What is Orthorexia?

There was no name for orthorexia when Lisa Fogarty started showing the signs of the eating disorder as a young tween. “I gave up eating foods with sugar when I was 12,” Fogarty recalls. “I lost a little weight and got positive attention for it, so I kept going. I remember loving how it felt to not feel full, so I gradually restricted more and more until I was skipping meals and labeling a lot of foods, including carbs and veggies like sweet potatoes, as bad.” Most of us associate some foods with being inherently “bad” for our bodies—after all, no one is eating a platter of brownies expecting it to make us healthier. But people with orthorexia don’t just categorize some food as “bad” and some as “good”: They’re preoccupied with the differentiation, and they eschew the “bad” and only eat the “good.” Put more simply, people with orthorexia are obsessed with healthy eating—to the point of what doctors call disordered eating (which commonly includes having an eating disorder). After dire warnings about the childhood obesity crisis in the aughts, Americans have slowly but surely come around to the idea that a nutritious diet is crucial to our overall health. Spend more than a few minutes on any social media site, and you’re bound to run into a slew of posts about eating healthy: Raw food. Clean eating. Farm-to-table. Whole30. Non-GMO. Surely those people are just trying to make good choices for their bodies, right? Well, most of them are! But what happens when you go from eating healthy so you can sustain your body and mind to allowing healthy eating to become an obsession? How do you go from a diet that’s designed to keep your heart muscles happy and your mind sharp to a therapist’s office and a diagnosis of orthorexia?

In 1997, a name appeared for the restricted diet that’s followed Fogarty and thousands like her into adulthood. That’s when Steven Bratman, MD, a physician from Fort Collins, Colorado, wrote an article in Yoga Journal that changed the face of the eating disorder discussion in America and around the world. It’s believed to be the very first time the term “orthorexia” was written down. Titled “Health Food Junkie,” the article centered around Bratman’s premise that healthy eating can be good for you, but it can also become an unhealthy obsession. “Many of the most unbalanced people I have ever met are those who have devoted themselves to healthy eating,” Bratman wrote at the time. “In fact, I believe some of them have actually contracted a novel eating disorder for which I have coined the name ‘orthorexia nervosa.’ The term uses ‘ortho,’ meaning straight, correct, and true, to modify ‘anorexia nervosa.’ Orthorexia nervosa refers to a pathological fixation on eating proper food.” How does someone end up, as Bratman described in 1997, “dominated by efforts to resist temptation, self-condemnation for lapses, self-praise for success at complying with the chosen regime, and feelings of superiority over others less pure in their dietary habits”? The experts say orthorexia has direct ties to other eating disorders (such as anorexia, bulimia, or binge eating disorder) and the risk factors inherent in them all.

Signs of Orthorexia

Of course, just because you love kale smoothies and could live the rest of your life without ever eating an Oreo doesn’t mean you’re orthorexic. Some people have better dietary habits than others, and just about every medical practitioner out there will tell you to eat a nutritious diet as often as possible. “Orthorexia is defined as an ‘unhealthy obsession’ with healthy eating, a term which literally means ‘fixation on righteous eating,’” says licensed marriage and family therapist Ashley Moser, site director at the Renfrew Center, an eating disorder treatment facility in Charlotte, North Carolina. Here’s how Moser says you can tell if you (or a loved one) might be crossing the line into an obsession with healthy eating:

Compulsively checking of ingredient lists and nutrition labels
Refusal to eat foods labeled as “unhealthy” or processed
Showing high levels of distress when “healthy” foods are unavailable
Variety of foods eaten becomes fewer and fewer
Increased social isolation and eating alone

Typically folks who battle orthorexia have similar risk factors to those who battle other eating disorders, says Lauren Smolar, director of programs at the National Eating Disorders Association (NEDA). She divides those risk factors into three categories: Social pressures, psychological risk factors, and/or biological predispositions. For example, someone with a family member who has (or had) an eating disorder might have a biological predisposition to disordered eating, whereas someone who struggles with weight stigma or teasing and bullying might have social pressures that increase their risk of an eating disorder, including orthorexia. From a psychological standpoint, issues such as body image dissatisfaction and a personal history of an anxiety disorder can up one’s risk for an eating disorder such as orthorexia. What’s more, there are typically what doctors call comorbidities that come along with orthorexia. That means that you can have two (or more) conditions at the same time. With orthorexia, that typically involves other eating disorders as well as an anxiety disorder and/or obsessive–compulsive disorder (OCD), Smolar says. OCD in particular is often found in folks with orthorexia, but because orthorexia isn’t an “official” diagnosis, there is little research on why the two crop up together so frequently.

Diagnosing Orthorexia: How does it work?

If you look at the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (more commonly known as the DSM-5), you won’t find orthorexia nervosa listed. The DSM-5 is the diagnosing manual used by the American Psychiatric Association, which declined to add orthorexia as its own diagnosis in its most recent edition. So does that mean orthorexia doesn’t exist as anything more than a word thrown out by Bratman once upon a time? Not at all, says Thom Dunn, PhD, a professor of psychological sciences at the University of Northern Colorado who has committed much of his time to researching orthorexia. Although orthorexia isn’t in the DSM, neither was binge-eating disorder before 2013, “although it was widely acknowledged that it existed before then,” Dunn tells HealthyWay. Researchers like Dunn have found conclusive evidence that orthorexia is real, and professionals in the eating disorder field—such as the folks at NEDA—do recognize orthorexia as something that can not only occur with other disordered eating conditions but is a separate condition in and of itself.

“The irony is that people are being unhealthy in their pursuit of being strictly healthy.” —Thom Dunn, PhD

What sets orthorexia apart from other eating disorders is an obsession with being “healthy” that takes someone to the point of actually being the exact opposite. “For some people, their desire to be healthy becomes all consuming and it starts to affect their ability to live their lives,” Dunn explains. “For some, they get malnourished. The irony is that people are being unhealthy in their pursuit of being strictly healthy.” So, if orthorexia isn’t an “official” diagnosis, how can someone be diagnosed with it? Often, patients aren’t—at least not where health insurance companies are concerned. “Most often these people get an anorexia diagnosis since they are underweight,” Dunn says. That can be enough to trigger a health insurance company to start paying for treatment. If not, practitioners like Dunn may diagnose someone with “other specified feeding or eating disorder” (OSFED), which is in the DSM. For Fogarty, that’s exactly what had to happen. Now 40, she spent her twenties and thirties drifting in and out of therapy for anorexia; it was at age 34 that a therapist and nutritionist both told her that she had “orthorexic tendencies” and began treating her for her food-related obsessions in addition to her tendency to starve herself. She works with a nutritionist now to help develop the skills she needs to vary her diet. “The biggest obstacle I have is overcoming the fear of new foods or foods that I still associate as bad,” Fogarty says, “like taco shells or white pasta. The recent campaign against carbs really screwed with my head a bit, I admit.”

Orthorexia Treatment and Recovery

For those who have extreme orthorexia that has caused them to become malnourished, hospitalization may be required. After all, Moser says, while it’s sometimes referred to online as the “good eating disorder,” there’s nothing positive about restricting your food intake to the point of getting sick. And someone with orthorexia can get very sick. “Some of the risks include medical complications from malnutrition, which affects every organ system in the body,” Moser points out. It’s a fact Fogarty knows all too well. When she was 21, she was slated to enter a hospital and be force-fed food, which is what first prompted her to seek treatment. Fogarty has been trying to make treatment work for nearly 20 years. That’s because there is no quick cure for an eating disorder. Often recovery begins with treatment—be it hospitalization or intensive, outpatient therapy—and turns into living in recovery.

Living With Orthorexia

It’s partly because of the near constant and often contradictory headlines about what different foods will do to our bodies (butter’s healthy—no, it’s not—wait, yes, it is!) that orthorexia recovery can be so difficult. While an alcoholic may be able to steer clear of bars and ask their friends to throw booze-free bashes, we can’t ignore all the news or stay away from the grocery store and its human-sized displays touting the purported benefits of the latest health craze.

“It is important to provide education on balanced eating and approach food with a more neutral stance of ‘all foods fit.’” —Ashley Moser, LMFT

That’s why orthorexia treatment focuses not just on therapy but on forming a healthier relationship with food. “It is important to provide education on balanced eating and approach food with a more neutral stance of ‘all foods fit,’” says Moser. “It’s helpful to remember these messages when faced with societal pressure to eat healthy.” If you’re struggling to develop a food plan without falling back on old habits, set up an appointment with a nutritionist. They can help you map out meals that are healthy—both in the sense of giving your body the nutrition it needs and in the sense of stretching beyond orthorexic tendencies. You may also want to start a food journal, which you can review and/or share with your nutritionist on a regular basis to ensure you’re actually meeting your nutrition goals rather than denying yourself. You can also work with a nutritionist to set goals that test the bounds of what you’ve come to consider as “safe” and “okay” foods. For example, Fogarty has been challenged by her nutritionist to eat dessert at least once or twice a week with her family. “That’s hard,” she admits. “But my nutritionist is trying to make me understand that the things I think will happen, like losing control or gaining 10 pounds overnight, won’t happen when you just let go of some of these fears. It’s an ongoing process and it takes therapy and nutritional counseling.” Not sure where to begin? That’s okay. Call the NEDA support line at 800-931-2237 or look into their online chat options to talk to someone on their team.

Orthorexia Is The Eating Disorder No One Talks About