She had recently gone gluten-free and dairy-free to address persistent bloating and fatigue. She skipped breakfast to support her circadian rhythm, and she was careful to avoid sugar and processed foods. She was proud of her discipline, and her lab work looked fine, but over time, her meals had become more stressful than nourishing. Dining out made her anxious, and she had begun to worry about even small deviations from her plan. No one had ever asked her if she was afraid of food.

As an internal medicine physician and Certified Eating Disorder Specialist, I see this story, or some version of it, all the time. A patient arrives having done “everything right.” They’ve cut out inflammatory foods, follow a wellness protocol, and track everything from glucose to gut health. But they’re not getting better, and under the surface, they’re exhausted, rigid, and increasingly afraid to eat. We often think of eating disorders in narrow terms: underweight teens with dramatic symptoms. But disordered eating is far more nuanced and far more common, especially among adults pursuing “optimal health.”

The changing face of disordered eating

Orthorexia nervosa, a term coined in 1997, describes an obsession with “healthy” or “clean” eating that becomes psychologically and physically impairing. It’s not a formal DSM diagnosis, but its clinical patterns are increasingly common. Patients restrict more and more foods in pursuit of purity, control, or symptom relief until their diets become so limited that physical and emotional well-being begin to suffer. These patients may not meet criteria for anorexia or bulimia. Their weight may be “normal.” Their intentions may be health-driven. But they are often undernourished, socially withdrawn, anxious, and distressed, and they’re rarely recognized as having disordered eating, especially when they appear highly functional. In fact, many are praised. Their discipline is admired. Their fasting, tracking, and restriction are validated by social media, wellness influencers, and sometimes even medical providers. This praise reinforces a dangerous cycle: the more rigid they become, the more approval they receive.

The role of medicine and its silence

In conventional medical settings, disordered eating can be easy to miss. We aren’t routinely trained to screen for it, especially in adults. Even in patients with amenorrhea, osteopenia, or GI distress, we may not ask about eating patterns unless there’s visible weight loss or a known psychiatric history. And when we do recommend dietary changes for diabetes, PCOS, GI conditions, or autoimmune disease, we often assume the patient will interpret and apply those recommendations in a balanced way. But for some, particularly those predisposed to anxiety or perfectionism, even medically sound plans can become overly rigid, triggering or reinforcing disordered patterns.

The intersection of lifestyle medicine, weight stigma, and disordered eating

At the same time, medicine is undergoing a cultural shift toward lifestyle-focused care, a movement that, in many ways, offers important correctives to overmedication and rushed visits. But within that shift, we must also acknowledge the shadow side: an often unexamined obsession with weight loss, “clean eating,” and metabolic optimization. In a country consumed by the “obesity epidemic,” it’s easy to conflate thinness with health and restriction with virtue. But this cultural lens often reflects fat phobia more than medical science, and it can lead clinicians to overlook or even encourage restrictive behaviors in patients who appear outwardly “healthy.” We may praise weight loss without understanding what drove it. We may recommend lifestyle changes that unintentionally reinforce shame or disordered eating. And we may miss the harm caused by messages that equate wellness with worthiness, especially for patients already predisposed to anxiety, trauma, or perfectionism.

Screening is simple and necessary

You don’t need to be an eating disorder specialist to make a difference, but you do need to be alert. Here are some questions I find useful in any outpatient setting:

• Have you noticed increasing anxiety around food or eating in public?
• Do you find yourself avoiding entire food groups?
• Are you afraid of what certain foods might do to your body?
• Have you lost weight intentionally but feel uncomfortable loosening control?

You can also use the SCOFF questionnaire, a five-item screening tool with high sensitivity. It takes less than two minutes and often opens the door to meaningful dialogue. If screening raises concern, referrals to a registered dietitian, therapist, or medical provider with ED experience should be considered. But even if referral isn’t immediately possible, pausing further restriction, offering nutritional flexibility, and validating the patient’s experience can reduce harm.

What gets missed and what it costs

Disordered eating is associated with increased cardiovascular risk, bone loss, infertility, and significant psychiatric comorbidity. And yet it’s still minimized, or worse, romanticized, under the guise of wellness. We may applaud the behavior before recognizing the cost. Patients with disordered eating are often intelligent, articulate, and deeply motivated to feel better. But control is not the same as health, and perfection is not the same as healing. If we only treat the symptoms without addressing the patterns driving them, we risk keeping patients stuck or even making them sicker.

A call to clinical curiosity

As clinicians, our job is not to enforce food trends or chase purity. It’s to treat the whole person with curiosity, humility, and context. That means asking not just what someone is eating, but how they’re eating and why. It means noticing when a health plan becomes a coping mechanism. And it means remembering that wellness without flexibility is often a mask for suffering. Eating disorders aren’t rare. They’re just rarely recognized in the places we’re not looking. And it’s time we started looking.

Sally Daganzo is an internal medicine physician.