Supporting Orthorexia Recovery

Orthorexia is not a clinically recognized eating disorder, but dangerous and life threatening all the same.  It’s characterized by extreme obsession with eating perfectly and correctly, which leads to under eating resulting in malnutrition.  While the physical effects are obviously of concern, the psychological effects are even more debilitating.  

Sufferers of orthorexia are less concerned with body weight and more concerned with the food quality itself.  What may start out as eating healthier to feel better, escalates to a quest for perfect health.  The irony is that health declines without adequate energy and nutrient intake - two things that are inadequate in these individuals.  Physical, emotional and mental health suffer greatly and recovery can take months to years depending on severity.  

I haven’t been shy about sharing my struggle with this disorder (here, here, here, here and here).  As I have worked on my own recovery, it’s become apparent to me that this disordered eating pattern needs to be treated according to it’s unique characteristics.  The same could be said of Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder (clinically recognized eating disorders), which all have equally unique diagnostic criteria and treatment plans.  

In general I try to avoid generalizations, but for the purpose of helping clinicians, family members and friends understand Orthorexia, here are a few things to consider when helping a patient or loved one:

1.  Nutrition professionals often ask their clients to consider how food makes them feel as a way to motivate them toward healthier or more moderate choices, or to become aware of how food feels in their body.  While this may be an effective strategy for some types of eating disorders or for the general population, refrain from reinforcing this in someone with orthorexia.  You’ll remember that this disorder is ALL about how food makes them feel, and they are hyperaware of every little food ingredient and possible effect or nuance in their body.  One treatment goal is to lessen that intense focus on food, food quality and possible physical symptoms (real or perceived).  Depending on their stage of recovery, they actually may feel better not eating at all.  This could be due to digestive adaptations to lack of adequate nutrition which makes eating uncomfortable and/or the intense psychological anxiety triggered by food and eating.  

2.  Orthorexia is characterized by obsessive thoughts and compulsive behaviors; perhaps this condition could be called the OCD of eating disorders.  The (few) foods allowed depend on the individual and is accompanied by ritualistic behavior (how the food is prepared, where they buy it, etc).  Patients tend to eat the same foods at the same times day in and day out.  Any amount of departure from their rigid structure will cause extreme anxiety, guilt and shame.  These individuals will also spend hours and hours and hours researching food issues and other environmental "toxins" (oh how I wish I could have back all that wasted time).  Finally, exercise is often another compulsive behavior and can progress to a full exercise addiction.  

Treatment, then, should include encouragement to break their self-imposed ritualistic behavior and use new skills (I personally think Acceptance Commitment Therapy is a perfect fit) to breathe into their anxiety.  For example, a patient could set a goal of not eating the same breakfast for 3 days in a row, only exercising 2-3 times a week (or of course complete exercise cessation depending on their current health), avoiding google searches about food or finding a non-food book to read.  This can encourage their brain to make new neural pathways, moving toward self-directed behaviors rather than functioning on autopilot according to their compulsions.  

3.  As you are reading this, I would have you turn your attention to your left thumb.  As you sense your mind focusing your attention there, what sensations come up for you?  Do you notice tingling sensations in your thumb?  Does it become warmer?  If I mention “arthritis”, does your attention become drawn to the joint in your thumb?  Does it feel sore?  

Knowing and understanding how the mind and body are interconnected (often done through mindfulness exercises or body scans) can be helpful for orthorexia sufferers.  On the one hand, they can come to know that hyperawareness and obsessive focus on the body can often create issues that may not actually be there.  On the other hand, they can learn to listen to their body sensations with openness and curiosity and respond in a way that meets their true needs rather than just feeding anxiety.  

Your body hears everything your mind says.  Often we think our body is working against us but I disagree; I believe it’s always protecting us from potential harm.  Our body is programmed for survival - from the stress response to the immune system to our ability to regenerate, heal and repair.  I have a theory (and please understand it is only a theory) that when we consistently think negative and fearful thoughts about food, our body begins to see it as a threat.  Literally.  Our immune system encodes it, our digestive tract rejects it and our brains see it as a source of anxiety.  What was once necessary is now the enemy - physically and psychologically.  Therefore, when someone with orthorexia (who has eliminated most foods and entire food groups - you can often count the number of foods they will eat on 1-2 hands) chooses to make peace with food, they may have to be patient as their body lets down it’s defenses and accepts a variety of food as good, wholesome, pleasurable and necessary (and adequate nutrition is essential for healthy digestion, immunity and mental health). While this will be more pronounced in Orthorexia, I think it can be found in anyone on the disordered eating/dieting spectrum.  I would be very cautious of accepting possible food intolerances as the final word…continue to work through possible physical and psychological implications with grace, patience and compassion.  Peel back the layers of what led to the disorder and discern what may still remain.  

One of the hardest issues to overcome will be the sense of superiority that "perfect, clean eating" provides these individuals.  They see it as disciplined and/or morally right.  If they quit eating a certain way, or eat foods they don't think are appropriate, they may feel normal or ordinary which is mental torture for them. Truly though, the disordered eating isn't the problem, it's the beliefs, life experiences and painful emotions that are alleviated by controlling food and their body in this way.  Provide them opportunities to work through their cognitive distortions to gain confidence in being who they truly are.   

4.  I’ve come to know that the further someone gets in recovery, the MORE support they need.  I don’t know if I can emphasize that enough.  When the body is starving, relationships are suffering and health is declining, it’s obvious that something needs to be done.  As recovery progresses, eating may “normalize” based on what is culturally acceptable.  This may mean that the individual is eating regularly but food choices are restrained or labeled (“clean”, “vegan”, “sugar free, “dairy free”, “gluten free”…etc).  I STRONGLY encourage labels to not be used.  Those recovering from Orthorexia should be encouraged to embrace their story, which means they will need to set certain boundaries to ensure full recovery and avoid the seductive and alluring voice of a diet, meal plan, food rules or labels.  They should feel empowered to make choices that are in their best interest, however that might look like for them, without feeling the need to label.  Honestly, this is actually where the perfectionistic tendencies often present in these individuals can help - don’t settle for a culturally acceptable partial recovery.  

5.  Last but not least, having a positive supporter while in recovery can make all the difference.  It’s easy to focus on behaviors but that may only encourage them to become more focused on them as well.  They will benefit from being reminded of all that they are outside of food and exercise, given that those things have consumed their whole world.  They will live up to what you make them believe about themselves so make them feel strong, worthy, loved and able to do hard things.  

I have to give my husband a lot of credit here.  He has been endlessly supportive and always positive about me, the situation and our relationship.  He has never said anything negative about my body at my lowest or my highest weight (not even a “you need to gain weight”).  He has always been thoughtful and sensitive in his comments and suggestions and patient as I work through issues at my own speed.  He has let me own my choices, never encouraging destructive behaviors while also allowing me room to learn and grow from the experience.  I never could have imagined what a gift he was the day I married him…everyone should be so lucky.  

Restrained and restrictive eating is celebrated in our society.  This makes recovering from any eating disorder very difficult without professional support.  I encourage anyone who is suffering to reach out for help - you are NOT alone and you (yes YOU) deserve a FULL recovery.  

Emily Fonnesbeck RD, CD