Eating Disorders

Clinical Applications of Orthorexia Nervosa (Part 3 of 3)

This blog wraps up a three-part series on orthorexia nervosa (ON). If you haven’t already, be sure to read Part 1 and Part 2, in which I provide historical context, recommended diagnostic criteria, and state of the research related to ON. This final blog post will focus on clinical strategies for screening and treating ON.

Screening for ON
While health care providers still are awaiting official diagnostic criteria, it’s possible to screen for an unhealthy obsession with nutrition and health in your practice. Keep the proposed diagnostic criteria close by, and, if you suspect someone is at risk, consider asking some of the following questions:

  • Are you spending more time thinking about your food choices than you wish you were?
  • Do you find that the main barometer of how you feel about yourself on any given day is based on how you’ve eaten?
  • Do you tend to demonize certain foods and think you can’t eat the foods you enjoy?
  • Are you flooded with anxiety, shame, guilt, or negative physical sensations when you eat something that’s not on your list of permitted foods?
  • Do you feel like your eating has become compulsive instead of an active choice?
  • Are you increasingly eliminating more foods and adding to your list of food rules to try to achieve the same health benefit?
  • As you cut out more foods and try to eat more healthfully, has your fear of disease gotten worse?
  • Does your eating regimen make it hard for you to interact with friends, family, or colleagues?
  • Are you likely to stay home from a social event over a fear of what type of food will be served?
  • Is your eating adding to your overall stress?
  • Has a medical professional told you that you’re experiencing negative health symptoms because of your strict diet?

Treatment Strategies
Treating ON is quite similar to treating other eating disorders in that the food and exercise rules and rituals are rooted in anxiety management and overly correlated with a person’s self-esteem or feelings of self-worth. Effective treatment will look different for each person, but below are a few interventions to consider.

Make a referral to a mental health provider. While this may feel overwhelming to you, it’s a critical first step. Consider using the following script: “The more I listen to your experiences related to food, the more aware I am that your food habits are closely related to your emotional well-being and self-esteem. I think you and I can do some great work around shifting some of those habits. But my sense is that we’ll have a lot more success if we get more support for your mental and emotional health. Have you ever considered working with a counselor? Would you consider working with a counselor?”

It may be necessary to reiterate that you’re equipped to help your client develop greater flexibility with eating and exercise but that the process likely will generate more anxiety for your client. Adding more support with a counselor is setting your client up for success through improved anxiety management and developing greater insight into the functionality of ON symptoms.

Also consider exposing your client to their moderately feared foods. After completing a thorough nutrition assessment and determining that this level of care is medically safe for your client, discuss with them the goals of nutrition therapy for ON. This includes exposure to and integration of feared foods into the diet to develop greater food variety, balance, and flexibility.

Complete a hierarchy of feared foods with the client and organize them by category: safe, moderately feared, and highly feared. Then work with your client to choose a moderately challenging food exposure (think a 4/10 level of anxiety, on a scale of 1 to 10) to be completed with you or on their own. This process should include providing a more realistic frame of thinking about the food and preparing the client for the anxiety they may feel as they eat this food. Providing education that this anxiety will dissipate on its own with time and repeated exposure is a critical part of coaching the client.

RDs often are the first to identify ON and are a critical part of the treatment team. This three-part series provides an overview of this condition, but it’s critical that dietitians stay abreast of the ever-evolving research related to ON to best treat this troubling illness.

— Marci Evans, MS, RD, CEDRD-S, LDN, CPT, is a Food and Body Image Healer™. In addition to managing her group practice in Cambridge, Massachusetts, Marci is shaping the future of dietetics by bringing her passion and skill into the eating disorders field to students, interns, and clinicians with online training and clinical supervision. Connect with her at and at all social media outlets @marciRD.

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