Do I have Orthorexia? 4 Questions to ask

Written by Meg Salvia, MS, RDN, CDE  from Walden Behavioral Care 

Is there such a thing as eating too healthfully?

Orthorexia can be bit of a tricky topic: while it isn’t formally included as its own eating disorder in the Diagnostic and Statistical Manual (DSM-5), there’s growing concern about the physical and psychological impact of striving to eat “properly” in overly “healthy” patterns. At the same time, it seems counterintuitive to be concerned about eating too healthfully.

When is this a problem, and what should you do if you have concerns that this might be an issue for you or someone in your life?

Orthorexia is a pathological obsession or compulsion to eat healthfully or purely. Anorexia nervosa, as included in the DSM-5, includes the hallmark drive for weight loss and thinness. With orthorexia, the goal isn’t necessarily weight loss but a drive to consume foods considered pure, natural, or virtuous—distress is typically experienced around foods perceived as unhealthy. It’s also separate from appropriate or constructive efforts at supporting bodily function, because orthorexia results in a negative impact on functioning or health. 

Although there isn’t an official screening tool or standardized diagnostic criteria to assess (yet this is a work in progress [2]), asking the questions below might highlight if or how orthorexic tendencies might be problematic. It can be helpful to take a look at this from both the mental health and physical health points of view.

1) If my eating choices are driven by a desire to support my body’s health, am I actually meeting my body’s needs?

To support our physical health, meals and snacks need to meet the basic principles of adequacy, balance, and variety. We need to get enough fuel (energy and hydration) to support metabolic functions, include all the major food groups (including carbohydrates, fats, and proteins) and be exposed to a wide variety of foods to engage our senses and provide an array of micronutrients.

It’s certainly possible that pursuing an aggressive eating pattern means we’re not getting all the nutrition our body needs in one form or another. If our choices are rigid, omit entire food groups, or get progressively more and more limited, malnutrition could be a problem.

2) Are you no longer eating foods you once enjoyed?

Often, choosing nutritious foods to help support physical function and overall health means adding foods to ensure adequate intake of healthful foods. “Pathological nutrition” (as eating disorders dietitian and orthorexia expert Jessica Setnick calls it) often results in reductions or limitations around intake. Preference for eating only healthy foods can be a socially acceptable way of restricting our intake.

Is there a sense of fear and anxiety around foods that once brought enjoyment and pleasure? Do you notice your food choices becoming narrower and narrower?

3) Do my eating patterns and choices impact my functioning and engagement in life?

Here are some of the ways that orthorexia can have a negative impact on your daily life, outlook, and mental health:

• Obsessive thoughts: frequent and intrusive thought patterns about what you’re allowed or not allowed to eat, what you’ve eaten in the past, or what you will eat in the future. These thoughts can occupy a large chunk of the day, distract from other activities, or be a frequent and repetitive focus of attention.

• Feeling isolated or socially limited: Do rigid eating patterns or limited permission to eat a variety of foods prevent you from hanging out with friends, socializing with coworkers, or joining family at meals or events? Are your eating patterns helping you plug in to your social life, or are they barriers? Are you only able to socialize with those whose eating patterns look like yours?

• Attaching moral value or self-worth to what are perceived as virtuous choices: Do you see yourself as a better person for the choices you make around food? Are you harsh on yourself when your meals and snacks don’t live up to your own standards? Is this an ever-moving target you never reach? Feeling a sense of accomplishment with nourishing and taking care of our bodies can be appropriate, but if this feels like a significant or inflexible part of your identity or how you judge your self worth, it can be a sign that it’s orthorexia.

• Harsh judgment of yourself or others’ food choices: Are you unable to eat at restaurants based on what else is on the menu? Is your social circle limited because of what others are eating? It might feel uncomfortable to recognize there’s an element of judgment in our assessment of others’ choices. What impact is this having on our lives?

4) What’s the deeper reason behind my food choices?

See if you can identify what is driving your quest to eat healthfully. Have you experienced a health event in your family that brought health and eating patterns to the forefront of your attention? Experiencing a loss or having a health scare often prompts us to evaluate our own health risks or those of other people in our lives; If this feels panicky or obsessive, though, that can be a red flag.

Does making specific food choices give you a sense of control or safety? Are you choosing foods based solely on the fact that they feel safe and won’t cause you anxiety?

If it feels like you’re experiencing any of the above symptoms, or answered yes to any of the questions, know that it is absolutely worth it to get help. As always, we’re here for support.


1. Setnick, Jessica. The Eating Disorders Clinical Pocket Guide, 2nd Edition. 2016 Academy of Nutrition and Dietetics.
2. Dunn TM, Bratman S. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors. 2016: 21(11-17).

Meg Salvia, MS, RDN, CDE is the dietitian at Walden Behavioral Care’s Peabody clinic. She sees adolescents and adults in the partial hospitalization program as well as in the binge-eating intensive outpatient program. She is also a board-certified diabetes educator (CDE). She began her career working in research at Joslin Diabetes Center and joined Walden Behavioral Care’s team in 2013. Meg earned a Master’s degree in nutrition from Boston University and a BA in English from Boston College.

This blog was originally published March, 2018 at and is republished here with permission. 

Recommendations for Parents of an Adolescent Discharging from Residential Eating Disorder Treatment

Written by Simone Arent of Walden Behavioral Care 

One of the biggest obstacles of eating disorder recovery may come after being discharged from a residential program. Helping your adolescent integrate back into their day to day routine can be challenging for everyone. Remember, recovery is not linear. There may be ups and downs as your family navigates returning to home, school, extracurricular activities, and most likely embarking on treatment in lower levels of care. Here are a few tips to help support this transition.

1.) Cultivate Trust and Open Communication

At the very beginning of the recovery process, trust may need repair. In order to restore trust, open and honest communication is encouraged. Creating transparent and nonjudgmental dialogue between family members can help to decrease shame and lend itself to improved understanding of one another–and the eating disorder. Individuals often find residential treatment to be a place that feels safe to discuss their feelings and thoughts related to their eating disorder. A goal would be to continue this progress at home following discharge. I often tell parents that cultivating an environment where candid discussion about the eating disorder feels comfortable, can help take the power away from the eating disorder, and increase confidence and motivation for recovery.

2.) Identify Triggers

Triggers can be defined as events that create some type of uncomfortable emotion for an individual. Some common emotions that are often reported in those living with eating disorders are shame, guilt, anxiety, sadness and stress among others. In order to best prepare for recovery success outside of treatment, it is crucial to have some understanding about what the triggers are for the individual and for the family. The goal then would be to create a game plan of how–as a family–you can cope in a safe and contained way when those uncomfortable emotions arise. Your treatment team can be great collaborators in helping you to identify these triggers and in brainstorming some helpful coping skills that might be appropriate to use in those difficult moments.

3.) Incorporate Supervision to Support Recovery

Following discharge, one challenge many families face is the increased need for supervision of the adolescent. Going from an environment with 24-hour supervision back home, can feel shocking to many adolescents who may have been in treatment for an extended period of time. After residential care, supervision of all meals and snacks is highly recommended. This added necessary precaution might be difficult with all of the other commitments you might have, so sometimes I suggest that parents/caregivers enlist the help of trusted friends and family for extra support. Oftentimes, schools are more than willing to provide space for the adolescent to be monitored for snack and lunch. In the beginning, supervision can be a lot to balance. Remember that the end goal is to eventually decrease supervision as trust is repaired and the eating disorder has less control.

4.) Ask for Help!

Supporting and caring for someone with an eating disorder can challenge a person or family system in ways you weren’t expecting. The road to recovery can also be long. We want to avoid burnout and running on empty so it will be important for caregivers to have space to talk about their experience and discuss strategies for managing their own emotions. These spaces can support caregivers in feeling and processing things as they arise. We often recommend that parents seek their own therapeutic support through avenues such as parent support groups in addition to family or individual therapy. In order to support your adolescent effectively, taking care of yourself is of utmost importance. Remember you are not alone, and it is okay to ask for help

To learn more about residential treatment at Walden Behavioral Care, please visit

Simone Arent is an adolescent clinical intern at Residential treatment, providing individual, group, and family therapy to adolescents. Simone received her Bachelor’s degree in Psychology from Western New England University, and is currently in pursuit of her Doctorate degree in Clinical Psychology at William James College. Simone works to meet each individual where they are at by using a strength-based approach, and incorporating dialectical and cognitive behavior therapies. In Simone’s free time, she enjoys being outdoors and solving Rubik’s Cubes.

This blog was originally published at in March 2018 and is republished here with permission. 


7 Things Providers Need to Know about Gender Identity and its Effect on Body Image

Written by Christine Lang, MSW, M.Div. from Walden Behavioral Care 

Christine Lang is an adolescent clinician in the partial hospitalization and intensive outpatient programs for Walden Behavioral Care, providing individual, family and group counseling for adolescents and families with eating disorders. This includes a specialized treatment track for LGBTQ individuals

Did you know that transgender youth are four times more likely than their female, cisgender, heterosexual counterparts to have eating disorders? There are many factors that contribute to this population’s higher incidence of increased rates of body dissatisfaction, elevated rates of co-occurring mental health conditions such as depression and anxiety and increased risk for bullying, psycho-social stressors and emotional distress.

Even if you don’t consider yourself a specialist in working with these populations, it is important to have a general understanding of why they might co-exist and how you can best support individuals who present with either or both of these conditions.

1. Both transgender people and people with eating disorders may experience body dissatisfaction – the source of it may be both different and similar. In our culture, we seem obsessed with a particular ideal of “beauty” — one that has prompted an unhealthy diet culture, as well as general body unhappiness. Similarly, a trans person’s body may not match up to our society’s binary gender ideals of either “masculine” or “feminine” bodies, which may cause trans people to embody another layer of body dissatisfaction; neither are their bodies the right gender nor do they fit society’s ideal body type of that gender.

2. According to the current research, it seems that the idea of “an ideal thinness” and the idea of “an ideal femininity/masculinity” are risk factors for developing eating disorders.

3. Not everyone whose gender identities differ from their sex assigned at birth has a negative body image.

4. As clinicians, it’s important to help individuals to understand the function of their eating disorder. Many transgender people report using food and behaviors as a way to manipulate their bodies in an attempt to “better” align with mainstream culture’s idea of beauty and femininity / masculinity. I’ve also seen cases where a client’s eating disorder has nothing to do with either of those things—rather eating disorder behaviors are utilized as a way to cope with difficult situations / emotions. Having this information will help to guide treatment and determine the most appropriate interventions.

5. Our job is also to create a safe space where clients can notice and process their negative thoughts. This means, doing your best to ask for and use preferred pronouns and being aware of the unique stressors that can often be experienced by this population. Eating disorder treatment is hard—we want to make sure we are fostering an environment where individuals can feel comfortable making their recovery their number one priority.

6. Just as we don’t blame parents for the development of their child’s eating disorder, it is important that we help individuals understand that they are not to blame for being gender dysphoric. Those who have gender dysphoria experience a fair amount of body dissatisfaction because of external pressures created by society, which often become internalized forms of oppression. As such, it is important to work with individuals on identifying the difference between external oppression that has been internalized vs their own values and beliefs. Similarly, we work with individuals with eating disorders to be better able to distinguish between the voice of the ED and their own unique thoughts and feelings.

7. In providing an ongoing clinical space for individuals to explore the intersection of their gender identity and eating disorder behaviors, as well as the appropriateness of hormone therapy for themselves, we as clinicians will be better able to help provide long term eating disorder recovery.

If you or someone you work with is transgender and living with an eating disorder, there is hope for recovery.


a) Author: Monica Algars, Katarina Alanko, Pekka Santtilla, N. Kenneth Sandnabba
Title: Disordered Eating and Gender Identity Disorder: A Qualitative Study
b) Jennifer Couturier; Bharadwaj Pindiprolu, Sheri Findlay, Natasha Johnson
Title: Anorexia Nervosa and Gender Dysphoria in Two Adolescents.
c) Stuart B. Murray, Evelyn Boon, Stephen W. Touyz
Title: Diverging Eating Psychopathology in Transgendered Eating Disorder Patients: A report of two cases.
d) Monica Algars, Pekka Santtila, N. Kenneth Sandnabba
Title: Conflicted Gender Identity, Body Dissatisfaction and Disordered Eating in Adult Men and Women
e) Lindsay A. Ewan, Amy B. Middleman, Jennifer Feldmann
Title: Treatment of Anorexia in the Context of Transsexuality: A Case Report
f) Sarah E. Strandjord, Henry Ng, Ellen S. Rome
Title: Effects of Treating Gender Dysphoria and Anorexia Nervosa in a Transgender Adolescent: Lessons Learned
g) Bethany Alice Jones, Emma Haycraft, Sarah Murjan, Jon Arcelus
Title: Body Dissatisfaction and Disordered Eating in Trans People: A Systematic review of the Literature


This blog was originally published on and is republished here with permission.