Wednesday, August 19, 2009

When Healthy Eating Becomes an Obsession

According to Wikipedia (accessed Aug 18), orthorexia nervosa is a term coined by Steven Bratman, a Colorado MD, to denote an eating disorder characterized by an unhealthy obsession (as in obsessive-compulsive disorder) with what the sufferer considers to be healthy eating. The subject may avoid certain foods, such as those containing fats, preservatives, animal products, or other ingredients considered by the subject to be unhealthy; if the dietary restrictions are too severe or improperly managed, malnutrition can result. Apparently, in rare cases, this focus may turn into a fixation so extreme that it can lead to severe malnutrition or even death.

Bratman asserts that “emaciation is common among followers of certain health food diets, such as rawfoodism, and this can at times reach the extremes seen in anorexia nervosa.” However, he states, “the underlying motivation is quite different. While an anorexic wants to lose weight, an orthorexic wants to feel pure, healthy and natural.” Orthorexic subjects typically have specific feelings towards different types of food. Preserved products are described as “dangerous”, industrially produced products as “artificial”, and biological products as “healthy”.

Orthorexia is currently not an official medical diagnosis, and it is not listed in the DSM-IV. There are however a few peer-reviewed studies on this condition in PubMed, including proposed diagnostic criteria.

Bratman proposes an initial self-test composed of two direct questions: “Do you care more about the virtue of what you eat than the pleasure you receive from eating it?… Does your diet socially isolate you?”. There is also a longer version of this test:

The Bratman Test for Orthorexia

- Do you spend more than 3 hours a day thinking about your diet?

- Do you plan your meals several days ahead?

- Is the nutritional value of your meal more important than the pleasure of eating it?

- Has the quality of your life decreased as the quality of your diet has increased?

- Have you become stricter with yourself lately?

- Does your self-esteem get a boost from eating healthily?

- Have you given up foods you used to enjoy in order to eat the ‘right’ foods

- Does your diet make it difficult for you to eat out, distancing you from family and friends?

- Do you feel guilty when you stray from your diet?

- Do you feel at peace with yourself and in total control when you eat healthily?

“Yes” to 4 or 5 of the above questions means it is time to relax more about food.

“Yes” to all of them means a full-blown obsession with eating healthy food.

Note: I could not find any published validation of this questionnaire!

Interestingly, the description of this condition reminds me of other irrational “healthy” behaviours I often see, like in people who firmly believe in the health merits of excessive exercise (fitness junkies), the miraculous benefits of nurtritional supplements, or, in the “opposite” sense, patients who are firmly convinced of the extreme “toxic” nature of pharmaceutical medications, which are to be avoided at all costs.

Patients with these “belief systems” are seldom open to rational discussion on these issues nor do they even see these beliefs to be a problem

In clinical practice, I find dealing with such individuals highly frustrating and certainly well-beyond the scope of my own practice. Recognizing such behaviours that often result in evident self-harm (or refusal of care), is one of the few true frustrations that I experience in working with patients, often leaving me no option but to refer them for psychological or psychiatric assessment and management.

I would certainly love to hear from anyone with experience in dealing with these issues.

AMS
Edmonton, Alberta

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5 Responses to “When Healthy Eating Becomes an Obsession”

  1. Michael Vallis PhD says:

    Interesting post. I have seen a number of these types of patients in my practice over the years. I think the best approach is to focus on the common threads that link these patients (obsessive compulsive features tinged with near delusional fixed beliefs) rather than try to come up with a label for the different presentations. Pursuing uniqueness might interfere with our understanding of how to help these people. I agree that psychological understanding is necessary. As such, looking at cognitive behavioural therapies, which would focus on cognitive restructuring interventions and exposure based desensitization interventions, along with medications if needed, would be a way to go.
    I think that CON will facilitate sharing of knowledge from those in the mental health field who work with OCDs and eating disorders and fixed belief systems with the medical and lifestyle focus.
    Michael Vallis, PhD
    Behaviour Change Institute
    CDHA and Dalhousie University
    Halifax

  2. Eating Disorder Self Help Strategies says:

    [...] Information On Eating Disorders [...]

  3. RG says:

    I’m not sure if orthorexia exists on a spectrum. I’m not a raw-foodist, but I do find that my “food rules” can be socially isolating. I’m leery of the calories in a typical restaurant meal, and while I allow myself a splurge once in awhile, even once a week is a lot less than would be normal in my socioeconomic strata, which would be more like 5 times a week (twice a week at work, twice a week with friends, once with family).

    I just see the whole issue as calories and nutrition based. I’m a small sedentary female, which means I just don’t burn that many calories even with a 45-minute walk. Once I eat my fruits, vegetables, dairy, protein, EFAs, I have 200 calories. That’s a small piece of dark chocolate, dinner roll, and small glass of wine. Or it’s a piece of cake. Or it’s a 1 oz bag of chips. Or it’s one sweet potato with a small amount of brown sugar. If I eat junk food, it either displaces the real food or it means I have to do extra exercise. Or I gain weight. A tall, active man would easily burn twice as many calories and would only need a little more vegetables and protein than I do, so they have more splurge calories.

    Honestly, I’m pretty happy with where I am and think everyone else is wrong. I think eating out should be a treat, rather than the default for lunch. I know I will eat more calories, and a heavier meal – some people may successfully avoid the bread basket and choose the baked fish, but I don’t see a point to paying to eat something I can effortlessly cook at home.

  4. RG says:

    PS – just as a point of comparison, my parents are fairly healthy eaters (Indian vegetarian low-fat) but are also short and sedentary. Both of them are about 30-40 pounds overweight, which means that they’re eating 500-700 extra calories every day. Where are those calories? Maybe they’re in the bread they eat with every meal. Or the weekly takeout pizza. Or the parties at friend’s houses. Or empty calories in rice.

    Here’s another woman’s response to the orthorexia quiz:

    http://skwigg.com/id8.html

  5. Razwell says:

    Hi, Dr. Sharma.

    A very intelligent man, Urgelt of YouTube, taught me that healthful eating means variety. I would say enormous variety is the top healthful eating principle.

    (All with the underlying understanding thet science has not sorted this out by any means. There are many, many nutrients not even identified yet by science, let along knowing how they all interact synergystically to produce health, or how a specific newly discovered nutrient benefits us).

    All dietary decisions carry *some* risk ,unfortunately.

    But generally “eating the rainbow “gives us fiber, phytochemicals, micronutrients that we thrive on. That seems to be likely a good idea. At least we do know leafy greens ( washed off of pesticides, sulfur compounds etc.) are a good thing generally.

    Thee is much more to health than food however, and these orthorexic people do not seem to have a healthful outlook. We are what we eat is NOT a good expression., and not true

    The truth is : we are what we experience.

    Take care,

    Raz

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