By Amy McHugh
For The Washington Post
Berry bowls. Erewhon smoothies. Chia pudding. Many of us mindfully sprinkle wheat germ on grapefruit or embrace whatever healthy food trend promises to deliver a longer lifespan, and what’s the harm of that?
But good intentions, it turns out, can go too far. In recent years, physicians and researchers have seen a rise in orthorexia, disordered eating focused on extreme healthy eating.
In 1997, physician Steven Bratman coined the term “orthorexia” (orthos, “right” and orexia, “appetite,” translating to “righteous eating”) in response to his patients who were fine physically but “driving themselves crazy” over their eating habits.
Bratman’s work observed two stages of orthorexia. Healthy orthorexia, with an interest in healthy eating with no pathological features, and orthorexia nervosa, with an obsessive focus on healthy eating.
“Many people are able to eat healthy without being orthorexic,” says Bratman. “The difference is the obsessiveness and restriction that causes harm.”
A ‘tricky’ eating problem
Orthorexia is linked to perfectionism, obsessive-compulsive disorder and anxiety. Characteristics include rigid food choices, meticulous planning and a focus on food as a source of health rather than pleasure.
The prevalence of orthorexia nervosa remains hard to pin down, with some research estimating 6.9 percent of the general population struggles with it vs. up to 35 to 57.8 percent of high-risk groups, which include health-care professionals, athletes, artists and others with perfectionist tendencies. Experts argue that the lack of a recommended diagnostic tool undermines the estimates of orthorexia’s prevalence, which can have significant mental and physical health consequences.
“Orthorexia is tricky because eating healthy is good for us,” says Jennifer Wildes, a psychiatry professor at University of Chicago Medicine. “But when it interferes with psychosocial functioning and the thought of eating birthday cake makes you burst into tears, it’s a big sign you need help.”
I know this well. During my senior year of college in 1997, I ate a sweet potato for dinner every night. I turned down dinners out with friends, fearing a deviation from my “safe,” healthy meal. I was obsessed with clean eating but wasn’t anorexic or bulimic, so there was little — if any — support available.
Some recent research suggests orthorexia is on the rise.
A study led by José Francisco López-Gil, a senior researcher in lifestyle medicine at the Universidad de Las Américas, hopes to clarify the condition’s prevalence, contributing factors and diagnostic challenges. López-Gil’s work emphasizes the need for standardized diagnostic criteria for the condition. “More research is needed, but that doesn’t mean [orthorexia] isn’t a real and significant condition,” says López-Gil.
Social media connection
Experts say social media plays a role in perpetuating orthorexia, although the extent is unclear. “It’s hard to tell if there’s an uptick in orthorexia because we’re better at recognizing it, or because of social media,” says Wildes. “Most likely, it’s both.”
López-Gil says higher social media use correlates with increased orthorexia symptoms, particularly within online “clean eating” communities. He also pointed to post-pandemic shifts in eating habits, increased screen time and heightened health anxieties as contributing factors.
“There’s always been a relationship between media consumption and perceptions of your body or eating behaviors,” says T. Makana Chock, a professor at Syracuse University’s Newhouse School of Public Communications. “But social media is different because it’s social, and humans have a visceral desire to belong to a group, even if it’s a group of people we’ve never met in person.”
A TikTok search for “clean eating” generated 64.5 million posts. “What I Eat in a Day,” a common term on social platforms, chronicles influencers’ daily food intake and hacks including filling up on bowls of cucumbers and calorie-deficit days.
“Orthorexics develop quite ornate rules around clean eating and living and adhere to them,” says David J. Alperovitz, director of the Klarman Eating Disorders Center at McLean Hospital. “People gravitate toward things they can control when they feel anxious, and food and diet, as well as weight, body shape and size, are quantifiable.”
Unlike those with anorexia nervosa, the research shows that individuals with orthorexia typically don’t struggle with perceived weight or body shape. The distinction is crucial, as many orthorexics are treated with traditional anorexia therapy, which may not be appropriate.
Ironically, despite consuming adequate calories, some orthorexic people can be malnourished because their limited diets don’t provide the nutrients they need.
“It’s difficult to recognize that the pursuit of healthy living can become extreme and create physical and psychological problems,” says Doreen S. Marshall, chief executive officer of the National Eating Disorders Association (NEDA). Marshall adds that the high mortality rate associated with eating disorders calls for increased attention and resources.
Getting help
Experts offer the following advice:
Don’t wait to get help: Marshall suggests starting with the NEDA screening tool, which was used 110,000 times last year and has been used more than a million times since its inception. NEDA offers a list of resources for specialists in every state. Treating both the mental and physical health of orthorexia is imperative.
Enlist professionals, and self-advocate: Treatment is most effective with a multidisciplinary team, including an individual therapist, psychiatrist, dietitian and, in some cases, a family therapist.
Because primary care doctors commonly fail to ask patients about their food choices and behavior unless there’s a red flag, Marshall suggests bringing the NEDA screening result to medical appointments and discussing ways to get help.
Outsmart the algorithm: Beat social platforms at their own game. Searching for travel destinations, sneakers or funny animal videos will change the content feed, Chock says. She recommends setting a timer for scrolling and limiting consumption to once or twice a day and checking the credentials of influencers whose nutritional advice you’re taking.
Head to the grocery store: Wildes sends her patients to the grocery store and asks them to list the foods they once loved that they no longer allow themselves to eat. Patients then eat something from the list on their own or in her office.
Because this can be difficult, Wildes also has her patients post a list of what they used to value in their life on their refrigerator, mirror or bedside. When eating food not on their “safe” list gets scary, they can refer to the list.
Resist labeling: Alperovitz warns families and friends to be mindful of the language they use about food and resist labels such as “good” or “bad.” Taking a moratorium from talking about food and offering support can be helpful, too.
“I see a lot of families who have an orientation to healthy eating, which is fairly normative, but their comments might align with a broader cultural conception of healthy, which, even though they’re well intended, fit this pattern of restriction,” he says.
People with orthorexia can break free from their behaviors, Wildes says.
“There just needs to be that little nugget that wants to change,” she says. “I think most people have it in them. The first step is getting help.”
