Treatment of Orthorexia Nervosa (Obsessive Healthy Eating)
Treat orthorexia nervosa with eating disorder-focused cognitive-behavioral therapy (CBT) as the primary intervention, combined with psychoeducation and nutritional counseling from a registered dietitian nutritionist, using the same treatment framework established for eating disorders. 1, 2, 3
Initial Assessment
Conduct a comprehensive psychiatric evaluation that specifically quantifies:
- Obsessional preoccupation with healthy nutrition and time spent planning/thinking about food 4, 3
- Emotional consequences (distress, anxiety) when self-imposed nutritional rules are violated 4
- Psychosocial impairments in work, relationships, and daily functioning 4, 3
- Nutritional status including weight loss, BMI, and signs of malnutrition 1, 4
- Co-occurring psychiatric disorders, particularly anorexia nervosa, OCD, and anxiety disorders 1, 5
Physical examination must document vital signs, height, weight, BMI, and physical signs of malnutrition or micronutrient deficiencies 1, 6.
Laboratory assessment should include complete blood count, comprehensive metabolic panel, and screening for nutritional deficiencies based on dietary restrictions 1, 6.
Obtain an electrocardiogram if there is significant weight loss or purging behaviors 1.
Primary Treatment: Cognitive-Behavioral Therapy
Implement eating disorder-focused CBT targeting:
- Challenging rigid food beliefs and dichotomous thinking about "pure" versus "impure" foods 3, 5
- Normalizing eating patterns and expanding food variety beyond self-imposed restrictions 1, 2
- Addressing underlying anxiety about health and contamination fears 3
- Cognitive restructuring of obsessional thoughts about nutrition 3
- Exposure therapy to feared "unhealthy" foods 3
CBT should be delivered in individual format, typically weekly sessions for 16-20 weeks 1, 2.
Nutritional Rehabilitation
Refer to a registered dietitian nutritionist (RDN) specializing in eating disorders for:
- Individualized meal planning that gradually reintroduces restricted food groups 1, 7
- Psychoeducation about balanced nutrition versus orthorexic misinformation 7, 3
- Challenging nutrition myths and correcting distorted beliefs about food 7
- Monitoring nutritional status and addressing deficiencies 7
The RDN must be perceptive to psychological triggers when exploring food belief systems and patterns of restriction 7.
Pharmacotherapy Considerations
Consider selective serotonin reuptake inhibitors (SSRIs) if:
- There is significant comorbid anxiety or OCD symptoms 3
- The patient has not responded adequately to psychotherapy alone after 6 weeks 1
- There are prominent obsessional thoughts about food purity 3
Fluoxetine 60 mg daily is the most studied SSRI in eating disorders 1.
Note: Orthorexia shares more diagnostic overlap with eating disorders (particularly anorexia nervosa) than with OCD, suggesting ED-focused treatments are most appropriate 5.
Multidisciplinary Coordination
Establish a coordinated treatment team incorporating:
- Psychiatrist or physician for medical monitoring and medication management 1, 7
- Psychotherapist trained in eating disorder-focused CBT 1, 3
- Registered dietitian nutritionist with eating disorder specialization 7
- Regular team communication to ensure consistent messaging about nutrition and recovery 1, 7
Treatment Monitoring
Track weekly:
- Weight and vital signs during active nutritional rehabilitation 1, 6
- Dietary variety and reduction in food restrictions 7
- Time spent on food-related obsessions and ritualized eating behaviors 4, 3
- Psychosocial functioning in work, relationships, and quality of life 4, 3
Common Pitfalls to Avoid
Do not validate the patient's extreme dietary beliefs under the guise of "healthy eating" - this reinforces pathology 8, 3.
Avoid focusing solely on weight restoration without addressing the underlying obsessional thinking patterns 1, 3.
Do not recommend restrictive diets (ketogenic, extreme low-carbohydrate, fasting) as these perpetuate the disorder 1.
Recognize that orthorexia can lead to severe malnutrition despite the patient's belief they are eating "optimally healthy" 8, 4, 3.