Orthorexia: When Healthy Eating Becomes an Obsession

A few years ago, I gave a presentation to an audience of physicians and hospital administrators based on my book, The Healthy Deviant: A Rule Breaker’s Guide to Being Healthy in an Unhealthy World. During my talk, I noted how deviating from the typical American diet — or just not eating what everybody else is eating — can lead to social awkwardness and stigmatization.

A doctor approached me after­ward to seek my advice. Her ­daughter was experiencing a different sort of problem: Her commitment to healthy, “clean,” ethical, and environmentally sustainable eating wasn’t causing her to become socially alienated; it was causing her to ­become seriously malnourished.

According to this worried physician-mom, her 19-year-old’s recent labs and scans showed not just significant nutritional deficiencies and hormonal imbalances but early signs of brain damage.

She said her daughter was willing to consume food, at least in principle. The problem was that, in practice, she had trouble finding enough foods that met her impossibly high standards. Once all her requirements were accounted for — organic, vegan, local, fair trade, gluten-free, low FODMAP, low histamine, plastic-free — there was almost nothing left for her to eat.

 

When Self-Care Turns to Self-Harm

In today’s hyperonline culture, we are bombarded by all sorts of emphatic “eat right” messages. Increasingly, they concern not just personal health but also planetary health, social justice, animal welfare, and more. And as growing numbers of people align themselves with diverging dietary dogmas — think paleo, keto, vegan, and carnivore — the debates around “optimal” eating grow ever more fierce.

Perhaps not surprisingly, these debates have given rise to a great deal of true-believerism about what each of us should and should not be eating. They may also be contributing to a form of disordered food restriction known as orthorexia.

The term “orthorexia nervosa” was coined in 1997 by Steven Bratman, MD, MPH, to describe a fixation on food quality, food preparation, and so-called clean eating. Today, the National Eating Disorders Association offers a list of orthorexia warning signs, including compulsive checking of ­ingredient lists and nutrition labels and the elimination of large categories of food (sugars, fats, carbs, dairy, grains, animal products) — coupled with an unusual interest in what others eat and a preoccupation with food purity.

Understandably, many conscious eaters are skeptical of the concept of orthorexia, seeing it as one way our unhealthy culture marginalizes healthy choices.

When I first read about orthorexia 10 or so years ago, I fell squarely into that skeptical camp. I had spent decades trying to explain my own ­gluten-free, low-dairy, whole-food eating — which works great for me — to folks who saw it as picky and ­unnecessary. And I’d seen so many other personalized nutritional protocols produce transformative benefits for family, friends, and readers.

[There] is no hard and fast line between nutritionally advisable behaviors and potentially dangerous — or even disastrous — ones.

So to me, this framing of health-motivated eating as a potential disorder felt like yet another tool to discourage and shame discerning eaters. I just didn’t see how a close reading of ingredient labels could present a danger to anyone. Surely, not reading them presented a far greater risk.

Then I heard that physician ­describe the struggles of her daughter, and I had to expand my thinking.

Even before I looked at this young woman’s social media feed, I had a sense of what I would see: a pale, frail person presenting as a healthy, happy influencer — surrounded by plates of food-styled veggies and fruits.

So I came to realize that orthorexia is, in fact, a real problem. In some ways, it is just the other side of our inherently unhealthy–culture coin.

On one side, we are besieged by ultraprocessed, factory-farmed, nutrient-poor, and inflammatory food products, many of which are undeniably harming our health. On the other, we face a complex web of dubious and contradictory optimal-eating standards, both from credentialed (but disagreeing) experts and from charismatic podcasters and social media influencers who broadcast a 24/7 stream of idealized “foodspo” images and restrictive-eating advice.

Accordingly, over the past few years, I have developed a more nuanced view of both the promise and risk of striving to maintain healthy food standards in our increasingly unhealthy culture. I’ve also learned there is no hard and fast line between nutritionally advisable behaviors and potentially dangerous — or even disastrous — ones.

 

The Good, the Bad, and the Never Good Enough

While orthorexia is not currently listed in the Diagnostic and Statistical Manual of Mental Disorders, it can be just as clinically significant as listed illnesses, like anorexia nervosa. It can similarly affect physical and mental health, from malnutrition and weight loss to anxiety and social isolation.

The National Alliance for Eating Disorders now recognizes orthorexia as a “serious disorder.” It also lists avoidant/restrictive food intake disorder as an area of concern; its symptoms and risks are nearly the same as orthorexia’s.

A systematic review investigating the prevalence of the disorder, published in 2023, found that of more than 30,000 participants, 27.5 percent presented symptoms of orthorexia nervosa. Another literature review indicated that dietitians and other healthcare professionals, such as medical students, may be at a significantly higher risk of developing orthorexia than the general population. People who exercise are also at higher risk.

Personality traits like perfect­ionism, conscientiousness, and obsessiveness may increase vulner­ability to orthorexia, and individuals who are observing food restrictions for medical reasons might face a heightened risk of developing orthorexic tendencies.

Some experts do question how much practical purpose such labels serve for those who exhibit the symptoms of eating disorders. “In my experience,” explains Geneen Roth, author of Women Food and God, “what’s more important than agreeing on a particular diagnosis or category of disorder is exploring the underlying attitudes and belief systems that give rise to all these tendencies in the first place.”

Roth prefers asking more psychological and spiritual questions:

• What is causing a person to relate to food in this highly regulated way?
• What is causing this person to allow or not allow themselves certain foods?
• What does this person believe will happen if they go outside of those restrictions and controls?

She says she’s found that most people with eating disorders have a “high degree of restriction, deprivation, or self-denial in their life that then expresses in relation to food.” At their core, she argues, “these individuals suffer from what I would call a self-honoring disorder.”

So, while an orthorexia diagnosis might be helpful in identifying potentially destructive patterns of thought and practice, the deeper work may involve uprooting the toxic beliefs from which they bloom.

 

Obsession on Tap

Whether you understand it as a lack of self-honoring or a surfeit of self-criticism, the rising tide of food obsession has not come out of nowhere.

Over the past couple of decades, social media has become an echo chamber of eat-clean exhortations. In many circles, what was once a mostly weight-based, diet-culture conversation has become a mass-market virtue competition focused on who can eat better, healthier, more selectively.

One 2022 study of food, nutrition, and weight-related posts on TikTok found that the hashtag ­#WhatIEatInADay had received 3.2 billion views. These types of videos, the researchers assert, “likely spread and encourage harmful dieting interventions to a vulnerable audience that may not have strong media literacy skills.”

In this environment, according to functional nutritionist Cindi ­Lockhart, RDN, LD, IFNCP, even folks without diagnosable disorders can easily fall prey to overrestriction — especially if they consume a lot of pop-health media.

While Lockhart hasn’t seen many cases of true orthorexia in her practice, she has seen a lot of new clients come in with “very long lists of things they say they ‘can’t’ eat.”

In many circles, what was once a mostly weight-based, diet-culture conversation has become a mass-market virtue competition focused on who can eat better, healthier, more selectively.

“Whenever I see a list like that, my first question to them is, ‘Why?’” she says. “When a client responds with, ‘Well, I read this book or I saw this movie or I listened to this podcast . . . ,’ my next question is, ‘Would you be open to exploring this more deeply?’”

For many of her clients, eliminating common first-line irritants — such as gluten, dairy, and added sugars — can lead to dramatic health improvements. In general, though, Lockhart still prefers to run labs and create individualized protocols rather than make blanket recommendations. Dietary diversity, she says, is too important to sacrifice foods unnecessarily.

And relying entirely on aggregated nutritional research has its own downsides. “Generalized scientific studies just aren’t going to be able to tell you whether a particular food is going to work for your particular body in this particular moment in time.”

When a client reports known food intolerances, Lockhart still investigates further. Oftentimes, she says, “that current intolerance may point to something else in their digestion, microbiome, or biochemistry that is amiss.”

Once they’ve addressed underlying causes, many of her clients are able to comfortably eat foods they believed were permanently off limits.

 

A More Nourishing Path

I believe it is possible to be a healthy eater and maintain enough flexibility to nourish yourself well under most conditions. I also know that, in our current food environment, it can be difficult to separate reasonable, self-sustaining food choices from self-harming ones.

For someone with an autoimmune disorder or a severe food intolerance, a restrictive diet and cautious approach to food might well be the wisest course; adherence to that sort of protocol can mean the difference between ongoing misery and a vital, enjoyable life.

By eliminating gluten for the past 30 years, I have avoided celiac disease, despite carrying celiac genes. ­Functional-medicine physician Terry Wahls, MD, reversed her multiple sclerosis using a paleo-adjacent food protocol she created (read more about her successfully journey at “How Terry Wahls, MD, Beat Multiple Sclerosis (MS).”) Neurologist David Perlmutter, MD, has helped many patients arrest supposedly incurable neurological disorders using nutrition- and lifestyle-based interventions.

So, wielding food as a primary tool in the management of chronic disease still makes good sense to me, even when that sometimes demands a stringency that strikes others as weird or extreme.

I think the condition known as orthorexia may be less about the foods we choose to eat (or not) and more about the motivations and mindsets that underlie those choices.

At the same time, I do not want to see more people going down the scary road that the doctor’s daughter did — and perhaps never coming back. When we struggle to distinguish between our physiological needs and our mental models of eating perfection, or when our search for “good” food leaves us feeling never good enough, it’s time to seek help.

I think the condition known as orthorexia may be less about the foods we choose to eat (or not) and more about the motivations and mindsets that underlie those choices.

Because no matter how healthy we believe our current food choices to be, if they do not honor the real needs of our body-mind, they are not healthy at all.