Orthorexia is evolving.
I initially described orthorexia nervosa based on patterns I observed while studying and practicing alternative medicine. Most of the people I had in mind were trying to treat or prevent illness by following one or another dietary theory. An overlapping category included those who had “fallen in love” with a theory of diet, whether for reasons of ideology (raw foods), ethics (veganism), philosophy (macrobiotics) or pure gullibility (Blood Type Diet). In all cases, health was the central focus, and food was the medium.
Today, the situation has evolved. I have recently been speaking on orthorexia in Norway and Sweden, and have been discussing it with numerous eating disorder specialists in the US, UK and Australia. I now find that while retaining many of its original features, orthorexia has also acquired some new characteristics. I will discuss these here.
One of the most dramatic changes in orthorexia is its current inclusion of exercise. It would now appear that the majority of people with orthorexia are also exercise enthusiasts of one sort or another, whether they do yoga, run or constantly work out at the gym. For some, exercise is as much a primary focus of their lives as eating, and out of the same motivations.
This all makes good logical sense. Exercise is at least as important as diet for improving health outcomes (and, for the non-overweight, far more important) Thus, any health conscious person would naturally exercise as well, and this seems to be occurring.
An interesting fact is that in the European press exercise is increasingly included as a defining characteristic of orthorexia. However, this is incorrect. While exercise enthusiasm and even exercise dependence may coexist with orthorexia, the term itself refers to obsession with diet, not with exercise.
Fitness vs. Fitness
In my day, to be “fit” meant one could easily walk up a long steep hill without breathing hard; it was an element of health as signified by aerobic capacity and endurance. But, as words will do, the term “fit” has migrated its meaning, and now signifies primarily a certain body type: lean and often muscular, radiating health. This is a significant change, an externalization of the concept of fitness, a merger between “healthy” and “sexy.”
To attain a fit body, one must monitor both exercise and food. Exercise helps reduce fat percentage and it’s the only way to build muscles. Close attention to diet, of course, is necessary to reduce fat percentage, and many people additionally believe that eating healthy food will make them look healthy. Purity of diet thus equals unblemished, glowing, perfect skin.
There have always been dual motivations for going to the gym and eating healthy food: to feel healthy and to look good. But I suspect that the appearance aspect of healthy diet has increased lately, due to celebrity endorsements and millions of Instagram photos. Currently, many people may be orthorexic at least in part for their looks rather than their health.
Anorexia in Disguise
I have resisted accepting this aspect of the evolution of orthorexia, because it cuts against my original concept. But honesty requires me to take note.
In my 1997 orthorexia essay and in posts up until now, I have maintained that while those with anorexia want to be thin, people with orthorexia want to be pure. However, I have been forced by reality to recognize that there is no longer such a hard and fast distinction. It appears that a high percentage of people with orthorexia these days DO have a focus on weight loss, at least to some extent. Because it is no longer socially acceptable for a non-overweight person to count calories, many who would otherwise be anorexic talk about “eating healthy” instead. This only “coincidentally” involves choosing low calorie foods. In Health Food Junkies I called this “covert anorexia,” but at the time it was relatively rare. Now it is common, even dominant.
In part this change is due to that fact that the very concept of “healthy” food has become, for many people, indistinguishable from that of “low-calorie” food. This conflation is perfectly reasonable, since maintaining normal body weight is the most important health-promoting aspect of dietary choices. However, it is a significant change from the healthfoodism that affected my patients, and it remains quite distinct from ideas in currently significant dietary theories such as macrobiotics, raw foods and paleo. Nonetheless, because it has become normative, this conceptual merging of “healthy” and “low calorie” brings anorexia and orthorexia closer together.
In addition, anorexia itself has been evolving (now commonly including investment in food quality), as has its DSM definition (which no longer includes BMI in its criterion.)
There do remain some definite distinctions: People are ashamed of their anorexia, but they actively evangelize their orthorexia. People with anorexia skip meals; people with orthorexia do not (unless they are fasting). Those with anorexia focus only on avoiding foods, while those with orthorexia both avoid foods they think are bad and embrace foods they think are super-healthy (such as the ubiquitous kale). And when an anorexic person is in treatment, they have no particular objection to being fed with Ensure or Boost except regarding the calories, whereas an orthorexic person would object to the chemicals.
But these differences are fairly subtle. Today, the majority of people with orthorexia may best described as having orthorexia with anorexic features, and a large percentage of those with anorexia as having anorexia with orthorexic features.
To make matters even more mixed up, there are people with orthorexia who purge via vomiting and use of laxatives for the conscious purpose of removing toxins rather than losing weight, thus bringing bulimia and orthorexia in alignment.
At a deeper level, all these variations amount to much the same thing: giving food far too prominent a place in one’s life.
Everything I have written above is anecdotal. To properly analyze trends in orthorexia, and its evolving relationship to and differences from anorexia, exercise dependence and personal vanity, one needs research. However, up until now there has not been a formal definition of orthorexia, and without such a definition meaningful research is impossible. There is a survey tool in common use called the ORTO-15, but it was developed without a definition of what it was intended to survey, and I do not believe it is effectively separates people with orthorexia from people who are merely health food enthusiasts.
To remedy these gaps, I have been working with a prominent psychologist of eating disorders, Thomas Dunn, PhD. We shall soon publish a set of formal criteria, and, shortly after, offer a survey tool that effectively picks out people who meet the criteria. This will allow formal investigation into the trends I’ve described above.
The Future of Orthorexia
In Norway, I spent time with Finn Skarderud, a prominent psychiatrist on the subject of eating disorders. Several times he said to me, “the body, and conceptions of the body, are fluid.” On my last day there, we discussed what I thought orthorexia would be like in the future. At first, I simply reiterated what I have often said: in the future there will be new and different diets, and what we call “healthy food” tomorrow will be different than what we think of it now. But upon reflection, I realized this was too limited a view.
To the extent that orthorexia is about the desire to achieve perfect health and to look like a perfect physical specimen, I believe that the focus of orthorexia will shift entirely in coming decades.
The only reason health conscious people obsess about exercise and diet is that they can’t think of anything else that will improve their health. (Some people do add herbal and non-herbal supplements, but conceptually these are just forms of “superfoods” already included in the category of diet.)
However, the sad fact is that these methods don’t actually do very much.
Seriously. Eating fantastic foods (whatever you believe them to be) can’t possibly, even in theory, have more than a few percentage point influence on health and longevity. Exercise is probably a bit more powerful than this, but it too is sharply limited. Add in all the other methods used by Silicon Valley’s current “biohackers” and it still doesn’t amount to a hill of legumes. People who eat perfectly, exercise constantly and take herbal and other supplements still get cataracts, arthritis, wrinkles, cancer, dementia and heart disease. They become old and frail. They die.
In future, however, it is highly likely that we will use entirely new and more powerful means to extend life, enhance health and reverse aging. One thinks of stem cells, DNA modification, smart implants and nano-technology; in other words, effective rather than goofy biohacking. Once it becomes possible to affect health and aging in ways much more powerful than the limp means of food and running, will our current fascination with food fall away, the impulse shift focus? Or will there be those who avoid the new methods, no matter how effective, and seek to cleave closer to nature, no matter how mortal?
Steven Bratman, MD, MPH