We all know it’s good to eat healthily. But can healthy eating go too far?
Orthorexia Nervosa is an eating disorder that most people have never heard of. Experts say orthorexia causes people to become obsessed with healthy eating to the point where it becomes damaging to their health and lives. People with orthorexia are obsessed with “pure” or “clean” foods and refuse to consume anything that falls outside of their created parameters.
There’s still relatively little information about orthorexia since it’s a new term that hasn’t yet been officially defined. But here’s what we know so far about this serious eating disorder, including symptoms and treatment.
Symptoms of Orthorexia
To be clear, orthorexia isn’t included in the Diagnostic Statistical Manual (DSM), which is considered the definitive source for recognized mental health disorders and their diagnostic criteria. Orthorexia is also not included in the International Classification of Diseases (ICD-10), which means there isn’t a clearly defined or established set of symptoms or diagnostic criteria for orthorexia, yet.
However, most mental health experts recognize the existence of orthorexia and have identified some signs and symptoms that could indicate someone has this disorder.
In general, orthorexia causes people to become obsessed with only consuming foods that are “healthy” or “pure.” They may become more and more rigid about the foods they allow themselves to eat, and become very upset when these “acceptable” foods aren’t available to them.
Some of the signs and symptoms of orthorexia include: 
- Worrying obsessively about the quality of the food they’re eating; for example, many people with orthorexia worry if their food is organic or pesticide-free
- Compulsive checking of labels and ingredient lists
- Spending too much time (more than 3 hours a day) thinking about their diet
- Only preparing their food in specific ways, like using only wooden tools or cutting vegetables in a certain way
- Refusing to eat food others have prepared
- Refusing to eat entire food categories because they’re “unclean” or unhealthy; for example, they may refuse to eat any carbohydrates or consume any food with salt
- Nutritional value of eating is more important to them than pleasure or flavor
- Refusing to eat out at restaurants
- Being critical of loved ones’ food choices
- Intense feeling of losing control, and using healthy food choices to feel in control
- Becoming very distressed when “pure” or acceptable foods aren’t available to them
- Obsessively following “healthy eating” blogs or social media accounts
- Spending an increasing amount of money to have access to “pure” foods
Orthorexia may or may not be joined with body image concerns. This has led experts to go back and forth about whether orthorexia is truly an eating disorder.
Often, people with orthorexia aren’t worried about how much food they’re consuming or their body image. They tend to be more concerned with what type of food they’re consuming (food quality, rather than quantity), and the health of their body on the inside. In fact, many people with orthorexia feel happy with and even proud of their body shape and size. They may feel like their healthy eating choices have helped them to maintain a “good” body.
But because orthorexia causes people to severely restrict the food they’re consuming, it often leads to severe weight loss. This can lead to dangerous health consequences, like malnutrition, that are similar to the consequences of anorexia nervosa.
Risk Factors for Orthorexia
Like other eating disorders and mental illnesses, there isn’t just one thing that causes orthorexia. Many different factors can combine to raise someone’s risk for orthorexia.
Research on orthorexia is still limited, so we don’t have all the information we need. But some factors that have so far been found to put people at higher risk for orthorexia include:
People who have family members with an eating disorder are more likely to develop an eating disorder themselves.
People who have a perfectionistic personality may be more likely to develop eating disorders like orthorexia. Perfectionistic people may be more likely not to be satisfied unless they’re following recommendations for a healthy diet to an extreme level.
History of mental illness or eating disorders
Having a history of mental illness, like depression, or a history of other eating disorders can increase your risk of developing disordered eating, including orthorexia.
Some studies have found that women are at higher risk for orthorexia, but many experts say both genders are equally at risk.  We need more research to be able to say if gender is really a risk factor for orthorexia.
Being a health professional
In one Turkish study, almost half of all physicians at one hospital were found to exhibit features of orthorexia.  Another study found that medical students also had high rates of orthorexic features. Dieticians were also found to be at high risk.
Some high-level athletes and other people who practice sports seriously were found to be at high risk for orthorexia. 
People who belong to “fitness” or “clean eating” communities on social media seem to have a higher prevalence of orthorexia. Higher Instagram use, in general, may also contribute to higher rates of orthorexia. 
How Is Orthorexia Diagnosed?
Because it’s not officially recognized in the DSM or the ICD, there are no official criteria to help treatment providers make a diagnosis of orthorexia. Providers who are familiar with this disorder may ask you questions about your eating habits and mental health to determine whether or not you may have it.
Dr. Steven Bratman, the researcher who coined the term “orthorexia” in the 1990s, proposed the Bratman Test for Orthorexia. This tool may help providers screen for unhealthy eating habits that lean towards orthorexic behavior.
The Bratman Test for Orthorexia  includes the following 10 questions:
- Do you spend more than 3 hours every day thinking about your diet?
- Do you plan your meals several days ahead?
- Is the nutritional value of your meal more important to you than the pleasure of eating it?
- Has the quality of your life decreased as the quality of your diet has increased?
- Have you become stricter with yourself lately?
- Does your self-esteem get a boost from eating healthily?
- Have you given up foods you used to enjoy in order to eat the ‘right’ foods
- Does your diet make it difficult for you to eat out, distancing you from family and friends?
- Do you feel guilty when you stray from your diet?
- Do you feel at peace with yourself and in total control when you eat healthily?
People who answer “yes” to more than 4 of these questions may be too rigid and might need help to relax about their food choices.
The ORTO-15  is another screening tool for orthorexia that’s been proposed. This tool asks people to rate 15 questions on a Likert scale.
Your treatment provider may or may not use one of these tools to help determine whether you have orthorexia. Since orthorexia isn’t yet officially recognized as a diagnosis, they may diagnose you with Eating Disorder Not Otherwise Specified, anxiety, or obsessive-compulsive disorder (if you meet the criteria).
Orthorexia and Obsessive-Compulsive Disorder
Although orthorexia is a disorder that primarily has to do with eating habits, some experts say it is more similar to obsessive-compulsive disorder (OCD) than it is to other eating disorders like anorexia or bulimia. And so far, research has found that people with orthorexia also have a higher-than-usual rate for OCD. 
OCD is a disorder that causes people to have obsessive and intrusive thoughts.  These thoughts can be about anything from germs to one’s own sexuality. The obsessions cause severe fear and anxiety for the person with OCD. These obsessions lead people with OCD to engage in compulsions or ritualistic or repetitive behaviors, meant to quell the intense anxiety that comes along with obsessions.
When comparing OCD to orthorexia, it becomes clear there are many similarities. Like OCD, orthorexia causes obsessive thoughts (about the “purity,” nutritional value, or cleanliness of food). People with orthorexia also compulsively limit or control the foods they eat in response to their obsessions about clean eating.
So is orthorexia primarily an eating disorder or an OCD-related disorder? That’s what researchers are currently trying to figure out. Some experts say that, since orthorexia isn’t usually about body image or weight loss, it’s not an eating disorder. Orthorexia also doesn’t usually begin with low self-esteem. But people with other eating disorders, like ARFID (Avoidant/Restrictive Food Intake Disorder), aren’t concerned with body image, either.
On the other hand, orthorexia does appear to have a lot in common with obsessive-compulsive and related disorders, like health anxiety disorder.
If and when orthorexia is included in the DSM, we will have guidelines on how to characterize it, as an eating disorder or something else.
Consequences of Orthorexia
Like eating disorders, orthorexia can cause serious and dangerous consequences for both physical and mental health.
People who severely limit their food intake, whether it’s because of orthorexia or an eating disorder like anorexia or ARFID, put themselves at high risk for severe weight loss and malnutrition.
People with orthorexia may think they’re making healthy food choices, but may lose weight unintentionally because they are so rigid in what they allow themselves to eat. For example, if someone with orthorexia cuts out all sugar or all carbs, they’re likely to lose weight, even unintentionally.
On top of malnutrition, severe weight loss can lead to:
- Weak immune system
- Brittle bones (osteoporosis)
- Electrolyte imbalance
- Slow heart rate
These are serious consequences, and can be life-threatening.
Even if orthorexia doesn’t lead to significant weight loss, it usually causes severe disruption in the person’s life.
Symptoms of orthorexia, like refusing to eat out at restaurants, can cause people with orthorexia to become severely socially isolated. They may also be judgmental of others’ food choices, which might isolate them even further.
There’s also the emotional distress that comes along with orthorexia. People with orthorexia may feel happy and in control when they’re able to follow their food regimen. But when “acceptable” foods aren’t available, they may become overwhelmed with anxiety and even panic.
Eating disorders like orthorexia often co-occur with other mental health conditions like depression and anxiety. As already mentioned, orthorexia, in particular, seems to frequently appear together with OCD.
Some people with orthorexia may start craving the foods they’re restricting, which may then lead to binge eating disorder or bulimia. Binging and purging behaviors are associated with their own set of serious health consequences.
In short, it may seem at first glance like the worst thing that can happen with orthorexia is you become “too healthy” — but, in reality, orthorexia is far from healthy. This disorder actually harms your health in serious ways.
Treatment for Orthorexia
Since orthorexia is still gaining traction in the medical world, we need more research to be able to determine what treatments are evidence-based for this disorder. But experts suggest two main ways of treating orthorexia: treating it like OCD, and treating it as an eating disorder.
Orthorexia can be treated as an eating disorder, especially if the person has a negative body image. This may involve helping someone notice their negative and irrational thoughts about their body and replacing them with more helpful thoughts.
But if someone’s orthorexia is more about obsessions about health than body image, then treatments that are used for OCD may be more helpful.
Some experts say that orthorexia may be easier to treat than other eating disorders because people with orthorexia want to fundamentally be healthy and take care of themselves.  If you have orthorexia, you may benefit from education about the real consequences of your eating habits.
Some specific treatment models that may be helpful for orthorexia include the following.
Exposure and response prevention (ERP)
ERP is considered the gold standard of treatment for OCD. It’s also helpful for people with specific phobias, anxiety disorders, and eating disorders.
ERP helps people lower their anxiety around specific triggers by helping them to intentionally expose themselves to these triggers. But instead of responding to the trigger with a compulsion (as OCD would typically have them do), the person is taught to sit with the anxiety, without responding to it, until it gradually goes away.
An ERP therapist may expose an orthorexic client to a food trigger, like being around or even eating “unhealthy” food. Exposure is gradual; people are exposed to foods that cause them the least anxiety first. Then, instead of reacting with any cleansing or purifying rituals (like fasting), the person is invited to sit with the intense anxiety that this trigger has caused them.
ERP is challenging, but it can be very helpful for people with orthorexia and other obsessive tendencies. The more you’re exposed to your fears, the more desensitized you become.
Cognitive-behavioral therapy (CBT)
Cognitive-behavioral therapy has been found to be helpful for people with eating disorders like anorexia or bulimia.  CBT is rooted in the idea that our thoughts, feelings, and behaviors are all interconnected and affect each other.
This may be a helpful treatment for someone with orthorexia if negative thoughts, about body image or health, are contributing to their eating behaviors.
For example, someone with orthorexia might see a plate of french fries and think, “That is so disgusting. French fries are pure fat and carbs. Plus, they’re not even fresh potatoes; they’re processed. I feel sick even looking at them.” If they find themselves craving the french fries, these thoughts might go even further: “I’m such a pig. Why don’t I have any discipline? What’s wrong with me? Why would I crave such disgusting, processed food?”
A CBT therapist may help this person notice how these thoughts are making them feel. They might help the person replace the thought with something more self-compassionate, like: “Everyone craves french fries sometimes, and eating a couple of fries will not kill me.”
We only have limited research on whether or not psychiatric medications might be helpful for people with orthorexia. In some cases, it might help manage symptoms of anxiety or depression.
Beat Orthorexia at The Center • A Place of HOPE
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