Orthorexia: When Healthy Eating Becomes Obsessive

Orthorexia: When Healthy Eating Becomes Obsessive

Can you care too much about a clean diet? Yes. It’s called orthorexia—a dangerous and obsessive preoccupation with eating healthy. In extreme cases, it can become so restrictive that it can chip away at the patient’s relationships, mental health, and physical well-being. While it’s not a recognized disorder in the current Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-5), psychiatrists like Dr. Neeru Bakshi say awareness of orthorexia continues to rise. Bakshi, the medical director at Eating Recovery Center in Bellevue, Washington, helps people reconcile destructive eating behaviors with the underlying desire to be healthier.

A Q&A with Neeru Bakshi, M.D.

What is orthorexia?

Orthorexia is a term coined in 1996 by Dr. Steven Bratman and is defined by an obsession with “healthful” eating. While it’s not an officially recognized eating disorder in The Diagnostic and Statistical Manual of Psychiatric Disorders, awareness of the condition has been on the rise. Orthorexia often starts as an innocent attempt to eat healthy but can take a turn to a fixation on food quality and purity. People with orthorexia can become consumed with what and how much they eat. This develops into a rigid eating style with a strong fixation on eating “well.” This obsession can in turn put a strain on other activities, interests, and relationships and can cause health issues.

Where do you draw the line between healthy and disordered eating?

While eating healthy is important, there is a blurred line in terms of being concerned with the quality of your food and taking it to the extreme. In order to potentially figure out where you draw the line between healthy eating and disordered eating in the context of orthorexia, you might consider asking yourself some questions:

  • Do you wish that occasionally you could just eat and not worry about food quality?

  • Do you ever wish you could spend less time focused on food and more time living?

  • Does it seem beyond your ability to eat a meal prepared with love by someone else—one single meal—and not try to control what is served?

  • Are you constantly trying to find ways different foods may be unhealthy for you?

  • Do love, joy, play, and creativity take a back seat to following the perfect diet?

  • Do you feel guilt or self-loathing when you stray from your diet?

  • Do you feel in control when you stick to the “correct” diet?

  • Have you put yourself on a nutritional pedestal and wondered how others can possibly eat the foods they eat? 

If you find yourself answering yes more than no to these questions, it’s worth considering whether what you’re doing is really beneficial to you or your health.

What are the warning signs or symptoms?

Certain behaviors are red flags. Some noticeable signs of orthorexia may be a strict avoidance of artificial colors, flavors, or preservatives; pesticides or genetic modification; fat, sugar, or salt; animal or dairy products; or other ingredients considered to be unhealthy. Again, while trying to avoid some of these things can be a healthy choice, an excessive preoccupation with avoiding them, to the point that it’s getting in the way of your life—such as opting out of going to dinner with friends because of it—may be a sign of orthorexia.

“Those struggling with orthorexia will adopt certain ‘healthy’ or ‘pure’ eating habits, typically driven by a desire to be more natural and pure.”

Some additional behavioral changes that might indicate orthorexia include:

  • Obsessive concern over the relationship between food choices and health concerns, such as asthma, digestive problems, low mood, anxiety, or allergies

  • Heightened concerned and compulsive need to read over health food ingredients

  • Consistently checking nutritional labels

  • Noticeable increase in consumption of supplements, herbal remedies, or probiotics

  • Drastic reduction in the number of foods considered acceptable choices, such that the sufferer may eventually consume fewer than ten foods

  • Increased avoidance of food groups due to food allergies, without medical advice (i.e., cutting out all sugar, gluten, carbs, dairy, meat)

  • Irrational concern over food preparation techniques, especially washing of food or sterilization of utensils

  • Experiencing anxiety when there is a perceived lack of healthy food options available

Are there any risk factors?

While orthorexia appears to be motivated by health concerns, there are underlying motivations, which can include excessive concern regarding health risks posed by certain foods, compulsion for complete control, escape from fears, desire to be thin, improving self-esteem, searching for spirituality through food, and using food to create an identity. Oftentimes people with orthorexia think they’re being better than others who cannot eat similarly and will punish themselves for slip-ups. Additionally, someone with poor self-esteem might tie their self-esteem to the purity of their diet. If this happens, a person typically gravitates toward consuming healthy food in order to get that boost of satisfaction, self-esteem, or fulfillment from eating pure.

Is there a connection between orthorexia and other psychological disorders?

Given that the disorder is obsessive in nature, there have been studies illustrating a link between those who develop orthorexia and obsessive-compulsive disorder. A study in the Journal of Neuropsychiatric Disease and Treatment in 2015 found “symptom overlap between orthorexia and anorexia nervosa, obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), somatic symptom disorder, illness anxiety disorder, and psychotic spectrum disorders.”

That same study also noted that the characteristics and temperaments associated with people who have many common kinds of anxiety may also be present in people who go on to develop orthorexia. Not everyone with anxiety will also develop orthorexia, but there is a belief that the same parts of the brain drive anxiety and orthorexia.

“Someone who develops orthorexia may have underlying feelings of anxiety, obsessiveness, or depression to begin with—and these conditions may worsen as the person becomes more isolated.”

Patients with anxiety and OCD who develop orthorexia could potentially exacerbate those preexisting mental health issues. For example, people with orthorexia often feel an overwhelming amount of anxiety about eating away from their home or comfort zone, feeling unsure whether there will be any healthy or pure food options available. This rigidity and fear that they won’t be able to adhere to their regimen end up further isolating the individual.

How is orthorexia similar and dissimilar to anorexia? Are people often coping with both?

That same 2015 study showed that there are certain traits often expressed in both those suffering from orthorexia and those suffering from anorexia:

  • Perfectionism

  • High trait anxiety: an individual who is prone to persistent, intense anxiety

  • High need to exert control

  • Potential for significant weight loss

  • Achievement-oriented individuals who value adherence to their diet as a marker of self-discipline and view deviation from the diet as a failure of self-control

  • Limited insight into their condition and often denial over the functional impairments associated with their disorder

That said, there are some key differences in the motivations that drive the disorders. Those struggling with anorexia maintain a fear of obesity and are more often preoccupied with restricting certain foods in order to achieve a certain weight. Dissimilar to those with orthorexia, they are more concerned with their body image than with the quality or pureness of the food.

Those struggling with orthorexia will adopt certain “healthy” or “pure” eating habits, typically driven by a desire to be more natural and pure. The study also noted that those with orthorexia often begin “entertaining unrealistic, if not magical beliefs about certain foods.” Another key difference is that anorexic individuals will conceal their habits, while those with orthorexia tend to flaunt their habits.

While the disorders can co-occur, typically people are not dealing with both disorders at the same time given those significant differences in the motivations that drive the behaviors.

Has social media's emphasis on healthy eating contributed to a rise in orthorexia?

That’s hard to answer definitively. Because there is no standardized way to diagnose or measure the symptoms of orthorexia, it’s difficult to attribute a rise in the number of people with orthorexia. That said, the ability to access information about clean eating is easier than ever before. For those who are already anxious about their health and wellness, the information online may further exacerbate how they act in regard to their eating, regardless of the validity of the information being presented.

What are the long-term health risks associated with orthorexia?

As the disease progresses, some of the long-term health risks of orthorexia can mimic those of anorexia due to its restrictive approach. Eventually food choices become so restrictive in both variety and calories that one’s health begins to suffer, causing malnourishment. This type of malnourishment affects the whole body and can lead to nutritional deficiencies, osteoporosis, heart disease, and endocrine dysfunction as a result of not getting essential nutrients.

In addition to the physical effects, as the disorder progresses, there are some long-term mental health risks that can be problematic if people do not seek treatment. Someone who develops orthorexia may have underlying feelings of anxiety, obsessiveness, or depression to begin with—and these conditions may worsen as the person becomes more isolated. This can put a strain on close relationships with family and friends, which need to be repaired.

What are the available treatment options? How do you stay on track after treatment?

The first step is for someone to recognize that something is wrong. This is a treatable illness that can be overcome with the right support and treatment. Someone struggling with orthorexia must come to terms with the fact that their desire to improve their health has done more harm than good. This realization alone can facilitate change.

The next step is to reach out for help from trained professionals. Therapists, dietitians, and physicians can help identify any underlying causes of the illness and develop steps to deal with them. A tool such as a food hierarchy could be used to examine how the person feels about certain foods and their willingness to eat those foods. This hierarchy is listed in order of fear levels associated with certain foods. With therapeutic support, an individual could be exposed to different foods that they may not typically choose for themselves, or foods that they were concerned about could be gradually reintroduced into their diets.

“Someone struggling with orthorexia must come to terms with the fact that their desire to improve their health has done more harm than good. This realization alone can facilitate change.”

There are many routes one can take to full recovery. Depending on the individual case and severity, there are different programs specialized to fit a patient’s needs. At the Eating Recovery Center, we have a PHP (partial hospitalization program) and an IOP (integrated outpatient program), which slowly help patients reintegrate back into their life. After treatment, we have an alumni community that offers continued outreach and support to help patients stay on track.

What’s the best way to support a loved one you think may be struggling with orthorexia?

The best approach is to show the individual love and gentle concern. If you can express your concerns and be open to sharing that person’s experience, the person will be more likely to open up and share. This may not happen immediately, but taking a consistent and caring approach is helpful.

For additional information about the Eating Recovery Center, call 877-789-5758, email [email protected], or visit eatingrecoverycenter.com to speak with a clinician.

Neeru Bakshi, M.D., FAPA, is a psychiatrist and the medical director for Eating Recovery Center in Bellevue, Washington. Bakshi received her medical degree from Texas A&M University Health Sciences Center College of Medicine and went on to complete her internship and residency at Baylor College of Medicine in the Menninger Department of Psychiatry and Behavioral Sciences and at the University of Washington. She is a fellow of the American Psychiatric Association and a member of the International Association of Eating Disorders, the Washington State Psychiatric Association, and the American Psychiatric Association. Bakshi is passionate about treating those struggling with eating disorders and educating people on the importance of mental health.

The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.