Article written for the National Council of Psychotherapists Journal “Fidelity” Orthorexia The “New” Eating Disorder

The advent of a new year is often a time when we decide to make changes based on our health. Many new year resolutions are about becoming healthier, fitter or leaner. At other times in the year perhaps after a period of overindulgence or as a result of a health scare we may also decide to alter the way we eat and live our lives. Embedded in the Zeitgeist of current culture is that it is good to be healthy and do what we can to move towards increased well being and physical as well as emotional health. Increasingly popular health related choices are to reduce saturated fat intake, limit red meat, reduce salt and sugar, to eat more fruit and vegetables or to eat organic. Responding to this market various “healthy food” services have popped up over the last decade which include: veggie boxes (locally sourced, seasonal organic vegetables delivered weekly to the door in a recycled box) and healthy snack packs (dried fruit, seed and nut combinations, similarly packaged) posted twice weekly to our office or home, as well as popular brands bringing out caffeine free, fat reduced, light or sugar free ranges of their usual products.

Many people opt to do a De-tox such as those popularised by Carol Voderman (1) or Gillian Mackeith (2). This would usually include cutting out alcohol, caffeine, dairy, wheat, sugar and salt and drinking more water, as well as eating more raw foods and juices.

For other people health improvement is about exercise and fitness, getting a personal trainer, joining a gym or starting a yoga class for example. Often trainers will promote healthy eating and it is not uncommon for us to link dietary changes (which can include taking vitamins and supplements) with a fitness or training regime.

Ethics and responsibility can be an additional concern in health related lifestyle changes and an example might be choosing to buy Fairtrade, or free range organic, or locally sourced in season produce and humanely killed animal products from local farm shops.

Sometimes there are so many mixed messages about food, health and diet it is difficult to choose which is best and what to do. On going debates include whether certain margarine is better than butter, whether sweetener is better than sugar, whether “brown” is better than “white” (pasta, bread, sugar, eggs) or white (meat) is better than red, whether skimmed is better than semi skimmed milk, or soya is better than cows milk, vegetarian is better than carnivorous and so on. Keeping up to date with a barrage of often conflicting information can be difficult for health conscious individuals and in particular those concerned about the diets of their small children (shall I allow my child to eat sweets or foods with additives and preservatives? Is there a link between this and hyperactivity ? Will my child sleep better with a glass of warm milk every night or is he more likely to develop allergies ?).

Imagine how difficult it is for someone who not only is a health conscious parent but also has what is known in person centred counselling as having an external locus of evaluation (looking outwardly for answers and wanting others to make the rules and decisions rather than calling on their own internal locus of control and judgements) ?

For the vast majority of people making lifestyle choices based on what they (or current thinking) believe to be best / healthiest results in a feeling of well-being. However, for some it can develop into an uncontrollable obsession and becomes a psychological problem. They become confused with what is best, they can obsess about their diet and / or exercise and invite “experts” (nutritionists, dieticians, lifestyle gurus, therapists) to help them. They spend hours worrying whether they have eaten the right balance of foods, fed their family the right things, done the right thing for their health and body and are seen to be healthy in their endeavours. The name given to this type of obsession is “Orthorexia”.

People who may have previously been affectionately referred to as “Health Food Junkies” or “Health Nuts” are now a cause for concern. There is also a resulting debate due to a backlash from the general public who say that healthy habits are to be encouraged and the consequences of becoming a nation obsessed with health is far preferable to becoming a nation of unhealthy, obese couch potatoes (3)

Orthorexia made the headlines in 2011, was debated on the radio and was featured in national newspapers and popular women’s magazines yet it is not classed as a mental health disorder in it’s own right and neither is it planned to be included in the 2013 version of the Diagnostic and Statistical Manual (DSM-V). Many therapists have never heard of it and therefore it may not be picked up in assessments or taken seriously.

What is Orthorexia?
The word “Orthorexia” means “the correct diet”, and was first coined by Steven Bratman MD in 1997 (4) to describe his own obsession with healthy foods and related difficulties. It is actually not new but has increased in line with current lifestyle trends. It is difficult to say how many people are affected but it is thought to be as high as one in 10 women and one in 20 men, with the National Centre for Eating Disorders reporting over 6000 calls a year in connection with this problem (3).

It has been described as an anxiety related condition sharing similarities with both Anorexia and Bulimia Nervosa and including elements of Obsessive Compulsive Disorder (3). It is a progressive condition that begins innocently enough with a dietary preference or choice but over time becomes something that takes up more and more time, thought, travelling to specialist shops, researching, planning and expense and leaves the sufferer feeling out of control, overwhelmed and no longer enjoying food.

It can socially isolate as it makes it very difficult to eat out or find food that is seen as “correct”. Eating a “correct” diet enables the person to feel that they have the same purity, quality, scarcity or worthiness as the food they eat. They can become polarised thinking of foods as either “good” or “bad” and therefore people who eat certain foods as “bad / unworthy” and people like themselves who eat healthy as “good / worthy”. In the same way a woman may choose an expensive handbag to feel good and worthy of it or deserve the best, a person suffering from Orthorexia will have a similar feeling about paying more money to source expensive fresh, raw, organic, free range, fair trade, best quality healthy foods.

For someone with Orthorexia, the “healthier” the diet they eat, the more worthwhile, valuable, righteous, virtuous and even spiritually cleansed they feel. They may come to dismiss anything that is not good enough to meet their high quality food standards and any person who eats such lower quality food. This inevitably causes family rifts and difficulties around meals, cooking shopping and so on.

Paradoxically Orthorexia can lead to malnutrition and illness. In 2008 a middle aged woman became brain damaged after a de-tox diet which involved cutting out all foods containing salt and drinking 6 or more pints of water each day. She won £800,000 in damages against her nutritionist who denies any wrong doing.

What is the difference between someone who wants to eat healthy and someone suffering from Orthorexia?
A healthy eater will have preferences and choices and will feel comfortable and in control around food with food and eating ultimately being a pleasure. A healthy eater may prefer to eat brown rice and organic foods, for example; however if they were invited to dinner and were served white rice and a dish that was not organic they would eat it without a second thought and enjoy it.

An Orthorexic develops progressively strict and irrational black and white rules about foods and would not eat anything at all and be hungry rather than break their strict code of what is right and what is wrong to eat. They would be the ones asking “has this got additives in it ? Is it organic?, I need to read the label” they will spend increasing amounts of time reading labels and researching, planning menus and spending more and more money on the food bill sourcing appropriate foods.

In this way, as opposed to pleasure and enjoyment, there is increasing anxiety and panic around food and eating. Meal times become fraught and pleasure they used to get from food dwindles away. Eventually the condition starts to take over their life and interferes with relationships and families.

It is not uncommon for the Orthorexic to spend several hours a day shopping for food in different stores (including health food shops, farm shops, organic retailers etc.) and another hour planning menus for the next day or the week. They will be up late or get up early cooking from scratch rather than rely on an occasional ready meal or takeaway which would allow them to have more time to relax. Eating out becomes very difficult and they may travel miles to a certain place that caters for their dietary requirements. They would often prefer to go hungry than eat something they deem to be unhealthy.

Here are some examples of the typical types of rules that the Orthorexic will make (the elipse represents a transition to another more strict stage which is a progression of the previous one). Of course there will be many such variations of rules in place at any one time, and each sufferer has a different set of rules. Their rules may change because of what has been read or published and what has been found when researching as well as what others are doing or what the latest advisor (personal trainer, nutritionist etc.) has suggested.

It is not uncommon for Orthorexics to cut out whole food groups (all meat, all dairy, all products containing Gluten, all sugar, sweeteners, additives, preservatives, all animal products and non organic products, all alcohol all caffeine) and so on. Whilst the original intention is more to do with health than weight loss a side effect of the condition is weight loss, dehydration and malnutrition.

Water:
Decide to drink more water …decide to get a filter for tap water.. buy bottled mineral water… decide to buy only bottled mineral water which comes in glass bottles because of a belief that plastic can contaminate the water…decide only to drink Evian due to the belief that it is the purest…decide that they need to drink a minimum of 2 litres of Evian in glass bottles only each day… will not go into any bar or cafe that does not stock Evian in glass bottles.

Sugar:
decide to eat less sugar…. cut out all sweets & decide to eat cereal bars instead of sweets .. read labels of cereal bars discover some have sugar and preservatives added … search out those with no added sugar find a certain brand that is sweetened naturally with honey…seek to go one better and find a similar brand that is sweetened with honey and is also an organic product without preservatives… decide to eat only organic fruits too.. decide to eat all organic foods with no sugar and no additives or preservatives which are in season and sourced locally …find a farm shop that can supply these items … panic when the local farm shop closes down and will be prepared to travel 50 miles out of town to find a similar farm shop

Meat:
decide to eat less red meat… decide to eat only chicken…eat only organic free range chicken… eat such chicken once weekly & eat vegetarian meals the rest of the week… research vegetarian recipes…source all organic vegetables that are currently in season and cook vegetarian dishes from scratch…cook separately each night because of the belief that microwaves and any other form of freezing and reheating may destroy some of the vitamins and enzymes in fresh vegetables. ..
Feel very anxious if offered chicken on a night that is a veggie night and will feel unable to eat it if it is not organic free range and contains any unknown sauces or stuffing or any vegetables that have been frozen and reheated.

How does it compare to other eating disorders?
It has been described as the cousin of Anorexia Nervosa (3) because like Anorexia it has a progressive nature. Sufferers often begin by cutting out one or two food types and making some rules for themselves based on choices related to healthy eating. It also has links with Bulimia, as it can be cyclic; for example a Bulimic will binge eat and then purge, an Orthorexic will De-tox and then Re-tox.

However, unlike Anorexia and Bulimia (typically illnesses which are seen in teenage girls) it is a condition increasingly seen in both men and women who are usually older and often middle aged; it is thought that this socio-economic group are already more likely to use farm shops and health food stores and have the social conscience, higher budget and perhaps time to research and source the correct “healthy” diet.

Unlike other eating disorders the intention is not to be thin or control weight but simply to be healthy and control the quality and respectability of food and liquid intake.
The male form of Orthorexia is often about muscle and weight gain (bulking up) through exercise and nutrition (including protein and vitamin supplements.)
The male Orthorexic equates health with strength, power, achievement and self challenge whereas the female tends to be concerned with health through pure foods representing purity, beauty, spirituality, cleansing and virtue.

Like other eating disorders it has links with low self esteem and self worth, self criticism and control and involves the emotions of fear & guilt. It can be seen as a subconscious and misguided attempt to increase self worth and value.

Unlike other eating disorders and perhaps because it is not widely known about or taken seriously it usually presents as something other than an eating disorder. Clients may present with general anxiety, food phobias, relationship and family difficulties and stress.

What can we do?
I think it is important for therapists to be aware of this condition, how it presents and manifests.
As previously stated clients will often present with problems such as relationship difficulties, stress & anxiety and so on. They are unlikely to recognise Orthorexia it in the same way they may recognise other (more well known) eating disorders. Because this condition is to do with being healthy it is often discounted it as being a problem. It is only in getting to know the client and finding out more about their lifestyle that it shows up.

I now include questions about lifestyle and diet in my assessment. You might also like to ask questions such as:

• Have you changed your diet or the type of foods you eat recently?
• How is your appetite?
• How would you describe your relationship to exercise?
• What is your view on healthy eating?

If you suspect Orthorexia then use the following yes or no screening questionnaire. The more questions that are answered positively, the more likely it is that the person has a problem.

• Do you spend more than 3 hours a day thinking about food?
• How much time would you usually spend some time planning the next days menu?
• Do you find that you are more interested in feeling virtuous or “good” by sourcing and preparing healthy foods than the pleasure you get from eating the food?
• Do you have certain health-based rules about food that are becoming more strict and rigid?
• Are you becoming increasingly socially isolated ? (when was the last time you ate out? Or went to friends for dinner?)
• Would you describe yourself as being self critical or self loathing?
• Do you feel that your food choices are controlling you?

If you suspect Orthorexia is a problem then it is treated in the same way you would treat other eating disorders (CBT, Motivational Interviewing, self esteem building and increase self value not based on diet or looks). Alternatively refer to a specialist eating disorder service such as
The National Centre for Eating Disorders (nationwide UK network of private practitioners)
or B-EAT (formerly the Eating Disorders Association) a charity organisation which offers resources, support groups and a list of private practitioners and organisations that may be able to help).

Melanie Phelps
Chartered Counselling Psychologist
Associate Fellow of the British Psychological Society
Practitioner for the National Centre for Eating Disorders
Interviewed on Radio 1 in 2011 about Orthorexia.

References & further reading:

1. Carol Voderman. (2000-2004) The 28 Day De-tox. (books, video, DVD)
2. Gillian Mackeith. (2004) You are what you eat. (book, TV series)
3. Daily Mail 28/3/11: “Obsessive Healthy Eating risking their lives with disorder Orthorexia”
4. www.orthorexia.com
5. Daily Mail 28/3/08: “Mother awarded £800000 damages after 6 pints of water a day detox diet left her with brain damage”
6. National Centre for Eating Disorders (NcfED) blog is featured on the Counselling Directory website How an Obsession with Healthy Eating can become something more serious.