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Thursday, 24 March 2011

Getting to Grips With Orthorexia: A Media Frenzy

I was asked to do an interview for the BBC on the subject of Orthorexia and since then, all hell has broken loose. There have been attacks from members of the public and health professionals about purportedly describing the quest to eat healthy food or even vegetarian food as a mental health disorder. I have even been accused to trying to promote the obesity epidemic by demonizing healthy eating.


The term “orthorexia”(correct appetite) was first coined by Stephen Bratman who observed some typical ways of thinking about food among people who had worries about the properties of food and its ability to do them harm. I didn’t need Bratman to teach me something I had noticed anyway among people who I met in my work with eating disorders. Orthorexia isn’t just about weight, it can be just an obsession with healthy eating as well as worries about weight in disguise. So, I agree that it is helpful to have a name for something with which I was familiar, because of my experience with people of all weights struggling with control of food.

In the course of my work I have met overweight clients who wouldn’t eat more protein because “I am vegetarian” and “I am also allergic to dairy foods” and “wheat makes me bloated.” I treat people who were binge eating and who had spent years “food combining” and going from one healthy diet plan to another; like the Stone Age Diet or the Fit For Life Diet. I noticed that some people bury the need to control their weight by a conviction that they are just trying to be “healthy”. Most diet books these days are published as healthy eating plans like the Metabolic Typing Diet.

I have seen orthorexic patterns expressed among vulnerable young girls who convince themselves that animal products would make them gain weight. This is often the start of a slippery slope. Although convincing themselves that this was “healthier” they went on to develop anorexia or bulimia.

I then saw it really taking hold as a result of celebrities and the media promoting the message that you are a good person if you go on a detox after holidays; and it is so easy for detoxing to become a way of life. Something you feel you cannot do without.

I have tried to point out many times that this thing "orthorexia" is not a medical condition. Mental issues defy attempts at categorisation because people come in many different packages. Anyway we must make a distinction between people who like to eat healthy food like me, without extreme ideas and rules, compared with people who have very rigid patterns of eating because of religion, weight control issues, ethical values, health issues and real or perceived health fears. Orthorexia is not just a description of behaviour, it is really about underlying motivations and the need for some people to escape from underlying fears by turning to the control of food in some predictable ways.

The need to eliminate certain food types, such as meat or wheat, or food groups such as all carbohydrates or all fats, resonates with anxiety disorder, obsessive compulsive disorder and even delusional disorder in some people. Delusional disorder is where people have extreme ideas about contamination or badness of certain foods. It is simply grist for the mill of anxious people that there are genuine health concerns about the foods we eat, to which attention might be paid.

I am often asked how many people there are with orthorexia. I have no idea, since not being an official “condition” no-one has developed a test for it with clinical validity. However, I see aspects of orthorexic thinking in a great many of my friends and colleagues who are adapting their diet, who have just happened to become uncomfortable with eating certain foods or who are convinced that certain foods will do them harm.

Experts have called “orthorexia” an “escape from anorexia” by helping people who “cannot starve” to find alternative ways of controlling food. The underlying common features, shared by both conditions, and which have nothing at all to do with food, are about finding ways to deal with things that lie beneath. Individuals with either condition are likely to have unmanageable feelings and negative core beliefs which are managed by control of food and weight.

How do we know that these are similar conditions? People with anorexia and orthorexia – even those who are not underweight – have similar characters. Both tend to be highly perfectionist, anxious, rigid, fearful of mess, have ascetic (purity) beliefs and even underlying fears of maturity. They also have a narcissistic need for status which can be acquired by having an unusual diet. People with orthorexic thinking often wear their eating choices as a “badge of pride.” It is no accident that the majority of people with anorexia are also vegetarian, with a suicide rate 57 times higher than we would otherwise expect.

Regarding the discomfort about vegetarianism: well, please don’t misinterpret what I am saying about its links to orthorexia. In a recent reply to an indignant writer, I proposed that while omnivorous eating is wired into our physiology, I accept that as humans we overlay moral and also emotional choices to our instinctive appetites. But where food and other choices are concerned, I believe that none of us is truly aware of the reasons why we do what we do. The research literature on the psychology of vegetarianism is interesting and begs to be read, especially by psychotherapists who work with the general public and who may be orthorexic themselves. I worry that conventional psychotherapy training does not require students to disclose and reflect on their own relationship with food. I am even more worried about eating disorder specialists who may be orthorexic, because these experts need to help sufferers feel comfortable with eating a wide variety of foods.

Spectacularly hidden

So orthorexia is hard to capture in single sound bites or short paragraphs written in the press. It’s one of these things which is widespread and yet spectacularly hidden because it comes in many guises. It only becomes a problem when it affects physical health due to nutrition deficiencies or it affects your social life to such an extent that you lose your friends, your social life, or become so obsessive that you know you have a problem. Most people do not want to change.

When looking for the cause of orthorexic faddism, (as opposed to food choices which are motivated by other things), we can see it everywhere in the society we live in. If you are not emotionally resilient, if you have body and weight issues and low self confidence, you will be vulnerable to all the messages about toxic qualities of food, foods that will make you gain weight or foods which are dangerous to eat side by side.

There are too many experts diagnosing food allergies or food intolerances which may not exist and who blame food allergies for making you fat. There are too many people telling you that eating meat will affect your health. Food faddism, disguised as nutritional misinformation has crept into the sports and fitness field, causing people to rely on supplements and on strange diets to make you fit, boost your endurance and build your muscles while making you lean. Even the food industry is getting in on the act. Not everyone is captured by this whirlpool of advice but it has a bad effect on some. Orthorexia can even start at home, when a boy or a girl sees a parent taking on strange eating plans.

I have chosen to be interviewed about orthorexic thinking because we need to legitimise- with a name if necessary - some patterns of eating that cause physical harm or which affect a person’s life. Some people become so obsessed with food that they can’t function properly anymore. These are people who cannot eat out unless they take their own box of food. These are people who are scared of eating carbs. Extreme cases get the headlines but there are many milder ones.

We do not need a genuine mental health concern to be clouded by people writing indignantly that they are not orthorexic just because they choose to eat organic food. The following questions might help you know if you or a loved one has the condition.

• Do you spend a great deal of time studying facts about food or food and health?
• Do you read a lot of books or visit websites about diets or healthy eating plans?
• Have you eliminated certain foods or food groups from your diet. If so, which?
• Is your diet solely organic?
• Would you describe yourself as interested, or obsessed about eating healthy food?
• Do you eat flexibly or do you have to plan your eating?
• If you were stuck somewhere and only unhealthy food was available, would you be able to eat it just once?
• Would you feel extremely guilty or anxious about eating foods on your forbidden list?
• Do you feel superior because of your eating choices or restraint?
• Does eating differently from others enable you to feel special?
• Do you have bad feelings about eating out, at social occasions where you cannot control the food?
• Do you refuse social invitations because you do not wish to eat the food?
• Do you feel that avoiding certain food groups (like carbohydrate) will help you control your weight?
• Are there foods that you think are bad to your health or bad for you – other than foods generally acknowledged as unhealthy or fattening such as “chips?”

There is no foolproof test for orthorexia, but answering yes to most of these questions suggests that someone has signs of it. There is little chance that people will go to a therapist and ask to be “cured” because there is a heavy investment in keeping the status quo. Eating habits are resistant to change, and, why start eating food that is going to make you feel afraid?

Eating disorders are not just about food of course. But if I have a client with an eating disorder who is also orthorexic, I may find them difficult to treat unless they are able to let go of some of their beliefs so that they can have a balanced, relaxed relationship with food.


  1. Labels labels labels. This is why treatment needs to be individualised. Breaking up broad eating disorder diagnoses into smaller fragmented groups just makes treatment more exclusive. As somebody who was diagnosed with bulimia initially and carried this label for the next 8 years I was treated as such (CBT & Prozac). My weight dropped steadily over those 8 years and all of a sudden I was re-diagnosed with anorexia (binge/purge subtype to be precise) which opened a whole lot of other treatment avenues to me (some which were wholly inappropriate) and also seemed (to some) to infer that I had changed personality and behaviourally over night. I had not. I truly believe that the illness I have at present is more akin to bulimia than anorexia. Certainly behaviourally at least. I have now been at an anorexic weight for 10 years. I binge (objectively NOT subjectively) and purge daily. At worst I get the full anorexia treatment regime foisted on me with no help whatsoever with the binge/purge behaviours (in fact b/p has been treated as a dirty little secret by professionals at times). I have been an inpatient on specialist units about 10 times. Same routine each time. Labelled anorexia..make do with a treatment programme broadly focused on restrictive anorexia. At best it might mention bulimia as something that might occur POST-anorexia but is seen as preferable. It's not. I suffered just as much psychologically with bulimia as I do with anorexia. Anyway, I know this was little off-subject, but it's my reaction everytime a new label is bandied around by the media. It seems to me a dangerous way of slicing and dicing folk until they fit into a nice neat little box. Well, unfortunately we're not all as tidy as that. Ok, it's helpful to identify behaviours and to treat them on an individual basis. But this is the place of the professionals and I could have bet that the media would grab onto it like a dog with a bone and turn it into something it never was. Orthorexia (if we MUST have another label) is an ASPECT of an eating disorder, in some folk, which should be treated. The same as b/p is an ASPECT of an eating disorder in some that should be treated. Labelling makes people think they know everything there is to know. It's misleading.

  2. Sorry Deanne if that sounded like an attack (I just re-read your post and my comment!). It wasn't meant as such. I'm personally just very wary of applying labels which I have seen exacerbate disordered behaviour in some folk, in that it's almost like another "badge" to add to the collection of ED behaviours.
    Sometimes I wonder if we are teaching vulnerable people "how to have an eating disorder"?...I don't know, I have no answers. All I see is revolving door syndrome and I desperately wish I knew a way to stop it. I don't think more labels(with the capability of being misconstrued and warped by the media) are the answer. But then, perhaps I live in an ideal world far from reality!

  3. Rufty is right to complain about labels, bear in mind Rufty that one in three eating disorder experts have a history of eating disorders and have been through it. We know that one behaviour can go before or after another and that labels don't capture what is happening to you. But I feel terribly sad about revolving door stories

  4. I think perhaps having been involved with people who come to you who are having problems, you have only seen mentally unwell people who are following these diets. This may have had a selective effect, leading you to conclude that such diets are often associated with mental health problems, and can be the cause of a deeper mental health problem (e.g. you mention the classic conditions like narcissm, anxiety ect).

    All of the people I know who follow these diets you mention (e.g.cutting out diary, trying different macro nutrient ratios to suit their matabolism) are perfectly sane, informed and often educated professionals. People who get on and help others, generally giving more than they take. They are experimenting with how to optimise their diet. How to live in the best way possible.

    As you can imagine, it is a big change, and many foods like wheat and diary, and processed foods like sugar, are actually strongly addictive. It can take a lot of will power to follow it, but there is nothing too bad about that. There is nothing wrong in telling yourself off if you miss a goal. Naturally there will be some pressure at first while trying to follow some of these diets, until they become more of a habit.

    There certainly is a positive way you can look at most of the people who follow these diets. Of course there are some people with problems who are following these diets and maybe looking for it to solve all of their problems. But these are a minority. It does not mean these diets are not worth following. Because anyone with a problem can look for something to solve it.

    On the subject of mental health, talking therapy is proven effective, and this can largely be treated at home.

    Most of the diets are not all different, most of them follow the same idea, that some foods are harming some of us (like wheat and diary) and we need to experiment by removing them for a while to see if we feel better. And getting the right balance of carbs, protein, etc for us. And if it works for us, to keep following it. There are some tradeoffs, but getting your energy back, or getting more energy, is great and is worth it. I see it as something that is mainly practised by healthy and perfectly sane (mentally) individuals. It does take some willpower, mainly because many of these foods are so addictive in the first place. But once the new "diet" becomes a routine, it no longer becomes a problem.

    Hope this helps, and wanting to hear your thoughts, Andrew.

  5. I havent replied to you Andrew for days and days due to pressure of work, training and so on.I suggest that to get to me fast you email deanne@ncfed.com
    Correctly my views are skewed by seeing so many people suffering from eating disorders and for who food restriction via avoidance of certain food types is an indication of "stuff" which has nothing to do with food.

    For so many people I have worked with the ONLY way they have been able to get their energy back and their sanity is to eat from all food groups including animal food and to stop having black and white thoughts where food is concerned.

    There are also a group of people in the USA who deliberately follow extreme food restriction for longevity and predictably eschew animal foods.

    The notion that making food the source of a great deal of emotional energy is a form of insanity is not what this blog is about, although I have spent many years looking at/ studying eating behaviour and find that food easily becomes a projection for other things that have nothing to do with food... for obviousl reasons, because it is there it is easily available and because we develop a very interesting relationship with food from birth. Food acquires manyu complex meanings and becomes entwined with our develomental and relational experiences. I would go so far as to controversially say that when "sane and rational" people start giving energy to finding a diet that makes them "feel better" something else is going on. Humans just used to eat what was there and now there is too much there, hence a great deal of anxiety about choices and rightness which is often a projection of other things.

    Of course if you were to eat a diet high in sugar or trans fats, or exclusively wheat you mightnt feel good; but we were not designed to have very selective diets in this form. Beware however of the placebo effect of changing your diet. Psychologists know what many of the benefits of diet change are about the BELIEF that you are doing something good to yourself.

    And turning to the subject of addiction. Oh dear.
    I really bristle at the word "addiction" having had this word applied in so many contexts from wheat to cleaning floors. I have jousted with this idea with very many psychotherapists including those in the addiction field with whom I am privileged to come into contact. This subject is emotionally hyperladen to many people and perhaps the subject of another blog. You might guess that I do not believe that wheat nor even "white flour" or sugar are per se substances to which a person can become addicted. After all fruits digest down into glucose just as sugar does albeit more slowly. And wheat, well that's another story altogether and there are some interesting bits of research which appear to prove once again that it's beliefs rther than the substance which alters behaviour.
    Once again since I often dont look at old blogs please email anything really pointed to deanne@ncfed.com