When Eating Right Goes Wrong

A patient of mine recently said she’d asked her boyfriend to take her out to a trendy new restaurant. He agreed at first, but soon started texting her detailed questions about the menu. Does it have anything zero-carb, he wanted to know. Is the beef organic? She looked at the menu but couldn’t tell, so she ended up calling the restaurant herself. When she went to her boyfriend with the restaurant’s answers, thinking this would settle the issue, he responded with more questions. Can the chef use butter instead of seed oils? Do they have any bread made with coconut or cassava flour? That’s when she began to wonder if this dinner date would ever really take place.

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Those who have been in situations like this — or who, perhaps, occupy the position of the boyfriend in this scenario — may be described as struggling to eat “right,” but such efforts toward correctness can cause problems even as they seek to promote good health. The term orthorexia, coined in 1997 by Steven Bratman in the Yoga Journal, describes this condition, with “ortho” meaning “correct” and “orexis” meaning “appetite.” If the word sounds familiar, it’s because it holds an echo of anorexia, although in this case the fixation is on the quality of the food consumed, not its quantity.

Even if its sufferers are trying hard to eat well, orthorexia can cause health problems. Dunn et al (2016) reports that the fixation on “eating right” can, in extreme cases, lead to malnutrition or to difficulties like alienation from one’s peers or stress within one’s relationship. (As Cena (2019) says, a situation like this needs to cause problems in either occupational or relational functioning to be called a disorder.) Plus, orthorexia can be harder to detect because it’s not easy to diagnose. Currently it lacks formal diagnostic criteria, although questionnaires and screens have been attempted in the past (such as by Donini et al in 2005). The DSM-V categorizes orthorexia as an “unspecified feeding and eating disorder,” rather than a syndrome in its own right. There’s also quite a bit of overlap (according to Pontillo et al, 2022) between orthorexia and obsessive-compulsive disorder, and it’s difficult to know where food-related obsessions and compulsions from a broader diagnosis of OCD might end and the specific criteria for orthorexia might begin.

To identify orthorexia, one can look for any one of a series of signs or symptoms; these indications comprise a long list. Even mild symptoms of orthorexia may indicate a condition with the potential to become more serious or more dangerous. According to Koven et al (2015), the following behaviors suggest — but do not exclusively identify — the risk of orthorexia:

• Refusal to eat anything other than a small group of foods
• Cutting out a large number of different food components, such as carbohydrates, dairy, meat, animal products, and sugar
• Compulsively checking nutrition labels or ingredient lists
• Exhibiting discomfort and distress when desired foods are not available
• Thinking about food too much
• Obsessively planning what to eat in advance of upcoming events

A more recent article by Harris et al in the Eating and Weight Disorders journal (2020) also implicates, in the genesis of orthorexia, high levels of perfectionism, potential feelings of superiority about nutrition, and intolerance of other people’s food-related decisions. Last year, Scheiber et al. (2023) also added to the list, noting that many people who obsess over eating right also obsessively follow food and nutrition influencers on social media.

Obviously it’s a good thing to eat healthy foods — so how, then, does this positive impulse turn into a disorder, and which healthy eaters should notice their minor symptoms lest they get worse? As Gorwood et al. commented in 2016, various factors may contribute to the development of an eating disorder like orthorexia: “food preferences, inherited differences in taste perception, food neophobia or pickiness… parental feeding practices, and a history of parental eating disorders.” Sometimes, orthorexia can be comorbid with — overlap with — anorexia nervosa or OCD. Perfectionism, rigid thinking, a preoccupation with details and rules, and a need for control can be present in each of these disorders. One way of spotting the difference is a psychological tell, according to Bratman (1997): people tend to hide their anorexia because of shame, but they are proud of orthorexia and may even actively promote their beliefs. Similarly, people with OCD often experience distress and discomfort with their symptoms, while those with orthorexia may show less of this, and thus can have less insight into the illness (Koven et al., 2016; Dell’Osso et al., 2016).

When it comes to treating orthorexia, there’s a positive twist: as Mathieu (2005) has said, because these patients are so focused on wellness, they may be somewhat more willing to enter treatment — although their disorder may also affect their decision-making and cause them to reject such medications. For orthorexia, no specific treatment protocol has yet been created, but a multidisciplinary team may be the best option. Mathieu (2005) indicates that SSRI medications (which are also used to treat OCD) can help reduce anxiety, obsessive thoughts, and compulsive behaviors. Koven et al. (2015) suggest that cognitive-behavioral psychotherapy can help reduce symptoms of orthorexia as well, in that CBT can be targeted toward specific, irrational thought patterns. Obsessive thoughts and compulsive behaviors may respond to exposure and response prevention treatment; anxiety about foods and at mealtimes can be addressed with relaxation therapy or mindfulness meditation skills. Another psychotherapeutic treatment goal would be to diversify the types of foods that a patient finds acceptable. And although further nutritional education can be helpful in correcting harmful or inaccurate beliefs about foods or food preparation, the discrepancy between such information and a patient’s preexisting beliefs can also create stress rather than relieving it. If orthorexia should lead to significant weight loss or malnourishment, Koven adds, hospitalization could be necessary.

With this level of treatment complexity required, and with its etiology still so vague, it’s not surprising that orthorexia still lacks an official diagnosis. Until more is known, many people experiencing these symptoms may remain confused between their genuinely healthy behaviors and those that emerge from compulsive health-seeking or inaccurate nutrition-related beliefs; their friends, families and partners will likely continue to bear the brunt of this confusion. And if you find yourself wondering if any of these categories applies to you, seek out more information from an experienced, trusted, educated healthcare professional — someone in the right position to offer you unbiased and accurate advice.

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