No one who ventures online can escape today's incarnation of wellness culture. The internet helps amplify every new diet and fitness trend - paleo, keto, detoxing, infrared spas, celery juice - and so on. Social media is dominated by celebrities and other influencers sharing how they obtained their flawless (read: filtered and Photoshopped) bodies.
Some of the latest diet trends focusing on locally sourced, organic whole foods - which wear the halo of "clean eating" and attract approval in the form of Instagram likes - can seem all-consuming. It's not surprising, then, that there is growing concern among dietitians about a little-known eating disorder called orthorexia nervosa. "I've heard from a lot of clinicians in the field who are seeing more of it," said Claire Mysko, chief executive of the National Eating Disorders Association in the US.
What is orthorexia?
Mysko describes orthorexia - a term coined in 1998 and not yet an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) - as "an eating disorder concerned with an obsession with health, wellness and clean eating".
It's similar to anorexia nervosa, in which the obsession is weight loss. Like anorexia, orthorexia involves food and nutrient restriction; this can lead to lowered metabolism, lowered sex hormones and loss of menstruation, brittle hair and dry skin, bone loss and cardiovascular issues.
Orthorexia would seem to be a condition uniquely suited to our times, when fats, carbs and processed food are demonised, and even people who don't have sensitivities to dairy and wheat are eschewing milk and bread. There is research to suggest such a connection: Most Dutch health professionals who participated in a 2018 study believe orthorexia nervosa is a disorder driven by Western cultural influences such as body ideals and a fixation on healthy living. And research from 2017 found that people who frequently used Instagram had a greater tendency to display increased orthorexia symptoms.
A hidden disorder
Notably, researchers also found that orthorexia did not carry the stigma of other eating disorders, such as anorexia and binge-eating. That means the condition can hide in plain sight, under the guise of good health. "We're living in this era of viral misinformation, where it is difficult to discern the evidence base, and even fringe ideas can seem mainstream," says Rhonda Merwin, an associate professor of psychiatry and behavioral sciences at Duke University. With such a heavy volume of content on social media, it isn't difficult to find fellow participants in extreme "clean eating" or other dietary regimens meant to control or eliminate foods.
Though the conditions in which orthorexia would seem to thrive might feel new, there's a moral component to "clean eating" - orthorexia's central fixation - that feels old. "This idea that exercising restraint over biological impulses is good and virtuous; there's a whole history of that," Merwin says. "There were saints who starved themselves to be seen as pure, divine and closer to God." She says striving toward increased "purity" is a mechanism of exercising control. Orthorexia is not dissimilar to anorexia in this way.
In fact, many clinicians see the overlap clearly. "The commonality between anorexia and orthorexia is perfectionism and anxiety, sometimes obsessive-compulsiveness," says Linda Hamilton, a clinical psychologist in private practice in New York City, specialising in eating disorders. "There's also often a desire to be thinner."
The condition can morph from a healthy intention into a means of control, Merwin says. "Oftentimes, the extreme nature comes in time," she says. "It starts with, 'I just want to be healthier,' but then more and more things become restricted." Maybe first it's dairy, then sugar, and then gluten or carbs. "It's the same with anorexia," Merwin says. "Nothing is ever enough."
Angela Guarda, an associate professor of psychiatry and behavioral sciences at Johns Hopkins Hospital, says anorexia patients typically "have a rationalisation for why they do what they do". With orthorexia, that rationalisation is clear and more societally accepted: "Those explanations are that they're vegan, gluten-free, lactose-free or so on," she says.
The flip side of the desire to consume only "pure" food - "organic" fruit or "pasture-raised" beef, for instance - is fear of prepared food. "Many patients with anorexia avoid prepared foods where they can't assess what's in the dish," Guarda says. "With orthorexia, it's similar; tofu with avocado in small amounts is [seen as] safer than a Thai curry."
Some factors may increase a person's risk of developing an eating disorder. According to Guarda, there is typically a "biological component" to the condition; if you have a relative who's struggled with an eating disorder, you are more likely to develop one than someone who has no family history.
There were saints who starved themselves to be seen as pure, divine and closer to God.Rhonda Merwin, Duke University
There are also common comorbid mental health conditions that frequently occur alongside the eating disorder. "It's very rare that you're struggling with an eating disorder or disordered eating and there's not some other mental health issue present," Mysko says. People with orthorexia often have anxiety and sometimes have obsessive compulsive disorder. "There is a fear of what is 'unhealthy', but with an undercurrent of thinness and an obsession with fitness," she says. "There may be a fear of weight gain, but what they verbalise is a fear of feeling like they're not being 'healthy.' "
According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), at least 30 million people suffer from an eating disorder in the US. But this does not account for all the men and women who are dealing with disordered eating symptoms, Mysko says. She believes the problem is downplayed. "We often hear that eating disorders affect a small number of people compared to obesity," she says. "But we have a real cultural problem on our hands. We need to talk about how many people are struggling, across all sizes, genders, races and socioeconomic classes."
A slippery slope
The problem with disordered eating - often a precursor to eating disorders, where behaviours start to become more rigid or compulsive - is that it's often not caught and treated early. "Eating disorders are very complex illnesses," Mysko says. "There are so many people with disordered eating who could be treated as outpatients, but to diagnose and treat [them], the person has to meet certain criteria. Sometimes, clinicians can't recognise it - and it's so validated in our culture."
After all, our culture reinforces that there are "good" foods and "bad". Good diets and bad. Good behaviours and bad. "We are inundated with messages," Merwin says. "These categorical terms are unhelpful and insert morality into eating. For individuals with orthorexia, trying to follow ever-expansive rules of what is healthy - or good for them - is debilitating."
Take the "clean eating" aspect of orthorexia - especially avoiding contamination in the food chain. The best way to actually avoid contamination and be as healthy as possible, Guarda says, is to diversify your diet and the number of food groups you draw from. "But we'll actually get patients who have high mercury levels because they're eating a can of tuna every day" (because tuna is high in protein, low in calories).
Moderation is key
So what does it mean to be healthy? "The key is moderation," Guarda says. "It is portion control, regular meals and a variety of foods." It is not restrictive diets. "If you look at people who maintain weight," Guarda says, "they do so eating a range of foods, including whole grains, as well as moving a lot."
There are just two criteria for diagnosing an eating disorder: distress and impaired function. If you or someone you know feels anxiety around food or eating, or starts to miss out on life because of their eating habits, it's time to seek help. "Once a person starts to isolate from social events, like refusing to go to a birthday party because they feel they can't eat what's offered, or not wanting to eat with friends at restaurants, they've reached an extreme," Merwin says.
If you notice a friend who is eliminating many foods from their diet or exhibiting rigid behaviours around health and wellness, try suggesting they seek guidance from a registered dietitian or clinician, rather than telling them what to do, Hamilton says: "You can say, 'You might be eliminating something you need.'"
If you believe that food has become a fixation for you and is affecting your day-to-day functioning, the US National Eating Disorders Association has a broad network of resources, including a screening tool and helpline, Mysko says. "On a personal level, talk to someone you trust about it. Find a professional who specialises in EDs," she says. EDreferral.com can also help you locate physicians and mental health professionals in your state that treat eating disorders.
Beyond that, beware of what you see on your social media feeds. "There are a lot of influencers in the health and fitness realm; some are trained, many are not. It's kind of like the 'wild, wild west' out there," Mysko says. "So, there's a whole conversation we need to start having about being able to recognise that what you're perceiving as health and wellness may actually be disordered."
The Washington Post