Are you an enthusiast for healthy food? That’s wonderful.

However, for some people, interest in healthy food can transform into an eating disorder. The following self-test is designed to help you determine whether you have come close to, or have already crossed, that line.

The Bratman Orthorexia Self-Test*

If you are a healthy-diet enthusiast, and you answer yes to any of the following questions, you may be developing orthorexia nervosa:

(1) I spend so much of my life thinking about, choosing and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work and school.

(2) When I eat any food I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods.

(3) My personal sense of peace, happiness, joy, safety and self-esteem is excessively dependent on the purity and rightness of what I eat.

(4) Sometimes I would like to relax my self-imposed “good food” rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make ANY exception to your diet, then this item does not apply.)

(5) Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own.

(6) Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me, or has caused other signs of malnutrition such as hair loss, loss of menstruation or skin problems.

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*There are a number of orthorexia self-tests on the Internet, including several that are purportedly designed by me.  However, this is the only self-test that I actually authorize and approve. I freely make it available to anyone who wishes to use it.

Adopting a theory of healthy eating is NOT orthorexia. A theory may be conventional or unconventional, extreme or lax, sensible or totally wacky, but, regardless of the details, followers of the theory do not necessarily have orthorexia. They are simply adherents of a dietary theory. The term “orthorexia” only applies when an eating disorder develops around that theory.

I feel a need to clarify the distinction because many articles on orthorexia incorrectly apply the term to people who merely follow non-mainstream theories of healthy eating. This incorrect usage is partly my fault, because in my original orthorexia essay I failed to emphasize the distinction

Here is the central point: Enthusiasm for healthy eating doesn’t become “orthorexia” until a tipping point is reached and enthusiasm transforms into obsession.

Orthorexia is an emotionally disturbed, self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable. A gradual constriction of many other dimensions of life occurs so that thinking about healthy food can becomes the central theme of almost every moment of the day, the sword and shield against every kind of anxiety, and the primary source of self-esteem, value and meaning. This may result in social isolation, psychological disturbance and even, possibly, physical harm.

To put it another way, the search for healthy eating can become unhealthy.

Diet as Risk Factor

The issues of “theory of healthy diet” and orthorexia are not entirely separate, because it isn’t possible to develop orthorexia without at first adopting a theory of healthy food. However, the specific details of the theory are almost irrelevant. Orthorexia = disordered eating in relationship to [insert any restrictive theory of healthy diet here, even mainstream medical theories.]

As a matter of practical fact, some theories present more risk of orthorexia than others. The more restrictive the diet, the more likely it is to set off the psychological factors that lead to an eating disorder.

The basic “clean eating” diet, which focuses on organic whole foods, free of preservatives, antibiotics and GMOs, barely qualifies as a restrictive theory of healthy eating at all, and only occasionally leads to orthorexia. Going gluten-free is useless for most, but it’s also harmless.

Similarly, the standard paleo diet is quite mild, and regardless of whether one believes the theory makes sense (I personally think it is quite absurd) becoming paleo seldom leads orthorexia unless further restrictions follow. Simply remember to take a gentle approach with yourself, as Neil Stephenson advises on his popular Paleoista blog.

Raw foods veganism is on the other extreme, and has a high orthorexic potential. This is a challenging diet to manage safely, and many people who will ultimately develop orthorexia begin as raw foods vegans. Nonetheless, there are many people who adopt the raw food vegan lifestyle and do not become orthorexic.

A truly extreme diet like fruitarianism is orthorexic almost by definition — it does not provide nutrition compatible with health, and in order to become a fruitarian a person must have already gone pretty far afield on the path of obsession. But with a nutritionally sound diet, what matters is not whether the theory is wrong or right, scientific or unscientific. It’s how it impacts you as a person.

People who get in trouble with theories of healthy eating often have an underlying predilection toward going overboard. As Jordan Younger writes in her excellent piece on Refinery29,  “Those of us who have a tendency toward extremes in other areas are more susceptible to developing it [orthorexia] — especially once we start cutting out entire food groups.“

To clarify, it IS possible to cut out an entire food group without being orthorexic — but a restriction so sweeping as that definitely puts one at risk.

The Tipping Point

Healthy diet turns into orthorexia when a boundary is crossed and a person’s relationship with food begins to impair various essential dimensions of human life. There is no bright line to mark this transition, but it can be recognized as a situation in which the search for a healthy diet has taken on a life of its own and no longer serves the goal of improving health.

Jaime A. Heidel captures this tipping point in her essay “Are you TOO Obsessed with Healthy Eating?” She began following theories of healthy eating in order to address certain personal health conditions. From a physical perspective, she found this effective. However, “somewhere along the line, my desire to keep my conditions under control developed into an obsession of the more questionable variety.”

She describes how “healthy” diet began to take over her life. “My diet became increasingly strict and I found myself feeling agitated and anxious whenever I couldn’t find organic or natural foods.“

Ultimately, she decided she should loosen up a little. “If your desire to eat healthily and avoid chronic disease begins to interfere with your daily living, social activities, and relationships, it may be time to take a step back.” Her conclusion: “While you’re in the process of improving and prolonging your life, don’t forget to live it.”

But even this advice will raise concerns for some people. In a post titled “Is Healthy Eating Doing us More Harm than Good?” popular blogger Kelly at Mummywrites says the same thing, but with a caveat: ” Life is too short to live on extreme diets, stressing about every morsel, but then life really will be short if we don’t look after ourselves!” [my italics]

Perhaps here it is worthwhile gently pointing out that the modern world is so chockful of chemicals that the trace quantity of pesticides and other chemicals in a serving of non-organic food simply doesn’t amount to disaster? The evidence suggesting potential harms caused by pesticides in food indicates at most a tiny fractional percent of an increase in the risk of health problems even when eating non-organic foods day in and day out. If you are afraid that occasionally straying off your perfect diet will give you cancer you might as well cower at home under your blankets.

A friend of mine is afraid of going to Italy because she thinks the leftover radiation from Chernobyl will kill her; in fact, the amount of radiation exposure on the plane trip to Italy is orders of magnitudes higher.

So let’s keep a sense of proportion: If you prefer to eat mostly organic, preservative- chemical- and antiobiotic-free foods (as I do!) and think that many overly processed foods are not foods at all (as I do!) it still doesn’t mean you have to follow those principles 100% of the time. That’s just perfectionism, obsession, orthorexia.

Trying to be perfect will make you crazy, in diet as elsewhere in life.

Lighten up a little. Be gentler with yourself.

To quote Jaime again: While you’re in the process of improving and prolonging your life, don’t forget to live it!

Steven Bratman, MD, MPH

Orthorexia is evolving.

I initially described orthorexia nervosa based on patterns I observed while studying and practicing alternative medicine. Most of the people I had in mind were trying to treat or prevent illness by following one or another dietary theory. An overlapping category included those who had “fallen in love” with a theory of diet, whether for reasons of ideology (raw foods), ethics (veganism), philosophy (macrobiotics) or pure gullibility (Blood Type Diet). In all cases, health was the central focus, and food was the medium.

Today, the situation has evolved. I have recently been speaking on orthorexia in Norway and Sweden, and have been discussing it with numerous eating disorder specialists in the US, UK and Australia. I now find that while retaining many of its original features, orthorexia has also acquired some new characteristics. I will discuss these here.

Exercise

One of the most dramatic changes in orthorexia is its current inclusion of exercise. It would now appear that the majority of people with orthorexia are also exercise enthusiasts of one sort or another, whether they do yoga, run or constantly work out at the gym. For some, exercise is as much a primary focus of their lives as eating, and out of the same motivations.

This all makes good logical sense. Exercise is at least as important as diet for improving health outcomes (and, for the non-overweight, far more important) Thus, any health conscious person would naturally exercise as well, and this seems to be occurring.

An interesting fact is that in the European press exercise is increasingly included as a defining characteristic of orthorexia. However, this is incorrect.  While exercise enthusiasm and even exercise dependence may coexist with orthorexia, the term itself refers to obsession with diet, not with exercise.

Fitness vs. Fitness

In my day, to be “fit” meant one could easily walk up a long steep hill without breathing hard; it was an element of health as signified by aerobic capacity and endurance. But, as words will do, the term “fit” has migrated its meaning, and now signifies primarily a certain body type: lean and often muscular, radiating health. This is a significant change, an externalization of the concept of fitness, a merger between “healthy” and “sexy.”

To attain a fit body, one must monitor both exercise and food. Exercise helps reduce fat percentage and it’s the only way to build muscles. Close attention to diet, of course, is necessary to reduce fat percentage, and many people additionally believe that eating healthy food will make them look healthy. Purity of diet thus equals unblemished, glowing, perfect skin.

There have always been dual motivations for going to the gym and eating healthy food: to feel healthy and to look good. But I suspect that the appearance aspect of healthy diet has increased lately, due to celebrity endorsements and millions of Instagram photos. Currently, many people may be orthorexic at least in part for their looks rather than their health.

Anorexia in Disguise

I have resisted accepting this aspect of the evolution of orthorexia, because it cuts against my original concept. But honesty requires me to take note.

In my 1997 orthorexia essay and in posts up until now, I have maintained that while those with anorexia want to be thin, people with orthorexia want to be pure. However, I have been forced by reality to recognize that there is no longer such a hard and fast distinction. It appears that a high percentage of people with orthorexia these days DO have a focus on weight loss, at least to some extent. Because it is no longer socially acceptable for a non-overweight person to count calories, many who would otherwise be anorexic talk about “eating healthy” instead. This only “coincidentally” involves choosing low calorie foods. In Health Food Junkies I called this “covert anorexia,” but at the time it was relatively rare. Now it is common, even dominant.

In part this change is due to that fact that the very concept of “healthy” food has become, for many people, indistinguishable from that of “low-calorie” food. This conflation is perfectly reasonable, since maintaining normal body weight is the most important health-promoting aspect of dietary choices. However, it is a significant change from the healthfoodism that affected my patients, and it remains quite distinct from ideas in currently significant dietary theories such as macrobiotics, raw foods and paleo. Nonetheless, because it has become normative, this conceptual merging of “healthy” and “low calorie” brings anorexia and orthorexia closer together.

In addition, anorexia itself has been evolving (now commonly including investment in food quality), as has its DSM definition (which no longer includes BMI in its criterion.)

There do remain some definite distinctions: People are ashamed of their anorexia, but they actively evangelize their orthorexia. People with anorexia skip meals; people with orthorexia do not (unless they are fasting). Those with anorexia focus only on avoiding foods, while those with orthorexia both avoid foods they think are bad and embrace foods they think are super-healthy (such as the ubiquitous kale). And when an anorexic person is in treatment, they have no particular objection to being fed with Ensure or Boost except regarding the calories, whereas an orthorexic person would object to the chemicals.

But these differences are fairly subtle. Today, the majority of people with orthorexia may best described as having orthorexia with anorexic features, and a large percentage of those with anorexia as having anorexia with orthorexic features.

To make matters even more mixed up, there are people with orthorexia who purge via vomiting and use of laxatives for the conscious purpose of removing toxins rather than losing weight, thus bringing bulimia and orthorexia in alignment.

At a deeper level, all these variations amount to much the same thing: giving food far too prominent a place in one’s life.

Research

Everything I have written above is anecdotal. To properly analyze trends in orthorexia, and its evolving relationship to and differences from anorexia, exercise dependence and personal vanity, one needs research. However, up until now there has not been a formal definition of orthorexia, and without such a definition meaningful research is impossible. There is a survey tool in common use called the ORTO-15, but it was developed without a definition of what it was intended to survey, and I do not believe it is effectively separates people with orthorexia from people who are merely health food enthusiasts.

To remedy these gaps, I have been working with a prominent psychologist of eating disorders, Thomas Dunn, PhD. We shall soon publish a set of formal criteria, and, shortly after, offer a survey tool that effectively picks out people who meet the criteria. This will allow formal investigation into the trends I’ve described above.

The Future of Orthorexia

In Norway, I spent time with Finn Skarderud, a prominent psychiatrist on the subject of eating disorders. Several times he said to me, “the body, and conceptions of the body, are fluid.” On my last day there, we discussed what I thought orthorexia would be like in the future. At first, I  simply reiterated what I have often said: in the future there will be new and different diets, and what we call “healthy food” tomorrow will be different than what we think of it now. But upon reflection, I realized this was too limited a view.

To the extent that orthorexia is about the desire to achieve perfect health and to look like a perfect physical specimen, I believe that the focus of orthorexia will shift entirely in coming decades.

The only reason health conscious people obsess about exercise and diet is that they can’t think of anything else that will improve their health. (Some people do add herbal and non-herbal supplements, but conceptually these are just forms of “superfoods” already included in the category of diet.)

However, the sad fact is that these methods don’t actually do very much.

Seriously. Eating fantastic foods (whatever you believe them to be) can’t possibly, even in theory, have more than a few percentage point influence on health and longevity. Exercise is probably a bit more powerful than this, but it too is sharply limited. Add in all the other methods used by Silicon Valley’s current “biohackers” and it still doesn’t amount to a hill of legumes. People who eat perfectly, exercise constantly and take herbal and other supplements still get cataracts, arthritis, wrinkles, cancer, dementia and heart disease. They become old and frail. They die.

In future, however, it is highly likely that we will use entirely new and more powerful means to extend life, enhance health and reverse aging. One thinks of stem cells, DNA modification, smart implants and nano-technology; in other words, effective rather than goofy biohacking. Once it becomes possible to affect health and aging in ways much more powerful than the limp means of food and running, will our current fascination with food fall away, the impulse shift focus? Or will there be those who avoid the new methods, no matter how effective, and seek to cleave closer to nature, no matter how mortal?

Steven Bratman, MD, MPH

Although the concept of orthorexia nervosa has been the subject of a great deal of media attention and is in wide use by eating disorder professionals, it has never been given a satisfactory formal definition. This omission has now been remedied in a newly published article in the journal Eating Behaviors I coauthored with Thom Dunn, Ph.D.

These criteria are intended as a starting point; we anticipate that they will be refined and modified over time. In particular, the references to weight loss remain provisional, pending research into the evolving relationship between orthorexia and anorexia.

Proposed Diagnostic Criteria for Orthorexia Nervosa:

Criterion A. Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue, but this is conceptualized as an aspect of ideal health rather than as the primary goal.  As evidenced by the following:

1. Compulsive behavior and/or mental preoccupation regarding affirmative and             restrictive dietary practices* believed by the individual to promote optimum health.**
2. Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame. 
3. Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy food.

*Dietary practices may include use of concentrated “food supplements.”

**Exercise performance and/or fit body image may be regarded as an aspect or indicator of health.

Criterion B. The compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:

1. Malnutrition, severe weight loss or other medical complications from restricted diet
2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviors about healthy diet.
3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior

In addition to these criteria, the published article also includes the following paragraph:

Other traits are commonly associated with ON in the literature. While the authors feel that these are not essential to making the diagnosis, they may help confirm it. These include obsessive focus on food choice, planning, purchase, preparation, and consumption; food regarded primarily as source of health rather than pleasure; distress or disgust when in proximity to prohibited foods; exaggerated faith that inclusion or elimination of particular kinds of food can prevent or cure disease or affect daily well-being; periodic shifts in dietary beliefs while other processes persist unchanged; moral judgment of others based on dietary choices; body image distortion around sense of physical “impurity” rather than weight; persistent belief that dietary practices are health-promoting despite evidence of malnutrition.

Cite as: Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17.

Last spring, I was honored to be asked to write the foreward to Jordan Younger’s memoir, Breaking Vegan. The book is now available in print. I expect it to have a major impact on public awareness of the concept of orthorexia nervosa, especially in her demographic, and will be of help to many who have gone down a similar road. I highly recommend it.

Breaking Vegan is also fodder for reams of hatemail, written almost if not entirely by those who have not read the book. I understand the instinctive protectiveness of vegans for veganism, but this book does not in any sense attack, disparage or criticize veganism! It was partly to protect against this natural but seriously mistaken reaction that I wrote my introductory words.

Note to vegans: Many of you find the title disturbing. I have been asked, “Why didn’t she call it ‘Breaking Orthorexia?'” Honestly, I personally would have loved the title to include the word I invented. But that would have been a truly terrible title. And, anyway, veganism (or, at least, plant-based diet) IS part of Jordan’s story. It’s also part of the story of many other people with orthorexia, and, because of this, I believe the title is perfectly appropriate, even if potentially misunderstood.

I do understand fears that the title itself will bring down criticism on  the vegan lifestyle. Unfortunately, it is impossible to perfectly serve all audiences simultaneously; every choice is a compromise, and every possible title will have its own issues. And I constantly hear Jordan publicly stating words to the effect of: “Veganism is great! It’s healthy and ethical. However, in some susceptible people, it can cause problems. I am one of those people. Here is my story.” Seriously, she’s not your enemy.

Below is the “director’s cut” of the foreward, as originally written, a bit longer than what is printed in Breaking Vegan.

Orthorexia Nervosa: The Health Food Eating Disorder

How can eating healthy food become an eating disorder?

On its face, the idea sounds ridiculous. We live in a society where high fructose corn syrup infests the supermarket shelves, antibiotics and other chemicals pile up in the food chain and obesity starts in childhood. Wouldn’t any intelligent person interested in their health want to find a better diet than the one that is on offer?

Yes of course!

Choosing healthy food does not equate to orthorexia. People can adhere to just about any theory of healthy eating without having an eating disorder (with the only caveat that such a diet must provide adequate nutrients). For example, veganism itself is not an eating disorder. Far from it. Veganism can be a wonderful, admirable healthy lifestyle, and its ethical and environmental motivations are exemplary.

Nonetheless, some people who are devoted to healthy eating develop an eating disorder in relation to that focus. Some vegans become orthorexic.

Consider the analogy of body weight. Everyone agrees that it is unhealthy to become overweight, and that it is sensible to avoid obesity. However, in connection to this goal, and in combination with other psychological factors, some people develop anorexia nervosa. A similar process can happen with healthy food. Just as some people in their quest to maintain healthy body weight go down an emotionally and physically unhealthy path, some people in their quest to eat healthy food develop orthorexia nervosa.

Orthorexia is not the same thing as devotion to healthy food. The latter is a conscious choice. Orthorexia an obsession with healthy food that involves other emotional factors and has become psychologically and perhaps even physically unhealthy. It is an eating disorder. [NOTE: For more information on the distinction, see Healthy Eating vs. Orthorexia.]

The Origin of “Orthorexia”

When I invented the term “orthorexia nervosa” 20 years ago, I didn’t realize I was naming an eating disorder. I was practicing a form of “tease therapy.”

I practiced alternative medicine at the time, and although I was a proponent of healthy diet I thought a few of my patients took it too far. I remember one in particular who began every visit by asking, “Doctor, what food should I cut out of my diet?” I came to feel that she did not need to cut anything out; rather, she needed to relax the grip of her mind and live a little.

However, because I had once been a raw food vegan myself (and, at other times, a follower of macrobiotics) I understood how difficult it would be for her to hear this. To ask her to lighten up on her diet was tantamount to asking her to embark on a life of crime. “Go and commit some larceny. It will be good for you.” She saw healthy diet as pure virtue. How can one lighten up on a virtue?

As a devious therapeutic technique, I decided to stand her virtue on its head by calling it a disease. I consulted a Greek scholar, and coined the term orthorexia nervosa. It is formed  in analogy to anorexia nervosa, but using ortho, meaning “right,” to indicate an obsession with eating the right foods.

From then on, whenever this patient would ask me what food she should cut out, I would say, half tongue-in-cheek, “We need to work on your orthorexia.” This made her laugh, and ultimately it helped her loosen the lifestyle corset. She moved from extremism to moderation.

Later, I published a funny article on the subject, and then a humorous book with a bad cover color scheme. I didn’t take my own idea too seriously. I was just trying to get a few overly obsessed health foodists to take a look at themselves.

It was only after the publication of the book that I began to realize I had tapped into something bigger than tease therapy: I learned that there are people who die of orthorexia.

That was a shock. I understood that people can make themselves crazy with healthy diet , but not that the problem can lead to death. However, orthorexia truly can kill, via malnutrition. People with this kind of severe orthorexia don’t think they’re too fat; they think they’re  impure. They want to cleanse, not to lose weight. The conscious motivation is quite different.

Because the concept of orthorexia was still little known, eating disorder specialists didn’t ask the right questions. They would say to such people, “You think you are too fat.”  But that is not what it feels like to be orthorexic. This misunderstanding led to treatment failure, with occasionally tragic results.

Even when orthorexia is not fatal, it can commandeer a person’s life. Eating disorders have that power.

The Power of a Word

Later, serious academic study of orthorexia began to occur. Organizations like the International Federation of Eating Disorder Dietitians (IFEDD ) and the National Eating Disorders Association (NEDA) began to discuss the concept at meetings and in their published literature. Thom R. Dunn Ph.D of the University of Northern California published a formal article on a case of orthorexia, and proposed diagnostic criteria. [Note: Dr. Dunn and I will be soon be publishing revised criteria that we expect to be definitive.] The authors of the DSM, the American Psychiatric Association’s classification and diagnostic tool, were even quoted as considering it for inclusion.

Perhaps most important of all, young women like Jordan Younger can now say to themselves, “I want to eat healthy food, but I don’t want to be orthorexic.”

Naming is powerful. When it comes to food, we need all the power we can get, because food can make you crazy. It hits you in the heart and goes to self esteem. It taps into all that is lonely and empty and needy, and promises to fill that emptiness. It triggers dark places. It can tie up your mind in knots so intricate and strong that even the search for healthiness can become unhealthy.

Against this, the word orthorexia is a signifier. It indicates a limit, a point not to go beyond even in search of healthy diet. Or, if you’ve already gone beyond, it can help you find your way  back.

This is what happened for Jordan. After achieving fame as proponent of veganism, she came to understand that she had orthorexia. Since then, she has been liveblogging her awakening. I do not in general recommend live blogging as a method of recovery, but it is brave.  Bravery is powerful and it is healing.

Do You Have Orthorexia?

Do you wonder if you have orthorexia? Read this book. Jordan’s journey does not describe every person’s path; it is personal to her demographic, her childhood, herself. But if you have orthorexia you will recognize yourself here.

Do you turn to healthy food for happiness, for meaning?

Eating the perfect diet might make you less likely to get cancer, and it could  prevent bloating and give you more energy. But it won’t make you happy. Using food as primary refuge is a form of spiritual materialism. You are filling the space that longs for love with mere stuff. To quote Jordan, “I was entering into a relationship with veganism …. veganism became my boyfriend, my best friend, and my confidant.”

Does your healthy diet make you feel important? “The strict diet helped me feel extraordinary when I was very fearful of being ordinary.”

Does healthy diet make you feel in control? Do you have to keep upping the ante to get the same kick? “[Veganism] triggered a desire within me to be more and more extreme, more and more pure, and to achieve more and more nutritional perfection to the point where no foods were safe. ”

Do you use diet to ward off anxiety, not just about health, but about everything? Has the idea of healthy food become a kind of brain parasite, taking over your life, ceasing to serve you and instead making you its slave?

If you recognize yourself in any of this, read this book. If it resonates, consider consulting an eating disorders specialist who appreciates orthorexia. It may change your life. It may even save it.

— Steven Bratman, MD, MPH

One of the most disturbing manifestations of orthorexia is its common occurrence among girls in early adolescence. A high percentage of the personal communications I receive on this blog involve such young women and their distressed parents. At the fragile physical onset of puberty, these girls are following “healthy food diets” that amount to starvation.

A frequent entry point for orthorexia in this group is ethical veganism. This is a philosophy with much to admire and naturally appeals to any idealistic person. Unfortunately, in a young women this noble impulse can combine with others that are less benign to create an eating disorder.

Perhaps the most powerful complicating factor is simply weight. Veganism (especially of the raw foods variety) just so happens to involve foods that are low in caloric density. A young vegan while only intending to eat healthy and spare animals pain can easily drop her weight to subnormal or dangerous levels. As soon as she does so, she notices (whether consciously or not) that she looks like the excessively thin female images that dominate in the culture. This is emotional heroin.

But it is heroin acting unconsciously. The young women I am talking about do not think much if at all about their weight. It’s all about health. Consciously, they want to become a perfect physical specimen, immune to health problems big and small, whether bloating, or fatigue or leukemia. Deeper within, they are trying to control something that can’t be controlled, the messiness of being human.

Health foodism presents an attractive solution. By concentrating all their attention on food (and perhaps exercise) they can escape the horrible complexities of life.

But food is too small a thing to bear so much soul; these young women take the power that by right belongs to them and give it away to food.  That’s practically the definition of an eating disorder.

Also, fasting makes you high. Fruit and vegetable smoothies are so luminous and pure that they seem to feel the body with radiant health. These girls feel fantastic; their intuition doe not tell them that they are starving themselves to death.

To make matters even more complicated, a part of the teenage girl’s mind wants to starve herself to death; wants, at least, to engage in some desperate self-deprivation. She also wants to be different, special and better. Being a teenage girl is hideously hard.

And she has practically no idea what she is truly feeling. That type of insight only comes to us after another decade or more of screwing up.

Even if she did have the insight, her brain is malnourished and not working properly.

She is in deep water.

Health Food Book Responsibility

The authors of health food books bear some responsibility. Young readers (like readers of any age) tend to believe that because an idea is published it has a greater likelihood of being true. But there is no filter, no requirement of accuracy required for a book to be published. People can write whatever they want.

And they write some seriously crazy things.

One of the most ignorant and harmful (even evil) health food theories I’ve run across states that menstruation is due to impurities in diet. Under the influence of this idea, one young woman with whom I am in contact believes that her amenorrhea may indicate she has attained a higher state of purity. Needless to say, this concept flies in the face of history, biology and common sense. Menstruation is above all things natural — but truly “natural” is messy, scary and often downright weird.  How much emotionally safer it is to pretend it all has to do with impure diet.

I was once the medical director of Prima Publications, a company that published books on alternative medicine. I remember evaluating one book proposal, and phoning the author to complain. “What you write in Chapter 1 — it simply isn’t true,” I said.  I was treated to a long silence before a puzzled voice said, “Yeah. Uh-huh.  I don’t get it. What’s the issue? ”

Of course, conventional medicine is highly imperfect. But at least it has some system for vetting knowledge. The system has many loopholes and failures, but it exists and works to some extent. There is nothing whatsoever to serve this role among alternative diet books. Authors can say anything they want, and people will believe them.

This is especially the case for young people, because alternative health books belong to a paranoid subculture that naturally appeals to person just beginning to learn that authority figures can be totally wrong.

There is, in fact, much to be paranoid about. Big pharma is in fact insidious and dangerous, agribusiness does not in the least have humanity’s best interest at heart, and conventional medicine has made and continues to make many errors. However, in practice what happens that these genuine issues open a door to an unlimited world of imaginary claims, where authors say whatever they want and then shut the door to critique by saying, “Of course they will tell you this is wrong. That’s what they always say.”

Getting Help

It is very difficult for a young girl with orthorexia to even recognize that she has a problem.  But if she does seek help, either at her own initiative or at the instigation of her parents, those she encounters may assume she has anorexia and treat her inappropriately.  For example, they may strongly encourage she consumes “foods” that restore caloric intake such as Boost or Ensure but that, for obvious reasons, will be perceived as refined, processed, chemical-rich and gross. This has a tendency to invalidate the source of the advice for a young person already inclined to distrust that advice.

I earnestly implore eating disorder specialists to listen to their patients and recognize the difference between orthorexia and anorexia, so as to be able to provide help that can be received.

If you are a young woman with orthorexia, don’t just listen to me. Seek the insights of other women, just a little older, who have gone through it and come out the other side.  They have learned a lot about themselves in the process, and can tell you what the road looks like from just a bit further on. Here are some names/links.  I intend to add more.

Jordan Younger

Kaila Prins

Maddy Moon

I also encourage you to contact these authors and see if they will talk to you personally. Maybe your story will resonate with them, and they will reach out.

One last thing:  At some level, you know that what I’m writing here is true.  There is just a louder part that has its finger in its ears and is shouting, “No! No! No!”  You don’t know how to sort out these internal arguments yet.

But you will figure it out, because deep down you are whole and sane.  You will find your way through the haunted forest. It won’t be easy, but eventually you will get where you want to be, and things will start making more sense.

Sincerely,

Steven Bratman, MD

PS. If you are a young woman who has recovered from orthorexia, and have a podcast or blog you think might be helpful for adolescent girls with this issue, please use the Contact form on this blog to get in touch with me.  I will add it to this page.

People who want to eat healthy food don’t become orthorexic unless there is something deeper going on. Often, that deeper something is best described as anxiety.

The most obvious anxiety related to orthorexia is fear of illness. You want to believe that if you are very careful with what you eat, you will be safe from every health problem that scares you, whether its cancer, bloating, blemished skin or depression. But it goes further than that. Whether you are conscious of it or not, somewhere along the line you began to use food as a primary strategy to fend off every kind of anxiety. When you are stressed about relationships, your job, the purpose of life or what your friends think of you; when it is guilt, shame, love or loss that has put you off balance, the magic cure is to eat pure food.

Deep down, you know perfectly well this is a lie you tell yourself in order to cope. While food is important for health, the slice of pizza you eat today is NOT going to give you cancer tomorrow, nor will eating the best diet in the world immunize you against illness. Furthermore, diet cannot give you love, friendship, meaning or happiness. Food, in the end, is just stuff you put in your mouth.  

One residential treatment program for orthorexia I recently heard about uses a clever strategy to help people understand how they use food to fend off all forms of anxiety. In this program, the food is served by a chef closely advised by dietitians. The rules of the game are that the chef may not under any circumstances reveal whether the food served in a given meal is organic or not, whether it has preservatives, contains GMOs, etc. In point of fact, the food served in the program is mostly organic and chemical-free, but not 100% of the time, and there is no way for the people who eat the food to know when they are consuming substances that their theory of eating would forbid. (People in the program also keep a journal of how they feel, and it turns out that they do NOT guess correctly when they have eaten “impure” food.)

As you might imagine, for a person with orthorexia this is extremely anxiety-provoking. Not only does it stimulate food-related worries, it removes the possibility of using food purity as a coping mechanism against other forms of worry. And that is the real point: The experience forces participants to begin to develop a range of ways to cope with daily stress, rather than abusing food purity as the answer to every problem. 

You might object that it is truly rational to be concerned about food additives, whether vegetables are organic, and etc. Wouldn’t any sane person would want to eat healthy food? Perhaps yes. But no matter what dietary rule you believe to be correct, it simply can’t be necessary from a health-related perspective to follow it without exception. The quantity of pesticides contained in a single serving of non-organic food is dwarfed by the quantity of chemicals taken in simply by living and breathing in the modern world. You focus on food because it’s something you can control. And that’s perfectly sensible — but only to a point. Past that point further purification of your diet won’t make you healthier; it will only make you more obsessive.

A mostly “pure” diet is good enough. Aiming for 100% is only an excuse not to come to terms with the elephant in the room: Life, in all its messy glory.

— Steven Bratman, MD, MPH

To contact me, leave a comment, or find me on Twitter @StevenBratman

In order to study a proposed psychological condition such as orthorexia nervosa, researchers utilize what is called a “survey tool,” a questionnaire that can identify people who may have that condition.

Such a research tool is tricky to create. The tool most commonly used up until now, the ORTO-15, is in need of updating, and various researchers are attempting to do this. Thom Dunn, the Colorado researcher who coauthored a paper with me outlining new formal criteria for orthorexia, is soliciting help in creating his own proposed improvement to the ORTO-15.

Those interested in participating are invited to complete a short survey about their eating and dietary habits. Dr. Dunn is looking for a wide range of individuals, including those who have no issues with eating and diet. The survey should take no more than 15 minutes to take, most spend 5 to 10 minutes on it. Responses are anonymous.

Eating clean grabs at you because it stirs the quest for purity. That’s what’s behind the cleanse, the detox, the quest for total avoidance of imperfect food. Orthorexia flows from the same impulse that drove the monks and nuns of the Middle Ages: cleansing from sin.

In dietary purity, one seeks to be physically holy, and holier than others. Just as the monk self-flagellated for sexual desire, the food purist self-punishes for wanting coffee, meat or sugar. “I have befouled myself with non-organic chips, I am unclean. ” Total commitment to a pure food diet is a vow of food chastity, a war against the lower desires of the flesh.

But the search for absolute purity is a rejection of the natural self.  It is as much a war against the body as the crusades of any puritanical religion.

James HIllman, the great Jungian, distinguished between soul and spirit. Spirit is the sky, the air, pure light, vast emptiness, the high you get while fasting. The soul is deeply felt passion, character and joy. To become pure spirit is to become an angel; to become soulful requires embracing the intestinal, sweaty, impure physical reality of human being.

It is a greater, and more difficult thing to be a whole human being than an angel.

Eat healthy food but sometimes give in to desire.

Don’t try to be perfect. Try to be whole.

–Steven Bratman, MD, MPH

To contact me, leave a comment, or find me on Twitter @StevenBratman

Orthorexia nervosa, as I defined it in 1996, indicates an unhealthy obsession with eating healthy food. The term is derived utilizing the Greek “orthos,” which means “right,” or “correct,” and is intended as a parallel with anorexia nervosa. I originally invented the word as a kind of “tease therapy” for my overly diet-obsessed patients. Over time, however, I came to understand that the term identifies a genuine eating disorder.

Please note that I do not, and have never claimed that vegetarianism, veganism, or any other nutritionally sound approach to eating healthy food is in itself a disorder. That would be absurd! Nor do I think that people who pay close attention to labels on the foods they mean to purchase are demonstrating a psychological problem (as some web articles on orthorexia would appear to imply.) Finally, I entirely agree that the problem of addiction to junk food is immensely more prevalent than obsession with healthy food.

Nonetheless, it is possible to have an unhealthy obsession with healthy food.

Anorexia is the parallel. Obesity is by far the biggest lifestyle-related health issue today, and every reasonably health-conscious person does what is necessary to achieve and maintain a normal BMI. Still, for various psychological reasons some people go overboard and become anorexic. Similarly, any reasonably health conscious person would wish to minimize intake of preservatives, pesticides, antibiotics and all the other garbage that pollutes our food supply. However, some people who are devoted to healthy eating go overboard and develop an eating disorder in relation to that focus, just as some people in their quest to avoid obesity become anorexic.

For people with orthorexia, eating healthily has become an extreme, obsessive, psychologically limiting and sometimes physically dangerous disorder, related to but quite distinct from anorexia. Often, orthorexia seems to have elements of OCD, as does anorexia. Some people with orthorexia may in fact additionally have anorexia, either overtly or covertly (using pure food as a socially acceptable way of reducing weight.) But orthorexia is usually not very much like typical OCD or typical anorexia. It has an aspirational, idealistic, spiritual component which allows it to become deeply rooted in a person’s identity. It is most often only a psychological problem in which food concerns become so dominant that other dimensions of life suffer neglect. In rare cases, however, it can be much more severe, even resulting in death via malnutrition.

The primary feature distinguishing orthorexia from anorexia is that while a person with anorexia focuses on weight, a person with orthorexia obsesses about purity. People with anorexia possess a distorted body image in which they see themselves as fat regardless of how thin they really are, whereas those with orthorexia constantly struggle against feelings of being unclean or polluted by what they have eaten, no matter how carefully they monitor their diet. Both conditions involve control, but whereas an anorexic seeks continually to reduce weight, an orthorexic feels compelled to achieve ever great heights of dietary perfection; to feel entirely clean, pure and transparent. Sometimes people recovering from anorexia “graduate” to orthorexia, keeping their disordered eating habits and moving the focus from weight to purity.

Although widely discussed by eating disorder experts, orthorexia is not yet a DSM diagnosis, and I am not sure that it should be. There is a tendency in the modern world to pathologize an increasing number of human behaviors and I have no desire to contribute to this trend. On the other hand, naming has power. I have heard people say, “I want to eat healthfully, but I don’t want to be orthorexic.” Perhaps this is the best possible use of the word.

Do you have orthorexia? Ask yourselves these questions: Do you turn to healthy food as a primary source of happiness and meaning, even spirituality? Does your diet make you feel better than other people? Does it interfere with relationships or work, friends or family? Do you use pure foods as a sword and shield to ward off anxiety, not just about health problems but about everything that makes you insecure? Do foods help you feel in control more than really makes sense? Do you have to carry your diet to further and further extremes to provide the same kick? If you stray even minimally from your chosen diet, do you feel a compulsive need to cleanse? Has your interest in healthy food expanded past reasonable boundaries to become a kind of brain parasite, controlling your life rather than furthering your goals?

Food, no matter how pure, cannot fill the space in your soul that longs for love and spiritual experience. If you are trying to use it for this purpose, you may have gone astray on your journey.

Perhaps the resources on this site may be helpful, including my occasional blog posts. You might consider reading my book, Health Food Junkies. But most of all, if you feel your condition has become too much for you to manage on your own, visit an eating disorder specialist who understands orthorexia.

Sincerely,

Steven Bratman, MD

To contact me, leave a comment, or find me on Twitter @StevenBratman