Orthorexia: An obsession with healthy eating not yet recognised by psychiatry

“When does ‘eating clean’ become an eating disorder?” That was the headline on Broadly writer Claudia McNeilly’s lengthy piece on a little-researched, still-disputed medical condition known as “orthorexia.”

Within 24 hours of publication, “orthorexia” was trending on Facebook and the piece had garnered thousands of comments. Half the responses were ecstatic: “Awesome article,” one person wrote. “[I] would get incredibly anxious in the presence of certain foods such as rice or white potatoes before realizing that I had some kind of problem but couldn’t pinpoint what it was until I finally heard the word ‘orthorexia.'”

The other half were contemptuous: “Signed, the junk food industry. #diseasemongering,” quipped one commenter. “Since WHEN is eating healthy a terrible thing?” raged another.

The Broadly piece this week was just the latest of many on orthorexia nervosa (literally, “correct appetite disorder”), an illness that has been making the rounds online, though it’s absent from all psychiatric manuals.

Most doctors don’t yet recognize “orthorexia,” at least, not as an official diagnosis. But people who have spent hours looking at images of food online probably will. It’s a perfect explanation for the fixation on “clean eating” that exists offline but can be exacerbated by the food blogs, or the anxiety around health that exists just outside the frames of carefully-crafted Instagram shots of well-composed plates. When Instagrammer Jordan Younger, better known as “the blonde vegan,” announced that she would be easing up on her restrictive-yet-aesthetically-pleasing diet because it was making her isolated and ill, the post was so popular it crashed the site. In it, Younger identified as orthorexic.

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“I think the images of all the really beautiful food — the joke for me is the kale smoothie — the endless kale smoothies are very pretty,” Steven Bratman, a doctor who coined the term, told Broadly. “A lot of it is wonderful food photography. I think this type of media is definitely causing orthorexia to reach a larger audience and a younger audience.”

Bratman didn’t originally intend for orthorexia to become a diagnosis. In 2009, he told the New York Times he used it for patients who kept coming to him with increasingly obsessive concerns about their diets.

“I would tell them, ‘You’re addicted to health food.’ It was my way of having them not take themselves so seriously,” said Bratman, who published a book on the condition.

Orthorexia, as Bratman defines it, is a disorder distinct from anorexia or bulimia. It’s not the diet that’s the problem — it’s the obsession that accompanies it. And unlike most other eating disorders, the orthorexic’s objective isn’t weight loss. It’s purity.

“The orthorexic’s inner life becomes dominated by efforts to resist temptation, self-condemnation for lapses, self-praise for success at complying with the self-chosen regime, and feelings of superiority over others less pure in their dietary habits,” he explained in a 1997 essay coining the term. Later in the essay, he recalled a patient who used a restrictive diet to treat her asthma: “When she took her four medications, she had a life. Now, all she has is a menu.”

Many psychiatrists believe that what some call orthorexia is really a form of anorexia or obsessive compulsive disorder, and studies have found that the symptoms of the former overlap significantly with the latter two. Like anorexics, people with orthorexia are preoccupied with food and the state of their bodies. Like people suffering from OCD, they are often searching for control. And, as with any eating disorder, orthorexia takes a mental and physical toll: the problem can be isolating and anxiety-inducing and often leads to unhealthy weight loss.

“I don’t think the symptoms are significantly different enough from bulimia or anorexia that it deserves a special diagnostic category,” Angelique A. Sallas, a clinical psychologist in Chicago, told the New York Times. “It’s an obsessive-compulsive problem. The object of the obsession is less relevant than the fact that they are engaging in obsessive behavior.”

An unhealthy attachment to “clean eating” may not signal a new kind of eating disorder so much as a new manifestation of an existing one. Angela Guarda, director of the Johns Hopkins Eating Disorders Program, told the Guardian that eating disorders may appear different depending on the time period, but the root cause is the same.

“Twenty years ago, many of the patients I saw with anorexia were vegetarians,” she said. “Now, they also talk about eating exclusively organic food or say that they are lactose intolerant and allergic to gluten, when their blood tests show that they are not. These explanations are convenient ways to hide their fear of eating high calorie foods or foods prepared by others which provokes anxiety.”

Orthorexia was considered as a new diagnostic category for the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the “bible” of diagnostic criteria published by the American Psychiatric Association, but it was ultimately discarded. This is mostly because there haven’t been enough studies published on the condition to distinguish it from other eating disorders.

“With behavioral disorders, we really need to assess the symptoms and make sense of the symptoms before we offer a diagnosis,” said Walter Kaye, the program director of the Eating Disorders Program at University of California, San Diego.

He added that the symptoms ascribed to orthorexia could be a manifestation of another, clinically recognized eating disorder.

“The dietary obsessions that people get into with anorexia often lead into these kinds of concerns with proper nutrition and healthy eating,” Kaye told The Washington Post. “There’s a great deal of overlap.”

Still, Kaye seemed cautiously intrigued by the term. Though he would never offer it as a diagnosis to a patient (“We treat people based on research” he said), he didn’t think it was necessarily a bad thing that people are identifying with it on their own.

Which more and more seem to be doing. Searches for the term “orthorexia” have slowly increased over the past decade — spiking every time someone goes public with their story about the disorder.

Younger, formerly “the blonde vegan” and now “the balanced blonde,” has become the most prominent poster child for orthorexia (she is currently promoting a book on her experience). The tone and aesthetics of her online activity haven’t changed — her Instagram account is still dominated by high-contrast food photos and motivational sayings for her 121,000 followers, she still hawks juice cleanses on her Web site — but the content has been tweaked. The occasional ice cream cone now appears in her Instagram feed.

Kaila Prins, a health coach who says she is a recovering orthorexic, told the Guardian that learning about the term helped her to cope with her disorder. Now she’s stopped reading health blogs and exultant Facebook posts about food, and she no longer Instagrams what she’s eating.

Prins, Bratman, and other researchers often make a link between eating disorders and social media sites that flaunt thin bodies and faux perfection.

“We live in a culture where eating disorders thrive because of the messages we’re exposed to,” Claire Mysko, head of youth outreach for the National Eating Disorders Association, told USA Today last year. “Social media heightens that exposure.”

But Kaye was reluctant to say whether cases of orthorexia, or any other eating disorder, can be tied to the Internet alone. Severe eating disorders are illnesses with biological roots, he said — you can’t just blame culture.

“But clearly people have a lot of interest in food and their body image and chemicals in food and things like that,” he said, and someone who is already prone to anxiety or an eating disorder will absorb that.

Washington Post