Starving. Bingeing. Shame. Guilt. Detox. Calories in. Calories out. Obsessing. Macros. Body fat. Perfection. Pressure.

These were the words uttered by a local personal trainer/nutrition coach recently when I asked her what “a healthy lifestyle” used to mean to her. She mentioned that being on social media as someone promoting health and fitness exacerbated her guilt if she would “go off track” by eating a “bad” food like pizza. There was no room for balance. She found herself in this spiral for almost two years all in the pursuit to have a “healthy lifestyle.”

“Orthorexia nervosa” is a term used to describe health-based extreme diets that threaten, ironically, one’s health. People with this condition often exhibit signs of eating disorders and obsessive-compulsive disorder. And the prevalence of the condition has increased with the current zeitgeist of clean eating, gluten-free, veganism, and organic options. America’s growing obsession with health has also extended to exercise, with more people engaging in compulsive, inflexible fitness regimens. These two trends have joined forces to create a phenomenon that has psychologists wondering: Is this health-crazed lifestyle just another eating disorder is disguise?

Unlike common eating disorders such as Anorexia and Bulimia — diagnosable illnesses clearly defined by a set of symptoms that directly harm the body — orthorexia does not have specific diagnostic criteria and it can easily be mistaken as an admirable quest to be “healthy.” In fact, many well-intending health care providers and loved ones could miss or unknowingly reinforce these behaviors. But people who struggle with this life-altering healthy lifestyle obsession often experience malnutrition, physical injury, increased symptoms of depression and anxiety, isolation, and an overall impairment of daily functioning.

Of course, not every person who strives to maintain a healthy lifestyle will develop a problem. However, there are many people who appear to be “healthy” who are actually deeply struggling.

So, how are we to know when we or someone else has taken it too far? Below are the top 3 red flags that might indicate a not-so-healthy relationship with a healthy lifestyle:

  • Flexibility. Psychologists often look to the variables of intensity, frequency, and duration when evaluating behaviors. Taken together, we can assess level of flexibility. Unless it is medically indicated by a physician, rigid eating and exercise plans that restrict several food groups and/or do not allow for rest are not necessary to maintain health and physical fitness… even for Olympians. For example, bringing your own dinner to a social event because the food served is not “healthy enough” demonstrates an unreasonable inflexibility that warrants concern. Eating the food at said social event but then experiencing guilt and shame followed by the need to compensate the next day by cleansing or detoxing is also of concern.
  • Pervasiveness. How much does this lifestyle bleed into other domains of your life? Something such as pre-planning the macros to be consumed and calories burned on a short vacation would be a noteworthy behavior. It demonstrates one’s preoccupation with food and health at a level that misses the point of a vacation. In this example where a person finds themselves out of their typical routine, vacation can become a stressor. Likewise, there is some cause for concern when a person finds themselves distracted by calculations and nutrition Google searches while at work or school. The preoccupation could reach the point of their productivity beginning to suffer.
  • Impairment. Understanding whether these behaviors are problematic largely boils down to the ratio between fulfillment and impairment. Are there any consequences to these behaviors? The presence of anxiety and depressive symptoms because of a person’s preoccupation with their healthy lifestyle is a decent indicator of a problem. Chronic stress fractures or an absence of menstrual cycles would also indicate that the level of nutrition and exercise is not beneficial to the person’s health. Relationships can become impaired as well. Compulsively calculating macronutrients on an app while out to a nice anniversary dinner with your partner would be suspicious. Continued patterns like this could eventually cause conflict within your relationships. Why? Because it inhibits your ability to be present, which makes intimacy and connection more difficult. Similarly, some of my clients have shared that their marathon training or rigidity around food made them feel “completely disconnected” from their day-to-day lives. This disconnection can cause friends and family to feel at fault and/or become frustrated with their loved ones, and it can increase feelings of depression in the individual’s daily experience.

While clear treatment guidelines have yet to be defined for this problematic phenomenon, people with orthorexia often benefit from some form of Cognitive-Behavior Therapy, to break the cycle and regain control of their life.

Jenna DiLossi, Psy.D, specializes in the treatment of eating disorders and cognitive-behavioral therapy (CBT). She co-founded the Center for Hope & Health, a treatment center that offers specialized evidence-based treatments for eating disorders and anxiety disorders.