Following the recent media focus on “orthorexia” and “ Clean eating”, I decided to do some research about this topic and add my findings and reflections to the blog.
As a Nutritional therapist with training in eating disorders, I have a particular interest in this area. I am interested in the boundary between healthy eating and obsession. What makes people go over that line? Could we as Nutritional Therapists be at risk of driving ourselves and others towards orthorexia? What can we do to avoid this?
What is Orthorexia?
Orthorexia is a term coined by an American doctor, Steve Bratman in 1997, so it is a relatively new condition.
Bratman is a self confessed ex-orthorexic and I would thoroughly recommend his very amusing account of his journey through orthorexia and subsequent recovery in his “1997 Orthorexia Essay” on his website (1)
Orthorexia is defined as being “ An unhealthy obsession with eating healthy food”. The term is derived from the Greek word “orthos”, which means” correct” (2). It is not officially recognized as being a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V), used to diagnose eating disorders, but a full criteria has been proposed recently by Dunn & Bratman (2).
These criteria are written to help health professionals with diagnosis, but I think that the following explanation (2) really encapsulates the essence of this condition:
“Orthorexia is an emotionally disturbed, self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable. A gradual constriction of many other dimensions of life occurs so that thinking about healthy food can become 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. This may result in social isolation, psychological disturbance and even, possibly, physical harm.
To put it another way, the search for healthy eating has become unhealthy.”
The few sufferers that I have encountered in my practice had all developed extreme anxiety around food, so that making every day food choices became a tortuous ordeal. They were spending hours online researching food and worrying about potentially harmful ingredients and as a result were completely perplexed and confused. They didn’t know what was safe to eat anymore and had made themselves ill by eating a very restricted diet of just a few foods such as brown rice and certain vegetables.
What is the difference between orthorexia and anorexia?
Whereas sufferers of the eating disorder anorexia have an unhealthy fear of weight gain and focus on the quantity of food eaten, orthorexics become obsessed with the quality and purity of their food. Unlike anorexics, they don’t strive to lose weight, but dangerously low bodyweight and ill health often results, due to extreme food restriction and malnutrition from an unbalanced diet. The 2 conditions may sometimes co-exist or follow on from each other. (3)
What both disorders do have in common is the underlying theme of anxiety and perfectionism, which drives the sufferer to use the disorder to deal with difficult emotions and stress.
How many people suffer from this disorder?
As there is no official diagnostic criteria for orthorexia, there is no reliable data for this particular disorder. One study (4) reported orthorexic symptoms occurring in 6.9% of the population, but this rose to 35- 57.8% in “high risk” groups, which included nutritionists and dieticians. I found the latter information rather alarming, but as I was not able to access the full study, I could not evaluate the methodology or population used to provide this data.
The following questionnaire was designed by Bratman (5) to diagnose orthorexia. Answering “yes” to 4-5 questions or more may indicate orthorexia.
Do you spend more than 3 hours a day thinking about your diet?
- Do you plan your meals several days ahead?
- Is the nutritional value of your meal more important than the pleasure of eating it?
- Has the quality of your life decreased as the quality of your diet has increased?
- Have you become stricter with yourself lately?
- Does your self-esteem get a boost from eating healthily?
- Have you given up foods you used to enjoy in order to eat the ‘right’ foods
- Does your diet make it difficult for you to eat out, distancing you from family and friends?
- Do you feel guilty when you stray from your diet?
- Do you feel at peace with yourself and in total control when you eat healthily?
(I answered “yes” to the second question, but I don’t think this is orthorexic – just organized!)
How does it happen?
Orthorexia can start off quite innocently with a desire to eat more healthily, sometimes in order to improve an existing health condition or to prevent a future one. As Nutritional therapists, this is the territory we are familiar with, so how can it all go so badly wrong?
The author, Jaime Heidel (6), describes how she started using diet to help manage her autoimmune conditions. This was working well for her on a physical level, but she realized she had reached an “unhealthy tipping point” when she observed her agitation and anxiety when she could not source all natural organic ingredients and that her dietary regime was interrupting her daily routines, social life and relationships. She realized that worrying about what she was eating could be more deleterious to her health than actually eating something “unhealthy”.
The National Eating Disorders Association (7), states that in addition to health motivations “..there are underlying motivations, which can include … compulsion for complete control, escape from fears, wanting to be thin, improving self-esteem, searching for spirituality through food, and using food to create an identity”. This last factor seems to be well exemplified in some of the popular “clean eating” blogs and instagrams. With the pressures of modern life, it is understandable that some people, including the bloggers, can be seduced by the information on these websites which promise a picture of health and happiness if you can just stick to the dietary rules advocated.
Heidel notes that her type A personality contributed to her condition. A tendency towards OCD can also contribute. So as with other eating disorders, it is the underlying emotional factors and personality traits which often drive the behaviour. For most people, striving to eat a healthy balanced diet is unlikely to trigger orthorexia. It may not be so much what you are eating or not eating but your attitude towards your food. Over thinking and rigidity are signs that the balance is tipping.
How can we help prevent orthorexia?
- It may seem blindingly obvious, but of course we can provide our clients with accurate evidence based information which can help dispel the myths and false promise propagated by “Clean eating”. We can explain, that the recipes that appear on these sites can be used, but the dietary advice is often not professional and not personalized to your client.
- Focus on food inclusions, rather than exclusions. Most people need a more varied diet and by adjusting their habits to eating more nutrient dense food they will start to decrease poor dietary habits. Recent research reveals that the microbiota, which we all know is fundamental to health, thrives on a wide variety of food, so explain this to your client.
- Be very mindful of elimination diets and emphasize that exclusions are not to be followed for longer than a certain period, unless really beneficial for health. (Obviously we would not want a celiac to eat gluten!) According to Bratman, the more extreme the dietary restriction, the higher the risk of developing orthorexia, so someone who is just aiming to eat organic whole foods and avoid processed food has lower risk than a raw food vegan. I am very conscious of explaining to anyone embarking on the FODMAP diet that this diet is only to be followed for 6-8 weeks and to ensure that a well balanced food plan is in place.
- Be mindful of your client’s mental well being. If they mention a history of OCD, eating disorders, or destructive perfectionism, do not encourage any extreme eating regimes. Encourage flexibility, realism and practicality. Some people may need to be referred to a nutritional therapist or counsellor with training in eating disorders.
To quote Heidel (6), “ While you are in the process of improving and prolonging your life, don’t forget to live it”.
- Bratman S. (2016) 1997Orthorexia Essay available at http://www.orthorexia.com/original-orthorexia-essay/ [accessed 23/10/16]
- Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17. Available at http://www.orthorexia.com [accessed 23/10/16]
- Bratman (2014) What is orthorexia? Available at http://www.orthorexia.com/what-is-orthorexia/ [accessed 23/10/16]
- Varga M., Dukay-Szabo S, Tury F, & Van Furth EF (2013) Evidence and gaps in the literature on orthorexia nervosa Eat Weight Disorders 18(2):103-11. [accessed 23/10/16]
- Food Today (2004) Orthorexia nervosa – when healthy eating is no longer healthy. http://www.eufic.org/article/en/page/FTARCHIVE/artid/orthorexia-nervosa [accessed 23/10/16]
- Heidel J. (2015) Ae you TOO obsessed with food? available at http://itoldyouiwassick.info/2015/04/08/obsessed-with-healthy-eating-orthorexia-nervosa/%5Baccessed 23/10/16]
- National Eating Disorders Association (2016) Orthorexia Nervosa available at https://www.nationaleatingdisorders.org/orthorexia-nervosa [accessed 23/10/16]
Joanna Oates, Nutritional Therapist and Lecturer
DISCLAIMER – this article is intended for information only and should not be considered to be nutritional advice. If you would like to change your diet please see a qualified registered practitioner for professional advice.