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Healthy Eating vs. Orthorexia

Adopting a theory of healthy eating is NOT orthorexia. A theory may be conventional or unconventional, extreme or lax, sensible or totally wacky, but, regardless of the details, followers of the theory do not necessarily have orthorexia. They are simply adherents of a dietary theory. The term “orthorexia” only applies when an eating disorder develops around that theory.

I feel a need to clarify the distinction because I have recently begun to encounter articles on orthorexia that incorrectly equate the two issues. This is partly my fault because my original orthorexia essay devotes some time to deconstructing dietary theories, for reasons that made better sense at the time than they do now.

Another contributing factor to the confusion, is that the research test used in Europe for studies of orthorexia, the ORTO-15, needs some further refinement; as currently structured, it seems to identify members of healthy eating subcultures rather than those who truly have orthorexia. (Researchers are in dialogue to remedy this.)

There even seem to be people who proudly name themselves “orthorexic” because they choose organic, whole, relatively unprocessed foods, free of preservatives, antibiotics and GMOs. I hate to disappoint you folks, but you need to follow a much more restricted diet than that have a chance at the name!

Enthusiasm for healthy eating doesn’t become “orthorexia” until a tipping point is reached and enthusiasm transforms into obsession.

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 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. 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.

 

Diet as Risk Factor

The issues of “theory of healthy diet” and orthorexia are not entirely separate, because it isn’t possible to develop orthorexia without at first adopting a theory of healthy food. However, in many ways, the specific details of the theory are irrelevant. Orthorexia = disordered eating in relationship to [insert any restrictive theory of healthy diet here.]

As a matter of practical fact, some theories present more risk of orthorexia than others. The more restrictive the diet, the more likely it is to set off the psychological factors that lead to an eating disorder.

The basic “clean eating” diet, which focuses on organic whole foods, free of preservatives, antibiotics and GMOs, barely qualifies as a restrictive theory of healthy eating and only occasionally leads to orthorexia. More risk accrues as increasingly practices related to the history of clean eating theories are added, such as detoxes, juice fasts and other “cleanses.”

Similarly, the standard paleo diet is quite mild, and regardless of whether one believes the theory makes sense or not, becoming paleo most often does not lead orthorexia unless further restrictions follow. Simply remember to take a gentle approach with yourself, as Neil Stephenson advises on his popular Paleoista blog.

Raw foods veganism is on the other extreme, and has a fairly high orthorexic potential. This is a challenging diet to manage safely, and many people who will ultimately develop orthorexia begin as raw foods vegans. Nonetheless, there are also certainly many people who adopt the raw food vegan lifestyle and do not become orthorexic.

A truly extreme diet like fruitarianism is orthorexic by definition — because it does not provide nutrition compatible with health. But with a nutritionally sound diet, what matters is not whether the theory is wrong or right, scientific or unscientific. It’s how it impacts you as a person.

People who get in trouble with theories of healthy eating often have an underlying predilection toward going overboard. As Jordan Younger writes in her excellent piece on Refinery29,  “Those of us who have a tendency toward extremes in other areas are more susceptible to developing it [orthorexia] — especially once we start cutting out entire food groups.“

To clarify, it IS possible to cut out an entire food group without being orthorexic — but a restriction so sweeping as that definitely puts one at risk.

 

The Tipping Point

Healthy diet turns into orthorexia when a boundary is crossed and a person’s relationship with food begins to impair various essential dimensions of human life. There is no bright line to mark this transition, but it can be recognized as a situation in which the search for a healthy diet has taken on a life of its own and no longer serves the goal of improving health.

Jaime A. Heidel captures this tipping point in her essay “Are you TOO Obsessed with Healthy Eating?” She began following theories of healthy eating in order to address certain personal health conditions. From a physical perspective, she found this effective. However, “somewhere along the line, my desire to keep my conditions under control developed into an obsession of the more questionable variety.”

She describes how “healthy” diet began to take over her life. “My diet became increasingly strict and I found myself feeling agitated and anxious whenever I couldn’t find organic or natural foods.“

Ultimately, she decided she should loosen up a little. “If your desire to eat healthily and avoid chronic disease begins to interfere with your daily living, social activities, and relationships, it may be time to take a step back.” Her conclusion: “While you’re in the process of improving and prolonging your life, don’t forget to live it.”

But even this advice will raise concerns for some people. In a post titled “Is Healthy Eating Doing us More Harm than Good?” popular blogger Kelly at Mummywrites says the same thing, but with a caveat: ” Life is too short to live on extreme diets, stressing about every morsel, but then life really will be short if we don’t look after ourselves!” [my italics]

Perhaps here it is worthwhile gently pointing out that the modern world is so chockful of chemicals that the trace quantity of pesticides and other chemicals in a serving of non-organic food simply doesn’t amount to disaster? The evidence suggesting potential harms caused by pesticides in food indicates at most a tiny fractional percent of an increase in the risk of health problems even when eating non-organic foods day in and day out. If you are afraid that occasionally straying off your perfect diet will give you cancer you might as well cower at home under your blankets.

A friend of mine is afraid of going to Italy because she thinks the leftover radiation from Chernobyl will kill her; in fact, the amount of radiation exposure on the plane trip to Italy is orders of magnitudes higher.

So let’s keep a sense of proportion: If you prefer to eat mostly organic, preservative- chemical- and antiobiotic-free foods (as I do!) and think that many overly processed foods are not foods at all (as I do!) it still doesn’t mean you have to follow those principles 100% of the time. That’s just perfectionism, obsession, orthorexia.

Trying to be perfect will make you crazy, in diet as elsewhere in life.

Lighten up a little. Be gentler with yourself.

To quote Jaime again: While you’re in the process of improving and prolonging your life, don’t forget to live it!

Steven Bratman, MD, MPH

 

 

 

Anxiety and Orthorexia

People who want to eat healthy food don’t become orthorexic unless there is something deeper going on. Often, that deeper something is best described as anxiety.

The most obvious anxiety related to orthorexia is fear of illness. You want to believe that if you are very careful with what you eat, you will be safe from every health problem that scares you, whether its cancer, bloating, blemished skin or depression. But it goes further than that. Whether you are conscious of it or not, somewhere along the line you began to use food as a primary strategy to fend off every kind of anxiety. When you are stressed about relationships, your job, the purpose of life or what your friends think of you; when it is guilt, shame, love or loss that has put you off balance, the magic cure is to eat pure food.

Deep down, you know perfectly well this is a lie you tell yourself in order to cope. While food is important for health, the slice of pizza you eat today is NOT going to give you cancer tomorrow, nor will eating the best diet in the world immunize you against illness. Furthermore, diet cannot give you love, friendship, meaning or happiness. Food, in the end, is just stuff you put in your mouth.  

One residential treatment program for orthorexia I recently heard about uses a clever strategy to help people understand how they use food to fend off all forms of anxiety. In this program, the food is served by a chef closely advised by dietitians. The rules of the game are that the chef may not under any circumstances reveal whether the food served in a given meal is organic or not, whether it has preservatives, contains GMOs, etc. In point of fact, the food served in the program is mostly organic and chemical-free, but not 100% of the time, and there is no way for the people who eat the food to know when they are consuming substances that their theory of eating would forbid. (People in the program also keep a journal of how they feel, and it turns out that they do NOT guess correctly when they have eaten “impure” food.)

As you might imagine, for a person with orthorexia this is extremely anxiety-provoking. Not only does it stimulate food-related worries, it removes the possibility of using food purity as a coping mechanism against other forms of worry. And that is the real point: The experience forces participants to begin to develop a range of ways to cope with daily stress, rather than abusing food purity as the answer to every problem. 

You might object that it is truly rational to be concerned about food additives, whether vegetables are organic, and etc. Wouldn’t any sane person would want to eat healthy food? Perhaps yes. But no matter what dietary rule you believe to be correct, it simply can’t be necessary from a health-related perspective to follow it without exception. The quantity of pesticides contained in a single serving of non-organic food is dwarfed by the quantity of chemicals taken in simply by living and breathing in the modern world. You focus on food because it’s something you can control. And that’s perfectly sensible — but only to a point. Past that point further purification of your diet won’t make you healthier; it will only make you more obsessive.

A mostly “pure” diet is good enough. Aiming for 100% is only an excuse not to come to terms with the elephant in the room: Life, in all its messy glory.

— Steven Bratman, MD, MPH

To contact me, leave a comment, or find me on Twitter @StevenBratman

On Purity

Eating clean grabs at you because it stirs the quest for purity. That’s what’s behind the cleanse, the detox, the quest for total avoidance of imperfect food. Orthorexia flows from the same impulse that drove the monks and nuns of the Middle Ages: cleansing from sin.

In dietary purity, one seeks to be physically holy, and holier than others. Just as the monk self-flagellated for sexual desire, the food purist self-punishes for wanting coffee, meat or sugar. “I have befouled myself with non-organic chips, I am unclean. ” Total commitment to a pure food diet is a vow of food chastity, a war against the lower desires of the flesh.

But the search for absolute purity is a rejection of the natural self.  It is as much a war against the body as the crusades of any puritanical religion.

James HIllman, the great Jungian, distinguished between soul and spirit. Spirit is the sky, the air, pure light, vast emptiness, the high you get while fasting. The soul is deeply felt passion, character and joy. To become pure spirit is to become an angel; to become soulful requires embracing the intestinal, sweaty, impure physical reality of human being.

It is a greater, and more difficult thing to be a whole human being than an angel.

Eat healthy food but sometimes give in to desire.

Don’t try to be perfect. Try to be whole.

–Steven Bratman, MD, MPH

To contact me, leave a comment, or find me on Twitter @StevenBratman

 

 

What is Orthorexia?

Orthorexia nervosa, as I defined it in 1996, indicates an unhealthy obsession with eating healthy food. The term is derived utilizing the Greek “orthos,” which means “right,” or “correct,” and is intended as a parallel with anorexia nervosa. I originally invented the word as a kind of “tease therapy” for my overly diet-obsessed patients. Over time, however, I came to understand that the term identifies a genuine eating disorder.

Please note that I do not, and have never claimed that vegetarianism, veganism, or any other nutritionally sound approach to eating healthy food is in itself a disorder. That would be absurd! Nor do I think that people who pay close attention to labels on the foods they mean to purchase are demonstrating a psychological problem (as some web articles on orthorexia would appear to imply.) Finally, I entirely agree that the problem of addiction to junk food is immensely more prevalent than obsession with healthy food.

Nonetheless, it is possible to have an unhealthy obsession with healthy food.

Anorexia is the parallel. Obesity is by far the biggest lifestyle-related health issue today, and every reasonably health-conscious person does what is necessary to achieve and maintain a normal BMI. Still, for various psychological reasons some people go overboard and become anorexic. Similarly, any reasonably health conscious person would wish to minimize intake of preservatives, pesticides, antibiotics and all the other garbage that pollutes our food supply. However, some people who are devoted to healthy eating go overboard and develop an eating disorder in relation to that focus, just as some people in their quest to avoid obesity become anorexic.

For people with orthorexia, eating healthily has become an extreme, obsessive, psychologically limiting and sometimes physically dangerous disorder, related to but quite distinct from anorexia. Often, orthorexia seems to have elements of OCD, as does anorexia. Some people with orthorexia may in fact additionally have anorexia, either overtly or covertly (using pure food as a socially acceptable way of reducing weight.) But orthorexia is usually not very much like typical OCD or typical anorexia. It has an aspirational, idealistic, spiritual component which allows it to become deeply rooted in a person’s identity. It is most often only a psychological problem in which food concerns become so dominant that other dimensions of life suffer neglect. In rare cases, however, it can be much more severe, even resulting in death via malnutrition.

The primary feature distinguishing orthorexia from anorexia is that while a person with anorexia focuses on weight, a person with orthorexia obsesses about purity. People with anorexia possess a distorted body image in which they see themselves as fat regardless of how thin they really are, whereas those with orthorexia constantly struggle against feelings of being unclean or polluted by what they have eaten, no matter how carefully they monitor their diet. Both conditions involve control, but whereas an anorexic seeks continually to reduce weight, an orthorexic feels compelled to achieve ever great heights of dietary perfection; to feel entirely clean, pure and transparent. Sometimes people recovering from anorexia “graduate” to orthorexia, keeping their disordered eating habits and moving the focus from weight to purity.

Although widely discussed by eating disorder experts, orthorexia is not yet a DSM diagnosis, and I am not sure that it should be. There is a tendency in the modern world to pathologize an increasing number of human behaviors and I have no desire to contribute to this trend. On the other hand, naming has power. I have heard people say, “I want to eat healthfully, but I don’t want to be orthorexic.” Perhaps this is the best possible use of the word.

Do you have orthorexia? Ask yourselves these questions: Do you turn to healthy food as a primary source of happiness and meaning, even spirituality? Does your diet make you feel better than other people? Does it interfere with relationships or work, friends or family? Do you use pure foods as a sword and shield to ward off anxiety, not just about health problems but about everything that makes you insecure? Do foods help you feel in control more than really makes sense? Do you have to carry your diet to further and further extremes to provide the same kick? If you stray even minimally from your chosen diet, do you feel a compulsive need to cleanse? Has your interest in healthy food expanded past reasonable boundaries to become a kind of brain parasite, controlling your life rather than furthering your goals?

Food, no matter how pure, cannot fill the space in your soul that longs for love and spiritual experience. If you are trying to use it for this purpose, you may have gone astray on your journey.

Perhaps the resources on this site may be helpful, including my occasional blog posts. You might consider reading my book, Health Food Junkies. But most of all, if you feel your condition has become too much for you to manage on your own, visit an eating disorder specialist who understands orthorexia.

Sincerely,

Steven Bratman, MD

To contact me, leave a comment, or find me on Twitter @StevenBratman