Orthorexia: Signs, Symptoms, & Treatments

Orthorexia is an obsessional focus on “healthy” eating.³ While there is no formal diagnosis of orthorexia, specialists in the field of eating disorders recognize it as being distinct from other conditions such as anorexia nervosa and obsessive-compulsive disorder (OCD). Generally, changing one’s diet is a positive step toward improved health. However, if one becomes fixated on self-imposed dietary restrictions, eating behaviors can quickly become problematic.

Signs of Orthorexia: What It Looks Like

Healthy eating alone is not an eating disorder. 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.

Professionals are seeing 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.

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.

According to NEDA (National Eating Disorders Association),¹⁷ common symptoms of this eating disorder include:

• 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 and 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 in nature a diet is, the more likely the individual will be to develop a resulting eating disorder.

Some of the more common risk factors of orthorexia include:¹²

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

There are similarities between OCD, anorexia and orthorexia. 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 diagnostic criteria outlined in the most current edition of 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 used for eating disorders that do not meet full criteria for other specific disorders or eating disorder presentations.¹

The challenge for medical and mental health providers is to differentiate the line 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 that they believe to be less nutritionally valuable. There is 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 are 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

A difficulty that eating disorder specialists encounter in treating orthorexia is that these individuals are resistant to hearing they need to modify their behavior. Amongst the campaigns against obesity in America, the urging to eat less sugar and carbohydrates, an insistence that we all need to be more active, is the voice of an eating disorder specialist trying to make the case that being ‘healthier’ has led to a potentially life-threatening condition. Dietitians struggle to convince patients that adding back those foods they have worked so hard to eliminate is the way to a healthier self.

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, residential or inpatient programs. The frequency and level of care a patient requires is dependent upon 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 some of the possible treatment options available to the eating disorder patient.

Common Types of Therapies

There are no specific treatments designed exclusively 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).⁷
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.

Cognitive-Behavioral Therapy (CBT)

Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy that 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.

Dialectical Behavioral Therapy (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.

Family Based Treatment (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.

Exposure with Response Prevention (ERP)

Exposure with Response Prevention (ERP)  is used to expose clients to that which they fear. In the case of an eating disorder it is 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 is 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. Specialists do not always endorse this practice 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 does not actually help with bone density and the best way to address this is to restore body weight.^2,13

Lifestyle Changes

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

Some 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 a support group 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 achieving 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

How to Get Help for Orthorexia

It is critical that those dealing with orthorexia seek out professional help, as it is unlikely the individual will be able to get back to a routine way of eating without some level of intervention. 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.

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.

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 Specialists (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 and Related Eating Disorders Statistics

Eating disorders are extremely prevalent in our world. 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 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 just some of the 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 orthorexia ⁸
• 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 fat.¹⁶

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

Similarities and Differences Between Orthorexia, Anorexia, Bulimia & OCD

Self-Assessment Tools for Orthorexia

There are no formal diagnostic criteria or medical tests for orthorexia, however there is one self-test endorsed by Dr. Steven Bratman. It is found on his website⁴ and is included here. Eating disorders can only be diagnosed by a licensed therapist, dietitian or physician. This is not meant to replace professional advice or provide a diagnosis of an eating disorder:

The Bratman Orthorexia Self-Test

If you are a healthy-diet enthusiast, and you answer yes to any of the following questions, you may be developing orthorexia nervosa:

• I spend so much of my life thinking about, choosing and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work and school.
• When I eat any food that I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods.
• My personal sense of peace, happiness, joy, safety and self-esteem is excessively dependent on the purity and rightness of what I eat.
• Sometimes I would like to relax my self-imposed “good food” rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make ANY exception to your diet, then this item does not apply.)
• Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own.
• Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me, or it has caused other signs of malnutrition such as hair loss, loss of menstruation or skin problems.

Additional Resources for Orthorexia

The following are helpful additional resources for anyone impacted by orthorexia:

• Eating Disorder Hope
• National Association of Anorexia and Associated Disorders 
• Gurze/Salucore Eating Disorders Resource Catalogue