Orthorexia: Signs, Symptoms, & Treatments

What Is Orthorexia?

Orthorexia nervosa 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.

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

Orthorexia Symptoms

Someone with orthorexia nervosa extremely restricts their diet to include only foods that are perceived as “healthy,” “pure,” or “good.” This may lead to symptoms of orthorexia, such as cutting out food groups, compulsive food label checking, and emotional overwhelm when “safe” foods are unavailable. Other symptoms include becoming overly invested in other people’s diets and showing intolerance for other people’s food beliefs.

Common symptoms of orthorexia include:¹

• Cutting out an increasing number of food groups: Someone with orthorexia may cut out certain food groups that they consider to be “unhealthy.” For example, someone with orthorexia may cut out all fruits because they consider any sugar to be unhealthy.
• Compulsively checking nutritional labels: Someone with orthorexia may develop the need to check all nutrition labels of food they are consuming to see whether the ingredients are “healthy” or “pure.”
• Feeling distressed when “healthy” foods are not available: Someone with orthorexia may feel anxious when “safe” foods are not available during events or social gatherings. They may become irritable or withdrawn or bring their “healthy” food to social gatherings instead of eating with others.
• Struggling with overall perfectionism: Research indicates people with orthorexia sometimes also struggle with perfectionism.² Perfectionism can lead people to feel their relationship with food needs to be “pure” or “perfect.”
• Increased interest in others’ diets: People with orthorexia are often overly interested in the diets of other people. They may comment on or critique the diets of friends and family members.
• Obsessive following of healthy lifestyle social media outlets: Someone with orthorexia may follow healthy lifestyle blogs or social media pages in an effort to learn how to craft the “perfect” diet. They may become entrenched in diet culture and obsessive about the information they find on these resources and exhibit the need to follow suggestions restrictively.
• Intolerance of others’ food beliefs that are different: Someone with orthorexia may become intolerant of other people’s beliefs around food, especially people who eat foods they consider to be “unhealthy” or “unsafe.” They may exhibit disgust, frustration, or anxiety when friends and family do not adhere to similar diet rules.
• Exhibiting feelings of superiority around nutrition: Someone with orthorexia largely operates around black-and-white thinking patterns where foods are considered either “good” or “bad.” They believe that they know what foods are “good” and may push these foods onto family and friends despite sometimes lacking actual education and expertise in nutrition.

Causes & Risk Factors of Orthorexia

Causes and risk factors of orthorexia nervosa include genetic factors, personality traits, economic status, and history of other mental disorders, such as anxiety or OCD. A history of restricting food intake or having a previous eating disorder diagnosis can also put someone at risk. Certain environmental factors, like having a career in a health-related field, are also risk factors for developing orthorexia.

Common causes and risk factors of orthorexia include:²

• Biological: Eating disorders have a genetic component, and orthorexia is highly inheritable. If someone has a family member, particularly a parent, who struggles with disordered eating, they are more likely to develop an eating disorder than someone who does not.
• Personality: Experts have found that individuals who are high on the personality traits of neuroticism and perfectionism may have an increased risk of developing orthorexia. These personality traits can lead to struggles with rigid thinking patterns, which is a hallmark feature of eating disorders, particularly orthorexia.
• Restrictive dieting: Past struggles with dieting cycles are also connected to developing 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.
• Negative body image: Body image and eating disorders are closely linked. Individuals who exhibit dissatisfaction with their bodies may be more likely to develop orthorexic symptoms as a way to cope.
• Certain media exposure: Exposure to “clean eating” trends and unrealistic body standards can contribute to the development of orthorexia nervosa. These trends can become obsessive and overwhelming to someone with a vulnerability to orthorexia.
• Previous or current eating disorders: Eating disorder development and recovery is not linear. Individuals who have a history of anorexia nervosa or bulimia nervosa can easily migrate into the world of orthorexia and vice versa.
• Healthcare-related fields, performers, and athletes: Individuals whose work involves their body being at peak performance are taught to be obsessive about the food they feed their bodies. This can have the unfortunate effect of causing fears surrounding food being “good” or “bad” and result in them developing orthorexia.
• Co-occurring disorders: Anxiety and eating disorders often go hand in hand because those with eating disorders use their behaviors to manage emotional states that they perceive to be negative.² This is also true for obsessive-compulsive disorder (OCD) and eating disorders.

Health Impacts of Orthorexia

Orthorexia negatively impacts someone’s physical, psychological, and social functioning. Psychological rigidity around food can lead a person to lack variety in their diet, leading to foodborne illness, infection, nutrition deficiencies, and health complications. When someone compulsively needs to eat “clean,” they may become overwhelmingly anxious about their health and judgmental of others. This can lead to relational issues, isolation, and feelings of shame and guilt.

Physical Impacts of Orthorexia

Physical impacts of orthorexia include various health complications and nutritional deficiencies. Since orthorexics tend to limit the variety of their food intake, they may lack the necessary proteins, fats, minerals, and vitamins found in more well-balanced diets. This can lead to malnutrition, weakened bone density, and weakened immune functioning.³ If someone consumes only raw or unprocessed foods to remain “pure,” this can also increase their risk for foodborne illnesses.³ Also, in low-body fat and underweight patients, amenorrhea (the absence of menstruation) can be an issue that can lead to osteopenia or osteoporosis.

Psychological Impacts of Orthorexia

The obsession of consuming only “pure” or “clean” foods can negatively impact someone’s psychological health. They may ruminate over personal illness or develop OCD tendencies around dietary habits. Feelings of shame, failure, and guilt when eating are common when individuals are unable to meet their own unrealistic standards for health.³ These individuals experience overwhelming anxiety when faced with consuming anything perceived as “unhealthy” or “toxic,” which may also cross over into non-food consumption like beauty products or household items.

Social Impacts of Orthorexia

When someone is overly concerned with “healthy” eating, it can strain their relationships. They may become overly invested in others’ diets or feel the need to place their food beliefs onto their friends and family, creating relationship conflict. Additionally, they may avoid going places, such as social gatherings, where any “unhealthy” or “toxic” food may be available.³ The “clean eating” lifestyle also promotes a sense of identity and purpose that can become so rigid it encourages isolation from friends or family who do not share these same food beliefs.³

Diagnosing Orthorexia

Orthorexia is not considered an official mental disorder or eating disorder by the DSM-5. However, orthorexia is generally classified by professionals under other specified feeding or eating disorders (OSFED) in the DSM-5. Professionals agree that people with orthorexia have a pattern of focus on food purity and health concerns that are indicative of disordered eating, but the DSM-5 has not established official criteria for orthorexia as a disorder on its own.⁴

The challenge for medical and mental health providers in diagnosing orthorexia is to differentiate between those who are safely pursuing improved health and those who have crossed over into disordered eating or an eating disorder. Indicators that someone has crossed over into disordered eating include 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.

Health professionals are still in conversation about exactly what criteria to include when diagnosing orthorexia, but the majority of experts break an orthorexia diagnosis into two parts:

Part 1: An Obsessive Focus on Eating Healthy Foods

The first part of an orthorexia diagnosis is an obsessive focus on eating only “healthy foods,” which include the quality and composition of all meals.⁵ This preoccupation with “healthy foods” leads the person to eat an unbalanced and restrictive diet, often cutting out whole food groups.⁵

The first set of requirements for an orthorexia diagnosis includes:⁵

• Eating only “pure” foods which has led to no food variety or balance
• Overwhelming concern about eating “impure” or “toxic” foods
• Fears of what eating “toxic” or “impure” foods will do to emotional or physical health
• Rigid avoidance of any food considered “unhealthy” due to specific contents
• Three or more hours a day spent researching, acquiring, or prepping foods
• Guilt or shame after consuming anything “unhealthy” or “impure”
• Intolerance of others’ differing food beliefs
• Spending in excess to ensure certain food quality and composition

An example of an orthorexic obsessive focus on eating healthy foods would be a young teenager who only follows “clean eating” social media and believes she must lead a dairy-free, gluten-free, and meat-free diet despite her family doctor and parents being concerned about low vitamin levels, persistent headaches, and isolating from friends. She currently only eats a specific vegan protein shake and certain fruits.

Part 2: Behavior That Disrupts Daily Life

The first part of an orthorexia diagnosis is that a person’s food obsessions and behaviors become disruptive to their daily life. Someone with orthorexia might notice that their physical, social, and psychological health is suffering because of their obsessions and behaviors around consuming only “healthy” foods.⁵

The second set of requirements for an orthorexia diagnosis includes:⁵

• Physical health issues such as nutritional deficiencies
• Social impairments, such as isolation
• Vocational or academic impairment, such as inability to focus or perform at work or school
• Psychological impairment, such as obsessional and distressing thoughts about food leading to compulsive and rigid food behaviors

An example of orthorexic behaviors that disrupt daily life would be a nurse who notices her obsession with eating only raw foods has led to headaches and fatigue at work, an inability to eat in the breakroom with colleagues, isolating from work or other social events with “processed” or “unhealthy” foods, and becoming overly invested in patient’s diets even when it is not relevant to their diagnosis.

Orthorexia 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 that 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.²

• Obsessive-compulsive disorder (OCD): The rigid food obsessions and following behavioral compulsions found in orthorexia are similar to the obsessive-compulsive cycle found in OCD. Both disorders contain compulsive behaviors that someone uses to cope with anxiety and distress around their obsessions.
• Anxiety: People who have orthorexia often have a predisposition for generalized anxiety that sometimes latches onto their food obsessions. For example, someone may start out just worrying about their general health, which leads to restrictive patterns around food characteristic of orthorexia.
• Depression: People with orthorexia often experience guilt, shame, and embarrassment around their eating habits when they consume anything “impure” or “unhealthy.” The inability to adhere to their own rigid standards can lead to poor self-image, which can persist into depression.

How to Cope With Orthorexia

The first step to coping with orthorexia is to seek a formal diagnosis and treatment plan from a therapist and registered dietician. However, there are also coping mechanisms that you can begin practicing now, including asking for specific support, diversifying your social media feeds, limiting time spent preparing or researching foods, and practicing exposure to new food values.

Here are six tips for how to cope with orthorexia:

1. Ask for Very Specific Support

If you are able to confide in your support system, it is important to be specific with your loved ones about the types of support you need. Sometimes, loved ones are unsure how to help. Requesting specific needs can help you both avoid pitfalls in communication or unmet expectations of one another.

Here are some examples of specific support you can ask for:

• “ Would you be able to go to the grocery store with me and help encourage me not to read nutrition labels?”
• “Can you drive me to my first therapy or dietician appointment?”
• “Can you sit with me while I unfollow some of these social media blogs?”
• “Would you be interested in going to a restaurant with me while I try a new food?”
• “Are you able to learn more about orthorexia so that I can feel better understood by you?”
• “Can you share your food values with me so I can practice being tolerant of other people’s food preferences?”

2. Unfollow “Clean Eating” Social Media

Experts indicate that social media contributes to eating disorders by setting unrealistic expectations and solidifies rigid food beliefs.³ Additionally, these blogs may sometimes spread misinformation about “clean eating,” which triggers underlying obsessions about health and “food purity.”³ It may be worthwhile to unfollow the social media accounts that trigger your orthorexic obsessions. Once you recover, you may be able to re-follow certain accounts, or you may find that you function better without being exposed.

3. Diversify Your Social Media

If you struggle with following only “clean eating” social media accounts, you probably lack diversity in your social media feed. When someone is exposed to only one type of lifestyle, this can become an unhealthy, obsessional, and fixed part of their identity. It may be worthwhile to follow social media accounts that are supportive of balanced diets and varying body types while you are in recovery. This might include body-positive therapists, dieticians, educators, activists, or fitness professionals.

Suggestions of hashtags to search for:

• #foodfreedom
• #intuitiveeating
• #antidiet
• #bodypositive
• #bodyneutrality

4. Find Treatment

Treatment for orthorexia will likely include a therapist and registered dietician at the outpatient level. Therapy approaches might include CBT, DBT, ACT, or family-based therapies.³ A therapist who is familiar with orthorexia can help you challenge thoughts, validate emotions, and practice new behaviors for coping with food obsessions and related compulsions. A registered dietician who is familiar with orthorexia can help you learn about how to plan, structure, and prepare meals for recovery.

5. Limit Your Time Spent Planning & Preparing Meals

Someone with diagnosed orthorexia spends excessive time researching, planning, and preparing meals. Due to food obsessions, their planning and preparation take up an unhealthy amount of time that might otherwise be spent on socializing, working, or other goals. Through recovery, a therapist can help you practice setting limits to time spent planning and preparing meals. For example, you might practice cutting the time you spend preparing a grocery list, shopping for food, or preparing weekly meals.

6. Expose Yourself to New Food Values

Sometimes, people with orthorexia struggle to hear and appreciate other people’s food beliefs and values. It is healthy and normal to have your own food beliefs. However, it is also important to learn how to appreciate and respond appropriately to other people sharing their food beliefs. Enforcing your own food beliefs onto others can lead to relationship conflict.   Practicing understanding others’ beliefs can help with recovery by widening your sense of food flexibility.

Ideas to practice flexibility around food values:

• Ask a friend to share what kinds of food they enjoy and practice finding commonalities and differences
• Attend a food festival of another culture and practice engaging with the food (Ex. If you can’t bring yourself to eat a food, try smelling or touching it)
• Order a food at a restaurant you would not normally order and practice trying one bite
• Research another culture’s food practices and find commonalities and differences with your own
• Commit to preparing one new food a week, even if you are not ready to try eating it just yet

Orthorexia Nervosa Treatment

Treatment of orthorexia involves a multi-step step cycle beginning with recognizing the developing symptoms, seeking out professional help, receiving a diagnosis, waiting for specialized care, participating in treatment, and achieving recovery.⁶ While no specific treatments are designed exclusively for orthorexia, therapy, medication, and lifestyle modifications can be implemented.

An 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 various settings, including outpatient and residential or inpatient eating disorder programs. The frequency and level of care a patient requires depends on the severity of both medical and psychological complications.

Therapy Options for Orthorexia

Therapy for orthorexia looks much like it does for those suffering from other eating disorders. The most common and widely accepted therapy 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). Oftentimes, orthorexia recovery will combine different modalities, as some modalities focus on teaching coping skills for an eating disorder, and other modalities focus on the underlying traumas and disorders that are driving the symptoms.

Therapy options for orthorexia include:

• Enhanced cognitive behavioral therapy (CBT-E): CBT-E assists individuals in challenging distorted thinking, behaviors, and emotions that serve to maintain their eating disorders. Self-monitoring homework assignments are often a significant part of CBT-E treatment. It allows a client to track symptoms and review their progress in sessions with their therapist in both outpatient and inpatient treatment settings.
• Dialectical behavior therapy (DBT): DBT for eating disorders helps clients develop new skill sets, including emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. These skill sets are designed to help individuals deal with anxiety, out-of-control emotions, and other issues that contribute to their orthorexia.
• Family-based treatment (FBT): FBT, also called the Maudsley Method, views the family as an integral part of the team and works to re-establish healthy eating patterns and interrupt unhealthy behaviors. During FBT, a family member is responsible for the refeeding process for weight gain or maintenance and recovery.
• Exposure and response prevention (ERP): ERP is designed to reduce the amount of emotional and physical distress a client experiences when confronted with a specific food, thought, or situation. During ERP, a therapist or registered dietitian will arrange experiential challenges to assist a client in facing fears such as eating in a restaurant, shopping for clothes, or going to a grocery store.

Medication for Orthorexia

Sometimes, medications are needed to assist a person with orthorexia due to anxiety or depression that may accompany an eating disorder. The most widely prescribed antidepressants used in these cases are selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft).These medications are used due to the relatively low rate of side effects and positive impact on depression, anxiety, and OCD.^7,8,9 Many will also receive medications and/or supplements to address medical complications related to their orthorexia.

Lifestyle Changes for Orthorexia

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 orthorexia 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

How to Find Professional Support For Orthorexia

If you are interested in seeking out care for yourself or a loved one suffering from orthorexia, an initial assessment with an eating disorder therapist 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.

An online therapist directory is a great way to find therapists in your area who specialize in orthorexia. If you prefer seeing a therapist remotely, there are many online therapy platforms that can provide you with specialized therapy from the comfort of your own home.

If you are considering medication, it’s recommended to see either a psychiatrist or nurse practitioner with training and experience specific to eating disorders due to the unique needs you may have.⁹ An online psychiatry service is an easy way to find qualified psychiatrists who have experience in eating disorders.

Cost of Treatment for Orthorexia

Orthorexia requires treatment from many professionals who collaborate to provide specialized care. The cost of orthorexia treatment varies depending on the length of time needed and the level of care required. 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, which makes early intervention imperative. The earlier a person gets into treatment, the less costly the treatment will be overall.

Orthorexia Treatment Timeline

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.⁷

How to Support Someone With Orthorexia

Supporting someone with orthorexia first includes encouraging them to seek professional support. This can help you draw boundaries between supporting as a friend and having a professional provide medical guidance to your loved one. Other steps to helping someone with an eating disorder include educating yourself on their diagnosis, seeking your own therapy, and supporting them as they practice exposures to new foods and values in recovery.

Here are some additional online eating disorder resources to check out:

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