and depth of clinical engagement are typically critical in enabling honest exploration of distress that has long been masked by apparent discipline or outward symbols of success34.

Ultimately – while further research is required, and clinical dialogue continues – orthorexia serves as a reminder that “health” is not always synonymous with “control”8. In this context, true psychological wellbeing is perhaps better reflected in adaptability, resilience, and the capacity to respond flexibly to changing internal and external demands. When eating behaviour is guided by fear rather than nourishment, even the most “clean” diet can become a source of harm1,13. Therefore, for individuals experiencing orthorexia, reclaiming health and quality of life likely involves restoring freedom rather than enforcing further rules; a process grounded in careful assessment, integrated care, and respect for the complexity of the individual experience.

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Orthorexia Nervosa: When “Clean Eating” Becomes an Overlooked Eating Disorder

What is orthorexia?

Why orthorexia may be missed

A fine line: health-conscious eating vs disordered restriction

Psychological and biological consequences

Assessment and early clinical signals

Beyond “clean eating”: pathways toward sustainable health

References:

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