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Orthorexia (Orthorexia Nervosa)

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Orthorexia is an obsession with healthy eating that involves excessive self-imposed restrictions that can lead to negative health effects.

 It’s not formally recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an eating disorder, but it’s beginning to get more attention among the medical community.

What Is Orthorexia?

Orthorexia is marked by a preoccupation with all things surrounding food, including obsessing over ingredients, what the next meal will be, and the eating habits of friends.

Orthorexia has been defined in research as an obsession with healthy eating to the point where it negatively impacts one’s well-being and may even contribute to malnutrition.

 A person might eliminate entire food groups deemed “unhealthy” or “impure” from their diet, making the list of foods they view as acceptable narrow and extremely limited.

The term “orthorexia” was introduced in 1997. It isn’t currently recognized as an eating disorder in the DSM-5, though it’s often referred to as an eating disorder by clinicians and some health organizations.

“There's increased awareness, and it's being identified and treated — when in the past it was getting misdiagnosed or even missed completely,” says Samantha DeCaro, PsyD, the director of clinical outreach and education at the Renfrew Center in Philadelphia.

Types of Orthorexia

You’ll find that the terms orthorexia and orthorexia nervosa are used.

 Some researchers state that orthorexia nervosa is an extreme version of orthorexia that’s paired with intense distress and anxiety to the point where daily life is affected.

More often, though, the terms are used interchangeably. In clinical practice, however, they mean the same thing, Dr. DeCaro says.

Outward signs of orthorexia are not necessarily visible. The signs are behavior-based. “Orthorexia is not necessarily driven by a strong desire to lose weight, and it's not necessarily driven by a strong desire to cut calories,” DeCaro says. “It's really driven by this desire to achieve optimal health.”

Signs and symptoms of orthorexia include:

  • Checking nutrition labels compulsively
  • Eliminating a large portion of food groups and only eating a narrow group of “healthy” or “pure” foods
  • Being overly concerned with the health of ingredients consumed
  • Body image concerns (though these are not always present)
  • Being unusually interested in what others are eating and feeling superior to them
  • A preoccupation with food and what might be served at an event
  • Feeling stressed when healthy foods aren’t available

DeCaro adds that malnourishment and weight loss are other signs that could result from the extreme restriction.

Because people with orthorexia may be overly concerned about where their food comes from, it can make social situations difficult. The individual might be unwilling to go to a restaurant or a friend’s house since they won’t know the source of each ingredient used in the food. Orthorexia can also invite uncomfortable social situations since people with orthorexia may look down on those who don’t have a similar approach to eating.

While DeCaro says eating disorders can develop for anyone, it seems there are some risk factors associated with orthorexia that span from psychological to sociocultural ones. These include:

  • Certain personality traits such as perfectionism and neuroticism
  • A history of dieting
  • Poor body image
  • Media exposure promoting clean eating and unrealistic bodies
  • The glorification of diet culture
Social media chatter that promotes clean eating and comparisons of body types also can fuel negative thoughts that lead to orthorexia. Heavy use of Instagram was found to be associated with increased symptoms of orthorexia in one survey of individuals who follow healthy food accounts.

Because it’s not officially recognized by the DMS-5, orthorexia isn’t consistently identified by clinicians.

 (And because there are no diagnostic criteria, technically orthorexia is not a diagnosis.)

Furthermore, the main symptoms of orthorexia — a focus on healthy eating — can blend in and overlap with wellness or diet culture and lead to it going unidentified, DeCaro says. “And, unfortunately, they can be seen as someone taking care of themselves.”

But there has been talk among the medical community on how to go about identifying it.

The proposed diagnostic criteria from a small group of researchers and clinicians (which have not yet been adopted by the wider mental health community, DeCaro says) include:

  • Preoccupation with the quality and purity of food
  • Excessive focus on the nutritional content of food
  • Rigid dietary restrictions
  • Impact on daily life and well-being
There are also some tools designed to help providers identify orthorexia. First, the ORTO-15 is a 15-question self-report screening tool.

 There’s also the ORTO-R, which is a newer, 6-question screening tool.

 And finally there’s the Bratman Orthorexia Self-Test.

Because orthorexia is considered an emerging disorder, more research is needed to determine standard treatment options.

Current strategies that are used involve counseling and therapy to help an individual recognize and acknowledge that being committed to healthy eating is one thing, but that it’s gone too far if it’s impacted your life in a significant way — and then taking steps to change thought processes and behaviors.

According to DeCaro, all eating disorders are best treated with an interdisciplinary team that includes a therapist, registered dietician who is knowledgeable about eating disorders, and a primary care physician. Family or another support system is also crucial in providing a safe space for the individual as they pursue treatment.

Medication Options

Currently there’s no research supporting the use of medications or drugs to help with orthorexia. But addressing other co-occurring diagnoses with medication can help.

“Eating disorders so rarely travel alone,” DeCaro says. Medications that address underlying depression, anxiety, post-traumatic stress disorder [PTSD], or trauma history — such as antidepressants or antipsychotics — can help, but these treatments should be highly individualized, DeCaro says. For those experiencing anxiety and obsessive-compulsive disorder (OCD) traits, serotonin reuptake inhibitors are an option.

Psychotherapy Options

The best ways to go about treating orthorexia (per the current evidence) are psychotherapy approaches and nutrition coaching. Some types include:

  • Psychoeducation informs individuals about the disorder, its impact on their physical and mental health, and psychological factors at play. This could come from a therapist, dietitian, primary care physician, and sometimes a psychiatrist, DeCaro says.
  • Psychotherapy involves sessions with a psychologist or therapist and works by increasing exposure to the foods that give the individual distress.

  • Cognitive behavioral therapy CBT targets the maladaptive behaviors and thoughts that are related to orthorexia in hopes that the individual can reframe the unhealthy aspects and develop coping strategies. A therapist, psychologist, or counselor may also use CBT to help an individual reintroduce foods they previously deemed “unhealthy.”
  • Nutritional counseling from a nutritionist or registered dietitian (RD) specializing in eating disorders can help restore a healthy approach to food and address any deficiencies.
  • Intuitive eating counseling sessions with a nutritionist or RD encourage paying close attention to internal hunger cues and giving the body nutrition for nourishment rather than restriction. Intuitive eating also tends to promote a positive body image and self-compassion.

The number of sessions needed for each of these types of therapies depends on the severity of symptoms, medical issues, and co-occurring psychiatric disorders, DeCaro says.

Other Complementary and Integrative Therapies

There are also mindfulness and acceptance-based interventions that complement the treatment options above.

Mindfulness interventions help individuals tap into the present moment and detach themselves from the negative thoughts. Acceptance-based interventions promote self-compassion without passing judgment.

Anyone can develop an eating disorder, no matter their race, socioeconomic background, age, or gender identity.

But you can proactively establish healthy eating habits to avoid developing orthorexia.

  • Eat a balanced diet and avoid extreme dieting.
  • Avoid supplements, laxatives, or herbal products designed for weight loss
  • Exercise.
  • Treat mental health challenges, such as depression, anxiety, or body image issues.

DeCaro also says there are protective factors that you can put in place to keep the risk of orthorexia or another eating disorder at a minimum, such as intuitive eating, stress management, learning to express your needs and emotions, and effective coping skills. She also says it’s important to avoid dieting or getting wrapped up in diet culture, because diets can be a gateway to disordered eating.

If you’ve fallen into these thought patterns and behaviors before, DeCaro suggests maintaining orthorexia management strategies and having a care team in place to help if you feel yourself slipping toward a relapse. “It might mean having more therapy sessions or going into a higher level of care where you have that support and structure to break the cycle,” DeCaro says.

It’s hard to say how long people tend to have orthorexia, as it isn’t officially recognized by the DSM-5 and therefore hasn’t been thoroughly studied, DeCaro says.

“It's probably safe to assume that with orthorexia (and with other eating disorders) we are probably underestimating the folks out there who have it and the length of time that they're struggling with it,” DeCaro says.

Part of the issue that delays identifying orthorexia is that behaviors may appear healthy on the surface and there’s overlap between orthorexia and wellness culture. “People may even praise the individual, saying ‘Look how healthy, look how disciplined they are,’” DeCaro says. “It can get minimized and dismissed.”

That said, the sooner someone notices signs of orthorexia and seeks help, the better their prognosis, DeCaro says.

Once a person begins treatment for orthorexia, they’ll likely undergo a physical examination because of the possibility of malnourishment.

“The behaviors around orthorexia [may] result in someone just not eating enough for their body and brain, so they start to see some of the issues secondary to that restriction,” DeCaro says. For instance, they may develop:

  • Osteopenia, or loss of bone density

  • Anemia, a lack of healthy red blood cells, which deliver oxygen around the body

  • Hyponatremia, abnormally low sodium levels

  • Pancytopenia, a condition with lower number of red and white blood cells in the body

  • Bradycardia, an unusually slow heart rate

  • Pneumothorax and pneumomediastinum, when air is present in the space between the lungs

Because of the lack of official diagnosis and synchronization of diagnosing criteria, it’s difficult to say how many people have orthorexia.

 This has created a challenge for clinicians and researchers who don’t yet fully understand this eating disorder and the impact it has.

Some research has attempted to answer this question, but the findings vary. According to one small study involving 275 college students, less than 1 percent of the population seemed to fit the definition of orthorexia.

Another review involving 11 studies found orthorexia affects about 7 percent of the general population, and that it may be more prevalent among healthcare professionals and performance artists — but the study authors also concluded that more research was needed to clarify diagnostic methods.

There is some overlap between orthorexia and other conditions, including:

  • Anorexia Nervosa Anorexia nervosa and orthorexia both involve extreme restriction, but orthorexia doesn’t typically come with the same fear of gaining weight that anorexia nervosa does. Those with anorexia focus more on food quantity, and those with orthorexia focus on food quality.

  • Obsessive-Compulsive Disorder (OCD) Like orthorexia, obsessive compulsive disorder comes with perfectionism, rigid thinking, and a preoccupation with rules.

  • Other Eating Disorders DeCaro says other eating disorders are also characterized by obsessive thoughts, compulsive behaviors, fears of certain foods, and avoidance of certain foods.
There’s also some debate as to whether orthorexia is a standalone eating disorder — or if it should be considered a subtype of either anorexia nervosa or obsessive compulsive disorder (OCD).

“I see it as its own syndrome,” DeCaro says. “I think it captures a very specific set of symptoms. And I think one day it probably will land in the DSM.” To establish orthorexia as a diagnosis in the DSM, DeCaro says there would need to be more compelling, peer-reviewed evidence that it is a distinct disorder with its own unique features and treatment needs.

An important way that orthorexia is different from many other eating disorders is that it doesn’t typically involve a preoccupation with thinness or body size, DeCaro explains. Rather, the central focus is on the quality and healthfulness of the foods.

Some believe that following a vegan or vegetarian diet are also related and can lead to orthorexia. One review showed that following a vegetarian diet was linked with orthorexia in 11 of 14 studies.

 But another found that no such association exists, and that people primarily become vegan or vegetarian for ethical reasons.

Psychology Today

Psychology Today’s “Find an Eating Disorder Specialist” tool can help you find a therapist who specializes in the eating disorder population.

National Alliance for Eating Disorders

The National Alliance for Eating Disorders offers tips on how to help a loved one who may be experiencing orthorexia. The organization also offers a free helpline, which is confidential and gives you an opportunity to speak with a licensed professional who can help if you’re struggling with an eating disorder.

Therapy Thoughts

The 25-minute “Orthorexia” podcast episode in this mental health series shares more information about orthorexia.

Enthusiasm for healthy eating is generally a good thing. It becomes unhealthy orthorexia when it’s obsessive and interferes with daily life. Though not officially recognized as an eating disorder, orthorexia can be very disruptive, but therapy can help with recovery. “You don’t need to do this alone,” DeCaro says.

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