Jason Wood was sitting in a restaurant on vacation with his husband, angry and upset because he couldn’t swap pita for fresh vegetables in his hummus plate.
The pain wasn’t overblown, Wood said. It was 20 years of an eating disorder and the anxiety and stress that comes with it culminating into one moment, he said.
Wood has orthorexia, an eating disorder that isn’t in the Diagnostic and Statistical Manual of Mental Disorders, also called the DSM, which is the formal guide for clinical assessment of mental health conditions. But clinicians are seeing a rise in orthorexia among patients, said therapist Jennifer Rollin, founder of The Eating Disorder Center in Rockville, Maryland.
“My hope is that it will be added to the DSM, but unfortunately, it just seems to be a very slow process to get something in there,” Rollin said.
Orthorexia is a fixation on eating “clean,” as defined by a set of rules dependent on certain individuals and the context they live in, said Dr. Jennifer Gaudiani, an eating disorder physician and founder and medical director of the Gaudiani Clinic in Denver. A November 2023 study found that about 3 in 10 participants showed signs of orthorexia.
Often, this disorder goes unnoticed or underestimated because it’s hyperfocused on healthy eating, said Wood, director of community engagement at the National Association of Anorexia Nervosa and Associated Disorders, alsn known as ANAD.
The lack of understanding around this condition kept Wood’s friends and family from raising concerns — sometimes applauding his efforts to stick with rigid eating principles — even as he withdrew from friends and lost so much weight he couldn’t keep himself warm, he said.
Here is what you need to know about orthorexia.
Diet culture in disguise
Focusing on eating healthy sounds like a good thing, right? Not always.
Eating disorders often have similar underpinnings: a genetic predisposition combined with environmental factors, Rollin said. And often the disorder centers around a set of rigid rules, whether it be calories, timing of eating or the ingredients in food, she added.
When those vulnerable to eating disorders latch on to only eating in a way they consider healthy, the behavior can go from a preference to an obsession, Rollin said.
Over the years, Wood said his list of unhealthy foods grew and those considered healthy kept shrinking until he found himself leaving parties because he couldn’t find anything he would allow himself to eat — and that left him with a lot of anxiety, he said.
For some — but not all — people with orthorexia, their body image may start to hinge on how closely they follow their food rules, Rollin said.
And with similar underpinnings behind them, orthorexia can morph into other disorders such as bulimia or anorexia nervosa, she said.
The motivations people with orthorexia may have, as well as the applause society gives them, might be labeled as health promotion or disease prevention, but often they are proxies for “pure, old-fashioned diet culture,” which prioritizes one ideal body shape and size, Gaudiani said.
“Some elements of it can be very like diet culture in disguise,” Rollin said.
And even if there isn’t shame around weight behind it, orthorexia and the steps a person takes to adhere to certain food rules can be expensive, distracting and distressing, Gaudiani said.
“It can also limit one from what one’s sort of greater goals and values are,” she added.
What is healthy anyway?
Another sign that the rules around eating are not just about health is the difficulty with defining what healthy even is.
In the 1990s, healthy, clean eating would be low-fat diets, Gaudiani said. Now, people are more likely to consider high-protein, high-fat, low-carb and low-sugar foods as healthy, she added.
Others would prioritize the food’s sourcing — such as whether it’s organic, non-genetically modified and local, Gaudiani said.
Of course, it’s not bad to want to eat a salad, Rollin said, but the problem arises when you think you can only have a salad.
Everybody is unique, and so the healthiest choice of food at any given moment will depend on an individual’s needs and the context that person is in, she added. Unless you need to eat a certain way for a medical condition, often the best course of action is listening to your body, Rollin said.
And when thinking of health, it is important you don’t only think of nutrition, Wood said.
A healthy life includes rich social relationships, time spent pursuing passions, enjoyable physical activity and enough brain space to find peace — all of which are hard to come by when you spend hours a day ruminating on what you “should” be eating.
“If you are somebody who just wants to live a reasonably balanced, social, connected life, orthorexia rules can really isolate you from peers because you end up turning down opportunities to eat with other humans because they don’t follow your same rules,” Gaudiani said. “Therefore, you say no, and your social world can really collapse down and become quite small.”
Living life again in recovery
If you or a loved one needs help for orthorexia, the good news is that treatment follows a similar path to established plans for eating disorders such as anorexia or bulimia nervosa. The bad news is that the lack of awareness among the public may present obstacles.
When looking at therapy, check for not only an eating disorder specialist, but one with experience with orthorexia, Rollin said. Not every specialist is going to have that expertise.
People with orthorexia may find themselves with a team that includes therapists and dietitians, similar to patients in treatment for other eating disorders, Rollin said. But those living with orthorexia will also likely face the added layer of unpacking their definition of health and reframing their ideas around it in a challenging way, she added.
The process may also involve working with those around you, Rollin said. More people are becoming aware that it isn’t a good idea to talk about food in terms of weight regularly, but fewer see talking about “healthy” or “unhealthy” foods as problematic, she said.
“It might take a fair amount of educating friends and family members, helping them to have understanding and compassion for why them commenting about the new juice cleanse they’re on is activating,” she said.
And those in recovery also need to have compassion for themselves, Gaudiani said.
“Nobody does this just for fun or to end up accidentally in trouble,” she said. “They start to do it because they’re feeling like their health benefits or they feel like there’s societal pressure, or it feels like it’s safe in some important way.”
The process of recovery may be difficult, but it is rewarding, Wood said. It has been almost four years since he said he hit rock bottom at that vacation dinner.
“I feel like I’m starting to live my life again,” Wood said. “I’m getting to take all of that time that I used to spend thinking about food and apply it to other aspects of my life. That has been, that’s been really great.”