At the beginning, the goal seems innocent, smart even: a vow to eat more whole grains, or more fruits and vegetables. But healthy eating can turn rigid and confining, wiping out whole categories of food one by one—first anything with additives, perhaps, then maybe nonorganic produce, and then another and another. It can become decidedly unhealthy. The focus on quality and purity can deteriorate into orthorexia, a term coined in 1996 by physician Steven Bratman to describe a "fixation on righteous eating." Like anorexia and bulimia, it can wreak serious damage on the health of someone trapped in the obsession.
"Orthorexia boils down to someone who is very, very concerned with eating what they consider the perfect diet," says Joy Jacobs, a clinical psychologist with the University of California-San Diego School of Medicine. "This is someone who takes healthy eating to an extreme and feels good about it. These people often have a sense of moral superiority." While others abuse their bodies, they know better.
Orthorexia is not a formally recognized psychiatric diagnosis or eating disorder, although most experts agree it blends elements of both. While an anorexic or bulimic person is fueled by a desire to lose weight, someone with orthorexia singlemindedly pursues health through food. Some with the condition eat only raw or organic foods. Some may follow a strict vegan or fruitarian diet. And others may eliminate sugar, processed ingredients, artificial flavors and colors, or anything that contains additives.
"As it becomes more and more restrictive, it begins to interfere with your quality of life and your wellness," says Sondra Kronberg, cofounder and nutritional director of the Eating Disorder Collaborative Nutrition Counseling Specialists of New York. "It starts controlling you, and you become trapped in this very narrow vision."
As the list of unacceptable foods lengthens, going hungry rather than eating something "unhealthy" seems increasingly reasonable. The obsessive behavior expands. A 2004 study at the University of Rome reported that out of 400 students surveyed, nearly 7 percent—more than the percentages of anorexic and bulimic students combined—suffered from orthorexia. Those students, wrote the researchers, "prefer to starve themselves rather than eat food they consider impure and harmful to their health."
Most experts agree the condition is becoming more common, encouraged by a rising volume of messages about the perils of obesity and the virtues of a selective, choosy way of eating. "If people are trying to eat healthier, that's a positive," Jacobs says. "The dark side is when it's taken to the extreme." Eliminating entire classes of food, such as carbohydrates or fats, can lead to nutritional deficiencies and malnourishment, Kronberg says, throwing off the balance of electrolytes to the extent of threatening the heart. And cutting out too many types of food can lead to significant weight loss, especially as the ability to gauge hunger and determine how much to eat is lost. Kronberg recalls one patient who was "emaciated" but believed nothing was wrong with her; her eating habits were part of her mission to be healthy.
The risks are more than physical, as those with orthorexia tend to isolate themselves. Because they may eat only specific foods in specific situations, dining at restaurants with friends becomes impossible. And their world revolves around planning, purchasing, and eating meals. "The preoccupation takes over your life and spills onto others, like your partner or your children, as you begin controlling what they eat as well," says Cynthia Bulik, director of the University of North Carolina Eating Disorders Program. And the condition can slide into other eating disorders. "I've seen troubling situations with patients or parents who are comfortable with an orthorexia label, because they don't think it's as scary as anorexia," Bulik says. "But sometimes it can be a stepping stone to a more serious eating disorder, and [that thought process] can be a barrier to getting the necessary care."
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Most psychologists and psychiatrists consider orthorexia a real condition, but it is not in the current Diagnostic and Statistical Manual of Mental Disorders (DSM), used by mental health professionals to diagnose and research disorders, nor is it in the first draft of the 2013 version. Without explicit diagnostic criteria, determining whether someone has orthorexia is subjective."There's no official line. The time to get concerned is when the behavior and preoccupation or obsessions start to interfere with life or create difficulties and distress," Bulik says.
As with obsessions and addictive behaviors in general, the first step in conquering the condition is to admit to the problem—which is especially hard with orthorexia because of the pride in adhering to stringent, positive limits. Treatment options mimic those of other eating disorders. Cognitive behavioral therapy teaches how to replace obsessive thoughts with healthier alternatives. Instead of fearing that going out to eat with friends will destroy his health, for example, an orthorexic learns to think, "I can eat at a restaurant and remain healthy." A gradual-exposure strategy, reintroducing a bit of chocolate and other forbidden foods one by one, is another common approach. Experts suggest working with an array of professionals, including a therapist and nutritionist, to begin to see food more realistically and rebuild a healthier, more balanced diet.
"We all want to live longer, and we all want to be healthier," Kronberg says. "What you put into your system does make a difference in how you function, behave, and think. But when you take that to an extreme, when you lose your flexibility, you're stressing the system—not supporting it. The most important factor is balance."