June 2009 Issue

Orthorexia: When Eating Healthy Becomes an Unhealthy Obsession
By Lindsey Getz
Today’s Dietitian
Vol. 11 No. 6 P. 40

There’s a fine line between including foods deemed healthy in your diet and eating nothing but! Teaching your clients the value of all foods can help them forge a healthy relationship with eating and may prevent them from taking their diet to a potentially dangerous extreme.

What could be wrong with a desire to eat healthy? After all, promoting healthy eating is part of a dietitian’s job description. But when the urge to eat healthy foods becomes more of an obsession, there may be an eating disorder in the works—and the consequences can be dangerous.

Although it is not yet a clinically recognized term or disorder, orthorexia is gaining wider recognition as cases continue to emerge and capture media attention. Steven Bratman, MD, author of Health Food Junkies — Orthorexia Nervosa: Overcoming the Obsession With Healthful Eating, coined the term to denote an eating disorder characterized by an obsession with eating foods deemed healthy.

Bratman began studying the condition after personally becoming obsessed with health foods. “I suffered from a psychological obsession with food,” he said in a 20/20 interview last year. “When I was involved with this, it took up way too much of my life experiences when there were other things I could have been doing.”

Like other eating disorders, orthorexia starts to negatively impact many areas of an individual’s life and, in some cases, can even lead to severe malnutrition or death, as the person increasingly eliminates food types from his or her diet.

“It’s not an official diagnostic term, but I think it’s something that’s important for dietitians to know about,” says Evelyn Tribole, MS, RD, owner of a California-based nutrition counseling practice and author of seven books, including Healthy Homestyle Cooking and Intuitive Eating. “If a client likes to always eat healthy, the question is whether it’s helping or hurting them. Is it something that affects their social life? For instance, are they no longer seeing their friends because they can’t go out to dinner? This is the type of indication that eating healthy is becoming an unhealthy obsession.”

Orthorexia could easily begin as simple healthy habits but then spiral out of control, adds Sondra Kronberg, MS, RD, CDN, a national liaison for the National Eating Disorders Association and the cofounder and nutritional director of the Eating Disorder Associates Treatment & Referral Centers and Eating Wellness Programs of New York. “The person takes something that’s normally considered healthy and good for their body and takes it to the extreme,” she says. “They wind up with disordered thinking and psychological torment. The behavior becomes restrictive to the degree that it begins to interfere with the person’s quality of life. And what starts out as something they are controlling becomes something that controls them.”

Unlike anorexia or bulimia, orthorexia is not about the desire to become thin. “The driving force seems to be a desire to eat a perfectly healthy or even ‘pure’ diet,” says Deborah Kauffmann, RD, LDN, owner of Mindfulness Based Nutrition Counseling in Baltimore. “For instance, organically grown vegetables and fruits may be thought of as ‘safe foods’ [for both those with anorexia and orthorexia] because they are seen as healthy and low in calories. But artificial sweeteners and diet frozen meals, which usually seem acceptable to someone with anorexia, would not be seen as acceptable to someone with orthorexic tendencies. Conversely, expeller-pressed canola oil may be acceptable to someone with orthorexia but not someone with anorexia because of the fear of weight gain due to eating fat.”

Impressionable Minds
Perhaps one of the most alarming trends associated with orthorexia is that children are picking up some of these tendencies. Kids who watch their parents obsess over certain foods may mimic that behavior. And well-intentioned parents who strictly limit their children’s sugar intake or try to feed them only organic foods may instill a sense of fear in their children that other foods are “bad” or that scary things could happen if they eat them.

“A few years ago, I had a 10 year old who was terrified of trans fats,” says Tribole. “Part of her treatment was me sitting down and eating a Ding Dong with her. Can you imagine a dietitian eating a Ding Dong with her client? But she needed a healthier relationship with food. She had to realize that you don’t eat one Ding Dong and end up with a clogged artery.”

“I believe many well-meaning parents, teachers, pediatricians, and even dietitians are passing on their beliefs about unhealthy foods to children,” says Kauffmann. “This can create not only orthorexia but eating disorders like anorexia, bulimia, and compulsive eating. Recently, I have seen children in my practice afraid to eat all kinds of foods because of things they have learned at home or in school regarding foods being unhealthy or fattening. In my practice, I often use the program in the book Preventing Childhood Eating Problems [A Practical, Positive Approach to Raising Children Free of Food & Weight Conflicts] by Jane Hirschmann and Lela Zaphiropoulos to teach parents how to help their children become healthy, intuitive eaters. Parents also need to understand that healthy bodies come in all shapes and sizes. Ellyn Satter’s book Your Child’s Weight: Helping Without Harming includes a wonderful appendix which reviews the literature regarding the actual relationship between weight and health in children.”

Parents must be especially careful with the behavior they exhibit around their kids and also keep an eye on whether they are too involved with their children’s diet, says D. Milton Stokes, MPH, RD, CDN, owner of One Source Nutrition, LLC in Connecticut. Parents can easily make the transition from being helpful and healthy to giving their children a complex about what they’re eating. “Kids have a natural appetite regulation,” says Stokes. “They eat when they’re hungry and stop when they’re full. That gets interrupted when mom starts pushing more or less food. Everyone should rely more on that physiological hunger rather than turning eating into something emotional.”

Developing a healthy relationship with food certainly seems to be a key to preventing these tendencies, and that means not tying words with heavy meaning to food. “In our society, food is constantly painted as this moral dilemma,” says Tribole. “A low-fat food may be termed ‘guilt free,’ for instance. But eating shouldn’t make you feel guilty. And we are constantly calling foods ‘good’ or ‘bad.’ Putting all of this weight onto what we eat, as though it actually affects who you are as a person, is where the problem is stemming from. And kids pick up on that.”

Instead, parents should teach their children about moderation. Frequently eating trans fatty foods such as French fries or processed snacks is not healthy behavior, but neither is becoming obsessive about avoiding them or being scared to be around such foods.

Warning Signs
Because orthorexia is not an officially recognized disorder and is somewhat controversial, many dietitians may be unfamiliar with it. Some physicians and other health professionals say orthorexia does not require its own classification because they believe it is a form of anorexia or obsessive-compulsive disorder.

Still, regardless of what orthorexia is called or how it is classified, dietitians should be aware of potential warning signs that could indicate something is wrong with the way a client views and eats food. The “worry factor” is one of the biggest indicators, suggests Tribole. “If a client has too much anxiety over what they eat, then that stress may be worse for their health than what they’re actually eating and can lead to these orthorexic tendencies,” she says.

If you have a client who follows a particularly restrictive diet, try to gain a sense of their feelings about food and whether they’re behaving obsessively. “In other words, if they go to a party and they’re only serving fried foods, are they going to be devastated? Are they not going to eat all night? These are signs that their behavior is extreme,” warns Tribole.

“Also look for any patterns that your client has become overly ritualistic when it comes to their diet,” adds Stokes. “If you find out it takes them an extraordinary amount of time to shop for food, that could be another indicator.”

Like other eating disorders, orthorexia may also have a lot to do with control. Those with orthorexia often want to be able to heavily regulate the health food they consume. Kronberg says this may be particularly true of clients who have an unmanageable illness and have become desperate to take control of their situation.

“If they have some illness or disease that medicine could not cure, they may become obsessed with their diet, something they feel they can control even when they can’t control the disease,” she explains. “Maybe they have cancer and they follow a macrobiotic diet extremely rigidly. Or maybe they have multiple sclerosis and they read a book that said to eliminate animal protein. These behaviors can start with good intentions but can lead to a restrictive diet, which isn’t healthy for the client.”

But a person’s desire to gain control doesn’t have to be the result of an illness. Orthorexia may stem from someone hearing about a negative effect of a food type or group and ultimately eliminating it from his or her diet. Fat is a good example, says Stokes.

“Some people may have this intense fear that fat is bad and will kill them, so they avoid it at all costs,” he says. “But in fact, fat can be healthy, particularly unsaturated fats, [which] may actually be able to protect our heart and lower our cholesterol. We don’t need much fat, but we do need some. It’s important for the health of our skin and our hair. And we also have fat deposits throughout sensitive places in the body, such as on the temples to protect the skull from impact or around the kidneys to provide some cushioning” should someone fall.

Some with orthorexia are focused more on what they do eat than on what they don’t. This could mean, for instance, eating only organic foods. But in many cases, orthorexic tendencies may drive a person to eliminate those foods that he or she believes to be bad—commonly carbohydrates, trans fats, animal products, dyes, and sugars. Doing so can ultimately lead to malnutrition.

A recent article on orthorexia that appeared in The New York Times reported on an 18-year-old girl who began her struggle with food when she started eliminating all carbohydrates, meats, refined sugars, and processed foods from her diet. By the time she had gotten rid of all of the foods that she thought were not “pure,” she had brought her daily calorie intake down to only 500. Her weight fell to 68 lbs, and she was repeatedly hospitalized until she finally received help and restored her weight.
Which food(s) your client may obsess over depends largely on his or her own experiences. “It’s all based on information,” says Kronberg. “People may have become carb restrictive because of the Atkins diet or fat phobic because of some various theories they’ve heard. It’s all about what they read or what they hear, and the obsession differs from person to person.”

How to Help
Dietitians who specialize in eating disorders are most likely the best match for someone dealing with orthorexia. However, all dietitians can learn to recognize early signs and perhaps even prevent orthorexic tendencies from developing. “In general, dietitians need to take the leading role in helping patients to ‘legalize’ all foods by educating about the nutritional value of all foods, as well as teaching mindful eating techniques and empowering individuals to use primarily internal cues when making eating decisions,” says Kauffmann.

Tribole adds that it’s important for dietitians to be careful that they do not generate or enable a client’s fear of certain foods or food types. While the average person may take advice about avoiding trans fats and apply it meaningfully to the diet, an individual who is bordering on developing an eating disorder may distort that information. “You may be giving out very ordinary nutritional advice, but if they have an eating disorder brewing and you don’t know it, then it could be taken the wrong way,” says Tribole. “It’s just important to pay attention to the way we give out orders to our clients.”

“Dietitians can end up being an ally to the disorder without even recognizing it,” agrees Kronberg. “Clients could come to you seeking assistance for their disorder, ways that they can be more obsessively healthy. It’s our job to recognize when it’s become a problem and balance things back out.”

Orthorexia may be an emerging condition, but dietitians should realize that they have the power to prevent it from becoming a more widespread issue. Kronberg notes, “We’re on the front line, so it’s crucial that we’re able to recognize early on when there’s a problem.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.