Coronavirus anxiety linked to obsessive healthy eating behaviors during the pandemic

New research suggests that anxiety about COVID-19 may have contributed to the development of orthorexia nervosa—an unhealthy obsession with eating “clean” or healthy foods—among adults in the United States. The study, published in Psychological Reports, found that people experiencing high levels of coronavirus anxiety were more likely to report symptoms associated with orthorexia nervosa. In addition, people with lower cognitive flexibility—a psychological trait that helps individuals adapt to stress—were more vulnerable to these symptoms when anxiety was high.

Orthorexia nervosa is a term used to describe a disordered eating pattern marked by an intense, obsessive focus on eating foods perceived to be healthy, pure, or “clean.” Unlike other eating disorders that often revolve around body image or weight loss, orthorexia is primarily driven by the desire to achieve perfect health through dietary control. While eating a balanced, nutritious diet is generally beneficial, orthorexia goes far beyond this.

People with orthorexia may follow rigid food rules that eliminate entire categories of food they view as unhealthy. This might include avoiding anything processed, cutting out carbohydrates, or insisting that all food must be organic, unrefined, or free from additives. Over time, these dietary rules become increasingly strict, and breaking them may lead to intense guilt, anxiety, or shame.

What distinguishes orthorexia from simply wanting to eat well is the degree to which the behavior interferes with daily life. Individuals with orthorexia may spend an excessive amount of time planning meals, researching food sources, and worrying about contamination or imperfection in what they eat. These behaviors can lead to malnutrition, social isolation, and significant psychological distress.

“My interest in orthorexia nervosa stems from the fact that it’s a significantly understudied eating disorder, despite affecting many people who become obsessively preoccupied with ‘healthy’ eating,” said study author Niki Hayatbini, a postdoctoral scholar at the University of Washington’s School of Nursing and Health Studies. “What’s particularly fascinating is that orthorexia often gets overlooked because society tends to view the pursuit of healthy eating as admirable and beneficial, which can mask the underlying psychological distress and functional impairment that individuals actually experience.”

“I became interested in understanding how cognitive functions might contribute to the development of orthorexic symptoms. The limited research on orthorexia—especially regarding cognitive functions like flexibility—presented an exciting opportunity to contribute meaningful knowledge to this field and help fill important gaps in our understanding of this eating disorder.”

The COVID-19 pandemic presented a unique context in which health-related anxieties were widespread and deeply personal. Millions of people faced daily concerns about infection, illness, and death. Previous research has linked anxiety disorders with various eating disorders, and many patients with disordered eating also report high levels of anxiety. The present study set out to explore whether a specific form of pandemic-related anxiety—coronavirus anxiety—was associated with orthorexia symptoms.

Coronavirus anxiety, unlike general concern about COVID-19, involves distressing and often debilitating physiological and emotional reactions to the threat of the virus. Symptoms may include panic-like sensations, obsessive worry, and sleep disturbances, all centered around fear of infection. The researchers hypothesized that individuals high in coronavirus anxiety might develop rigid eating habits as a way of managing perceived health threats, and that reduced cognitive flexibility could exacerbate this relationship.

The researchers recruited 324 adults in the United States in February 2021 through Amazon Mechanical Turk, a crowdsourcing platform. Participants ranged in age from 19 to 75, with a mean age of 38, and were compensated for their participation. Most had some college education, and the sample was racially and economically diverse.

Participants completed several standardized self-report questionnaires. To measure coronavirus-related anxiety, the researchers used the Coronavirus Anxiety Scale, which captures both psychological and physical symptoms of anxiety tied specifically to COVID-19.

“We used the Coronavirus Anxiety Scale (CAS; Lee, 2020), which classifies scores of 9 and above as representing pathological levels of anxiety,” Hayatbini noted. “In our sample, the mean score on the scale was 8.74, with a wide range (SD = 5.08). Our data suggest that some people were experiencing very high levels of anxiety due to the COVID-19 pandemic. This kind of anxiety does not disappear after the stressor is gone and may need attention from trained therapists.”

Orthorexia symptoms were measured using the Eating Habits Questionnaire, which includes subscales for healthy eating knowledge, positive emotions about healthy eating, and problems arising from overly rigid eating behaviors. Cognitive flexibility was assessed using the Cognitive Flexibility Inventory, which evaluates a person’s ability to view challenges from multiple perspectives and perceive stressful situations as manageable.

The researchers also collected information about participants’ body mass index (BMI), education level, income, and whether they had tested positive for COVID-19, as these variables could influence both eating behaviors and anxiety.

The data supported the central hypothesis. Coronavirus anxiety was significantly associated with increased symptoms of orthorexia nervosa. People who scored higher on the Coronavirus Anxiety Scale were more likely to report problems related to healthy eating, such as stress in relationships or disruptions in daily life caused by rigid dietary rules. These individuals were also more likely to believe they knew more than others about healthy eating and to report positive feelings tied to their dietary choices.

The researchers then examined whether cognitive flexibility could explain this relationship. They focused on one dimension of cognitive flexibility—participants’ belief in their ability to manage difficult situations. Those with high coronavirus anxiety tended to have lower scores on this measure, indicating they were less likely to see stressful circumstances as controllable. This in turn predicted more severe problems with orthorexic eating behaviors.

Statistical modeling showed that cognitive flexibility partially mediated the relationship between coronavirus anxiety and orthorexic symptoms. In other words, people who struggled to adapt to stress were more likely to cope with their anxiety by turning to restrictive eating habits. However, this mediation effect was limited to the “problems” subscale of orthorexia. Cognitive flexibility did not explain the relationship between anxiety and positive feelings about healthy eating or knowledge-related beliefs.

“Anxiety about getting sick or dying due to COVID-19 motivated some people to obsess about healthy food,” Hayatbini told PsyPost. “Especially if they were also less flexible in appraising their daily challenges as being controllable. People’s eating habits were altered during the COVID-19 pandemic. Our work shows that high levels of anxiety related to getting sick or dying due to COVID-19 (i.e., coronavirus anxiety) were more likely to make some individuals obsess about eating healthy food.”

“Furthermore, we found that lower levels of cognitive flexibility—specifically, flexibility in appraising everyday challenges as controllable—was a mediator in the relationship between coronavirus anxiety and orthorexia nervosa symptoms. Our work suggests that people who had high levels of coronavirus anxiety along with lower levels of cognitive flexibility were more likely to be burdened by the symptoms of orthorexia nervosa.”

“Psychologists paid attention to those who drank too much or ate unhealthy food during the pandemic,” Hayatbini continued. “But there were people struggling who did not get attention because they were doing the ‘right thing’ by eating healthy. Social media in the year 2021, when we collected our data, was full of postings about people baking bread and eating comfort foods due to the anxiety of the pandemic.”

“However, there were also people who responded to the anxiety of the pandemic by eating healthy food. These people did not get any attention because we associate healthy eating habits with being healthy. Orthorexia nervosa is an eating disorder that challenges this basic assumption. Individuals with orthorexia nervosa become obsessed with eating healthy. Their obsession often becomes debilitating and has a negative impact on their relationships. Our data suggest that in the midst of the pandemic, both anxiety about getting sick or dying from COVID-19, along with reduced cognitive flexibility, contributed to enhancing symptoms of orthorexia nervosa.”

Interestingly, the other component of cognitive flexibility—generating multiple solutions to problems—was not linked to coronavirus anxiety. It was, however, positively correlated with the positive feelings subscale of orthorexia. This unexpected finding suggests that people who are better at considering alternative perspectives may still derive satisfaction from their rigid eating behaviors, potentially viewing them as effective or adaptive during uncertain times.

While the findings are notable, the study has some limitations. The use of self-report measures may not accurately capture behaviors or mental processes, and cross-sectional data cannot establish causality. For example, it is possible that people with orthorexia symptoms became more anxious during the pandemic, rather than anxiety causing the symptoms. Future studies using behavioral tasks and longitudinal designs are needed to clarify these dynamics.

“This is the first study that we know of to examine the relationship between coronavirus anxiety and orthorexia nervosa,” Hayatbini said. “This is a single-point correlational study that used self-report measures. Although our analyses are well powered, the work must be replicated before any firm conclusions can be drawn.”

Another area for future research is the long-term impact of pandemic-related anxiety on eating behaviors. The study showed that the average coronavirus anxiety score was close to the clinical cutoff, with some individuals experiencing significant distress. Understanding whether these elevated anxiety levels lead to persistent disordered eating is a critical question for public health and mental health professionals.

“My long-term goal is to help establish orthorexia nervosa as a legitimate clinical concern that deserves proper recognition and treatment approaches,” Hayatbini explained. “The research on cognitive flexibility in orthorexia has shown conflicting results across different studies, so I want to continue investigating these cognitive mechanisms to better understand how people with orthorexia symptoms process and respond to stressful situations. I hope this research will inform clinical practice and help therapists better support individuals struggling with orthorexia, especially during times of heightened stress or uncertainty, like pandemics.”

“Our study showed that during the pandemic, people experiencing high coronavirus anxiety were more likely to develop problematic relationships with healthy eating, which suggests that orthorexic behaviors can sometimes emerge as maladaptive coping mechanisms during stressful times. Therefore, it’s important for people to understand that orthorexia exists on a spectrum.”

“There is a difference between making healthy food choices and becoming so rigid about ‘clean’ eating that it causes significant distress and interferes with daily life. I’d also like to emphasize that while our findings are promising, they need to be replicated in clinical populations and with longitudinal designs to better understand the causal relationships. This research area is still in its early stages, and we need more studies to fully understand orthorexia and develop effective treatments.”

The study, “Coronavirus Anxiety Associated With Heightened Orthorexia Nervosa Symptoms and Reduced Cognitive Flexibility,” was authored by Niki Hayatbini, Katherine Knauft, and Vrinda Kalia.