Orthorexia Nervosa: A New Eating Disorder?
Monday, May 22, 2017
Most people are aware of the eating disorders Anorexia Nervosa and Bulimia Nervosa. These eating disorders are defined by whether the individual is at or below ideal body weight. Newer eating disorders in the latest edition of the Diagnostic and Statistical Manual of the American Psychiatric Association – 5th edition (DSM-5) include Binge Eating disorder and Avoidant/Restrictive Food Intake Disorder (ARFID). But have you heard of Orthorexia Nervosa? The term was first coined by physician Steve Bratman in the late 1990s after watching individuals who had pathologically healthful eating. In other words, people were making themselves sick by sticking to a disordered eating pattern that they thought was benefitting their health.
While not in the DSM-5, Orthorexia Nervosa (ON) has primarily the interest of European Scholars. Interest in the US started to pick up steam in 2015. This is when Jordan Younger, who blogged under the name “the Blonde Vegan,” announced to her 70,000 social media followers that she had the condition. This caused a flurry of interest in among media outlets in the US, and she appeared on shows such as Good Morning America. At the time, there had been only one paper published in mainstream US psychiatry journal on the topic.
While research in this area is still growing, the consensus among those who study the phenomenon agree that ON is not like traditional eating disorders. Unlike Anorexia or Bulimia, those with ON do not seem to have a disrupted body image, nor a drive for thinness. Their compulsions around food are not to be thin, but to be healthy. Of course, those who regularly practice healthy eating are not pathological. It’s those whose drive for healthy eating makes leads to being malnourished who have trouble. This is also the case for people whose healthy eating makes it difficult for other people to be around them.
Most people probably have a friend or relative who may have features of ON. That is, everyone knows someone who may get a little carried away about their healthy eating. When this becomes concerning is when the individual starts having health effects from their diet. Low energy, malnutrition, and electrolyte imbalances can be common. It is also an issue when their eating habits start interfering with holding down a job. Or when the individual starts aliening friends or family due to their dieting.
For example, one woman reported that she was strict about healthy eating. On the surface, there is nothing wrong with this. However, she had restricted what she would eat to only a few food groups, and eating outside her home was almost impossible. She would simply bring her own food. This was a source of contention between the woman and her boyfriend. Things boiled over when the boyfriend asked this woman to go to dinner with his parents. “But,” he said, “You have to promise not to be weird about food. Please, this is important to me.” The dinner had barely started when the woman got into a fight with the waitress over the content of the croutons in her salad. “We broke up that night,” she said.
How many people suffer from ON is up for debate. Many studies with European samples report an impossibly high prevalence rate. While most eating disorders affect about 1% of the population, some of these European studies found prevalence rates as high as 70%. A study that my colleagues and I conducted in Colorado in 2016 found 60% of our sample of college students met criteria using an Italian measure to assess for ON. Oddly, only 20% reported even dieting at the time. Ultimately, we concluded that researchers are using a flawed instrument to measure ON and the true prevalence is less than 1% of the population.
The most severe cases of ON that I have seen in clinical practice are instances where people have died from malnutrition. In each of these instances, the patient started restricting their intake in order treat some medical malady. One gentleman had been told by a chiropractor that by eliminating trans-fats from his diet, he could cope with an auto-immune condition. Unfortunately, the patient took this advice too far, and he had removed most food groups from his diet, restricting his intake to only eggs. His insight was very poor and he ultimately died from malnutrition.
Fortunately, cases like this one are few and far between, but as awareness of orthorexia grows, so will our understanding of this condition.