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.

Edmonton, Alberta