Orthorexia- Obsessed or Just Healthy?

I wonder how many people, after reading the definition of orthorexia, think to themselves, "Wow, is that ME?!" 

According to the National Eating Disorders Association, orthorexia is defined as the following: an obsession with proper or ‘healthful’ eating. Other definitions include "a medical condition in which the sufferer systematically avoids specific foods in the belief that they are harmful" as a description of it. Depending on co-existing behaviors, it is often treated on the spectrum of anorexia or obsessive compulsive disorder.

 IMAGE FROM koven et al., Neuropsychiatr dis treat., 2015 (full paper  here )

IMAGE FROM koven et al., Neuropsychiatr dis treat., 2015 (full paper here)

There is no doubt that eating well can become an obsession, but I want to highlight the very fine line between consciously choosing nutrition that serves you, and a pathologic state of fear towards foods one feels are harmful.  When I read the available definitions of orthorexia, I feel they are too vague to be considered an actual medical condition; this is probably why it has yet to be adopted by DSM (Diagnostic and Statistical Manual of Mental Disorders) as an actual diagnosis.  

For a real life example, I present to you my brother: he's vegan, and has been for several years.  Being vegan is important to him for a number of reasons including ethical and environmental concerns.  If you look at NEDA's warning signs of orthorexia, you may think he meets these criteria. He systematically avoids foods (read: any animal products) because of his beliefs that they are morally harmful. He will compulsively check food labels and go to extreme circumstances to avoid animal products (like that time he basically lived off of bread and corn for a month while working in Croatia.)  Do I think my brother has orthorexia? No... I think he's vegan.  If he were to also narrow his food groups even more, and become obsessed with the food choices of others, and spend hours a day obsessing over his choices, that's a different story.  But taking a general approach to nutrition that feels good to him both physically and mentally is NOT pathologic.

Eating disorders are a very real and dangerous thing.  Medical conditions related to consistently poor eating habits are also a very real and dangerous thing.  So how do we approach improving nutrition without becoming so obsessed that our overall health (read: mental health) suffers? The answer to this rhetorical question is an astounding, "It's complicated."  In a wonderful review paper (Haman et al., 2015) the authors describe the birth of orthorexia from the concept of "healthisim." This term was coined from our culture putting an emphasis on personal responsibility for one's state of health (via exercise, diet, and avoidance of risk factors)  and with a moral obligation tied to that success, which could be measured via body size and shape.

If you're privileged enough to have internet and you're reading this, you very likely live in a world of surplus food and consequently an algorithm of choices for how to eat. Likewise, if you happen to still be reading, you probably have a good general sense of nutrition. The latter is not necessarily the case for the majority of citizens in westernized countries and hence, we have overwhelming morbidity/mortality related to modifiable lifestyle related diseases. Once it was established  several decades ago that nutrition is related to disease, in marches experts of all kinds telling us what/when/how to nourish ourselves with generic and conflicting advice, with each person expecting their nugget of advice to work for everyone. Those who chose to listen have felt the immense levels of blame thanks to healthism if they did not meet society's standards for what health looked like. "Low fat. No, no, low carb!  Soy is good for you! No, soy is bad for you.  Vegetarians live longer so don't eat meat. But maybe it's just the quality of the meat and actually it's not bad for you at all. BE AFRAID- sugar hides in everything. Don't fear sugar, just count your macros and eat what you want." And the dialogue goes on. And on. AND ON. Add in the potentially toxic effects of social media (cough *instagram fitness models* cough) and we have a recipe for disaster. For the minority of people who have been paying close attention to all the studies and recommendations over the years, you can imagine how easy it would be to develop fear around food.  

Orthorexia exists because there are so many choices, and for people who find navigating this to be too overwhelming, they have to compartmentalize everything into "good" and "bad." I will never fault someone for being aware of their nutrition choices (you can imagine that I am HYPER-aware given my profound interest in the idea of food as medicine) and I applaud anyone who is new to lifestyle modification.  However I would encourage anyone on the beginning of their health journey to develop guidelines that are meant to be ignored sometimes.  No single food should ever be TRULY off limits unless 1) you have a moral or ethical reason not to eat it-- i.e., keeping kosher, being vegetarian/vegan, etc., or 2) you have a real allergy. 

I can imagine that an outsider who peers at my meals may wonder if I have orthorexia.  I read food labels and genuinely enjoy learning about nutrition.  On a regular basis my meals are undeniably healthy and there are things I routinely avoid, namely trans fats and most added sugars. These foods do not serve me 98% of the time and over the years have realized I feel better both physically and mentally when I eat in this way. But if any food comes along and I want it, I eat it. There are no rules, and food availability has never deterred me from social life. But you can bet I went back and forth wondering if I had "a problem" once the word orthorexia was introduced into my vocabulary. Surely most dietitians and nutritionists can also relate to this questioning. It took a whole lot of self awareness and reflection to realize that eating well for vitality versus fear are two completely different scenarios. Its important to point out that there is undeniably a link between use of social media (specifically following nutrition related accounts) and the incidence of orthorexia. I won't apologize for eating [my version of] healthy, because it does nothing but serve me. However I do urge you to consider if following me or anyone else has made you too stressed or obsessed with health and food choices; unfollow us immediately. You don’t need those feelings.

On the grand spectrum of nutrition, the more pressing public health concern is on the complete opposite end of the spectrum: complete lack of awareness of what someone is feeding themselves. I'm not here to blame anyone for their food choices causing disease; quite the contrary-- I certainly can't expect anyone to engage in their nutrition choices when everything out there is just so conflicting and complicated.  In our little bubble of wellness-minded individuals we often forget this, but I see it every day in my patients.  I have received shocked looks when telling one patient that highly sweetened iced tea is not actually a better alternative to their husband's soda.  Or the time my patient was baffled that Sunny Delight didn't provide the same nutritional value as eating a whole orange. My patients aren't dumb-- many are simply unaware, overwhelmed, or (on occasion) uninterested in understanding how food can affect their health.  If persistent education from the media and healthcare providers can reach out to more of the majority to engage in individualized lifestyle modifications (minus the blame and body size association please), I feel that this is worth "the risk" of a very tiny minority becoming so hyper-aware that it backfires into a situation of orthorexia.  This is not to downplay it, but to point out that NOT addressing nutrition on a global scale has far greater consequences than completely mitigating the risk of orthorexia.

In short, food and rules: two things that should have nothing to do with each other. Choose nutrition that makes you feel good over time, barring in mind that your social and mental health should be equivalent priorities to your physical health. The way you eat doesn’t have to look like anyone else’s, so long as it works for you. The End :-)

Sincerely,

Shanny DO