(CNN) — Jason Wood was sitting at a restaurant with his husband on vacation, angry and upset because they couldn't swap pita bread for fresh vegetables in their bowl of hummus.
The pain was not exaggerated, Wood said. She said it was 20 years of an eating disorder, and the anxiety and stress that came with it, peaked in one moment.
Tree has orthorexia, an eating disorder not listed in the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM, a systematic guideline for the clinical assessment of mental health conditions. But doctors are seeing an increase in orthorexia among patients, said therapist Jennifer Rollin, founder of the Center for Eating Disorders in Rockville, Maryland.
“My hope is that it will be included in the DSM, but unfortunately, the process of getting something there seems to be very slow,” Rollin said.
Orthorexia is an obsession with “clean” eating, defined by a set of rules that depend on certain individuals and the environment in which they live, said Dr. Jennifer Goutiani. In a Denver November 2023 study, three out of 10 participants showed symptoms of orthorexia.
The disorder is often overlooked or underestimated because it focuses so much on healthy eating, said Wood, director of community engagement for the National Association of Anorexia Nervosa and Associated Disorders (ANAD).
A lack of understanding of the condition prevented Wood's friends and family from voicing their concerns (sometimes praising her efforts to adhere to strict dietary principles), and even as she distanced herself from her friends and lost a lot of weight, she was unable to maintain the weight. Body temperature, he said.
Here's what you need to know about orthorexia.
Food culture in disguise
Focusing on eating healthy sounds like a good thing, right? Not always.
Eating disorders often have the same underpinnings: a genetic predisposition combined with environmental factors, Rollin said. Whether it's calories, when to eat, or what's in the food, the disorder often centers around a strict set of rules.
If people who suffer from eating disorders stick to eating only in ways they consider healthy, the behavior can go from a preference to an obsession, Rollin explained.
As the years went by, Wood said her list of unhealthy foods grew and what was considered healthy shrank until she stopped going to parties.
For some, but not all, people with orthorexia, their body image depends on how strictly they follow their eating rules, Rollin said.
With similar foundations, he said, orthorexia can evolve into other disorders such as bulimia or anorexia nervosa.
The motivations people with orthorexia have and the applause society gives them may be labeled health promotion or disease prevention, but they are often substitutes for a “pure, old-fashioned food culture” that prioritizes an ideal. Body size and shape, Gaudiani said.
“Some elements can look like food culture in disguise,” Rollins said.
Even without weight shaming behind it, orthorexia and the steps a person takes to adhere to certain dietary rules can be costly and cause suffering, Goutiani said.
“It can limit us in terms of what our biggest goals and values are,” he added.
What is healthy?
Another sign that dietary rules are not just about health is the difficulty in defining what is healthy.
In the 1990s, a healthy, clean diet consisted of low-fat foods, Gaudiani said. People are now increasingly considering foods high in protein and fat, but low in carbohydrates and sugar, to stay healthy, he said.
Others prioritize the food's origin, such as organic, non-GMO and local, Koutiani said.
Of course, Rollins said it's not wrong to want to eat salad, but the problem arises when you think you can only eat salad.
Every person is unique, so making healthy food choices at any given time depends on each person's needs and the environment they find themselves in, he said. If a medical condition doesn't require you to eat a certain way, the best course of action is to listen to your body, Rollin said.
When thinking about health, it's important to not just think about nutrition, Wood said.
A healthy life includes social relationships, time devoted to your interests, enjoyable physical activity, and enough brain space to find peace—all of which are hard to achieve if you spend hours a day thinking about “what to eat.”
“If you're someone who wants to live a reasonably balanced, social and connected life, the rules of orthorexia can isolate you from your peers because you reject opportunities to eat with other human beings because they don't follow the same rules as you.” Gaudiani said. “So, if you say no, your social world collapses and becomes much smaller.”
Live life back
If you or a loved one needs help with orthorexia, the good news is that treatment follows a similar path to established programs for eating disorders like anorexia or bulimia nervosa. The bad news is that lack of awareness among people will present obstacles.
When seeking treatment, make sure it's not just an eating disorder specialist, but someone experienced in orthorexia, Rollin said. Not all professionals have that experience.
People with orthorexia may meet with a team that includes therapists and dietitians, just like patients in treatment for other eating disorders, Rollin said. But people living with orthorexia face an additional layer of unraveling their definition of health and reshaping their ideas around it in challenging ways, she added.
This process can also involve working with the people around you, Rollin said. More people realize that it's not a good idea to constantly talk about food based on weight, but fewer people find it problematic to talk about “healthy” or “unhealthy” foods, he said.
“You often need to educate friends and family to help them understand and have compassion for why their new juice detox ideas are triggering them,” she said.
And those in recovery need to have compassion for themselves, Goutiani said.
“No one does it for fun or to accidentally get into trouble (…) They start doing it because they feel its health benefits or they feel there's social pressure, or they think it's safe to do,” he said.
The recovery process can be difficult, but it's rewarding, Wood said. It's been almost four years since that Christmas party hit.
“I feel like I'm starting to live my life again,” Wood said. “I used the time to think about food and other aspects of my life. “It was really cool.”
