Orthorexia

These days, having a supper party among friends can involve major logistics. We have to know in advance who is vegetarian or vegan, who is avoiding carbs and who won’t eat dairy food. We have to cater specially for people who claim that they are allergic to wheat, or who are on some sort of intermittent fasting plan for their health or who can only eat foods consistent with their Ayurveda type. Selective diets such as avoidance of pork or shellfish can be consistent with religious affiliation in the Jewish or Moslem faith.   There are people with real medical problems like diabetes who need to watch their diet with the help of a qualified dietician. There are people who claim to have concerns about cruelty to animals. There are people with real food allergies that can kill them through a process called anaphylactic shock. Research cited in a 2019 edition of the Eating Disorder Journal of Treatment and Prevention shows that far fewer people actually have food intolerance or IBS than think that they do.  We would describe them as the worried well. Food faddism in adolescents and adults is an increasingly common condition in developed countries which has not been officially recognised and thus is not classified as an independent mental health issue.  The term Orthorexia (coined by Steven Bratman) comes from the Greek word orthos which means proper and orexia (appetite). It is characterized by pathological obsession for biologically pure or right food which leads to important dietary restrictions. Orthorexic people begin by eating well and then spiral into an obsession or fixation with moral goodness, purity, clean eating, and a certain smugness. They exclude food from their diets that they consider impure because of content such as animal meat or dairy food because they believe themselves intolerant or allergic or even righteous and moral.

It takes a social anthropologist to explain how societies adopt trends to guide behaviour and to confer a sense of being good, connected and or in control. More primitive societies take guidance from the interface between availability of resources and elders, religious and/or tribal rules to achieve these goals. In developed countries, influence now assails us from all directions; good bad and ugly. Many people accept that self-care will entail taking some control of diet, sleep, activity and reducing stress. For a few thousand pounds, any untrained person can take a short course in becoming a health blogger and influence the vulnerable to adopt behaviour disguised as healthy but with dangerous consequences. There is also a wealth of information – some conflicting and some untrue, delivered to us via an active and pervasive media. This applies not only to food and to its qualities but to broader issues such as the effects of food production on the environment. We might well be gaining in knowledge but not in wisdom. Confirmation bias (Kahneman) leads us, once influenced down a certain pathway, to attend only to information which reinforces our views, of which much is irrational. Where there is conflict and uncertainty, vulnerable individuals keep themselves safe by adopting rigid dietary practices which are reinforced by bonding with individuals who hold the same views and strengthened by the use of mantras “All food which isn’t clean is dirty,” “Cows’ milk is only good for cows” “wheat gives you wheat belly”.

Orthorexia can be minor and inconsequential even if it is a bother for people organising a supper party. At its most extreme, health suffers, other interests diminish, relationships are affected and their quality of life is impaired.  One orthorexic person said, I am painfully aware that I am a bore even if I strive for it to be a closet bore. I am no less aware than I am a type like many of my ilk- city living, and more than a tad a control-freak.  One well known former anorexic, now a Clean Eating warrior, said fiercely of her views that clean eating would “save the entire planet.” Who wouldn’t be vegetarian! The association with eating disorders occurs where the dietary restriction is a proxy for weight loss or weight control. For example, some vegetarians refuse to eat meat because of its so-called fat content. Orthorexic people share characteristics with anorexics such as perfectionism, maturity fears, asceticism (purity drives), high levels of disgust and an obsessive personality. Like anorexics, orthorexics feel special and different regarding their eating habits, but would have extreme emotional reactions if dietary rules are breached. Some experts believe that Orthorexia is an “escape” from becoming Anorexic by limiting the diet to deal with anxiety about food without the consequences of being over thin.  Orthorexia can be a way out from an existing anorexia because it confers the same kind of moral rectitude which people with anorexia seem to crave.   I am not skeletal any more but I will never touch meat, bread or anything that comes from a cow. Bear in mind that there are also many people with orthorexia who are normal weight or overweight and have no apparent drive for thinness. Their orthorexic behaviour might be the symptom of something else. So, a differential diagnosis with chronic delusional disorder, Anorexia, and OCD is needed for people considered to be orthorexic.

Susie Orbach, a well-known psychotherapist dislikes the term “Orthorexia” but says that it captures something about our cultural thrust to try and carve up food into ‘goods and bads’ like a more elegant version of the classic diet used to be. She says, you think you are looking after yourself, but it can be the basis for feeling disturbed about foodstuffs that used to be taken for granted. Orthorexics’ claim to be healthy makes this kind of food management self-legitimising and it is also competitive. I would go back to basics and ask – what is the problem to which this is the solution?  It is not medical – it is psychological.

How to treat orthorexia   Very few people with orthorexia (like anorexia) want help because it would mean them having to eat foods they deem contaminated or toxic. They also share a refusal to consider their eating habits worthy of professional treatment unless the degree of interference in life or episodic breaches of control that arise from dietary restriction feel unbearable. Resistance to treatment will include secret beliefs about harm, about no longer being special, no longer feeling smug about their choices and being weak for violating dearly held values about animals or the environment. We admit, reluctantly, that there is no one-size-fits-all treatment for people with orthorexia unless the consequences of their orthorexia are extreme and they do not wish to live in this way anymore. Then it is important to engage sensitively with the person. We may only begin this process of engagement by asking them to explore the pros and the cons of the orthorexic lifestyle and untangle the beliefs and values that led to orthorexic choices in the first place. They may need medical evidence that they do not have the physical problems that have led them to imagine certain foods do not suit them. Only a fully trained eating disorder specialist can design a holistic treatment plan which addresses the emotional fragilities and the perfectionist attitudes which maintain the orthorexia – the “problems for which this is the solution”. This takes time and sensitivity.