Orthorexia: When Healthy Eating Gets Unhealthy

Often, it feels like every time we turn around, there’s a new diet fad, exercise craze, or best-selling book proclaiming itself to be the key to health.

Unfortunately, as Western society increasingly prioritizes clean eating, physical exercise, and other forms of “healthy living,” clinicians have seen another trend: orthorexia.

A relatively new term, orthorexia is still taking shape as a concept, and is not yet mentioned in the Diagnostic and Statistical Manual of Mental Disorders. The original definition by doctor Steven Bratman and writer David Knight described orthorexia as an obsession with proper nutrition, dietary restrictions, and specific food preparation methods.

Other research suggests we should include preoccupation with exercise as a component of the definition as well. In short: we’re still trying to figure out exactly what it means. Not only does orthorexia overlap other disorders, but it’s also hard to tell when a specific diet becomes a problem.

Orthorexia, Anorexia, and Anxiety

According to authors Nancy S. Koven and Alexandra W. Abry, orthorexia appears to mimic other disorders such as anorexia (an eating disorder) and obsessive-compulsive disorder (or OCD, an anxiety disorder). Like anorexia and OCD, individuals with orthorexia have a few traits in common: perfectionistic tendencies, an anxious outlook, and difficulty being flexible in how they see the world.

On the other hand, orthorexia has some distinct differences. What sets it apart from anxiety and OCD?

1. Orthorexia is more specific. First, in orthorexia, we see greater emphasis on food quality, along with unrealistic beliefs about food and an overall desire to maximize health.
2. Orthorexia is not often a secret. In addition, people with anorexia and OCD tend to be secretive about their behaviors and symptoms, fearing other people will judge them or try to intervene. In contrast, people with orthorexia appear to flaunt their healthy choices, making their beliefs and habits well-known to those around them. They’re excited about their healthy lifestyle.

Although clinicians now understand more about orthorexia as a unique problem, distinct from disorders with similar symptoms, we still have no official diagnostic criteria. Scant research and flawed measures make diagnosis tricky.

Diet or Disorder?

Even the man who coined the term orthorexia carefully distinguishes between a strict diet and a clinical disorder. In fact, Bratman recently clarified his thoughts about it, pointing out that a healthy diet isn’t a problem unless it intensifies into an obsession.

While he and other researchers are still working on exact diagnostic criteria, we have to do the best we can with what we’ve learned so far. Just because a person adheres to a strict or unusual diet doesn’t mean they have a disorder.

Fortunately, clinicians are accustomed to working in gray areas. Most only worry about a behavior when it becomes severe enough to disrupt daily life. In my practice, for example, I’m most interested in how well my clients are functioning. I can still help people who want to change problem behaviors, even if those behaviors don’t exactly fit a diagnostic pigeonhole.

For Bratman, the patients who raised concern were those whose “exuberant pursuit of physical health had spawned a rigid, fearful, and self-punishing lifestyle that caused more harm than good.” Using this mindset, along with the general diagnostic framework’s researchers propose, we can recognize signs of possible orthorexia.

Warning Signs

When considering the following warning signs, remember we’re looking at an overall pattern of behavior that gets in the way of daily life, not just one or two habits or beliefs. These clues suggest a person may have taken a healthy lifestyle to an unhealthy extreme:

• Excessive time spent thinking about, planning, and preparing food. Likely, the time spent doing these things limits time available for other activities.
• Anxiety regarding health, types of foods, or food contamination. Severe food-related anxiety and perfectionism makes it hard to be flexible about food — in social settings and otherwise.
• “Healthy habits” begin to interfere with social life. People avoid social situations because unpredictable settings might keep them from meeting their strict food standards.
• Excessive exercise. A person works out too long, too hard, or too often.
• Significant weight loss or negative changes in health. Rigid eating habits persist even when the person’s health suffers.
• Excessive focus on moral implications of food choices. The person worries more about what a food choice means for their moral standing than whether that choice actually supports health.
• Excessive focus on body image. Anxiety about appearance or unrealistic opinions of body image remain, despite evidence to the contrary.

Getting Help

If you or loved one has signs of disordered eating or exercise, there are good treatment options. Because eating disorders affect both physical and mental health, they must be treated using a whole-person approach.

Although working with multiple providers can be overwhelming, each person plays an important role in recovery. This team effort includes mental health, medical, and nutrition professionals, each of which brings unique expertise.

Physicians will assess and monitor your physical health, recommending a pace of change that is healthy for you. A nutritionist can teach you about required nutrition, identify food misconceptions, and plan a recovery diet that meets your nutritional needs. Finally, a mental health professional can use cognitive behavioral therapy and behavior modification to change unhealthy thoughts and habits into more functional ways of thinking and behaving.

We’re still working to pin down orthorexia’s specifics, but we can help when healthy habits go awry. By consulting with specialists trained in eating disorders, you can have a truly healthy lifestyle.