Recognizing orthorexia: When eating healthy becomes an eating disorder

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Recognizing orthorexia: the unofficial eating disorder that takes clean and healthy eating too far

Once upon a tricky few years ago, this writer’s life was consumed by an eating disorder.

Some people can recognize they’ve developed an eating disorder from the first changes in their behavior. Others may never admit it to themselves. And then there’s a whole lot of in-between.

For me, the moment of realization came one blistering hot summer afternoon at a White Sox game. I was sitting in the stands amid a cyclone of smells — funnel cakes, brats, Cuban sandwiches and cotton candy.

By then I was an expert at ignoring my own hunger through exercise. A pang would always turn into a run or calisthenics session. And here I was again — my stomach growling, my mind telling me to get up and move — which was nonsensical in the middle of a baseball game.

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As the game wore on, it became too much. I got up and walked around the stadium concourse, getting my exercise fix. And then I did something I hadn’t done in years: I caved to my hunger pangs with a salty bag of peanuts.

Back in my seat, feeling guilty for eating, I, for the first time, started to wonder what my carefully crafted dissonance of ‘healthy’ and ‘unhealthy’ really meant.

What was my relationship with exercise and food? When did my best intentions blur into destructive behavior?

With help, I was able to recognize that I had anorexia athletica: a compulsive desire to exercise, as if I was training to compete in — and win — an Olympic hockey tournament, 10 marathons and the CrossFit Games, all at once. And with it came an obsessive, restrictive relationship with food.

There were more workouts each day than meals, which, when eaten, were intentionally small — a skimpy peanut butter and jelly sandwich, half an apple, a few bites of a cereal bar. I counted calories with painstaking obsession, never approaching amounts my body needed. While I stared down hourslong workouts without fear, I succumbed to mini-anxiety attacks when faced with salad dressing, pre-buttered toast or birthday brownies passed around at school. If I did indulge, I was consumed with regret.

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For the longest time, I confused my obsessive behavior with dedicated training. While I thought I was being the healthiest athlete possible, I was actually quite the opposite — lacking a life of balance, pleasure and self-actualization.

Instead of enjoying lunch with friends, I signed up for an exercise class. I took leaps to eliminate desserts from birthday celebrations. My self-esteem was measured, each day, in what I thought I saw in the mirror.

It took a long time to recognize the line between healthy and compulsive behavior. And this is the same challenge for many who are — consciously or unconsciously — experiencing orthorexia, an eating disorder that takes the idea of clean eating way too far. Like anorexia athletica, it is often experienced by those whose good intentions become obsessions.

Behaviors between the two conditions can blur into each other. It’s possible for one with anorexia athletica to exhibit signs of orthorexia, like I did, or with obsessive-compulsive disorder (OCD), or other combinations.

And while orthorexia is an “unofficial” eating disorder — not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) — it is recognized by clinicians and therapists and can be treated.

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Grid spoke with experts about how orthorexia is defined, the societal pressures that exacerbate it and how to know if you are crossing the line between healthy living and orthorexic behavior.

Orthorexia is built on a fallacy of one ‘correct’ way of eating …

Unlike anorexia — in which individuals experience body dysmorphia and fixate on the quantity of food they eat — those with orthorexia prioritize the perceived healthiness of their meals, a subjective and moving target.

Most people experiencing orthorexia, said Julie Raymond, a licensed therapist and director of eating disorder services at Cityscape Counseling, try to stick to whole foods, like fruits and vegetables over anything refined or processed. An emphasis on foods with buzzwords, she said, is also common among her patients: locally grown, fresh, organic.

These kinds of concerns can be summarized as an obsession with purity. A commonly cited characterization of orthorexia, pulled from a book about the condition published at the turn of the millennium, is that it is, “a disease disguised as a virtue.” Those were the words of Steven Bratman, a physician who is credited with first coining the term in the late 1990s, when actress Suzanne Somers became a New York Times bestseller for pushing an anti-carbs regime and the peak of skim milk sales, according to research by Agricultural Economic Insights.

The problem, as expressed by the National Eating Disorders Association (NEDA), is that “people with orthorexia become so fixated on so-called ‘healthy eating’ that they actually damage their own well-being.”


… and actually leads to unhealthy, incomplete diets

This misconstruction is even built into orthorexia’s name — “ortho” is a Greek prefix that can mean ‘right’ or ‘correct.’ It implies, Raymond said, “that there is one correct way to eat. But when taken too far, this can actually be very damaging.” Eating only healthy foods doesn’t necessarily translate to an overall healthy diet.

In an attempt to fulfill their definition of a healthy diet, some with orthorexia actually end up depriving themselves of nutrients that are important to a complete diet; NEDA cites malnutrition as a risk. As it took me a while to relearn, a balanced diet includes carbs, fats and sugars — those I was missing by completely swearing off foods I deemed unhealthy.

“Our body actually needs some fat,” said Ellen Astrachan-Fletcher, the regional clinical director at Eating Recovery Center, Illinois, and a lecturer at the Northwestern University Feinberg School of Medicine’s psychiatry and behavioral sciences department.

And it took so much relearning to remember that dessert isn’t inherently harmful. There’s a reason that the food pyramid includes sweets. Food is, after all, also a social and pleasurable experience.

Is there anyone to blame for these standards?

There is no one place to point a finger, most experts agree. That said, the flourishing wellness culture that pervades social media doesn’t help, said Astrachan-Fletcher.

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Social media influencers sharing lifestyles that promote restriction take a lot of the blame. “Marketing banks on convincing people that certain things are good,” Astrachan-Fletcher said. “Our society promotes disordered eating. It’s their bread and butter, so to speak.”

Last year, a report from the Tech Transparency Project shed light on “Thinstagram,” the communities of Instagram, buoyed by algorithmic trends, that encourage disordered eating behavior. It isn’t hard to find the next big diet, detox or cleanse — Kim Kardashian going on a juice cleanse to lose a certain amount of weight, or many of Gwyneth Paltrow’s controversial Goop trends tend to make headlines.

“People get influenced by those harmful messages and harmful behaviors,” Raymond said. “Can social media make someone who’s already susceptible or vulnerable develop [an eating disorder]? Yes.”

Orthorexia, like all eating disorders, comes down to control

At the end of long, exhausting days — complete with multiple workouts and fewer meals in between — I would feel a fleeting sense of reprieve. This is a common thread spanning all disordered eating behaviors, orthorexia included — a desire to decrease one’s anxiety by controlling a certain outside element of their lives.

Astrachan-Fletcher describes this as “emotionally over-controlling behavior.” There is an inclination, she said, to “push away” the human connection from certain scenes or behaviors that typically release endorphins — such as exercising or eating.

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This balance is especially difficult for athletes, whose passions and livelihoods are entangled with nutrition, working out and maximizing their individual performance.

Saroya Tinker, a professional hockey player for the Toronto Six of the Premier Hockey Federation, said anxiety about her body image — while eating enough to be able to practice and play at the highest level of the sport — has been an ongoing negotiation throughout her career.

“Having a healthy body is one thing, and looking what you think is your best, is totally different,” Tinker said. Hockey players in particular have what is known as “hockey butt” — thicker thighs and muscular glutes that come from skating. The result is a body type that isn’t considered conventionally slim. “As an athlete, the most important thing is how you feel, but I still have those difficult days where it can be hard to find a balance.”

So where is the line between eating healthy and orthorexia?

Both Raymond and Astrachan-Fletcher agree that the tipping point when healthy eating turns into orthorexia comes down to obsession. It’s one thing to avoid sweets and plan meals with fruits and vegetables in advance, so you don’t end up stopping, say, for fast food. It’s another thing to let that way of eating rule your life.

Eating healthy foods also doesn’t necessarily translate to a healthy lifestyle.

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“If it is preoccupying your days to the point that you’re organizing your life around [ensuring healthy meals], and no longer listening to your body, you’ve hit a threshold,” Raymond said.

“If you would rather exercise than see a friend; if you cannot break a [food] rule without extreme distress; if your mood shifts [due to food], it is an eating disorder,” Astrachan-Fletcher said. “You have to address the potential that there is an old story that keeps someone stuck.”

Because orthorexia is not in the DSM, it remains, technically, undiagnosable. However, this is a function of a slow-to-update world of medicine. Since the first DSM, published in 1952, there have been only five new volumes. DSM-5 was released in 2013 and updated in March 2022 (DSM-5-TR) with new diagnostic guidelines and language changes for clarity.

Anorexia, bulimia, binge eating disorder and avoidant/restrictive food intake disorder (ARFID) are the four diagnosable eating disorders, per this latest update. A catch-all fifth — other specified feeding or eating disorder (OSFED) — is an umbrella term to include orthorexia, anorexia athletica and others. “Individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa,” the latest DSM-5-TR was updated to say.

Most facilities and doctors that work with people who have eating disorders understand what orthorexia is and how to treat it.

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Even if an official diagnosis of anorexia (which, because it is in the DSM and, therefore, what insurance will usually cover) is given, orthorexia-specific treatment can be tailored to the individual. Relearning how to exercise and eat, without being eaten up, is a journey for me and many. For those who it helps to place a name with an embraced challenge — this is orthorexia.

If you believe you or someone you know has an eating disorder, contact the National Eating Disorders Association for help or more information.

Thanks to Alicia Benjamin for copy editing this article.