Clinical research on orthorexia

Orthorexia started is medical as well as its cyberculture career as a descriptor for what Bratman thought was a pathological state he had himself achieved once he decided to self-medicate with food. His original “Health Food Junkie” article details how a mélange of alternative therapies and practices including yoga, vegetarianism and veganism, raw food diets, macro diets and others were recruited with righteous zeal in the quest for absolute health. However, this pursuit started claiming the whole of Bratman’s life: “The problem of my life’s meaning had been transferred inexorably to food, and I could not reclaim it”, he recalls. As a holistic and alternative healer, Bratman had wanted to avoid medication and overcome some minor health conditions through diet alone, but found himself beholden to a strict, obsessive routine, in which any transgression became a moral and spiritual calamity, to be atoned for with more punishing dietary restrictions. What had started as self-care had devolved into compulsive self-denial. Bratman eventually recanted his views after being gently led out of his self-inflicted regimen by fortuitous encounters with a series of spiritual leaders; subsequently, he started seeing the same behaviour in many others, especially in the alternative treatment communities he was a part of. He has since become much more sceptical of his own medical practices and regretted steering drug-avoidant patients suffering from easily treatable disease into orthorexic behaviour. -For example, one of his patients who successfully managed her asthma through to an increasingly strict elimination diet ended up worrying about food most of her time, to an extent that severely restricted or complicated her travel, and her social and private life; Bratman ruefully mused that perhaps taking regular asthma drugs might have given her life back, even if it would have compromised her naturopathic beliefs.

Bratman is, therefore, orthorexia’s patient zero—and one of its most zealous theorisers and popularisers through his book (Health Food Junkies, 2000), website (orthorexia.com), Twitter account and clinical articles (a coauthored clinical review on orthorexia in 2016). His story hit a nerve with the popular public, and the term “orthorexia” began to spread slowly through a burgeoning network of health-oriented websites and blogs in the early 2000s before it was eventually picked up mostly by European researchers and investigated as a viable diagnostic category. Bratman’s description of a dietary zeitgeist that pushes obsessive perfectionism in pursuit of the chimaera of health seems spot on. How did that, however, get taken up by clinical investigators? It is possible that clinicians recognised that the popular momentum was building toward recognising orthorexia as a new and distinct disorder and seized the opportunity to break new ground by giving it scientific recognition. Scientific publication practices favour, after all, pioneers—scientific scoops, so to speak. Internet culture contributes to the velocity of the information: speed and instantaneous access to information from all corners of the globe accelerate the uptake from popular to clinical literature, and, as we shall see, back to social media. Orthorexia transformed from a bon mot into a scientific concept through a series of (mostly internet-based) popular accounts that built up a critical mass of interest in and support of the concept.

To wit, one of the first and most influential studies on orthorexia, by Donini et al,9 cited copiously, alongside Bratman and Knight’s book, popular media, such as health and wellness websites (some of which are currently defunct or inaccessible in their earlier incarnations).10

The desire to eat healthy foods is not in itself a disorder, but the obsession for these foods, together with the loss of moderation and balance and the withdrawal from life caused by this food habit, can then lead to orthorexia. The causes of orthorexia, which are often hidden behind a very deep and seemingly attractive belief, may be found in the illusion of total health, with no pathological risks, the desire for total control of one’s own life, a latent conformism (“healthy eating” may be an alibi in order to follow the socially and culturally accepted terms of beauty, without having to confess a belief in them), the search for an identity and spirituality in eating behaviour, the belief that one’s own theories on eating are the best (social isolation).11

Donini et al thus extended the definition of orthorexia to a behavioural disorder rooted in a deeper social pathology (perfectionism, desire to conform, but also to feel morally superior, and desire to control one’s health) and which shares a lot in common with OCD-spectrum disorders. While Bratman and Knight had proposed some diagnosis criteria, Donini et al were the first to develop an instrument for diagnosing orthorexia—a questionnaire dubbed ORTO-15,12 which would yield an orthorexia score. Applied in its first incarnation by its developers, the instrument found that approximately 6.7% of the population is orthorexic; applied in a later study by a different team to a different population, it found an orthorexia prevalence of 57.6% in the general population (with a ratio of 2:1 women:men).13 Clearly, the instrument was deeply flawed. Both ORTO-15 and the original Bratman Orthorexia Test have been deemed to be of “poor methodological quality” due to the widely divergent cut-off points for the diagnosis and inconsistent results that pointed to a lack of basic validity.14 One persistent critique was linguistic and cultural. For example, it was pointed out that ORTO-15 was developed for an Italian sample, and the questions did not translate well (or rather, precisely enough). Indeed, the English version of the ORTO-15 includes many questions that point to a cultural confusion rather than to a pathological condition. For example, “When you go in a food shop do you feel confused?” or “Do you think that on the market there is also unhealthy food?” would prompt most honest test takers to answer “always” or “often”, triggering higher scores and therefore a greater likelihood to be classified as orthorexic. Nevertheless, ORTO-15 and its variants endured and became the de-facto standard for diagnosing orthorexia.15 The roughly 6%–7% prevalence for orthorexia among the general population proposed by Donini et al held up in other studies as well,16 but other researchers found a much higher prevalence among select groups such as, for example, Turkish medical residents17 or athletes among others.18

Efforts are underway to develop more refined diagnosis criteria, and studies and reviews continue to be published in various medical and scientific journals; recently, Bratman himself coauthored such a review and advanced more clear guidelines for the definition of orthorexia lined along two major criteria: (1) “Obsessive focus on ‘healthy’ eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy”; and (2) “The compulsive behavior and mental preoccupation becomes clinically impairing”.19 Other researchers dwell on the intersection between orthorexia, anorexia and obsessive-compulsive disorder, and postulate a high correlation between obsessive compulsive personality disorder and the likelihood of developing orthorexia. Perfectionism, anxiety, guilt over breaking “food rules”, pursuit of an idealised body image and obsession with food purity were found to be among the most salient points of intersection among these three conditions.20

Like other recently recognised eating disorders (eg, binge eating), orthorexia has been slowly working its way into therapeutic practice, if not into the DSM. A 2011 study found that about 25% of psychologists considered it a creation of the popular media, but 68% of them thought that it deserved more attention.21 Currently, a few DSM diagnoses would probably accommodate orthorexic symptoms under their umbrella: Avoidant/Restrictive Food Intake Disorder or ARFID, Other Specified Feeding and Eating Disorders or OSFED, and Unspecified Feeding and Eating Disorders. ARFID, typically diagnosed in childhood, is characterised by “avoidance based on the sensory characteristics of food, and/or concern about aversive consequences of eating”, leading to significant weight loss and dependence on enteral feeding or oral nutritional supplements, and “marked interference with psychosocial functioning” (DSM-5). Orthorexia may hit some of these notes, but it differs in motivation and manifestations; for example, ARFID sufferers are not typically “health fanatics”, as orthorexia sufferers purport to be. OSFED and UFED are characterised by “symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class” (DSM-5)—where the clinician may choose to specify (OSFED) or not (UFED) the reason that the patient does not meet the criteria for any other specific eating disorder. Orthorexia may fit under either of these diagnoses, but again, its particular characteristics as set forth by Bratman are lost.

Orthorexia was not the only term vying for a spot in the DSM-522 (other EDs that were also being researched but not recognised separately as a diagnosis include Night Eating Disorder, Muscle Dysmorphia and Emetophobia), but it has certainly been the one amassing more research than others, mostly in Europe and (sporadically) Latin American countries. The real growth in orthorexia studies came after the DSM-5 team stopped considering input. In fact, about 100 out of the 132 articles indexed in PubMed under “orthorexia” by mid-2019 have been published after 2013 (by contrast, there were only six listed in 2005).23 Quite a few of these articles are in languages other than English. One other issue that likely prevented orthorexia from being included in the DSM-5 was an absence of evidence for treatment. Unlike other psychiatric treatments driven by pharmaceutical companies (eg, for depression), eating disorders in general and orthorexia in particular are notoriously hard to treat, particularly via psychopharmacology. Indeed, none of the studies to date have looked at clinical interventions for orthorexia—rather, they are, by and large, observational studies.

Thin/healthy, anorexia/orthorexia

Orthorexia and anorexia nervosa share many similarities, and certain patient accounts claim that one can lead to another, or that they exist on a continuum.24 When it comes to gender distribution, however, it is harder to draw parallels. While anorexia is diagnosed predominantly (though not exclusively) in young women, gender appears to be a fuzzier factor in orthorexia. There may be several causes for this. First, given the aforementioned problems posed by the current diagnosis instruments, it is hard to reliably assess orthorexia prevalence in any population, let alone along gender lines. Second, in the studies already conducted (admittedly, methodologically flawed or using unreliable diagnostic instruments), it is difficult to discern a consistent gender pattern—in some, women appeared more likely to meet the orthorexia diagnosis criteria, while in others there was little difference between genders. That said, the orthorexia online confession genre (a subtype of the mental illness/eating disorder recovery story) is replete with women’s stories. Accounts written by men exist, but are notably rarer; more often, we find accounts about men (“My son/brother/patient suffers from…”).25 Other demographic criteria seem equally hard to pinpoint. While anorexia affects mostly white, young or very young, middle-class women, orthorexia seems a little less discriminating in terms of age and race as well, according to the studies to date, although the economic criterion (middle to upper class) appears relatively stable. This may have something to do with a cultural tendency to regard the confessional genre as an inherently “feminine” genre, especially when it comes to eating disorders. The gender distribution of orthorexic behaviours (and the prevalence of orthorexia in general) is, for now, an unresolved issue. It is perhaps of interest to note that other at-risk groups such as trans-gender youth26 or autistic people27 seem to have a higher incidence of eating disorders than the general population. While beyond the scope of this paper, these correlations suggest that there may be much more to explore in terms of eating behaviours and marginalised groups in terms of gender, sexuality or disability, with race remaining an unclear factor.

Orthorexia is similar to anorexia, bulimia or over-eating disorders (the classic triad of eating disorders) in that it shows the same preoccupation with food and a variety of anxious and stress-related behaviours. However, where the three major eating disorders display “a consistent disregard for bodily needs”,28 orthorexia, paradoxically, errs in the opposite direction: sufferers are too preoccupied with the exact micronutrient formula that would address physical deficiencies or improve bodily health. In order to properly distinguish orthorexia from anorexia nervosa, researchers (and Bratman in particular) have been adamant that the motivation for the restrictive eating behaviour must be health rather than thinness; however, in practice, these terms are hard to separate since in western culture, overweight is usually equated with ill-health and thinness with fitness and beauty. The confessed orthorexic sufferers have social media accounts filled with thin and glowingly fit bodies, and they sometimes admit that an implicit goal is an ideal (low) body weight. One recovering orthorexic recounts the praise she got for her diminishing size after she started a severely restrictive diet and explains it as follows: “Unfortunately, in our society, thin is congratulated. The word thin is packaged in more empowering language, with Instagrammers using candy phrases like ‘I am happy and grateful’. But they just want to look great in their bikinis. I got sucked up by Instagram, and couldn’t help but compare myself”.29

Usually, the dietary behaviour is also accompanied by an obsession with exercise—undertaken in the name of health and beauty alike; however, there is disagreement on whether excessive exercise fits into the orthorexic pattern. For some, it would belong among orthorexia symptoms, though Bratman disagrees.30 Whether accompanied by obsessive exercising or not, restrictive dietary rules made in the name of health are more acceptable than if made in the name of thinness. In a culture hyper-aware of the dangers of anorexia, “thin” is seen as an unacceptable motivation and oppositional to “health”—whereas in practice the distinction might be indiscernible.31 Moroze et al describe the case of a 6′2″ tall man who weighed only 100 lbs at the date of hospitalisation, and who received an informal orthorexia diagnosis (and an official, DSM-sanctioned one of ARFID); the patient declared to be interested in “treating my body like a temple and giving it the pure building blocks it needs”.32 He was aware that he was too thin, but rejected the implication that his diet was deficient: one can argue effectively against thinness as an ideal, but not against health. Most orthorexics report experiencing similar self-reported magical thinking about food: a careful elimination diet would be a cure-all for everything from a vague sense of unease, to allergies, to cancer. The benefits are elusive, as the bar is always moving: it is the dieter’s fault for not strictly adhering to the regimen. An anonymous contributor to a blog on orthorexia writes: “Researching food consumed me. I went to see a naturopath who cut out every potential allergen from my diet. I can tell you logically that I do not have a food allergy, because I did not see a huge improvement. But don’t worry, there are lots of people online who say that I should have done it longer, I still needed to cleanse, I didn’t do it right, etc. There is still enough room for doubt that I didn’t do it perfectly, that I can allow myself to continue to do it”.33

Media and the spread of eating disorders

The rise of anorexia has been linked to the focus of fashion magazines and the fashion and entertainment industry on excessively thin models or actresses. While underlying causes of eating disorders are indeed complex (eg, trauma, environmental stressors, comorbidities with other conditions, etc), media’s popularisation of messages such as “healthy is the new thin” aids in the cultural contagion (what Brumberger once called “psychic epidemics”34). Health is a “collective sociocultural product” that provides what Horwitz calls a “script” shaping, justifying and legitimising illness.35 Horwitz (2002) proposed a “structuring perspective” for understanding mental illness, which “emphasizes how cultural forces, not the unconscious or underlying disease entities, are associated with the overt symptoms of mental disorders”.36 From this perspective, anorexia is a response to the cultural constructs of a particular society at a particular moment in time: “The emphasis on thinness as an attribute of female beauty that motivates eating disorders can only structure obsessions and compulsions in modern Western societies where the negative consequences of excessive food consumption are an issue”.37 Horwitz, invoking Brumberg (1992), believes that media can “precipitate the spread of eating disorders”.38 Brumberg had indeed traced the contours of a “psychic epidemic” in which anorexia was spread via popular accounts of the disease, celebrity biographies, memoirs, women’s magazine articles, but also via the “mass-market weight control industry” and oral lore. She argued that “food and diet are the arenas in which affluent young women in the postindustrial world work out struggles for autonomy and identity, connection and control” and that “the current cult of diet and exercise is the closest thing our secular society offers young women in terms of a coherent philosophy of the self”.39 And more recently, Kravetz has made a compelling case in Strange Contagion that the spread of bulimia nervosa, a disease unheard of before 1972, was due to the zealous popularising of early research on the topic by women’s magazines and TV reports, combined with the relentless glorification of thinness and appearances in general, creating “a perfect storm of catchable body image standards”.40

Indeed, by the early 2010s, there are more and more popular reports about orthorexia as a “new eating disorder”—both in print and in social media (the latter aided, no doubt, by Bratman’s own quite active Twitter account). Time wrote about the losing battle to integrate orthorexia into the DSM, a report that was later picked up by Self magazine (2011). Citing only the Time report and Bratman’s article and book, Self nevertheless provided a symptoms checklist (from Bratman and Knight’s book) to its readers so they could figure out whether they were at risk. From there, orthorexia slowly percolated into social media and became a hashtag. Thus, the uptake of the concept from the medical community to the individual internet user is also mediated via popular media.

The initial response to the concept on community forums, Twitter and Instagram was sceptical, coming from the position that orthorexia is an invention, a made-up word meant to excuse the unfit, overweight masses devoid of willpower and shame those determined enough to achieve their health and fitness goals. A whole thread on a bodybuilding forum in 2006 is devoted to poking fun at the concept (“yea man… i can't stop eating healthy!!! HELP!!!”; or: “should i medicate myself with milkshakes and six dollar burgers?”).41 Many of the earlier tweets about orthorexia express the same type of doubts:

Dr. Funke: @ocdla story on #Orthorexia seems like an eagerness to pathologize (24 Mar 2011)

Yana Faykina: Apparently #eating #healthy is now termed as #orthorexia and considered a #disease! LOL (26 Apr 2011)

The turning point in the orthorexia story arc occurs in 2014, when popular Instagrammer and blogger Jordan Younger, aka “The Blonde Vegan”, confessed to being orthorexic. Younger detailed her struggles with this eating disorder in her 2015 memoir Breaking Vegan. Younger figured out her diagnosis at the prompt of a therapist who gave her Bratman’s article to read. Her announcement that she would quit veganism in order to recover from orthorexia produced an uproar among her Instagram and blog followers; subsequently, her story was reported in numerous major media outlets, including TV, newspapers, and numerous health websites and magazines. Bratman himself wrote an endorsement and preface for the memoir. The case provided vindication for Bratman and the early adopters of the diagnosis, and fed back into the clinical literature. In the introduction to a scientific review that Bratman and Dunn wrote for Eating Behaviors in 2016, they explicitly refer to Younger’s case and the media amplification effect:

The public’s awareness of this condition began changing in the summer of 2014. This is when a young woman in New York named Jordan Younger, author of a highly successful blog called “The Blonde Vegan”, surprised her 70 000 Instagram followers by admitting that she suffered from an eating disorder that was not based on the quantity of her food intake, but its quality…. Younger reported that her drive for healthy eating had become pathological and resulted in malnutrition. Major media outlets reported her plight and she was interviewed on programs like ABC News’ Good Morning America and Nightline programs (J. Younger, personal communication, April 9, 2015) inspiring a flurry of other media coverage, such as articles in the Wall Street Journal and Popular Science […]. It is remarkable that this kind of media coverage has been generated for a condition not recognized by the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) and not well understood [emphasis mine]. (p. 12)

The coverage was remarkable, indeed. The popularity of this story appears to breathe life into orthorexia research on the clinical side, and particularly in the confessional stories on social media (see, eg, Hemshaw, 2015; Oksman, 2015; Farhoud, 2017; Matthews, 2017; Chalmers, 2017; Fasanella, 2018). Starting around the same time as Younger’s case, health, food, and fitness instagrammers or bloggers seem to come out in larger numbers as orthorexics, now that they have a name for their more or less subtly disguised obsessive food behaviours. Many of their stories seem still novel and have enough “shock” value that they merit detailed media coverage, in an effort to inspire recovery in others. My informal Twitter survey of #orthorexia hashtags shows that the early (2010s) negative/sceptical perceptions of orthorexia are on the wane after 2015. The debate about the existence of the concept of orthorexia seems increasingly tilted toward “yes”. Even in stigma, orthorexia seems to have caught up with other eating disorders (a dubious honour): a recent study showed that orthorexia elicits by the same type of negative stigma that surrounds anorexia and binge-eating disorders (Simpson and Mazzeo, 2017). On occasion, the authors of this study remarked, orthorexia can trigger even more negative attitudes than other eating disorders, as it is considered more likely to be self-inflicted, and thus a result of a correctable weakness on the part of the sufferer.

Orthorexia and the digital ecological niche

The media ecology I previously described can be better understood by employing Ian Hacking’s concept of “ecological niche” that can give rise to transient mental illness, developed in Mad Travelers (1999). “When is traveling mad?”, Hacking asks in his exploration of “traveling madness” or hysterical fugue—a short-lived psychiatric syndrome characterised by the patient’s sudden urge to abandon their homes and travel for long periods of time, usually in a trance-like state. Similarly, we may ask, When is eating mad? Sure, anorexia and bulimia may be characterised as “mad eating”—disordered eating patterns leading to the wasting and deterioration of the body. But when does healthy eating become—well, its very opposite?

To explain the mental illness once known as fugue, dromomania or “ambulatory automatism”, Hacking employed the concept of an ecological niche, characterised by “four principal vectors”: “medical taxonomy, cultural polarity, observability, and release”.42 In other words, the new diagnosis has to fit on a nosological continuum (in the fugue’s case, hysteria and epilepsy) and on a cultural continuum (“between romantic tourism and criminal vagrancy, one virtuous, one vicious”).43 It also had to be observed as a phenomenon, and to offer some sort of psychological release to the affected: “Fugue was a space in which dysfunctional men, on the edge of freedom yet trapped, could escape”.44 Mutatis mutandis, orthorexia nervosa exists on a continuum of eating disorders (anorexia, bulimia, OSFED and ARFID) and, just as importantly, between two opposite cultural poles: healthy and unhealthy eating, both actions that have acquired moral significance (healthy eating is a virtue, eating junk food or neglecting to eat a “balanced diet” is a sin). Orthorexia has been observed, measured and documented in a variety of populations, and it offers the affected an acceptable way to achieve a socially acceptable appearance and status (with health trumping thinness in terms of motivation). Orthorexic behaviour comes with some benefits: it offers the affected a way to achieve virtue through a socially acceptable behaviour conferring benefits in terms of appearance and status. Anorexia becomes socially unacceptable because it cultivates an extreme and unhealthy thinness; orthorexia is socially acceptable because it cultivates, or rather, it performs healthy behaviours (including, often, thinness). Furthermore, it may offer relief and order in a cacophony of choices and dietary regimens competing for our attention, or temporary relief from physical ailments that the orthorexic believes respond to diet.

The emergence of orthorexia occurs in the context of an exploding “wellness” industry broadly defined—which includes health and fitness gurus, alternative therapies, online health magazines, companies and blogs, and myriads of social media accounts of perfect bodies, vibrant meals and “wellness” inspiration. Recall that Hacking’s second ecological niche vector had to do with cultural polarisation. Indeed, we live in a world where eating habits are polarised: the extremes of “clean eating” now seem to counterbalance the “junk food” trends that drove American food consumption for several good decades and that are currently vilified in the press as well as in scientific literature. The “clean eating” revolution is intensely amplified by the digital revolution. We are awash in digital wellness, as Silicon Valley is driving the “appification” of health and “disrupting” the healthcare industry. What that means is that for every aspect of our well-being broadly defined (disease, diet, exercise, mindfulness—in and by themselves culturally constructed categories), we are likely to find a multitude of websites, blogs, social media accounts, apps and gadgets that will “guide” our search for “wellness”. In terms of dietary advice alone, the amount of information on what, how, when, or even where or why we should eat abounds; as is characteristic of the majority of such information, it is only occasionally vetted or supported by credible, sustained evidence.

In all fairness, government-mandated nutritional guidelines and medical and nutrition science in general have at least partially surrendered their credibility as new science tends to contradict old guidelines—for example, the old recommendation that we eat “fat free” foods to prevent heart disease might have led, according to some accounts, to an over-reliance on high-sugar, low-fat foods, which precipitated weight gain and an epidemic of obesity and related metabolic diseases such as type II diabetes. Our institutions of higher learning and the food industry have helped research and develop a multitude of highly processed foods which, while satisfying and with a long shelf life, also accelerated the obesity epidemic and promoted, in some people’s view, a variety of social ills in the name of convenience (for example, the over-reliance on fast food and TV dinners was blamed for the erosion of the rituals of the home-cooked meals, which had been seen as strengthening social cohesiveness). In the wake of new and contradictory evidence regarding the value of nutrients in maintaining health, the famous “food pyramid” promoted by the USDA has crumbled, and it seems that no replacement (such as MyPlate) has had staying power so far. No wonder, then, that regular persons wondering how to eat healthy would turn for guidance elsewhere.

Against a backdrop of systematic failures of industry and science, a digital industry of food advice has flourished. Exploiting knowledge and need-based gaps, digital entrepreneurs, from run-of-the-mill bloggers to mega-celebrities like Gwyneth Paltrow, launched (mostly) earnest efforts to educate and “empower” consumers, and make an honest profit as a result. User-driven forums, collectives and communities have also been eager to offer a platform for sharing advice, judgement and encouragement. The rhetorical appeals of such sites are extremely compelling: who doesn’t want to eat “clean”, “pure” foods, and feel energised, better than well? The discursive uptake of “clean eating” concepts is deeply internalised in the ex-orthorexic confession genre. Daniella Isaac, former health and food blogger, explicitly draws the line between “googling” and her own orthorexia: “… I began looking into clean eating, reading blog posts online and popular books. I read Deliciously Ella’s story about having an autoimmune disease like me, which she cured by changing her diet, so I related to her. I cut out sugar, dairy and my gluten free substitutes like bread and pasta. I remember Googling ‘what does Miley Cyrus eat?’ Apparently she is free from everything, so I thought, ‘great, I’m doing it right!”45 She is not the only one to cite blogs and other social media accounts as a portal for orthorexia, and like many others, she shared her diet and habits, as well as her recovery, via social media.46 “I felt proud, getting validation from the amount of likes on my photos on Instagram”, Isaac recounts.

Before Web 2.0 offered platforms to health and wellness seekers and purveyors, Nikolas Rose wrote presciently about this new regime of expert self-surveillance in the name of health: “In the new modes of regulating health, individuals are addressed on the assumption that they want to be healthy, and enjoined to freely seek out the ways of living most likely to promote their own health”.47 There are many examples of digital health entrepreneurs who transformed their dietary counter-expertise into very lucrative franchises (eg, Vani Hari aka The Food Babe, David “Avocado” Wolfe, Belle Gibson, Freele “The Banana Girl”, etc).48 While mainstream health and fitness magazines also spread plenty of food advice, it is the enormous free platforms offered by social media that are key to these health gurus’ success. This “digital wellness” proliferation is no mere fluke in the context of eating disorders. Researchers have long recognised the role of media—and multimedia in particular—in perpetuating eating disorders as a lifestyle.49 Robin Jensen, writing in 2005 (on the cusp of the Web 2.0 revolution), analysed pro-anorexia and bulimia websites in order to establish how they use narratives and imagery built on popular, well-established appeals media: images of thin celebrities, popular health campaigns and Christian myth. Jensen calls these tactics (meant to promote anorexia as a conscious, personal choice) “lifestyle imagetexts” which “demonstrate that, although the mainstream position is that eating disorders are diseases to be cured, much mainstream discourse implies the opposite, that eating disorders are not diseases but reasonable choices”.50 This argumentative tactic makes anorexia seem socially acceptable—and, as it turns out, also makes orthorexia seem acceptable (as evident in Isaac’s example above—“What does Miley Cyrus eat?”). In a media landscape replete with appealing images of toned, fit celebrities, a growing visual food culture (including ubiquitous instagrammed lunches and cooking shows), and permeated by the imperative to “take control of one’s health”, there is no shortage of models that one may follow down an orthorexic path. Where the successful blogger or instagrammer (like Younger) engages in the performance of health online, her tens of thousands of followers engage in the “performance of similitude”.51

The role of visual culture in the “viral” replication of orthorexia has been confirmed by a recent study by Turner and Lefevre (2017),52 who found that the prevalence of orthorexia is much higher among social media users—49% of the Instagram users they surveyed were found to scale high on the ORTO-15 scale. Instagram, which they call “the platform of choice for the healthy eating community”, was by far the medium most likely to have that effect compared with other social media platforms such as Twitter. The authors explained these results through the “image-focused nature of Instagram”, which presupposes images are more memorable than words in the context of food, the selective nature of the medium (once you decide to follow a particular type of account, you will be more likely to be exposed to the same type of content—eg, health bloggers) and the “celebrity” effect in that those with the “most liked” content will be regarded as health authorities.

Orthorexia nervosa and its many proposed avatars (among which are healthy anorexia, organorexia and nutrichondria) could be subsumed under the umbrella of cyberpathies, spread through the “viral” content of popular blogs and Twitter, Facebook and Instagram accounts. An alternative term that has been proposed is “cyberchondria”, which Stone and Sharpe describe as “the excessive use of internet health sites to fuel health anxiety”53; but that implies that orthorexia is on a par with hypochondria, which is to say, fake, not real, “all in one’s head” (a phrase that can only be uttered with irony). But even imaginary diseases may cause suffering—or rather, can be experienced as suffering. Phenomenologically, orthorexia seems real enough, even though it may be culturally bound and may have an upcoming expiration date. Its digital transmission, so to speak, has already been prefigured by Elaine Showalter in her book Hystories, 54 where she suggested that illnesses can be spread in the form of pathogenic ideas over the internet. As a cyberpathy, orthorexia lures the digital flâneurs in search of non-conventional health advice and colonises their imagination with promises and cajoling, micronutrient formulas and “biohacks”, and aspirational/inspirational content. Memes, pictures of “healthful” and colourful meals and tan, muscular bodies in yoga poses, enthusiastic product endorsements, and sage dietary and living advice proliferate in uncontrollable, unknown numbers, evangelising the populace into the Gospel of Health.

That orthorexia can be propagated so widely now is, therefore, a function of the cyber-zeitgeist. Instagram and other social media channels can be both vectors of transmission and of recovery. Younger, for example, has an active presence online through her blog and Instagram account and also through Facebook, Twitter, Snapchat, Pinterest, YouTube, a podcast and a smartphone app. To add to Hacking’s concept, we can say that orthorexia as cyberpathy emerges from a particular digital ecological niche enhanced by Web 2.0’s system of social influence and the digital entrepreneurial economy. In many cases, orthorexia (just like anorexia, perhaps) becomes a public performance, coming to life in digital form on lively social media accounts—while the orthorexic’s body and actual social life withers IRL—(in real life). Online forums impart advice, judgement and blame (which is, according to the logic of healthism, always on the individual). All is done in pursuit of health as a socially normalised imperative that individuals strive to achieve while maintaining ideals of “purity” (ie, natural, organic, clean) situated at the polar opposite of those embodied by modern mass culture (ie, artificial, toxic, junk). The underlying ideology of orthorexia is, thus, healthism.

Healthism and orthorexia

Orthorexia as a “pop psychiatry” diagnosis appears to be a pathological manifestation of “healthism”,55 a belief that holds the individual responsible for his or her own health, thus neglecting the multitude of forces outside an individual’s scope or power that can influence one’s health: socioeconomic status, genetic factors, environmental and work-related factors, accidents, and so on. Healthism underscores western neoliberal practices focused on the individual’s duty to maintain his or her own health; conversely, disease is often something that can be blamed on the individual who did not scrupulously adhere to those practices. To be not just healthy but healthier than healthy, the neoliberal citizen must stay vigilant and informed in regard to the newest health developments, have infinite therapeutic choice (hence, the proliferation of “alternative” health regimens), and be highly suspicious of conventional science and medicine—hence, seek and trust “natural” or folk remedies and pseudo-spiritual schemes.56

I have mentioned the term “alternative” several times already and while the constraints of this paper do not allow for a more thorough criticism of the concept, I must at least point out that alternative food therapies have long been hailed as preventative medicine; but if “alternative movements” had started as a rejection of conventional status quo and sometimes as a social justice solution, they often turned into a consumerist endeavour.57 Kim Q Hall describes the “alternative food movement in the United States” as “a neoliberal hygienic eating project fixated on the achievement of virtue, health, and good citizenship through appropriate consumer choices at the table”.58 Under the imperative of health, it is one’s civic duty to “learn” or “be informed” about alternative ways of healing, and to—or as Nikolas Rose pointed out, “the citizen as consumer is to become an active agent in the regulation of professional expertise”.59 Hall also points out the ableist implication of this neoliberal project since the idea that one can achieve “perfect health” through nutrition ignores the fact that those living with chronic illness and disability will never, by definition, achieve “ideal” health: “[…] the alternative food movement tends to present disability and the end of the heteronormative family meal as signs of the harm of the industrial food system and, thus, perpetuates ableist, heteronormative, and gendered assumptions about good lives and good food”.60 While time does not permit a full exploration of this idea here, it seems quite plausible that similar ableist assumptions lie at the core of orthorexic behaviours.

Healthism’s cornerstones are personal and personalised care regimes of the self, an inwardly oriented ethics in which the self is the main client and beneficiary of carefully curated food fads, fitness cults and spiritual practices (eg, fat free, sugar free, gluten free, paleo, raw, keto, vegan, hot yoga, crossfit, etc). Toxins abound and multiply in the world of conventional industry and medicine (healthism can be conventional drug-avoidant, though other non-conventional drugs and substances like alcohol can be occasionally rationalised); therefore, the body must be cleansed or detoxed regularly—practices which, no matter how thoroughly debunked by science (a functioning liver is all you need to “detox”), show no signs of going away. There are, of course, legitimate concerns and legitimate critiques of junk food, unhealthy habits (eg, smoking) and so on—but healthist zeal swings the pendulum far and wide, creating a series of artificial binaries, such as natural/chemical, organic/GMO, clean/junk, whole/processed, authentic/artificial.61 Impurity, therefore, contributes to a host of bodily and spiritual diseases among which are obesity, depression and anxiety.62 In a study involving anorexia and orthorexia sufferers in Australia, Musolino et al argue “that orthorexic practices are embodied enactments of care, in which implicit ethical values are endlessly tinkered with” (2015, p. 19). Orthorexia is embodied habitus: it demands control over the body, and it has fluid borders and protean manifestations. It relies on the tropes of “natural”, “pure”, “raw”, “vegetarian/plant-based” and “real”,63 and uses restriction as a moral imperative to achieve that pure state. Dietary choices end up equating moral choices; the dieter’s adherence to the diet is a test of his or her character, moral fibre and rectitude; any deviation from it is felt as a failure and induces feelings of guilt, remorse and worthlessness.

The ultimate shield against real or potential disease incubating in an impure, flawed world is purity. The orthorexic will eliminate harmful or potentially unsuitable substances from the diet, according to a logic that shifts with the winds of the food faddism du jour; hence, the obsession with cleanses, juices, veganism, or raw and organic food. On one level, this betrays magical thinking. On another, it is a fool’s errand. Alexis Shotwell64 argues passionately against this type of purism, writing that “personal purity is simultaneously inadequate, impossible, and politically dangerous for shared projects of living on earth”.65 Her critique of healthism (which, in an interview, she calls “a purity politics of despair”66) aims at its individualistic solutions for problems that are social and global in scope and cannot be solved with “personal” choices. Using the trope of energy, Shotwell shows that the level of purity that some proponents of “pure” foods claim to abide by is a mere illusion: energy—either in the form of electricity or the form of food that fuels our bodies—is produced by a complex entanglement of natural and human factors, requiring no small amount of destruction and creation, suffering and joy. Let’s take the case of veganism, for example, one of the diets readily adopted by orthorexics as it seems to fit the restrictive ideals they strive for. Even the strictest vegans, Shotwell reminds, consume food produced through muted cycles of animal suffering: many bugs, earthworms, and other creatures are routinely displaced, mutilated and killed during any crop cycle, to say nothing of the back-breaking and underpaid manual labour of the agricultural worker who picks, washes and packages our lettuce, or the fossil fuels burnt during the transportation of that lettuce. Nothing we consume is cruelty free (or rather, free of suffering, as Shotwell puts it). Is the life of an earthworm killed in the process of harvesting worth less than that of a cow? Antispeciesist vegans would be hard-pressed to answer that question. In general, food, like the world itself, is never “pure”—and “purity” itself is a negotiated term with no fixed boundaries. “If we orient toward eating as though we can personally exempt ourselves from ethical and physical ill-effects, we’re engaging in a perpetually failing purity project”, Shotwell writes.67 She argues instead for embracing the messy entanglements in which we find ourselves as living, breathing, ingesting and excreting bodies: allowing ourselves to feel joy in such interconnectedness rather than chase the pernicious ideal of purity. Thus, orthorexic ideals of pure food are, at best, a mirage. To note, the idea of diet as a mirror of character is also, to a large extent, present in anorexia; purity is sought either by denial of food (in anorexia) or by selecting only “pure” foods (orthorexia).68

Orthorexia is a disorder of excess but also of confusion in the face of excess. It is a disorder of abundance and rigidity, and also a disorder of privilege, both relying on and generating costly practices, usually accessible only to the well-off (cleanses, organic juices, gym habits, etc). As Juliane Cheek remarked, being healthy in the context of healthism does not simply signify the absence of disease, but an enhanced state of being (“wellness”,69 perhaps?) that engages a variety of “lifestyle choices and technologies that once would have been considered at the periphery of health, if indeed part of it at all”.70 Thus, healthist behaviours constantly push the boundaries of what is considered healthy; at their extreme, these sophisticated dietary practices and complex exercise regimens achieve the opposite of health.

The Blonde VeganBalanced Blonde: a study in healthism and orthorexia

It was Younger’s memoir Breaking Vegan: One Woman’s Journey from Veganism, Extreme Dieting, and Orthorexia to a More Balanced Life 71 that pushed orthorexia to the forefront of social media and by all accounts is responsible for the rising awareness of the disorder. Media coverage of her case seem directly correlated with a spike in the use of the hashtag “orthorexia” on Twitter (from 224 and 652, respectively, in 2013 and 2014 to 1615 in 2015).72 Bratman wrote its preface and featured Younger’s case prominently in the review paper he co-authors on this topic (Dunn and Bratman, 2016). The book is notable also for the way it redefined veganism as an eating disorder (which occurs in the title: veganism is something she needs to “recover” from); her announcement spawned heated debates within the vegan community and most popular media framed her story as an “ex-vegan” story (rather than an eating disorder recovery story). Finally, the memoir is a textbook example of the commodification of healthism. Younger is a master marketer and she is the main product that she is selling—her image, her practices, her words, her diets, her exercise regimen.

Following a path that had already been prefigured by Bratman in the original orthorexia essay, Younger’s orthorexic behaviour started with a desire to improve her well-being—she had apparently always suffered from unspecified digestive issues. As her first juice cleanse left her feeling pure and healthy, she decided to become a vegan and share her experiences with the world via blog and Instagram, both of which were wildly successful—so much so that she c0uld make income selling ads as well as yoga apparel and cleanses on her site. Her memoir reveals that behind the smiling Instagram façade she was consumed with guilt over her food choices and could not enjoy time with family or friends. Moreover, she flirted with extreme cleansing regimens and other food fads that left her depleted and hungry. After a period of vague stomach complaints, she broke her vegan routine with a piece of salmon and never looked back. Younger describes “coming out” to her “Blonde Vegan” community as terrifying—and indeed, the backlash was immense. She lost a lot of followers, and she claims she received death threats for her change of heart. Buoyed by the sympathetic response of the media and her book deal, Younger moved from New York back in her native California where she continues to blog, podcast and practice yoga.

In talking about her body, Younger very deliberately describes a feeling of being dissociated from it: the theme of “listening to the body” is a constant hum throughout the book. Evidently, the body is a project distinct from self, one that needs to be tamed, remedied, controlled, always in an antagonistic relationship with the disciplinarian self. This dissociation seems to be a requisite of food-centred healthism, and it has been commented on extensively in feminist scholarship: “A diet-centered life requires a divided position toward one’s embodiment”, writes Talia Welsh.73 When Younger stopped menstruating, she failed to see this was a clear signal from her body that something was wrong; conversely, when she finally decided to listen to her body, she realised that her vegan diet was never for her in the first place.

We get little sense of who the “real” Jordan Younger is throughout the book, other than her constant struggle to achieve health (and, we sense, beauty, fame and financial success). Younger is a digital entrepreneur and citizen-consumer turned health expert despite the fact that, like many other similar figures, she has no medical or nutrition training. Rather than being a subject, she is what Byung-Chul Han in PsychoPolitics calls a project, borne out of the neoliberal pressure to improve ourselves, and disguised under the cloak of “freedom” to choose (we should remember that “alternative” food, medicine, etc also appeal to us because they offer us choices and apparent freedom from the conventional industries of food and health):

Today, we do not deem ourselves subjugated subjects, but rather projects: always refashioning and reinventing ourselves. A sense of freedom attends passing from the state of subject to that of project. All the same, this projection amounts to a form of compulsion and constraint—indeed, to a more efficient kind of subjectivation and subjugation. As a project deeming itself free of external and alien limitations, the I is now subjugating itself to internal limitations and self-constraints, which are taking the form of compulsive achievement and optimization.74

Younger is in a continual quest to improve herself, or, rather, her body. However, this is not the desire to live a good life, but one for self-optimisation, which, according to Han, “follows from systemic constraints—from the logic of quantifying success on the market”.75 Younger is an “entrepreneur of the self”. Byung-Chul Han describes this position as logical consequence of neoliberalism: “As a mutant form of capitalism, neoliberalism transforms workers into entrepreneurs. […] Today everyone is an auto-exploiting labourer in his or her own enterprise”.76 Younger, like Gibson, David Avocado Wolfe, Vani Hari and the legions of social media “influencers”, participates in a form of “unlimited self-production”77 which dictates that they engage in mostly transactional relationships with others. The digital health entrepreneur has followers rather than friends. Han defines freedom itself in terms of friendship, pure and non-transactional; when one makes “friends” in order to garner “likes”, the relationship is no longer free or non-exploitative.78 Social media becomes a dispositive of transparency in the service of this type of self-exploitation.

Younger displays the “classic” orthorexia obsession with cleanliness, cleansing and purity, and documents her rigid rituals faithfully. Any break with protocol triggers feelings of guilt and uncleanliness. Her description of the elation she felt when she cleansed or she felt a “pure” feeling in her stomach are reminiscent of anorexia symptoms (and in fact she is accused by the vegan community of lying about anorexia and needlessly blaming veganism for her problems). Eventually, Younger admitted she had an eating disorder (to the surprise of no one in her circle of family and friends) and found a name for it with the help of a therapist: orthorexia. Curing it required, apart from a few chemical adjuvants, more embodied practices, which are documented on her new blog, The Balanced Blonde. 79 The current blog’s focus the remains food and fitness, and many entries seem to advocate a milder, friendlier form of orthorexia repackaged as “balance”. If orthorexia is obsession with health/eating right, it is unclear how her current practices are anything less than that.

Younger spends some time in the memoir detailing her feelings about veganism and deploring the responses she got from the vegan community. This conflict is revealing in and by itself regarding the general attitudes towards veganism, though it is slightly beyond the scope of this paper. For now, let me acknowledge that there are plenty of bad, pseudoscientific arguments for veganism and plenty of serious, ethically grounded arguments for it. The former type of arguments are colonised by healthism and its host of usual suspects: emphasis on pure, organic, “whole” foods, pseudospiritual claims about the benefits of eating “life” (=plants) versus eating “death” (=dead animals), belief in alternative, pseudoscientific practices, and cherry-picked evidence that veganism is the fountain of all health, preventing and even curing cancer, diabetes, heart disease and a host of other ills. These are the types of claims that Younger’s severely restrictive diet was based on. The latter type of arguments are animated by social justice and fairness, an emphasis on the welfare of animals, environmentalism and antispeciesism. Younger denouncing her veganism was perhaps necessary on her path to recovery; however, this abandonment of vegan principles and her implied equation of veganism with an eating disorder proved to the vegan community that the main topic of concern for Jordan Younger was Jordan Younger, rather than common vegan concerns such as saving the planet or justice for animals.80 In that, vegan critiques of Younger’s enterprise seem to be on target. In fact, some recent work in critical animal studies has interpreted orthorexia as an attempt to pathologise veganism (Taylor, 2011; Stănescu and Stănescu, 2018).81 The healthist enterprise is ultimately a solipsistic enterprise. As an entrepreneur of the self, Younger’s practices revolve around monetisation—of her blog and of her audience. Perhaps nothing captures this feature better than the title of Younger’s next book: Going Viral: A Guide To Becoming The Boss Of Your Own Life, & Turning Your Blog Into A Business. The pursuit of health online can be profitable, but it can only be achieved by viral replication into the body digital, and through the commodification of the self.

Conclusion: orthorexia as transient mental illness and cultural pathology

If you don’t have your health, you have nothing, the saying goes. But, conversely, or perhaps perversely, one who only has health would also have nothing in terms of lived life. Devoting our time on earth to the single-minded pursuit of health reduces one’s humanity to a mechanistic, dissociated view of the self, and denies the potential richness of life. Health is a sum zero game. “Health”, writes Byung-Chul Han, “represents the ideal of bare life”.82 When we fill our lives with the obsessive pursuit of health—through whatever flavour of purity and ascetic self-control captures our imagination, we opt out of the messiness, entanglements, and complex relationships that form the embodied, rich experiences of life (as per Shotwell); we swap richness for sanitation, eschew adventure for bottled formulas, commodify our relationships with self and others. In effect, we opt for “bare” or empty life: a closed, regimented system that cannot be open to being in the world. Pursuit of health as both prerequisite and goal is, of course, also ableist and classist (with racist and eugenicist roots83); similarly, in Against Health, Metzl makes a convincing argument that health “is a term replete with value judgments, hierarchies, and blind assumptions that speak as much about power and privilege as they do about well-being”.84 Pursuit of absolute health is also reductive, reliant on a version of body-as-machine; to compensate for the soullessness of the machine, we are often offered corporate pseudo-spirituality in the form of yoga/wellness programmes or techno-mindfulness through meditation apps. As long as we keep consuming in order to “improve ourselves to death”,85 we lose track that there should be something beyond the flat ceiling of health. “If a horizon of meaning extended beyond bare life, the cult of health would not be able to achieve this degree of absoluteness”86

Orthorexia is an apogee and blind spot of the cult of healthism. It empties out the sufferer and turns to consumption of “pure” foods as solution; it also reinforces an isolating, quasi-solipsistic view of health and fulfilment that eschews critiques of the larger social contexts determining health and illness. Bratman, the “original” recovering orthorexic, wrote, “Perhaps most dismaying of all, I began to sense that the poetry of my life had diminished. All I could think about was food”.87 Under the unexamined imperatives of health, purity and freedom of choice, in the age of social media, and under the reign of alternative food regimes, those who are privileged and abled enough are always susceptible to some form of orthorexia. It is less relevant at this point to wonder whether orthorexia is a “real” mental disease (nor is it helpful to reopen the debates about the reality of mental illness in this context). What is more relevant is that the behaviours described under its umbrella are real and have real consequences. Its future medical classification status notwithstanding, orthorexia as a cyberpathy filling a neoliberal ecological niche is relevant as a contemporary cultural pathology colonising our healthist habitus.