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Internal medicine physician Sally Daganzo discusses her article “The hidden epidemic of orthorexia nervosa.” Sally explains how the pursuit of a perfect diet can spiral into a debilitating obsession where food rules dictate a patient’s entire life. She describes how individuals often adopt restrictive protocols to manage inflammation or gut health but end up suffering from intense anxiety and social isolation instead. The conversation highlights the “shadow side” of lifestyle medicine where well-meaning advice can inadvertently trigger disordered eating in vulnerable patients. Sally challenges the medical community to look beyond normal lab results to recognize when wellness culture has become a source of suffering. Learn how to spot the subtle signs of this hidden condition and help patients prioritize flexibility over rigid control.

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Transcript:

Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Sally Daganzo, internal medicine physician. Today’s KevinMD article is “The hidden epidemic of orthorexia nervosa.” Sally, welcome back to the show.

Sally Daganzo: Thank you for having me. I am excited to be here.

Kevin Pho: All right, so give us some context. Tell us what orthorexia nervosa is and why you decided to write this article on KevinMD.

Sally Daganzo: I think orthorexia is a bit known, and maybe some people have heard of it. Basically, it is trying to eat correctly all the time. Some people might call it clean eating or something like that, but it is when it basically takes over somebody’s life. It is not an official ICD-10 code or DSM diagnosis as far as I know. But it is something that I think people likely underrecognize.

So that is the context. It is sort of this healthy eating taken to an extreme where it becomes inflexible. Since I do a lot of eating disorders, that is my primary practice. I have also recently trained in functional medicine, which is maybe similar to lifestyle medicine. There is this convergence of those two that I sometimes see or maybe recognize more. That is what prompted me to put this out there for other people to maybe be on the lookout for.

Kevin Pho: All right, so what separates adherence to a diet to something more pathological like you suggest here?

Sally Daganzo: I think it can start innocently. I liken it to somebody who might be predisposed to something like OCD or obsessive-compulsive disorder and you may not know it. It may be that somebody has a heart attack and then they decide they want to stop eating meat or whatever it is, and then suddenly it just sort of takes over their entire life. They are afraid to go out with friends because they don’t know what is on the menu and if they will be able to eat anything. It may be they are eating something different than the rest of their family. Like with any sort of psychological diagnosis where it is interfering with their ability to do their day-to-day life, they can become sad about it and it takes over all of their thoughts. It may not be all, but it can be hard to recognize. It is a fine line I think.

Kevin Pho: Now, when a patient with this condition presents to you at a clinic, what are some typical presentations or stories that you see?

Sally Daganzo: Typically, they may come in with an eating disorder. We are already looking at that. So that is maybe separate but overlapping, and that includes anorexia, bulimia nervosa, and binge eating disorder, which are these other DSM-defined things.

But you might see somebody with something we are familiar with like small intestinal bacterial overgrowth or SIBO. Maybe I think it is a little bit trending on the internet these days, or maybe not so much, where people feel bloating or they feel uncomfortable in their stomach. So they might have seen their regular doctor or they may have seen a GI doctor who said: “Oh, just take Pepcid or omeprazole.” That doesn’t really help, and also that has other problems. Then they are looking for more answers.

People often turn to food because it is everywhere. They are looking for answers and think: “Well, maybe if I get rid of gluten.” At least out here in California, gluten is seen as this awful evil thing. Or maybe they cut out dairy because a lot of people are intolerant to dairy. Those are the two biggest ones and often we are recommending that. It sometimes does help.

So maybe they get rid of those things or maybe they come in wanting to get rid of them. Then suddenly they are either losing weight or they start eliminating more and more things because they feel a little bit better. Then they think: “Well, maybe if I also get rid of this adjacent thing like all grains, because I heard the carnivore diet was good from another person.” It kind of ends up being this obsession with asking what is the next thing to get rid of to feel even better.

Maybe they did get a little improvement because a lot of people do feel less bloated when they cut out gluten. That is probably true for everyone just by the nature of how gluten acts in our body. But this becomes sort of an addiction almost to finding what to get rid of next until they are severely limited. Then when you try to add them back is the other thing. There is a lot of fear around it. They think if they add it back, something bad will happen. They may not say that, but it is almost like this resistance to putting it back in. That is where I liken it to something more like OCD. It is like they just can’t do it. They may even recognize it is a problem and don’t know how they got there.

So that is what I see. I think maybe in the primary care setting or somewhere else, it could be more subtle. My point in writing this is when we recommend some of these lifestyle interventions, I think it comes from a place of yes, these are the right things to do. They are going to help. But maybe screening for anxiety disorders or even family history and making sure you have a follow-up check-in are basic steps to make sure it doesn’t go too far. I think we are just not used to thinking that way with this obesity epidemic, which we cannot deny either. I think that is also an ongoing situation.

Kevin Pho: So one of the things I am hearing is that sometimes well-meaning advice in a primary care office or from a family member could actually trigger this shadow side of lifestyle medicine if that patient is predisposed. You mentioned a history of anxiety, for instance. It could trigger this orthorexia nervosa.

Sally Daganzo: Right. Yeah. Actually, just yesterday I was seeing a young person with anorexia, so this is slightly different, but hers is a very orthorexic form. It looks like she is eating spa food all the time and she is a teenager. I mean like yoga retreat food. It is not weird food, but just not what a teenager would be eating. I have three teenagers. Or even adults wouldn’t eat this way.

But it was interesting because her parent shared with me that he has a memory of her going to a health class in middle school or elementary school. She has no recollection of it. She came home and they had talked about healthy eating and food groups or something seemingly benign at school trying to teach about healthy eating. It seems innocuous. He acted like that was a light switch where it was like: “Oh, I could do that. I could eat healthy.” So there is also this perfectionism that can happen.

In adults, we may take it for granted that that is not an issue, but something can trigger that. We don’t have time to screen for every single thing. But I do think we take that nutrition advice for granted, and sometimes it is simply in an after-visit summary that we send to somebody. It may not even come out of our mouths as a conversation because we don’t have time. So that is where I think a little more thought and care could go a long way to protecting us from having another problem.

Kevin Pho: What are some of the long-term consequences if this isn’t diagnosed and treated appropriately?

Sally Daganzo: I mean definitely it could turn into anorexia. But also just eliminating food groups leads to malnutrition. Like with any sort of extreme diet, if you are eliminating whole food groups, you really don’t function well. You need your omega-3s, you need your vitamin A, and you need all these things that we learn about in medical school. Then we just sort of assume the engine is going to work no matter what we give it. We spend a lot of time on that as well. But we actually need a very complete diet to really thrive.

Even the other place I see it is things like perimenopause or as we are getting older. People feel more tired. We are taking care of our parents or our children. There is a lot going on in midlife, and so people think they can just clean up their diet. Then the other thing we see is lower calories, like just a lower intake overall, which actually gives us less energy and less nutrition. We are not always talking about that either.

You could get all the consequences you could get with anorexia or malnutrition, like osteoporosis and dementia. The list goes on. I mean, the most obvious one would be things just like anxiety and depression because our mood is really not well supported when we are not well-nourished. People want to work the system. They think: “Well maybe if I just take a multivitamin, that can do it.” But it is not the same. You need the food.

Kevin Pho: So in your story, you said that something as benign as a health class can sometimes trigger this. So tell us how we could individualize nutrition and diet advice. For me as a primary care doctor, if I wanted to give nutrition advice in the exam room, what are some ways that I could individualize it to that patient? What are some questions I could ask before I give that advice that may uncover a predisposition to this? What are some approaches for that?

Sally Daganzo: I think just asking something like: “Have you ever been afraid of gaining weight?” is a basic question. Or: “Have you ever been scared of food? Do you have a history of an eating disorder?” If these are people in their fifties, they may have had a history in their teen years and just thought it was gone. I see that all the time where it just resurfaces and people are taken by surprise almost that they didn’t think it could happen.

I think that is pretty natural. If you are going to go into a conversation about nutrition, I think it is a pretty obvious or natural question to say: “Hey, before we talk about this nutrition advice, I just want to double check, do you have any history of being fearful of food or history of an eating disorder or even family history of anything like OCD?” if you wanted to get more into that.

I think just asking for that is important and people are pretty honest. You can frame it in the way any primary care doctor would. Just frame it in a way like: “So I can give you the most careful, personalized advice about this.” I think it is really reasonable. I know I definitely wasn’t doing that at all until I started seeing more and thinking about it.

There has just been this wave with the GLP-1 receptor agonists. There has just been a lot more attention around nutrition and lifestyle medicine in the last couple of years. It seems like a good opportunity for us to rethink how we are delivering this. For doctors, very basic advice like: “Just eat this balanced diet and don’t eat so much garbage,” can be a problem. Suddenly people hear “garbage” and it is off the rails. People take what we say seriously. Not everyone listens, and a lot of people don’t make changes. But then there are these people that really take it to a T.

Kevin Pho: Now, if someone were diagnosed with orthorexia, what are some treatment approaches that you have implemented in your own clinic?

Sally Daganzo: The main thing is I always work with dietitians. Not everybody is willing to see a dietitian, but I find a dietitian to be one of the most valuable people as part of a treatment team. A lot of places do have access to that. A great dietitian, even just one visit with them, is helpful.

Also, look at what they are most afraid of and what is driving that. Ask how we can just do a gentle exposure if you think that they have eliminated a bunch of foods but you know they are not really having anorexia. Talk about what they can reintroduce, which is kind of the treatment we would do for something like OCD too. It is just this exposure therapy. Kind of rip the band-aid off and see what is going to happen if you eat a piece of bread if you have been not eating gluten for a long time.

Actually counsel them that the first time they reintroduce something, they might feel kind of bad. That is something to be expected. If you have eliminated a lot of foods and you add them back, your body may not be used to it. That doesn’t mean you are allergic or intolerant, which I think is the other trap people can get into. They get rid of something and they add it back and think: “Oh, I can’t eat it because now I feel funny.” Well, their microbiome probably changed. I don’t know what is happening on the molecular level, but our bodies adapt to what we give it.

So I think having that anticipatory guidance about what to expect if we do add things back is important. Work with them on not having things be black and white and being comfortable with a gray area and flexibility. It is hard. But I think naming it helps people see that maybe they have taken this too far when it is not really a clinical anorexia. Recognizing that even your doctor is saying that you don’t have to be so strict can also be a relief for some people. It doesn’t have to be that you can’t have any cholesterol or eat an egg ever again if you have had a heart attack.

That is working with the gray area and helping these sort of perfectionist, rigid type people work in that gray area, which nobody really likes. Nobody likes gray areas.

Kevin Pho: We are talking to Sally Daganzo, internal medicine physician. Today’s KevinMD article is “The hidden epidemic of orthorexia nervosa.” Sally, as always, let’s end with take-home messages that you want to leave with the KevinMD audience.

Sally Daganzo: I think the biggest one is what you mentioned earlier. If you are giving nutrition advice, just check in if they have ever had a history of an eating disorder or being afraid of food. I think that is an easy one to implement. I hope that some people will do it at least some of the time and see if that opens up any conversations with your patients. I think you could help a lot of people.

Kevin Pho: Sally, as always, thank you so much for sharing your perspective and insight and thanks again for coming back on the show.