Lena Shields doesn’t want to lose any more weight. But at 5 foot 6 inches and 103 pounds, it’s hard to keep the weight on when she avoids so many basic foods.

The Elmhurst native, who currently attends Vassar College in New York, won’t eat gluten and dairy and only eats quinoa or alternative grains. She also sticks to lean meats, vegetables, and fruit.

“I’m not going to see a weight [on a scale] and say I want to go lower,” she said. But she acknowledged that she's obsessively concerned with being healthy, a condition for which she is undergoing treatment. She asked that her name be changed for this article. 

A fixation on “healthy” eating can lead to an unhealthy set of problems, especially when people eliminate many products and foods from a normal diet. Orthorexia nervosa, a term coined by Colorado physician Steven Bratman, defines this subset of people who are obsessed with eating healthy.

“While orthorexia begins with a desire to achieve better health, it's very connected to an underlying fear of food. If I believe the food will make me sick, I become afraid of it, and I avoid it and, bit by bit, continue to avoid more and more food types,” said Ellen Astrachan-Fletcher, a clinical psychologist and director of the eating disorders clinic at the University of Illinois at Chicago.

About 10 million females and 1 million males in the United States suffer from an eating disorder, according to the National Eating Disorders Association.

Like Shields, one of Astrachan-Fletcher’s former patients was orthorexic. The 19-year-old college student sought professional help after her preoccupation with eating “healthy” foods prevented her from eating enough to study or carry on regular activities.

“She just didn’t have the time, because she was so focused on finding the right foods, and eating the right foods, and figuring out what foods made her sick [and] what foods were good for her,” said Astrachan-Fletcher. The patient dropped out of treatment because she didn’t want to eat regular foods and preferred to continue her orthorexic behavior.   

Officially, the behavior remains a condition without a name. The term is not included in the latest version of the Diagnostic and Statistical Manual of Mental Disorders used by the American Psychiatric Association. But orthorexia nervosa is slowly gaining more attention in the medical community. Several studies, all performed outside the U.S., have investigated this phenomenon.

A 2008 study published in the Turkish Journal of Psychiatry, for example, reported a strong correlation between those who exhibit obsessive-compulsive tendencies and orthorexia, and found that women were more prone to developing the disorder.

An Italian study published in Eating and Weight Disorders, an Italian medical journal, examined 404 volunteers and found almost 7 percent of them suffered from orthorexia, defined by the researchers as “a combination of those with obsessive-compulsive personality features and exaggerated healthy eating behavior.”

The main categories for eating disorders are anorexia nervosa, where a patient severely limits eating and weight, bulimia nervosa, characterized by binging and purging episodes, and eating disorder not otherwise specified. Orthorexia would fall under the third category, but many experts believe that many of its symptoms may align it with anorexia.

“Foods get categorized in both disorders as good or bad. So with orthorexia, food makes you healthy or not. With anorexia, it makes you fat or not. But either way they get the good-bad categories and the 'bad' gets cut out,” said Astrachan-Fletcher.  

Eventually, so many foods get thrown on the “bad” list that patients exhibit rigidity in thinking and tend toward damaging behaviors, such as isolation and avoiding social situations where one cannot control one's foods. 


She explained that many orthorexics might initially start eliminating some foods because they believe their health will improve in the process. While anorexics are afraid of getting fat, orthorexics care less about their weight and more about their perception of health, said Astrachan-Fletcher.

For Shields, her problems with eating started in high school. A star athlete on the swimming, soccer, and golf teams, a chance visit with a chiropractor sparked her downward spiral into an eating disorder. 

“He gave me a list of good and bad food groups - no grains except for oatmeal, no fake sugars and no high fructose corn syrup,” she said. She doesn't blame the chiropractor, though, and said that she took the recommendations too far.

She quickly dropped weight, going from 118 pounds to under 100. When she began golfing competitively in college, her problems worsened. During one golf tournament in Boston, her heart rate dropped to 35 beats per minute, resulting in her being rushed to the nearest emergency room.  

Restricting and eliminating certain foods from the diet can be done in a healthy way, said Kelly Devine, a Chicago-based nutritionist and founder of Devine Nutrition in Chicago. For example, vegans, who eliminate all animal products from the diet including honey, and even raw foodists, who stick to a mostly raw diet and don’t heat foods above 116 degrees, can be healthy. The gold standard for determining healthy diets can be evaluated using lab tests, such as checking for blood sugar levels, said Devine. 


“[Initially], orthorexia hurts more mentally than physically. It’s one thing to eat healthy but occasionally indulge. [But] some people get so obsessed that they can’t eat at a work party,” she said.

Linda Van Horn, a clinical nutrition epidemiologist at the Feinberg School of Medicine at Northwestern University, agreed.

“The fundamental issue [with orthorexia] is the obsessive-compulsive nature of food intake,” said Van Horn. “Anything too extreme can be unhealthy.”

Eating healthfully is important for prolonging life and staving off disease. But the problem with orthorexia is that patients “disguise a disease as a virtue,” wrote Bratman in "Health Food Junkies," a book he co-wrote on the subject of orthorexia with David Knight.

“During my professional practice I met thousands of individuals whose defining interest in life was eating according to one or another theory,” Bratman wrote. “The obsessive nature of orthorexia frequently leads to a loss of all sense of proportion and an inexorable progression toward greater extremes of diet,” he wrote.

He detailed how the macrobiotic diet, for example, begins with grains like brown rice, and vegetables and beans and “progresses to rice alone,” which can be detrimental to one’s health.  

Treatment options remain similar for orthorexia and other eating disorders and, as such, orthorexia doesn't merit a separate category, said Astrachan-Fletcher.

Also, there’s a high-level of crossover when it comes to eating disorders, said Astrachan-Fletcher. A bulimic can become anorexic, or vice versa. And during the course of treatment, both anorexics and bulimics move through  variations of eating disorders.  

This was Shields' case. Her orthorexia switched to bulimia during college while she was studying abroad in China, which prompted her to temporarily return home and seek treatment with a psychiatrist, Gerri Katz, in Glen Ellyn.

Orthorexia should be treated as anorexia, said Astrachan-Fletcher. According to the National Institutes of Health (NIH), the treatment for anorexia is three-pronged: "restoring the person to a healthy weight, treating the psychological issues related to the eating disorder, [and] reducing or eliminating behaviors or thoughts that lead to disordered eating, and preventing a relapse."

Additionally, for treatment of orthorexia, as for all eating disorders, it’s important to separate the "voice" - one's own thoughts - at the root of the disordered eating. Those eating disorder thoughts are commonly nicknamed “Ed,” according to Astrachan-Fletcher.

“We also need to understand what the eating disorder is doing to help a person as well as helping the sufferer understand what harmful things the eating disorder is doing to their lives,” she said. Learning more effective coping mechanisms through therapeutic methods such as dialectical behavioral therapy, cognitive behavioral therapy, or family therapy is another crucial component of treatment, she said.

For Shields, her fight against orthorexia remains a daily struggle. For example, eating sandwiches and other foods that are mixed up are hard for her.

“It’s very OCD-ish," Shields said, referring to traits of obsessive-compulsive disorder. "Everything has to be [arranged] in a particular manner, in a particular way,” she said. But she hopes that with continued treatment, she will be able to regain control over her eating patterns. She holds phone sessions with Katz three times a week. She also meets with an eating disorder support group on campus and sees a nutritionist in New York during school sessions and a nutritionist in Illinois when she returns home during school breaks. 

Taking a recommended diet to the extreme, she said, started the whole mess.