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Is orthorexia an eating disorder? The debate over a new illness

From nothing-but-organic to gluten-free everything, an obsession with purity may be ushering in a new era of disordered eating. But the medical community can’t agree on how to handle it.

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Kale orthorexia gif. Photos, Sian Richards.In 2012, Sue Ryder* was diagnosed with anorexia nervosa. By then, the 20-year-old from Saskatchewan was so thin and weak she could barely stand and had to spend five weeks in a hospital. When she was finally discharged, Sue was excited by the prospect of building a normal life: going to university, dating and meeting new friends. But as she began to recover and put on weight, the way she thought about food shifted again.

“I became less focused on weight and uber-focused on eating healthy,” she says. First, Sue cut out all meat except fish, and then all foods with gluten. Processed sugars came next, and then products that contained GMOs. Within months, her relationship with food had once again become debilitating. “Even if I’m just considering having rice cakes or rice crackers, I’ll carefully weigh the pros and cons of each. What are the ingredients? What is the glycemic index? I can spend hours on these types of decisions.”

Despite an all-consuming preoccupation with everything she eats, Sue now has a healthy BMI and follows a diet that meets her recommended caloric requirements, which means she no longer fits the classic profile of an anorexic. Instead, her obsession with food is closer to what some experts call orthorexia nervosa, or a “fixation on righteous eating.” Orthorexia is a controversial diagnosis: Unlike anorexia and bulimia, it’s not recognized as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of mental health disorders created by the American Psychiatric Association. Its existence is also rejected by most disordered-eating specialists in Canada. “The term orthorexia appears mainly in the news,” says Dr. Blake Woodside, medical director of the Eating Disorder Program at Toronto General Hospital. “It’s a made-up eating disorder; it doesn’t exist.” But a growing number of patients — and their advocates — say otherwise.

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Prior to the publication of the DSM-5 in 2013, the National Eating Disorders Coalition in Washington lobbied, unsuccessfully, to have orthorexia recognized as an official diagnosis. But since then, both the U.S. National Eating Disorders Association and the National Eating Disorder Information Centre in Canada have updated their websites to include information on orthorexia. Support groups are proliferating online, and last June, Jordan Younger (a.k.a. the Blonde Vegan) created a stir among her 70,000 Instagram followers when she announced on her blog that she was abandoning her strict vegan lifestyle because it had led to orthorexia. She has since renamed her blog the Balanced Blonde.

“There’s widespread international interest in orthorexia,” says Dr. Steven Bratman, the California-based occupational-health physician who coined the term in a 1997 article for Yoga Journal. “And it’s definitely increasing.” For those who identify as orthorexic, Bratman has become something of a heroic figure, a phenomenon that has taken him by surprise. Bratman says that he created the term simply to help his patients realize that instead of being healthy, their eating habits were disordered.

“I was seeing more and more people coming into my office and asking, ‘What food should I cut out now?’ But it was only after the Yoga Journal article was published — and I saw the response — that I realized I had really hit on something.”

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Bratman expanded his theory of orthorexia as a bona fide eating disorder in his 2004 book, Health Food Junkies. His website has since become an international hub for people who are struggling with their obsession with healthy eating, as well as a point of contention for his detractors. “There are some people who think I’m working for Monsanto or McDonald’s — that I’m trying to promote an unhealthy diet,” Bratman says. But he argues that publicly discussing orthorexia allows people to recognize that they might have a problem, which is often the first step to getting treatment. The only difficulty, he says, is that it’s hard to treat orthorexia without first defining it as an official disorder.

Fad diets have existed for centuries, but it’s only recently that the idea of evaluating food from every nutritional angle has become a fad unto itself. In the last decade, both the diet and beauty industries have shifted from promoting fat loss and thinness to a rhetoric of health and purity. You can now eat — and wear — an endless array of organic, vegan and gluten-free products. It didn’t take long for people to embrace the idea that a pure, healthy diet is the ultimate virtue. Dr. Paul Garfinkel, a professor of psychiatry at the University of Toronto, says that in the past 10 years, he’s seen a dramatic increase in the number of patients who exhibit excessive thinking about the nutritional merit of their food. “There’s a strong portion of our society that feels that diet is crucial to health,” he says. “But the scientific evidence about our diets has always been unsteady. Fats used to be the devil, and now it’s carbohydrates.” When Bratman began working with 0rthorexics in the 1990s, he says people were slavishly following macrobiotic diets. “Now you don’t even hear about macrobiotics,” he says. “It’s all gluten-free or raw food or veganism.”

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Orthorexia has entered the public consciousness alongside a number of trendy terms for disordered eating, largely invented by the media — drunkorexia, manorexia, bigorexia — that Woodside says trivialize the severity of “true illnesses” like anorexia or bulimia. He argues that the term orthorexia can be attributed to a pop-psychology culture that is quick to pathologize every quirk or poor decision as a disease. Anorexia, on the other hand, “is recorded in the medical literature as far back as 1693, has core features that are stable across time and cultures, and has a mortality rate of up to 20 percent.”

When Woodside hears Sue’s story, he sympathizes. “But what goes through my mind is not that she has orthorexia, but that by focusing on the minutiae of food and eating, she may be distracting herself from something else that’s going on: anorexia, social anxiety, depression. I think that what’s called orthorexia is actually a symptom of another disorder, rather than a disorder in itself.”

Garfinkel acknowledges that there are some advantages to having orthorexia recognized as a disorder in that we can study it and learn more about it. “But if you keep slicing the pie thinner and make it so that every symptom has a separate disorder,” he says, “I don’t think that helps people.” He uses anxiety as an example. “There are many sources of anxiety, and you don’t call every one a separate disorder. When thinking about disorders, we have to ask ourselves how creating this label will help people. Are people not getting treatment because we don’t have this as a diagnosis? I don’t know the answer, but my personal response would be no.”

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In a 2014 paper for Psychosomatics, Thomas Dunn, a psychologist at the University of Northern Colorado, argued the case for creating a separate diagnosis for orthorexia. He proposed criteria for that diagnosis, including symptoms like a fixation on food quality and an intensity of obsession that disrupts people’s lives. Dunn says his theory is that orthorexics fit into the same rough demographic as anorexics. “There might be higher rates among men than what we see with anorexia,” he says. “But orthorexics tend to have the same high income levels, high levels of achievement and similarly obsessive qualities.” Orthorexics also often become underweight as a result of restricting their diets. Although orthorexia can coexist with anorexia (in the same way anxiety can accompany depression), Bratman says there are important distinctions between the two conditions.

“Anorexia is the fear of weight and a desire to be thin,” he says. “Orthorexia is the desire to be pure. Orthorexia is more like an addiction — people put all of their life’s meaning into eating healthy food.” Bratman tells the story of a massage therapist from California who identified as orthorexic but was misdiagnosed with anorexia. “She saw a specialist who kept asking, ‘Why do you want to lose weight?’ ” he says. “But she didn’t want to lose weight: She wanted to be pure.” The patient died of heart failure in 2003, a tragedy Bratman says was preventable.

Applying an anorexia treatment plan to orthorexia patients can push them too far out of their comfort zone at a critical moment of recovery, he says. “Treatment for anorexia is typically very conventional-medicine based,” he explains.

It frequently involves a diet plan of processed, non-organic foods coupled with antidepressant medication, which orthorexics regard as toxic, leading them to refuse treatment. Bratman says that while orthorexics might benefit from a modified version of the standard eating plan designed for anorexics, it would need to consist of foods that don’t conflict with typical principles of healthy eating. “It’s perfectly possible to have a healthy recovery plan that’s vegan or that doesn’t contain genetically modified foods,” he adds.

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Bratman says that if a DSM category were to be created for orthorexia, it would be important not to condemn otherwise healthy diets. “While the diets that orthorexics follow might not be well studied, they aren’t inherently unhealthy. The last thing we want is court cases where kids are taken away from their parents because they were feeding them a vegan diet.”

The DSM definition would have to be very clear so that it doesn’t implicate people who are, say, into raw food for ethical reasons, adds Sue. It’s the obsession with food, not the food itself, that makes orthorexia dangerous, she says. “Being into raw food might be trendy, but having a panic attack because you ate a bite of cooked broccoli is disordered.”

After Sue was discharged from the hospital, she began working with a psychiatrist and a dietitian who treated her under the DSM category “Eating Disorders: Not Otherwise Specified (EDNOS),” which is a broad label that covers disordered behaviours ranging from binge eating to eating while sleepwalking. Although she feels that not having an official label for her condition undervalues the severity of what she’s going through, Sue says she trusts her psychiatrist’s approach. “He believes that you’re the captain of your own ship,” she says. “Even if orthorexia is not a diagnosis, these are my symptoms — so he treats them.” On this particular day, she is debating whether to have an apple or an orange for tomorrow’s morning snack. One has more sugar, and the other more fibre. Sue says she’s trying hard to remember her dietitian’s advice about balance. “She says there are no good and bad foods, just sometimes foods and everyday foods,” she says. “I like that — and I think I’m going to get there eventually.”

*Name has been changed.