When ‘eating healthy’ becomes disordered, you can return patients to genuine health

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Orthorexia nervosa, from the Greek orthos (straight, proper) and orexia (appetite), is a disorder in which a person demonstrates a pathological obsession not with weight loss but with a “pure” or healthy diet, which can contribute to significant dietary restriction and food-related obsessions. Although the disorder is not a formal diagnosis in DSM 5,1 it is increasingly reported on college campuses and in medical practices, and has been the focus of media attention.

How common is orthorexia?

The precise prevalence of orthorexia nervosa is unknown; some authors have reported estimates as high as 21% of the general population2 and 43.6% of medical students.3 The higher prevalence among medical students might be attributable to the increased focus on factors that can contribute to illnesses (eg, food and diet), and thus underscores the importance of screening for orthorexia symptoms among this population.

How do you identify the disorder?

Orthorexia nervosa was first described by Bratman,4 who observed that a subset of his eating disorder patients were overly obsessed with maintaining an extreme “healthy diet.” Although diagnostic criteria for orthorexia nervosa have not been established, Bratman proposed the following as symptoms indicative of the disorder:

  • spending >3 hours a day thinking about a healthy diet
  • worrying more about the perceived nutritional quality or “purity” of one’s food than the pleasure of eating it
  • feeling guilty about straying from dietary beliefs
  • having eating habits that isolate the affected person from others.

Given the focus on this disorder in the media and its presence in medical practice, it is important that you become familiar with the symptoms associated with orthorexia nervosa so you can provide necessary treatment. A patient’s answers to the following questions will aid the savvy clinician in identifying symptoms that suggest orthorexia nervosa5:

  • Do you turn to healthy food as a primary source of happiness and meaning, even more so than spirituality?
  • Does your diet make you feel superior to other people?
  • Does your diet interfere with your personal relationships (family, friends), or with your work?
  • Do you use pure foods as a “sword and shield” to ward off anxiety, not just about health problems but about everything that makes you feel insecure?
  • Do foods help you feel in control more than really makes sense?
  • Do you have to carry your diet to further and further extremes to provide the same “kick”?
  • If you stray even minimally from your chosen diet, do you feel a compulsive need to cleanse?
  • Has your interest in healthy food expanded past reasonable boundaries to become a kind of brain parasite, so to speak, controlling your life rather than furthering your goals?

No single item is indicative of orthorexia nervosa; however, this list represents a potential clinical picture of how the disorder presents.

Overlap with anorexia nervosa. Although overlap in symptom presentation between these 2 disorders can be significant (eg, diet rigidity can lead to malnutrition, even death), each has important distinguishing features. A low weight status or significant weight loss, or both, is a hallmark characteristic of anorexia nervosa; however, weight loss is not the primary goal in orthorexia nervosa (although extreme dietary restriction in orthorexia could contribute to weight loss). Additionally, a person with anorexia nervosa tends to be preoccupied with weight or shape; a person with orthorexia nervosa is obsessed with food quality and purity. Finally, people with orthorexia have an obsessive preoccupation with health, whereas those with anorexia are more consumed with a fear of fat or weight gain.

Multimodal treatment is indicated

Treating orthorexia typically includes a combination of interventions common to other eating disorders. These include cognitive-behavioral therapy, dietary and nutritional counseling, and medical management of any physical sequelae that result from extreme dietary restriction and malnutrition. Refer patients in whom you suspect orthorexia nervosa to a trained therapist and a dietician who have expertise in managing eating disorders.

It is encouraging to note that, with careful diagnosis and appropriate treatment, recovery from orthorexia is possible,6 and patients can achieve an improved quality of life.


The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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