Orthorexia: Signs, risk factors, and treatment

Written bytherapist.com team

Last updated: 09/14/2023

Reviewed by Stephanie Steinman, PhD, CSAC

As a person with Type 2 Diabetes, I have to be careful with what and how much I eat, how much I exercise, how well I sleep, etc. If I am not planning ahead and taking precautions (while also trying to enjoy what should be pleasurable experiences), I could find myself with either blood sugar that is too high (which can result over time in damage to my heart, kidneys, peripheral nerves, etc.) or blood sugar that is too low (hypoglycemia) which is a miserable experience that feels like having a horrible anxiety attack. Of course, if my blood sugar were to drop extremely low, serious injury or death could occur. In the context of my condition, I found the following article on “orthorexia” very interesting and worth the time reading. I will be making comments within the article as indicated by >> << brackets. I hope you find this article interesting and helpful as well.

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What is orthorexia?

Orthorexia nervosa, usually referred to as orthorexia, is an unhealthy obsession with healthy eating. It involves compulsively pursuing a diet you believe will maximize your well-being, even when it seriously disrupts your life.

The diet can vary and might mean eliminating entire food groups, tracking every nutrient and ingredient you put in your body, or doing “detoxifying” fasts and cleanses. Some people may be trying to reach personal health-related goals, while others may be looking to manage specific food allergies or intolerances.

It’s hard to estimate how common orthorexia is because we don’t have standardized diagnostic criteria for it. Estimates of the percentage of people affected by this disorder range substantially depending on the research methods used and the location of the people studied.

Is orthorexia an eating disorder?

Orthorexia isn’t formally classified as an eating disorder, but it is a form of disordered eating. So far research shows that orthorexia shares symptoms with several disorders, including obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), illness anxiety disorder (often informally called “hypochondria”), and even psychosis.¹

When does healthy eating become unhealthy?

One of the challenges of orthorexia is being able to recognize when healthy eating has turned into an unhealthy obsession. That line can be blurry, especially since there’s no such thing as a “perfect” diet—what’s healthy for one person may not be healthy for another.

Generally speaking, problems can start when your food choices and eating habits start to harm your mental and physical health. This could look as simple as not enjoying daily meals because they lack variety, or it could be as serious as developing social isolation, food-related anxiety, or nutrient deficiencies.

Signs of orthorexia are even harder to spot if your eating habits are motivated by health-related goals and you’re seeing results you want. For instance, if your appearance has changed, your energy has improved, or other people have taken positive notice of your efforts, you may be more likely to focus on those upsides and downplay any problems.

Signs and symptoms

The following may be warning signs of orthorexia:²

• Obsessive thoughts about the quality of your diet
• Preoccupation with nutritional value, ingredients, and how they affect you
• Rigid, restrictive meal plans
• Anxiety when faced with the prospect of eating certain foods
• Perfectionism in how you eat, such as always trying to get the “right” balance of nutrients
• Avoidance of foods, ingredients, and food groups you feel aren’t healthy or pure
• Frequent fasting, cleansing, or detoxing
• Extreme worry about illness
• Social isolation due to food restrictions
• Feelings of guilt or shame after eating particular foods
• Concerns about body image
• Focusing on how healthfully others are eating

>> Notice some key words in these bullet pointed symptoms that can be true of many mental health conditions: Obsessive, preoccupation, rigid, restrictive, anxiety, perfectionism, avoidance, extreme worry, social isolation, guilt or shame, body image, and comparing oneself to others. I find in my own clinical practice (I am not an eating disorders specialist but focus on trauma to a great extent) that trauma survivors often use these same words in their language or in their behaviors.<<

These common beliefs about food and eating may contribute to orthorexia:

• I must eat in a specific way to be healthy, look a certain way, or feel good about myself.
• Food is good or bad, right or wrong, healthy or unhealthy, clean or unclean.
• Planning and tracking everything I eat is necessary for success.
• Nutritional value and purity is more important than taste, satisfaction, or pleasure.
• “Cheat meals” or indulgences in certain foods are rewards for healthy eating.
• Straying from my diet should result in punishment or tighter restrictions.
• Failure to stick to my diet reflects a lack of willpower, self-control, or motivation.
• I should avoid situations where “healthy” food isn’t available or “unhealthy” food is too tempting.
• Someone I admire eats in a restrictive way, so I should too.

>> Notice again the “extreme” types of statements, self-condemnation, and “black and white” thinking <<

Causes and risk factors

The causes of orthorexia aren’t yet known, but several factors may contribute. Some of the biggest risks include preexisting mental health issues such as obsessive-compulsive traits, a history of disordered eating or eating disorders, and negative body image.³ Having a family member with an eating disorder may also be a risk factor. Low self-esteem doesn’t seem to be associated with orthorexia, but preoccupation with weight and appearance are.⁴

Personality traits—especially perfectionism—may also make someone more likely to develop orthorexia.⁵ A strong need for control can also lead to an obsession with food choices.

>> I have had clients and a few acquaintances who are in recovery from substance abuse who state that orthorexia is a “replacement addiction” for them and because it’s viewed by them as “good” and “healthy,” they do not see a problem with it. <<

Age may play a role, but we don’t yet know for certain. Some research indicates that adolescents and young adults are especially vulnerable, while other studies show no significant difference in susceptibility between adolescents and adults, suggesting that the disorder can happen at any age.^{6, 7}

Social factors in orthorexia

Commonly held beliefs about health or body image can sometimes cause us to take our habits too far. Orthorexia seems to occur most often in people who are:

Well educated and high earners: People with a higher socioeconomic status can access and afford healthy foods more easily, which may lead to a greater focus on diet as a source of health or wellness.⁸

Studying or working in health- or fitness-centered fields: In a study of more than 600 dieticians who completed a survey about their eating habits, more than half were at risk of having or developing orthorexia.⁹ Other professionals who may have higher risk include nutritionists, health care students, fitness and yoga instructors, gymnasts, trainers, and dancers.¹⁰

Athletic: People who exercise regularly tend to have higher rates of orthorexia, especially endurance athletes and participants in fitness trends like CrossFit.^{11, 12, 13}

Following special diets: People who adhere to vegetarian, vegan, paleo, gluten-free, all-organic, and other exclusionary diets may be more likely to develop orthorexia.¹⁴ The results on this are mixed, though—other research concludes that following a special diet isn’t a risk factor.¹⁵

>> As I noted in my opening, as a person with Type 2 Diabetes, adhering to a low carbohydrate diet is a must if I want to keep my blood sugar at a normal, healthy level. <<

Reading health-related media: Health-focused blogs, magazines, podcasts, books, and social media are full of advice, sometimes contradictory, on what people should and shouldn’t eat. Wellness and health commentators who promote rigid or restrictive diets can give followers a false impression that certain eating habits are necessary for physical and mental well-being.¹⁶ The healthy-eating community on Instagram, in particular, is associated with higher rates of orthorexia.¹⁷

Using diet and fitness tracking apps: Many people who struggle with disordered eating and use fitness and diet tracking apps feel those apps contribute to unhealthy eating behaviors.¹⁸ Tracking apps tend to encourage obsession, dependency, fixation on numbers, and rigid dieting.¹⁹

>> As a simplistic analogy, keeping lists can encourage obsession, dependency, and fixation on numbers or accomplishments for someone with an overly controlling type personality. If the items on the list are marked off as done, the person feels good about themselves. If ANY items are left un-marked or undone, then a corresponding feeling of guilt and failure can result. In this sense, unless we are doing something hurtful to ourselves or someone else, leaving something undone that results in shame or guilt is a problem. <<

How orthorexia affects your mental and physical health

Mild symptoms of orthorexia may look like feeling a bit sluggish or low. More severe cases can cause serious distress or a decline in mental health. The disorder is associated with:²⁰

• Lack of interest in everyday activities
• Anxiety
• Depression
• Chronic fatigue
• Insomnia
• Strained relationships and social isolation
• Other eating disorders, including anorexia nervosa and bulimia nervosa

If orthorexia is severe enough to lead to malnutrition, it can cause physical health problems like hormone issues, menstrual irregularities, low bone mass, vitamin D deficiency, and unstable blood sugar levels.²¹ Some people with physical health conditions may also focus too much on healthy eating to help combat their symptoms naturally, only to wind up making their health worse.

Diagnosis and treatment

Even though orthorexia isn’t officially classified as an eating disorder, mental health professionals may be able to detect and diagnose it using tools such as the Eating Habits Questionnaire or the Dusseldorf Orthorexia Scale, among others.²² Note that while these tools can be helpful, they’re not always reliable, and they may falsely identify people as having orthorexia.

For a more thorough diagnosis, mental health professionals should also consider a client’s history of disordered eating or eating disorders, links to other mental health concerns (such as anxiety), changes in their social life, malnutrition, and weight loss.

Orthorexia tends to be treated similarly to other eating disorders. This may include a combination of therapy, psychoeducation, medication, and, in severe cases, hospitalization.²³ More research is needed into how effective these treatments are for orthorexia.

Therapeutic approaches for orthorexia include cognitive behavioral therapy (CBT), which may be especially helpful for perfectionists, and exposure and response prevention (ERP), which may help with obsessive-compulsive habits. Holistic therapeutic methods that promote relaxation, such as mindfulness and meditation, can also help people reduce their food-related anxiety.

>> While not mentioned in this article, EMDR (Eye Movement Desensitization and Reprocessing) is very useful for helping those with negative emotional self-statements (Negative Cognitions) that are irrational heal and live according to truth <<

How to get help

If you or someone you know is struggling with orthorexia, disordered eating, or an eating disorder, seek help as soon as possible. Start by contacting your primary care doctor or a mental health professional who specializes in eating disorders.

If you’re in crisis and need immediate help, call the 988 Lifeline at 988 or text HOME to the Crisis Text Line at 741741. Both of these free, confidential resources are available 24/7.

Another option is to build a support network. Organizations focused on helping people recover from eating disorders and disordered eating include:

• National Eating Disorders Association, a comprehensive support resource for individuals and families.
• National Association of Anorexia Nervosa and Associated Disorders (ANAD), which offers virtual support groups, one-on-one mentors, and resource guides for recovery.
• Project Heal, which helps people who can’t afford eating disorder treatment get the help they need.
• The Alliance for Eating Disorders Awareness, which offers support group and a daytime helpline where you can speak to a licensed professional.
• Eating Disorder Hope, which has a directory of eating disorder treatment centers, programs, and other resources.

It is possible to live a healthy lifestyle free from obsession. Browse our directory to find a therapist who can help you learn to maintain healthy habits without harming your mental or physical health.