Orthorexia: Signs, Symptoms, & Treatments

What Is Orthorexia?

Orthorexia is more than “clean eating,” it is an overly rigid set of rules about food. People who suffer from orthorexia may begin with a genuine desire to live in a healthier manner. Most people with orthorexia have been restrained eaters for quite some time prior to requiring treatment.

Who Does Orthorexia Affect?

Professionals see orthorexia in children, adolescents, men, and women. In most children and adolescents, choosing to eat a bit healthier is considered a good thing and is encouraged by parents, teachers, and medical providers. Children and teens tend to be somewhat suggestible, so when they are faced with messages that certain foods are “bad,” they can be easily influenced to change their way of viewing food and their bodies.

How Orthorexia Presents In Different People

Children may no longer purchase meals at school due to their belief that the lunches are too unhealthy. They may start skipping desserts, after school snacks, and reject their once favorite meals in order to conform to their idea of what is good for them. A child or teenager may become less social due to their fear of having to eat “bad” foods while away from home.

Young people may start refusing invitations to socialize with their friends. Parents may notice that their children or teens spend more time hovering in the kitchen in order to monitor whether their meals are being prepared to their rigid standards.

In older adolescents and adults, some of the same symptoms are present. There may be a decrease in socialization due to the person’s inability to find “healthy” foods to consume. As the individual pursues more and more purity in their intake while seeking perfection, it is harder to maintain social relationships.

People may give up activities outside of work and school due to the time required to meal prep, menu plan, and research new ways to eat better. The transition from healthy to disordered eating is consistent among all age groups.

Symptoms of Orthorexia

Orthorexia is an eating disorder characterized by an extremely rigid way of eating and thinking about food as it relates to health and wellness. Often a person suffering from orthorexia believes that they must follow a set of self-imposed rules to either remain healthy or avoid some feared or unknown medical issue in the future.

If you or someone you know is regularly commenting about the health benefits of a specific way of eating or the negative impact of eating certain foods, you may be dealing with the symptoms of orthorexia.

Symptoms of orthorexia can include:¹⁷

• Compulsive checking of ingredient lists and nutritional labels
• An increase in concern about the health of ingredients
• Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products)
• An inability to eat anything but a narrow group of foods that are deemed “healthy” or “pure”
• Unusual interest in the health of what others are eating
• Spending several hours per day thinking about what food might be served at upcoming events
• Showing high levels of distress when “safe” or “healthy” foods are not available
• Obsessive following of food and “healthy lifestyle” blogs
• Body image concerns

Causes & Risk Factors of Orthorexia

Not every diet leads to an eating disorder or even to orthorexia specifically. However, orthorexia does not exist in the absence of a pre-existing, rigid health focus. The more restrictive a diet is, the more likely the individual will be to develop a resulting eating disorder.

Common risk factors of orthorexia include:¹²

• Restrictive diets
• Anxiety and/or obsessive compulsive disorder (OCD)
• First degree relatives with an eating disorder or anxiety disorder (i.e., parent, sibling)
• Previous or current eating disorders such as anorexia nervosa or bulimia nervosa
• Perfectionistic tendencies
• Higher socioeconomic status
• Healthcare related fields, performers, and athletes

There are similarities between OCD and orthorexia vs. anorexia. Anxiety is a commonality among most individuals with eating disorders because those with eating disorders use their behaviors to manage emotional states that they perceive to be negative. This is also true of individuals with obsessive-compulsive tendencies. Individuals who have a history of anorexia can easily migrate into the world of orthorexia and vice versa.

Diagnosing Orthorexia

Eating disorders are diagnosed using an industry accepted set of criteria outlined in the the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Individuals who present with signs and symptoms of orthorexia will likely be diagnosed with what eating disorder specialists refer to as OSFED, or “other specified feeding or eating disorder.” This is a category of eating disorders that don’t meet full criteria for other specific disorders.¹

The challenge for medical and mental health providers is to differentiate between those who are safely pursuing improved health and those who have crossed over into disordered eating. A person may begin their pursuit of health by eliminating highly processed foods along with other items they believe to be less nutritious. There’s nothing pathological about reducing processed or packaged foods in favor of lean meats, fruits, and vegetables.

Indicators that someone has crossed over into disordered eating is a tendency to completely avoid eating when they’re unable to find foods that meet their high standards of health, they have to prepare the foods themselves, or they progressively eliminate more and more foods from their list of “acceptable” foods. These behaviors can and often lead to medical and psychological complications.

Treatment of Orthorexia

While there are no specific treatments designed exclusively for orthorexia, therapy, medication, and lifestyle modifications can be implemented. A difficulty that eating disorder specialists encounter in treating orthorexia is that these individuals are resistant to hearing they need to modify their behavior. Dietitians and therapists struggle to convince patients that adding back those foods they have worked so hard to eliminate is the way to a healthier self.

Here are forms of orthorexia treatment:

Therapy

Therapy for orthorexia looks much like it does for those suffering from other eating disorders, such as anorexia, bulimia, and binge-eating disorder. Eating disorders are similar at the core while presenting with varying symptoms. The individual’s team will consist of a licensed therapist (LPC, LMFT, or PhD), a registered dietitian (RD), a primary care physician, and possibly a psychiatrist.

Treatment options are available in a variety of treatment settings, including outpatient private practices, intensive outpatient programs, partial hospitalization, and residential or inpatient programs. The frequency and level of care a patient requires depends on the severity of both medical and psychological complications.

The team lead (usually the therapist) will coordinate care with the patient and her other team members. Individual and family therapy, nutrition counseling, medical monitoring, and medication management are possible treatment options available to the eating disorder patient.

Common Types of Therapy For Orthorexia

The most common and widely accepted treatment modalities for eating disorders in general are cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), family-based therapy (FBT), and some type of exposure therapy (ERP).(FN7)

It is important that any treatment plan contains some type of evidence-based treatment; one that is backed by scientific research and has been proven to be successful.

CBT

Cognitive behavioral therapy (CBT) assists individuals in challenging distorted thinking, behaviors, and emotions that serve to maintain their eating disorders. This type of treatment focuses on helping the eating disorder client recognize and change negative thinking and behavioral patterns.

Self-monitoring homework assignments are often a significant part of CBT treatment. This allows a client to track symptoms and review their progress in sessions with their therapist in both outpatient and inpatient treatment settings.

DBT

Dialectical behavioral therapy (DBT) is a type of cognitive-behavioral therapy that was developed by Marsha Linehan for the treatment of suicidal clients and borderline personality disorder. DBT is designed to help clients develop new skill sets through modules such as emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. These are designed to help individuals deal with anxiety, out-of-control emotions, and other issues that contribute to one’s eating disorder.

FBT

Family based treatment (FBT) is also referred to as the Maudsley Method. This is an approach that is effective with young patients and adolescents. It involves putting a family member in charge of the refeeding process for weight gain or maintenance and recovery.

The family is an integral part of the team and works to re-establish healthy eating patterns and interrupt unhealthy behaviors such as purging and over-exercise. The family member prepares and serves meals until the client can function on their own again at an age-appropriate level.

ERP

Exposure and response prevention (ERP)  is used to expose clients to what they fear. In the case of an eating disorder, it’s often fear of foods and situations that create anxiety related to body image. ERP is designed to reduce the amount of emotional and physical distress a client experiences when confronted with a specific thought or situation.

Often a therapist or registered dietitian will arrange for experiential challenges to assist a client in facing fears such as eating in a restaurant, clothes shopping, or going to a grocery store.

Medication

Sometimes, medications are needed to assist a person with orthorexia due to anxiety or depression that may accompany an eating disorder. The most common medications used to treat these conditions in those with eating disorders are antidepressants and anti-anxiety medications.²⁵

The most widely prescribed antidepressants used in these cases are selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft).25 These medications are used due to the relatively low rate of side-effects and positive impact on depression, anxiety, and OCD.^{13, 19, 25}

When combined with psychotherapy, SSRIs have proven to be a helpful addition to the treatment plans of eating disorder patients.¹³ However, medication alone is not an impactful treatment option for orthorexia. It’s recommended that eating disorder patients on psychotropic medications are seen by either a psychiatrist or nurse practitioner with training and experience specific to eating disorders due to the unique needs of this population.¹³

Many will also receive medications and/or supplements to address medical complications related to their eating disorder.²⁵ Patients suffer with vitamin and electrolyte deficiencies as well as hormonal imbalances. When a patient eliminates entire food groups and severely restricts caloric intake, things such as iron, potassium, calcium, cholesterol and glucose are impacted.

Also, in low body fat and underweight patients, amenorrhea (the absence of menstruation) can be an issue which can lead to osteopenia or osteoporosis.

Oral contraceptives have historically been prescribed in these cases; however, specialists don’t always endorse this as it masks symptoms of eating disorders, artificially starts menses, and prevents professionals from monitoring the client’s body to recognize signs of recovery. Studies have shown that this doesn’t actually help with bone density. The best way to address this is to restore body weight.^{12, 13}

Lifestyle Changes

In addition to the formal treatment a person receives for orthorexia such as therapy and medication, there are lifestyle changes that can help as well.

Lifestyle changes that can help manage an eating disorder and related conditions include:

• Spending time with family and friends to increase support and accountability
• Making sure to get adequate sleep to reduce stress, anxiety, and depression
• Participating in activities that increase relaxation and decrease stress, such as meditation, listening to music, yoga, art, or massage
• Reducing exposure to social media to decrease anxiety, depression, sleep disturbance, and exposure to a culture of dieting
• Joining an eating disorder group therapy or increasing circle of friends to help with feeling less alone while dealing with treatment and recovery

Intended Treatment Outcome & Timeline

The timeline for treatment of an eating disorder involves a multi-step step cycle beginning with recognizing the developing symptoms of an eating disorder, seeking out professional help, diagnosis of a possible eating disorder, waiting for specialized care and confirmation of an eating disorder, participating in treatment, recovery, and in some cases, a relapse leading back to the first step of the cycle.²³

The intended outcome when treating any eating disorder is for the individual to be free from most or all symptoms. Professionals attempt to assist the person in getting to a place in which their disorder is no longer impairing their physical and emotional health or interfering with social, educational, or vocational pursuits.

There are no standard lengths of care to achieve recovery from an eating disorder regardless of the type of treatment used. The longer a person goes without care, the more likely they are to experience periods of partial recovery and relapse requiring additional treatment.²³

Cost of Treatment

The cost for eating disorder treatment varies depending upon the length of time needed in treatment and the level of care required. Eating disorders require treatment from many professionals collaborating with one another to provide specialized care. Most commercial insurance plans will cover some of the treatment needed.

The higher the level of care, the more financial investment is required of the patient. Psychiatric hospitalization at an eating disorder facility is more costly than weekly outpatient appointments, for example. Inpatient treatment for eating disorders in the US ranges from $500-$2000 per day.²¹

Outpatient therapy appointments vary from state to state and the qualifications of the provider seen. The national average for a 50-minute counseling session is $90.²⁴ The cost for nutritional counseling is also variable and is not always covered by commercial insurance.

Long-term outpatient therapy and medical care can cost as much as $100,000.²¹ The expense related to the treatment of an eating disorder makes early intervention imperative. The earlier a person gets into treatment, the less costly the treatment will be overall.

Co-occurring Disorders

Co-occurring disorders are common for someone living with orthorexia. Given the nature of orthorexia, anxiety and depression can be underlying issues which manifest into orthorexia under the disguise of “healthy eating” for better coping with those mood disorders. To add, those with OCD, which is rooted in anxiety and a rigid sense of control over situations or rituals, can develop orthorexia. Since it can be so limiting, having behavioral tendencies for binge eating and bulimia are also common.¹²

How to Get Help For Orthorexia

If someone is interested in seeking out care for themselves or a loved one, an initial assessment with either an eating disorder therapist or registered dietitian is a good place to start. These individuals are trained to recognize and diagnose eating disorders. They will then make appropriate recommendations for additional providers if necessary.

In the most severe cases, professionals may refer to treatment facilities or hospitals specializing in the care of those with eating disorders including intensive outpatient programs, partial hospitalization programs, or inpatient facilities.

To start your search for a therapist, use a free online therapist directory.

How to Get Help For a Loved One

If you suspect that a loved one is suffering from an eating disorder, encourage them to schedule an appointment with their primary care physician or locate an eating disorder specialist through their insurance carrier. When searching for specialists, one credential to look for is a therapist who is a Certified Eating Disorders Specialist (CEDS).

These therapists are certified by the International Association of Eating Disorders Professionals (IAEDP) due to their highly specialized training and years of experience in the field of eating disorders.

Online resources are also available through some of the following agencies:

• National Eating Disorders Association (NEDA)
• Alliance for Eating Disorders
• ED Referral
• Eating Disorder Hope

Orthorexia & Related Eating Disorders Statistics

Eating disorders are extremely prevalent. In fact, 50% of Americans know someone with an eating disorder. Girls as young as age six are worrying about their bodies and thinking about dieting. Bullying related to body size, social media’s focus on thinness, beauty, and fitness, and the diet culture all contribute to one’s desire to alter our genetic make-up.¹⁶

Here are related statistics regarding eating disorders and orthorexia:

• 10% of male college athletes are at risk of anorexia and 38% for bulimia¹⁶
• As many as 71% of college students engage in behaviors that can be considered symptomatic of orthorexia⁸
• Higher Instagram usage is associated with a greater tendency towards orthorexia²⁶
• Girls who diet frequently are 12 times as likely to binge as girls who do not diet¹⁷
• 9% of the US population (28.8 million) will have an eating disorder in their lifetime¹⁵
• Less than 6% of people with eating disorders are medically diagnosed as “underweight”¹⁵
• The best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness¹⁶
• 40-60% of elementary school girls (ages 6-12) are concerned about their weight or about becoming too fat¹⁶

Orthorexia vs. Anorexia, Bulimia, & OCD

Orthorexia differs from other eating disorders such as anorexia and bulimia in that it is not as focused on the quantity of food consumed but rather the quality of or source of food. Cases of orthorexia can go undetected due to the person’s focus on health vs. weight or body image.

Our society expects this of individuals and celebrates those who succeed in this area. Below is a comparison chart of the similarities and differences between orthorexia and the three most closely related conditions:

Similarities & Differences Between Orthorexia, Anorexia, Bulimia & OCD

Final Thoughts on Orthorexia

If you or someone you love is struggling with orthorexia, there is hope to recover and live a healthy life ahead. Working with a doctor, therapist, and a strong support system can make a big difference in how you feel.