Orthorexia: when healthy eating turns against you

[summer]

The Guardian

The summer Kaila Prins turned 13, she started breaking out in hives all over her body. Her mother remembered that when she was a baby she had tested allergic to soy, so encouraged Prins to cut that out of her diet, bringing her attention to ingredients for the first time. Prins had never paid much attention to what she ate, enjoying the occasional McDonald’s meal or a few chunks of cookie dough like many other teens. But what began as an allergy-related need to pay attention to food labels slowly turned into an obsession that took a toll on the young girl’s health.



A self-described perfectionist, Prins took label reading seriously. She decided to get healthy while cutting out soy. She began by cutting out excessive fat and added sugar, which soon morphed into eating only whole wheat bread, peanut butter, fruit and salad. By the end of the summer, at 5ft 4in (162.6cm), her weight had dropped to 97lbs (43.9kg).

Initially, relatives didn’t seem worried about her physique, but instead applauded her healthy eating habits. “A family member who never complimented me before told me how good I looked,” says Prins.

But as Prins got older, her healthy eating, coupled with increasing amounts of exercise, began to dictate her life. By high school, she was captain of the cross country team. By college, she was biking for six miles a day on top of an hour or more at the gym.



After college, she began religiously following all the eating rules in Oxygen Magazine, a publication devoted to “clean eating” for female bodybuilders. She started working out with a personal trainer to compete in bodybuilding figure competitions. As her obsession with healthy food escalated, she became a vegan, which caused her to break out in acne so bad that she felt ashamed to go to work. She stopped menstruating. And still she thought she was healthy. She got certified as a personal trainer.




“When I was at the gym I wore a sports bra, and other women would tell me that I looked amazing and asked me how they can look like me,” Prins remembers.



But inside, Prins was miserable. She remembers going on a date with a guy that took her to a gourmet pizza place and then the theater. She ate her slice and spent the entire play unable to focus on the stage, ruminating about how “unclean” she was for eating that one slice of pizza. She did not let the guy kiss her goodnight because of how “unworthy” she felt. Instead, she had a panic attack, ran to a 24-hour diner and bought a huge brownie. She forced herself to eat the whole thing as a sort of punishment for being “unclean”.



Prins was becoming depressed, even suicidal. A former star student, she had enrolled in a master’s program at Columbia University, but after her first semester she was in danger of failing. With all her thoughts on what to eat and how much to exercise, she could not focus on her studies. She left Columbia after one year. She tried therapy, only to drop out when she began arguing with her therapist over whether or not lettuce is a carbohydrate.



Although Prins knew something was wrong, she did not find a name for it until she stumbled upon a book on orthorexia nervosa by Dr Steven Bratman. Bratman first coined the term in 1997 for a pattern of healthy eating that crosses over into eating disorder territory. “Ortho” means right or correct, and “rexia” means desire. In other words, a desire to be correct. Prins finally knew what was wrong with her.



Distinct from other eating disorders, orthorexia is “an unhealthy obsession with otherwise healthy eating”, according to the National Eating Disorders Association. It’s unknown how widespread the condition is because it is not currently recognized as a clinical diagnosis. As awareness of healthy eating grows and more consumers than ever before go vegan and gluten free, clinicians say they are encountering more patients presenting orthorexia symptoms. Now, some health experts are calling for its formal recognition.



Last year, a prominent health food blogger, Jordan Younger, announced to her followers that she was battling orthorexia, making headlines in fitness and lifestyle magazines. Since then, Younger has devoted her blog, and her Instagram account, which has 120,000 followers, to balanced eating and raising awareness of orthorexia.



While Younger has recently published a book about her experience with orthorexia, there is debate in the psychiatric community over a diagnosis. The latest version of the psychiatric diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5, came out in 2013 but did not include orthorexia as a separate diagnosis from anorexia nervosa.

Dr Thomas Dunn, a professor of psychology at the University of Northern Colorado, is one of the few researchers who has been published in peer-reviewed journals on orthorexia. He believes that it should be a separate diagnosis.



Dunn sees the differentiation in the motivation of patients: “People with anorexia restrict their intake by following healthy diet fads to be thin. People with orthorexia restrict their intake by following a healthy diet to be healthy.”



To Dr Angela Guarda, director of the Johns Hopkins Eating Disorders Program, the orthorexia label reminds her of another label from 10 years ago – the female athlete triad. It was a label for women who exercised too much, ate too little and stopped menstruation – all things that happened to Prins.

Eating disorders reflect the culture, says Guarda. “Twenty years ago, many of the patients I saw with anorexia were vegetarians. 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.”



The debate in the psychiatric community over a diagnosis of orthorexia is “a bit of a vicious circle” according to Dr Cynthia Bulik, professor of eating disorders at the University of North Carolina at Chapel Hill. “It is not a bona fide diagnosis, so there is no research on it; however, since there is no research on it, we know very little about whether it actually should be a disorder,” she says.



While it’s difficult to gauge the prevalence of orthorexia without a diagnostic code, around 30 million people are estimated to suffer from an eating disorder in the US, according to the National Association of Anorexia Nervosa and Associated Disorders.



These days, most of us probably know at least one person who, in an effort to be healthy, has gone on fad diets, cut out entire food groups or subsisted on juice for days at a time. Supermarket grocery aisles are stocked with gluten free products and soy cheese, while raw food and vegan restaurants seem to pop up every month in a big city. Mintel, a research firm, estimates that sales of gluten free products have increased 63% from 2012 to 2014, despite celiac disease (gluten intolerance) affecting only around 1% of the US population. Meanwhile, vegan cheese sales saw an increase in 22.7% in 2014 over last year, according to natural foods market analyst company Spins.



In our current food-obsessed culture, healthy eating can take on a quality similar to religious fervor, in which certain foods are sinful and eating in a certain rigid way is godly and rewarded, says Sondra Kronberg, a nutritional therapist and spokeswoman for the National Eating Disorders Association.



But it’s a slippery slope from trying to eat right to developing an eating disorder. People start to restrict certain food groups with the best of intentions. “First vegetarian. Then vegan. Then raw, then they run out of things to eat,” says Dunn.




As with anything else, some people are good at moderation, while others fall into an obsessive pattern and let it take over their lives. “Healthy food is better for you, but there is an extreme; everything is toxic in extreme,” says Guarda.



Prins eventually sought professional help from eating disorder specialists and began to recover using a system she calls “discovery” – her name for learning who you are and what you like. She stopped reading blogs on healthy eating and blocked the transformational stories on Facebook.



“I still eat healthy,” Prins told me, “but I don’t Instagram it, I don’t tweet it. I like vegetables, but I also like stand up comedy. I can go work out or I can also go hang with my friends instead.”



Not every eating disorder story has a happy ending. “I just am scared for where the world is going,” Prins says. “We are so obsessed with nutrition, it is hard to distinguish between people who are orthorexic and people who are just health conscious.”

[picksthemusic]

Minus the exercising part, this describes my SIL very well.

[miniroller]

Huh. I've definitely seen these healthy-eating-obsessive traits in a couple people I know/ knew. I appreciate that it's finally getting some attention, & do hope that it's recognized as a clinical diagnosis soon. It's definitely becoming more widespread in today's culture.

[wambam]

I have unfortunately seen this term thrown around inappropriately to describe people who make a priority of healthy eating and that's really frustrating. But it's also very real and I'm glad that it's getting some traction so that people who are struggling can get help.

[lifetaketwo]

I'm a lurker who wanted to thank you for posting this. This is my dad, and we are in the trenches trying to figure out what to do. In the past 3 years he's gone from 180lbs (his normal) to 110 and has shrunk 5 inches. He's dying and it's terrible to watch. His "healthy" is based on the era of low/no fat so he only eats fruit, raw vegetables, and handfuls of dry cereal.

[lingome]

Jan 24, 2016 18:45:28 GMT -5 @dontcallmeshirley1 said:

So, I understand the difference in diagnosis based on motivation, but anorexia has a physical component as well (one must be underweight, yes?). Is this the case for orthorexia?

I wonder the same thing... Without a physical component it must be a difficult disorder to accurately diagnose. I suppose you could say that orthorexia is the case when the behavior is interfering with quality of life... But even then, how do you draw the line between dysfunction and it being someone's "thing", which it may legitimately be (especially if someone is on the road to a healthier life from a less than healthy one)?

[bears]

I'm having a hard time seeing how this is different than anorexia. It seems like a subset of that disease. What am I missing?

[aurora]

Jan 24, 2016 19:47:07 GMT -5 bears said:

I'm having a hard time seeing how this is different than anorexia. It seems like a subset of that disease. What am I missing?

It does seem like the results are very similar, but the article includes this line:

Dunn sees the differentiation in the motivation of patients: “People with anorexia restrict their intake by following healthy diet fads to be thin. People with orthorexia restrict their intake by following a healthy diet to be healthy.”

so it sounds like it's really about the motivation for the behavior, and maybe to some extent what foods are selected.

[AAM2012]

Jan 24, 2016 18:32:05 GMT -5 lifetaketwo said:

I'm a lurker who wanted to thank you for posting this. This is my dad, and we are in the trenches trying to figure out what to do. In the past 3 years he's gone from 180lbs (his normal) to 110 and has shrunk 5 inches. He's dying and it's terrible to watch. His "healthy" is based on the era of low/no fat so he only eats fruit, raw vegetables, and handfuls of dry cereal.

I'm sorry your dad (and you and your family) is going through this.


Curious, and you may not know...aren't there some people who live off of only fruits and veggies and do well? I believe there's an ultra runner who is one that comes to mind.

[penguingrrl]

Jan 24, 2016 19:47:07 GMT -5 bears said:

I'm having a hard time seeing how this is different than anorexia. It seems like a subset of that disease. What am I missing?

IME anorexia stems from body image issues and a desire to be thin. I've known several people who were/are anorexic and even at dangerously low weights felt they needed to lose weight (the scariest was my childhood best friend who was 5'6" and under 80 lbs and still felt she needed to lose).

Orthorexia stems from wanting to be healthy, not necessarily wanting to be thin per se. they want to make sure to only eat extremely nutritious and "clean" food, but it's not motivated by a desire to lose weight but rather an obsession with health.

[lifetaketwo]

Jan 24, 2016 20:21:01 GMT -5 AAM2012 said:

Jan 24, 2016 18:32:05 GMT -5 lifetaketwo said:

I'm a lurker who wanted to thank you for posting this. This is my dad, and we are in the trenches trying to figure out what to do. In the past 3 years he's gone from 180lbs (his normal) to 110 and has shrunk 5 inches. He's dying and it's terrible to watch. His "healthy" is based on the era of low/no fat so he only eats fruit, raw vegetables, and handfuls of dry cereal.

I'm sorry your dad (and you and your family) is going through this.


Curious, and you may not know...aren't there some people who live off of only fruits and veggies and do well? I believe there's an ultra runner who is one that comes to mind.

Thanks.  It's really hard to watch, and all of my immediate family is dealing with it very differently.


I'd imagine they are taking vitamins and are actively tracking protein intake.  He doesn't even cook his vegetables in oil so he gets next to no fat.  We are trying to get him to eat beans in his dry salad, so he started adding a tablespoon.  That's it for the whole day.  He won't eat any of the higher protein grains, so it's basically a sugar diet.  The worst development so far is that he was diagnosed recently with osteoporosis.  It's so severe the doctor compared my 56 yo dad's bones to a woman in her mid-eighties.  Maybe 8 years ago he was still a triathlete.

[lifetaketwo]

Jan 24, 2016 20:26:47 GMT -5 penguingrrl said:

Orthorexia stems from wanting to be healthy, not necessarily wanting to be thin per se. they want to make sure to only eat extremely nutritious and "clean" food, but it's not motivated by a desire to lose weight but rather an obsession with health.

This is the case with my dad, especially in the beginning.  It almost seems like a control issue now.

[penguingrrl]

Jan 24, 2016 20:35:33 GMT -5 lifetaketwo said:

Jan 24, 2016 20:26:47 GMT -5 penguingrrl said:

Orthorexia stems from wanting to be healthy, not necessarily wanting to be thin per se. they want to make sure to only eat extremely nutritious and "clean" food, but it's not motivated by a desire to lose weight but rather an obsession with health.

This is the case with my dad, especially in the beginning.  It almost seems like a control issue now.

I'm so sorry. That must be so stressful to watch. I wish I had advice, but all I can do is send you hugs.

[bears]

Thanks everyone for explaining the differences.

[5thofjuly]

It seems like the difference between eating healthily and orthorexia is degree of intensity, especially related to feelings about what happens if you "fail" (see this woman's story.) It makes me worry that those who have healthy diets will dismiss this as a real issue because they feel personally attacked, when, really, they're not on the same plane.

I particularly liked this quote:


As with anything else, some people are good at moderation, while others fall into an obsessive pattern and let it take over their lives. “Healthy food is better for you, but there is an extreme; everything is toxic in extreme,” says Guarda.


It's interesting. It seems to me like Orthorexia is a way of rationalizing disordered eating. I read something similar about juice "cleanses" once- the vast majority of people could do one with no issues. Those who were prone to EDs were likely to be triggered by them but simultaneously felt OK fasting on juice for a month at a time because it was "healthy."

[lifetaketwo]

Jan 24, 2016 20:42:40 GMT -5 penguingrrl said:

Jan 24, 2016 20:35:33 GMT -5 lifetaketwo said:

This is the case with my dad, especially in the beginning.  It almost seems like a control issue now.

I'm so sorry. That must be so stressful to watch. I wish I had advice, but all I can do is send you hugs.

Thanks

[frlcb]

I belong to a healthy living group on FB and see this in a few women on there. They scare me and are so intense that I can't read what they post because they sound crazy.

[summer]

I had never heard of this before yesterday. I was watching a diet show on one of the British channels and they were talking about it so I went to look it up. I immediately started thinking about my friend's wife. Not sure If I should send him this though. Her eating habits are reallly starting to affect their relationship.

[mrsukyankee]

I'm dealing with this quite a lot in teenager girls. It's tough to work with because 'who doesn't want to be healthy?' The guilt they feel if they eat anything outside the realm of their rules is huge. And the restrictions get bigger and bigger.

[Aquatica]

Thank you for sharing this. I'm glad in recent years that awareness is spreading on eating disorders such as this and binge eating disorders.

[secretlyevil]

I'm glad this is finally being recognized and professionals see the difference between this and other EDs.

[omgzombies]

Jan 24, 2016 18:45:28 GMT -5 @dontcallmeshirley1 said:

So, I understand the difference in diagnosis based on motivation, but anorexia has a physical component as well (one must be underweight, yes?). Is this the case for orthorexia?

I would imagine if it eventually gets a DSM listing it will, but even then I'm pretty sure you can be overweight and still anorexic, because you are not required to meet all criteria, just most of them. So if you are 100 lbs overweight, but suddenly start eating nothing but some lettuce once a day, and it's become a fixation in your life, you could still be diagnosed with anorexia.  Feel free to correct me on this, it's been a while since my Psych classes.  But right now it's still unofficial, so some doctors may require being underweight as part of their diagnoses, while others may not.

[darnkatz]

Jan 25, 2016 8:17:59 GMT -5 1234FIF! said:

This is sad and scary. My goodness.

Here's a side question. Why would veganism give her a terrible case of acne?

The article said she was eating a lot of fruit and nuts. Both of those things make my skin break out terribly, so that could be it. Just speculation, of course. 

[ellipsis]

Thanks for sharing. I always thought orthorexia had more to do with being gym/workout obsessed (rather than "healthy obsessed"). Is there another term for that?

[partyinmytummy]

Jan 24, 2016 20:10:45 GMT -5 aurora said:

Jan 24, 2016 19:47:07 GMT -5 bears said:

I'm having a hard time seeing how this is different than anorexia. It seems like a subset of that disease. What am I missing?

It does seem like the results are very similar, but the article includes this line:

Dunn sees the differentiation in the motivation of patients: “People with anorexia restrict their intake by following healthy diet fads to be thin. People with orthorexia restrict their intake by following a healthy diet to be healthy.”

so it sounds like it's really about the motivation for the behavior, and maybe to some extent what foods are selected.

I actually see it as being more of a subset of OCD. I do think it deserves its own diagnosis, though.

[tiramisu]

Jan 25, 2016 8:23:06 GMT -5 omgzombies said:

Jan 24, 2016 18:45:28 GMT -5 @dontcallmeshirley1 said:

So, I understand the difference in diagnosis based on motivation, but anorexia has a physical component as well (one must be underweight, yes?). Is this the case for orthorexia?

I would imagine if it eventually gets a DSM listing it will, but even then I'm pretty sure you can be overweight and still anorexic, because you are not required to meet all criteria, just most of them. So if you are 100 lbs overweight, but suddenly start eating nothing but some lettuce once a day, and it's become a fixation in your life, you could still be diagnosed with anorexia.  Feel free to correct me on this, it's been a while since my Psych classes.  But right now it's still unofficial, so some doctors may require being underweight as part of their diagnoses, while others may not.

I haven't read the diagnostic criteria in a while, but if I remember correctly, being at 85% of one's ideal body weight is one of the necessary criteria for anorexia.

There are other eating disorders that do not have a weight component as a requirement for diagnosis, as far as I remember.

ETA: Just quickly checked diagnostic criteria and I was wrong, that's not part of diagnosis, at least not in DSM 5. They removed other physical symptoms for the diagnosis (like amenorrhea) in part because some of those symptoms are gender biased.

[darnkatz]

Jan 25, 2016 20:36:33 GMT -5 1234FIF! said:

Jan 25, 2016 8:41:57 GMT -5 darnkatz said:

The article said she was eating a lot of fruit and nuts. Both of those things make my skin break out terribly, so that could be it. Just speculation, of course. 

OK. I always think of poor diets leading to bad skin so that was puzzling me

To be fair, I would consider consuming only bread, fruit, salad, and peanut butter to be a pretty poor diet. 

[miniroller]

Jan 25, 2016 9:07:05 GMT -5 ellipsis said:

Thanks for sharing. I always thought orthorexia had more to do with being gym/workout obsessed (rather than "healthy obsessed"). Is there another term for that?

Just coming back to this thread, & have to admit your post made me realize the only time I'd previously heard this term was in relation to exercise addiction. (Can only recall fiction literature examples ) This article was very enlightening. Though I'm also curious if a(n) uber-physically-fit/workout-obsessed term exists, as ellipsis asked..?

[lolaburns]

I saw this on the app and hope you don't mind me sharing.

I'm an anorexic (in remission) and I was actually hospitalized with in 1993 with a person that would have been considered " orthorexic". I believe at the time she had a diagnosis of EDNOS, which stands for " eating disorder not otherwise specified". All persons who don't meet the clinical criteria of bulimia or anorexia nervosa and binge eating disorder are generally given this diagnosis when they display symptoms of an eating disorder, but don't completely meet the guidelines for a more formal diagnosis.

Every eating disorder is different , but it is the case for myself and most anorexics that I have known, that we did NOT desire to be healthy. Towards the bottom of my journey out of my deepest hole I didn't want to let go of my anorexia so badly that I honestly didn't care if I died. The desire was to be very thin and our struggles were not necessarily about the food.

I can see how orthorexia can evolve into anorexia or bulimia very quickly.

Anorexics, binge eaters and bulimics generally don't care about the cleanliness or healthy nature of food. They pay attention more to the quantity not how healthy it is. I think that's one of the biggest differences. An anorexic generally will have an extreme fear of all food, not just unhealthy food.

I'm glad this is on the radar. I was actually scrolling through Instagram today and wondering the repercussions of some of these fitness/clean eating bloggers and IG'ers...I couldn't help but wonder how it impacts disordered eating.

[msmerymac]

Jan 24, 2016 20:21:01 GMT -5 AAM2012 said:

Jan 24, 2016 18:32:05 GMT -5 lifetaketwo said:

I'm a lurker who wanted to thank you for posting this. This is my dad, and we are in the trenches trying to figure out what to do. In the past 3 years he's gone from 180lbs (his normal) to 110 and has shrunk 5 inches. He's dying and it's terrible to watch. His "healthy" is based on the era of low/no fat so he only eats fruit, raw vegetables, and handfuls of dry cereal.

I'm sorry your dad (and you and your family) is going through this.


Curious, and you may not know...aren't there some people who live off of only fruits and veggies and do well? I believe there's an ultra runner who is one that comes to mind.

Fruitarians, unlike vegans, only live off of the fruits that are grown by plants, so they don't have to actually kill plants (the way you would by, say, consuming a root vegetable). But they are able to eat enough healthy fat, like avocados, olives, nuts and seeds, and oils. 

I sometimes think I see orthorexia in vegan and vegetarian communities. Meal plans that are 1200 calories per day. "Before" photos of people at perfectly healthy weights. Veganism, especially, and especially when it's for "health" reasons and whole-foods plant-based, seems like a really convenient way to justify a restrictive diet.