November 2014 Issue

Understanding Orthorexia — When Healthful Eating Becomes an Obsession
By Lindsey Getz
Today's Dietitian
Vol. 16 No. 11 P. 18

With intentions to live a healthier lifestyle, Kristen began eliminating unhealthful foods from her diet. She avoided trans fats and processed foods high in sodium and sugar, and started eating more whole foods. Not only did Kristen avoid certain foods and ingredients, but she also began eliminating entire food groups: dairy, grains, and meats. In her quest to follow a perfect diet, there weren't too many foods remaining that she felt comfortable eating. The countless hours it took her to read ingredient lists and prepare meals limited her time for social activities and decreased her productivity at work. Her interest was becoming an obsession. But it wasn't until this obsession had completely taken over her life that Kristen realized she had a problem.

It's hard to imagine healthful eating ever being a problem. But it's possible to have too much of a good thing. If clients are exhibiting signs that healthful eating is becoming an unusual preoccupation, as in Kristen's case, they may have an eating disorder called orthorexia, characterized by an obsession with eating only healthful or pure foods. A disorder like Kristen's can consume a person's life and, as with any disorder, those afflicted need to get help.

Crossing the Line
Orthorexia, although it has its own distinguishable characteristics, is recognized as "other specified feeding or eating disorder," in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. In many cases, it begins with adopting simple healthful habits that eventually spiral out of control as the individual becomes obsessed with becoming "purer and healthier," says Sondra Kronberg, MS, RD, CDN, CEDRD, a national liaison for the National Eating Disorders Association, and cofounder and nutritional director of the Eating Disorder Treatment Collaborative Nutrition Counseling Specialists and Eating Wellness Programs of New York.

"Society definitely pushes healthful eating, but there is a fine line," says Kelly Pritchett, PhD, RDN, CSSD, an assistant professor in sports nutrition at the University of Georgia, and a spokesperson for the Academy of Nutrition and Dietetics (the Academy). "Orthorexia may start as an innocent attempt to eat healthier or to eat clean, but it turns into an unhealthful obsession."

Kronberg agrees: "It may begin with good intentions of trying to eat mostly organic, clean, or healthful foods. But in time, things tend to get narrower. For instance, they might go from eating only the meat of grass-fed animals to eating no meat at all. It just keeps being 'not good or pure enough' and as time goes on the patient has very little choice of what they are even willing to eat."

Marjorie Nolan Cohn, MS, RD, CDN, ACSM-HFS, a national spokesperson for the Academy, experienced this with a patient who became so obsessed with where her food came from that she began ordering seafood products costing an exorbitant amount of money from an organic farm in Alaska; this was all she felt comfortable eating. "When a patient is going to extreme measures to find foods he or she is willing to eat, that could be a clue that they may be crossing the line," Nolan Cohn says.

Hidden Problem
The obsession that accompanies orthorexia can be a fixation on certain aspects of eating, or it can encompass a number of specifics. "The person may start out avoiding artificial colors, preservatives, pesticides, certain fats, sugar, and salt," Pritchett says. "In extreme cases, the individual may prefer to starve themselves rather than consume food they consider harmful to their health."

Another clue that someone's "healthful" eating habits could be disguised as an unhealthful obsession is if they interfere with their social life, Pritchett says. These healthful eating habits may begin to get in the way of relationships with family and friends and ultimately lead to withdrawal from social interaction and other activities.

"A patient's healthful eating habits may be turning problematic if they're not willing to eat a meal out of the home," Nolan Cohn adds. "A defining characteristic of orthorexia is if they're missing out on social occasions or not participating in certain functions because of the food being offered there. A patient with orthorexia also spends a lot of time thinking, planning, and organizing their food—when they'll eat it, how they'll eat it—and meticulously measuring things."

Because so much of this behavior takes place at home, Nolan Cohn says orthorexia often is difficult for outsiders to recognize. To the coworkers at the office, it might seem incredibly healthy that someone is bringing in a beautiful salad each day. But Nolan Cohn says that if the individual is taking an hour to prepare it each night and is obsessive about the exact ingredients, there may be an issue.

"The problem is that this is not only very difficult to recognize, but the behavior often receives a lot of positive reinforcement," Nolan Cohn says. "Others will see the healthful eating habits of someone with orthorexia and praise them on how 'good' they are. They don't see the unhealthful obsession behind it all."

In fact, it may even be difficult for dietitians to recognize there's a problem. As RDs make certain recommendations for healthful habits, they may see their client's adoption of those habits as success. If they don't realize what it's taking for their client to achieve those habits (for instance, avoiding social situations or shopping at multiple grocery stores), then they might not realize their client has crossed a line.
"If the individual doesn't see their habits as problematic, it can be very difficult for a professional to know what's going on behind the scenes," Nolan Cohn says. "You can have orthorexia and be obsessed with food, to the point where it's having a negative effect on your life, but you still may have no medical consequences of a traditional eating disorder. You may still be a healthy weight and continue getting your period. For these reasons it's not always easy to diagnose."

When Help Is Needed
Unfortunately, it's not just adults who are struggling with orthorexia. Kronberg has found that adolescents also are adopting these habits. "I'm seeing it in younger and younger patients," Kronberg says. "There's this element of clean eating that's mixed into their obsession. They will eat only organic, or they will become obsessed with foods that may contain chemicals. All of this is driven by the media culture of our time but also by the parents."

And while many individuals with orthorexia may have other eating disorders, such as anorexia or bulimia, there are those who are focused only on healthful eating. Orthorexia is different from eating disorders that are fueled by a desire to be thin, Kronberg explains. "It gives them a sense of purity to eat 'clean,'" she says. "It's about being pure, healthy, or even 'good,' and they use food to achieve that. The problem is how they feel if they don't eat that way. They have extreme guilt and feel like a failure. As it becomes more extreme they may not eat much at all."

If their eating behavior reaches this level, the problem becomes recognizable. In fact, patients who get to a point of extreme avoidance frequently may feel dizzy or pass out, Pritchett says. At this point, they also may be very thin and fatigued and may have developed anemia and low blood pressure. "These are, of course, red flags," she says.

But the earlier signs are psychological. The line has been crossed when healthful choices produce anxiety, stress, and obsessive behavior, Pritchett adds. That's the point at which the orthorexia must be addressed and the individual must be helped.
"Referral to a physician if the individual is not already seeing one is important to stabilize any medical issues," Pritchett continues. "As with other eating disorders, a multidisciplinary approach that includes the physician, a psychiatrist, and an RD is warranted. The patient may benefit from inpatient or outpatient treatment programs, depending on the situation."

Nolan Cohn says that some form of "exposure therapy" also may be needed to ease the individual back into healthful eating behaviors. For instance, an RD could help them to recognize that everything they eat doesn't need to be organic. If they go out to eat with friends, they can order off the menu even if they don't know about every single ingredient.

"You need to help the patient recognize their limits," Nolan Cohn says. "Everyone has some quirks. Most dietitians like myself, for instance, would avoid trans fats in any grocery store–bought product. It's OK to have your habits. But you have to be able to recognize when you've crossed the line and it's no longer just a quirk. That's where patients need the help."

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

Table 1

Characteristics of Healthful Eating vs Orthorexia

Healthful Eating                                                                                  Orthorexia

Consistently chooses the healthiest items on a menu

Doesn't eat out due to lack of control over every ingredient on the menu

Packs lunch instead of choosing unhealthful fast-food choices

Spends hours meticulously prepping food

Skips dessert most of the time

Won't treat themselves to dessert even on special occasions

Reads ingredient labels

Fixates on ingredient labels while shopping at the grocery store

Avoids unhealthful items that contain trans fat or sugar

Avoids certain food items to the point where the individual barely eats or doesn't eat at all

May make specific dietary choices such as going gluten-free or vegan

Spends inordinate amounts of time thinking about healthful food choices

May feel bad about making an unhealthful food choice

Expresses emotional turmoil because of an unhealthful choice and can't forgive himself or herself

Contemplates making healthful food choices but still socializes with friends and enjoys life

May withdraw from friends and experience decreased quality of life