When does healthy eating become obsessive?
Jess, a West Coast resident who asked that her last name not be used, showed up at the dinner party with a bag of her own food: greens, fruit, a little Tupperware of chicken. She was just trying to eat really healthy, she said. Bread was out of the question, and she couldn’t eat the beans in the soup, so that was off-limits, too.
Low-calorie, low-fat, sure. But food-restrictive eating, like Jess’s, can be signs of orthorexia, an increasingly common form of disordered eating. Unlike anorexia, which addresses how much you eat, orthorexia is about what you eat. And nutritionists and psychologists say that they’re seeing it more often, especially in the face of restrictive food trends, like gluten-free, and growing information about where food comes from, and how it’s grown and processed.
Orthorexia isn’t exactly new. Dr. Steven Bratman coined the term in 1997, but since then it’s been flitting on the fringes of formal diagnosis. It’s been lumped in with other eating disorders, like avoidant/restrictive food intake disorder, or considered a form of OCD.
But recently there’s been a rise in research about it, and there’s a movement afoot to parse it out from other forms of disordered eating for inclusion in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM, the bible of psychiatric disorders.
"The message in the past has mainly been about thinness but there’s been a turn and it’s become more about cleanness and purity," says nutrition therapist Sondra Kronberg, who says that she’s seeing it more frequently. "Those same people who struggle with compulsion and rigidity in their eating will take that cultural message to an extreme. It interferes with their quality of life."
Last summer orthorexia made news when widely read vegan food blogger Jordan Younger announced that she’d been suffering from it, and that her hyper-restrictive diet had both made her sick—she’d stopped getting her period and had hormonal imbalances—and sent her into panic attacks in the grocery store. "I had known in the back of my mind for a while that I had developed many fears surrounding food, and it was clear to me that I was becoming more and more limited in what I was comfortable eating," she says. No two eating disorder cases are alike, but Younger is somewhat typical of what’s seen as orthorexia. She says she has an "all or nothing" personality that made her prone to compulsive healthy eating, and that her heavy digital involvement made it even harder to break off. She said she became even more compulsive because she was posting everything she was eating, and comparing herself to other people’s Instagrams.
Younger self-diagnosed after being called out by a friend who had similar unhealthy habits, but it’s complicated to diagnose and treat eating disorders when they’re not clearly defined, which is why there’s a current push to get orthorexia officially designated as an eating disorder.
Doctors and other clinicians who treat eating disorders use the DSM, to evaluate and prescribe treatment. The fifth edition of the DSM came out in late 2013 and orthorexia wasn’t included. Dr. Tim Walsh, who chaired the DSM-5 Eating Disorders Work Group, says part of that was timing: They’d changed the criteria based on published research and when they did a literature review in 2009, there wasn’t enough published about orthorexia to warrant a change, even though people were talking about it. "The thinking about orthorexia has merit, but whether we need a new diagnostic label, I don’t know," he says. Ultimately, the working group thought that doctors could use the same criteria listed for avoidant/restrictive food intake disorder to diagnose orthorexia.
Walsh says the system isn’t perfect, even though they try to be as objective as possible. The study-based criteria set up a chicken-and-egg scenario. Researchers don’t want to study things that aren’t in the DSM, but if there isn’t appropriate research nothing new can be added to the manual.
He says they’ve seen a lot of new research about orthorexia since they planned out the last DSM, and that they’re trying to keep their eyes on cultural causes. He believes eating disorders can be socially triggered, and, like what Kronberg is seeing, that the current food landscape plays a part. He says bulimia, which was added to the DSM in 1979, is an example of what that can look like. "There’s a social, environmental pressure there," he says. "We’d see an outbreak on a college campus in one sorority or dorm."
The fourth DSM was published in 1994, but Walsh says they’re already thinking about tweaking the new one, and that it won’t be 20 years between volumes again. He said they switched the labeling on the current edition to be Arabic numerals, so that they can potentially publish a version 5.1.
So, how in the meantime, can research add understanding? Some scientists are trying to quantify the orthorexia diagnosis. Doctors from a group of universities in Colorado published a 2014 study outlining criteria called "Microthinking about Micronutrients: A Case of Transition from Obsessions About Healthy Eating to Near-fatal Orthorexia Nervosa and Proposed Diagnostic Criteria," that outlines a five- step standard. This includes delineation between orthorexia and other anxiety disorders. "We know precious little about it and need to study it further," says Thomas Dunn, one of the authors.
What we do know is that it has physical consequences, like kidney malfunction, but that it’s also a social issue. People with orthorexia avoid family dinners, because they don’t want to be pressured into eating something they haven’t deemed healthy. They get paralyzed in the grocery story by trying to pick the least toxic kale. They bring their own chicken to parties. That’s the sticking point, where healthy eating ticks over into compulsion.
Kronberg says that even without the official diagnosis she’s seeing it and treating it. With someone like Jess, she says she uses cognitive therapy, and tries to get her to manage their feelings so they can change their behavior. "If you cut something out it’s hard for the compulsive brain to add it back in," she says. "That’s the way it is with most eating disorders, it starts out with a choice."