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When is eating right unhealthy? It depends on your level of dedication — or obsession (orthorexia nervosa anyone?).

“Some people can border on the irrational and only eat salmon prepared from this one place in Washington that was cooked over a cedar plank,” Dr. Thomas Dunn of University of Northern Colorado told CNN. “If you’re losing friends because no one wants to go out with you because you’re such a horrendous pain in the ass about where and what you’ll eat, you have a problem.”

That problem is called orthorexia nervosa, Greek for “fixation on righteous eating,” and it’s only now being recognized as a mental disorder. While not in the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), — the closest equivalents are Eating Disorder Not Otherwise Specified and Avoidant/Restrictive Food Intake Disorder — it is not any less real to those suffering from it.

But where do we draw the line between healthy eating and obsession?

Orthorexia Nervosa: Honey, I Shrunk The Diet

“Enthusiasm for healthy eating doesn’t become ‘orthorexia nervosa’ until a tipping point is reached and enthusiasm transforms into obsession,” writes Dr. Steven Bratman, an alternative medicine practitioner turned medical doctor who first coined the term. He writes on his website that orthorexia nervosa is “an emotionally disturbed, self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable.” As the list of acceptable foods shrinks, the rest of life is compressed until thinking about healthy food “becomes the central theme of almost every moment of the day, the sword and shield against every kind of anxiety, and the primary source of self-esteem, value and meaning.”

In other words, no, being a raw food vegan is not an eating disorder unless it becomes your identity.

“[It’s] basically feeling you’re not enough as is,” says Z. Zoccolante, an eating disorder blogger for Healthy Place, the nation’s largest mental health consumer website.

Living Traditionally is cynical of the diagnosis, blasting it as pseduoscience pushed by Big Pharma. The website reads: 

Perhaps some people do take it too far to the point of self-harm, but the problem we face with a toxic food system is a much larger threat … In an attempt to curb the mass rush for food change and reform, psychiatry has green lighted a public relations push to spread awareness about their new buzzword ‘orthorexia nervosa,’ defined as ‘a pathological obsession for biologically pure and healthy nutrition.’ In other words, experts are saying that our demand for nutrient-dense, healthful food is a mental disorder that must be treated”

To that, the National Eating Disorders Association (NEDA) writes “Following a healthy diet does not mean you are orthorexic, and there is nothing wrong with eating healthfully.” Unless, the site warns, one of three things happens: there’s a problem if it takes up most of your day and most of your attention; you’re in trouble if, as the Tori Amos joke goes, you have enough guilt to start your own religion if you deviate from that diet; also, it’s a problem when it leaves you isolated and alone.

The American Psychiatric Association (APA) agrees. The website reads:

Veganism and clean eating have seen a surge in popularity in recent years. Many people enjoy these diets and feel that it benefits their health. The decisions to eat food that is closest to its natural state and/or not to eat animal products are not inherently problematic choices or cause for alarm. Being mindful about what we consume is a great way to live a healthy life — it is when the need to eat ‘good’ foods becomes ‘extreme, obsessive, psychologically limiting, and sometimes physically dangerous’ that it is disruptive to an otherwise healthy life.

Eat Right, Exercise, Die Anyway?

Dr. Theresa Rohr-Kirchgraber, executive director of the Women’s Center for Excellence at Sidney and Lois Eskenazi Hospital in Indianapolis, said a patient asked her when eating right and exercising became a bad thing.

“When it becomes excessive,” she said. “When it makes you get it done. When it interferes with activities of daily living.”

Zoccolante agrees: “If there’s anxiety, if there’s depression, if there’s any sort of compulsion,” she says. “Like all addictions, it starts off feeling great, and as you go further along, it starts to erode pieces of you … If you’re being honest with yourself, it’s about your relationship with your body and food.” She draws the line — ”It’s a very fine line” — at the point in which a person is not getting their nutrients.

Bratman uses the parallel of anorexia. We all know that being overweight or obese is unhealthy — thanks Mrs. Obama! Anyone with a shred of health-consciousness will eat a healthy diet. But some people take avoiding bad foods too far and become anorexic, avoiding any food and exercising strenuously. Orthorexia nervosa is a healthy diet taken to the extreme of malnutrition and self-starvation.

Rohr-Kirchgraber recalls one patient, a surgeon, who had this condition. The surgeon would grill food at the beginning of the week and only eat that — since the hospital cafeteria food was not prepared in a certain way, the surgeon would not eat any of their food, which led to problems getting through the day, especially when his food rations ran out. Skipping meals because a pure enough food isn’t available is not unusual. Neither is picking out food that one isn’t sure about despite trying to land a client over a meal.

“It’s a struggle at the dinner table because you’re anxious about the food,” says Rohr-Kirchgraber. “Healthy eating is good, but when it becomes an obsession, when it becomes restrictive, there’s a problem … There are ways to do healthy eating that aren’t harmful.”

A Fear Of Being Ordinary

So how do you know when eating right has gone horribly wrong?

One way is when it’s life-threatening. For example, Bratman names Kate Finn on his website as a victim who died from orthorexia nervosa — heart failure triggered by starvation, to be exact. Finn, who was initially diagnosed with anorexia nervosa, “resisted the diagnosis and their recommended treatment because it just didn’t seem to fit,” Bratman writes. “She wasn’t afraid of being fat. She didn’t want to be thin. She just wanted to eat healthy food. In her mind, she was sick, and therefore needed to cleanse. As a result, she brought her weight down so low it killed her.” It is unclear what she was eating at the time of her death, but Finn wrote in Beyond Veg that she was following a “Natural Hygiene” diet of fruit for breakfast, salad for lunch, and “heavier protein-type foods” for dinner, along with grains for lunch and dinner.

Another warning sign is when dieting crowds out all else. Timberline Knolls, a women’s residential treatment center near Chicago specializing in eating disorders and other addictions, explains:

A person with orthorexia nervosa will be obsessed with defining and maintaining the perfect diet, rather than an ideal weight … Orthorexia symptoms are serious, chronic, and go beyond a lifestyle choice. Obsession with healthy food can progress to the point where it crowds out other activities and interests, impairs relationships, and even becomes physically dangerous … The person with orthorexia may lose enough weight to give her a body mass index consistent with someone with anorexia (i.e., less than 18.5).

Jordan Younger, author of the book Breaking Vegan, is one example. She initially became vegan to ease digestive problems (they didn’t stay cured), but it soon took over her life. She writes in the book:

I was entering into a relationship with veganism … Veganism became my boyfriend, my best friend, and my confidant … The strict diet helped me feel extraordinary when I was very fearful of being ordinary. [Veganism] triggered a desire within me to be more and more extreme, more and more pure, and to achieve more and more nutritional perfection to the point where no foods were safe.

Three-week juice cleanses and guilt for eating solid food became her normal.

Younger, who ran a 30,000-subscriber blog called The Blonde Vegan, wasted away to 101 pounds. Her hair started falling out. Her blood sugar was chaotic. She even stopped menstruating, at which point she became concerned. After a conversation with a friend, she realized her fixation on eating right had become unhealthy, and she found Bratman’s website. After therapy, she transitioned to a more balanced diet and wrote she was no longer vegan. Her website crashed and she received death threats.

Younger changed the name of her blog toThe Balanced Blonde, and although she still posts recipes like “Maca Mocha Pumpkin Banana Bread” (gluten-free, paleo, and refined sugar-free) and promotes plant-based cleanses, she’s not as rigid about diet as she was. She now works as a health coach and encourages her readers to listen to their bodies when it comes to what to eat.

Zoccolante, who initially followed the raw food diet and a vegan diet, agreed with the fear of being ordinary driving orthorexia nervosa. She said trauma and low self-esteem contribute to the disorder.

“[Orthorexia] makes you feel extraordinary,” she says. “You’re not — just another statistic.”

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Finding A Solution

Treatment centers are recognizing orthorexia nervosa and offering therapy programs. According to the Eating Disorder Task Force of Indiana, a team-based approach is the best way to address an eating disorder. Psychotherapy is necessary to address the underlying emotional concerns. A physician should be involved because the rigid diets common to orthorexia nervosa can cause severe physical problems. Nutritional counseling from a registered dietitian can also be very helpful since people with eating disorders may not understand what constitutes healthy eating — yes, you do need good fats.

The group reports that most treatment can be done on an outpatient basis. However, when the individual’s life is in danger, inpatient treatment should be done at a hospital that has a specific eating disorders program. 

“Individuals and their families should ask if hospital staff or outpatient professionals have specific training in treating eating disorders,” the site reads. “Membership in the Academy for Eating Disorders is also a plus.”

It is unclear whether orthorexia nervosa is a unique eating disorder or obsessive-compulsive disorder with disordered eating habits. It is not abnormal to be concerned with the safety of our food supply and what we put in our bodies considering the crap added. But it’s safe to say there is a problem when the quest for the perfect diet results in malnutrition.

Becky Oberg is a professional writer living in Indianapolis. She enjoys acting, singing, playing video games, and playing with her pet rats. You can also find her on Twitter, Facebook, Google+ and LinkedIn, and on her blog, One Woman and a Laptop. You can find her ebook, “Comforting Tamar”, on Amazon.

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