When Does ‘Clean Eating’ Become Disordered?
This term was coined in the late 1990s by Steven Bratman, MD, to describe those experiencing "an unhealthy obsession with eating healthy food." Though not everyone agrees on the label (and it's not currently listed in the Diagnostic and Statistical Manual of Mental Disorders, the assessment criteria used by psychiatrists), a 2011 survey showed that two-thirds of respondents—psychologists, psychiatrists, nurses, and social workers—reported working with patients who presented with "clinically significant orthorexia."
"Orthorexia often starts out as an innocent attempt to eat more healthfully, but can take a turn to a fixation on food quality and purity." —Neeru Bakshi, MD
Neeru Bakshi, MD, a board-certified psychiatrist and medical director of the Eating Recovery Center in Washington, describes how well-intentioned mindful eating can go off the rails. "Orthorexia often starts out as an innocent attempt to eat more healthfully, but can take a turn to a fixation on food quality and purity," she says. "This then develops into a rigid eating style, which can crowd out other activities, interests, and relationships, and can cause health issues."
As you might imagine, it can be difficult to distinguish between a commitment to healthy eating and this pathological condition. The latter is characterized by rigid dietary restrictions and ritualized eating—but couldn't those same words be used to explain your weekly meal prep or dairy-free life? What are the specific signs that identify orthorexia?
Common signs of orthorexia, a form of disordered eating
1. Attempting to control *everything* about the foods you eat
Food Coach NYC founder Dana James says disordered eaters attempt to exercise complete control over their diets. “There’s an extraordinary amount of fear [for them] to eat something that is outside of their healthy eating program, whereas a healthy eater is okay with that,” she says. So while a healthy eater may be willing to eat non-organic veggies if that's the only option, for example, someone who struggles with orthorexia might choose to not eat at all in this scenario—even if they're very hungry.
According to Dr. Bakshi, this behavior (which Younger documents in her book), can lead to social isolation, e.g. not being able to eat out at a restaurant or even a friend's house. For some who struggle with this disorder, Dr. Bakshi says, an "irrational concern over food preparation techniques, especially the washing of food or sterilization of utensils," may also become an issue.
2. Thoughts dominated by healthy eating
James further notes that a person dealing with a disordered relationship to food will have diet-oriented thoughts most of the time. “When you trust the way you eat, you don’t think about it,” she says.
Such generally aversive musings, she says, are often distorted, too. “‘Healthy’ is actually knowing that your body can handle things like a little bit of sugar,” says James.
Women's health expert Aimee Raupp adds that checking in with your emotional state—e.g., "Does eating give me anxiety? When? Why?"—can help you to gauge whether or not you have an issue. “If [eating something outside of your specific dietary program] is affecting your mood, then for certain there’s a bit of a disorder there,” she says.
Younger builds on this, adding what she's gleaned from her own experience. "I always tell people, when their thoughts about food start to become negative or obsessive in any way, their passion for healthy eating may be taking a swing toward the unhealthy side," she says. She keeps herself in check by asking questions such as, Does my relationship with food make me happy? and Does my food energize and fuel me? Are my thoughts about food positive, balanced, and joyful? "If the answers to any of those questions are a no, I do the internal work to ask myself what I am really trying to control or compensate for with food," Younger says. "If the answers are a 'yes,' then I know I am in the right place!"
3. Elimination of certain foods, even though you're not allergic
Frequent or excessive elimination of new food groups is another sign of orthorexia that Dr. Bakshi, Raupp, and James all point to. One day you're a vegetarian, then a vegan, then a raw vegan, then a Paleo raw vegan, and so on, until there's almost nothing left to eat. In fact, an ever-narrowing list of acceptable foods is one of the top signs of the disorder as listed by the Eating Recovery Center.
While James does note that sometimes, elimination diets are necessary in order to remedy a health crisis, she'll see patients who have adopted an incredibly restrictive diet prescribed for these purposes as their everyday, forever diet. This, she says, can sometimes become a disordered state. Dr. Bakshi also notes that the elimination of foods for allergy-related reasons without medical input is considered to be a sign of the disorder; however, it's worth noting that avoiding something because it doesn't make you feel good is fine so long as the list of foods avoided doesn't become, say, longer than the list of foods you still allow yourself to eat.
4. Excessive worry about the potential health risks of certain foods
One day, you're terrified of tomatoes because some new study says they cause heartburn. The next day, it's sushi (mercury!). The following, it's legumes. Dr. Bakshi considers this pattern of behavior a stop sign. "Obsessive concern over the relationship between food choices and health concerns such as asthma, digestive problems, low mood, anxiety, or allergies [is another potential warning sign]," she says.
The key in this phrase is "obsessive"—there's nothing wrong with evaluating the health effects of specific foods, to be clear. It's only when these thoughts form repetitious loops, become irrational, or affect your quality of life that they point to an issue.
The Food Therapist author Shira Lenchewski, RD, points out that it's easy for people to become overwhelmed by the sheer volume of health information available today, and that this may cause some to go to unhealthy extremes in their diet curation. "There are so many scare tactics out there," Lenchewski says. "Some of it is based on science, but [people will] pull out one piece of information, take a hardline approach, and then feel like total failures if they’re not implementing it," she says.
5. Increasingly complex supplement regimens
Dr. Bakshi notes that a "noticeable increase in consumption of supplements, herbal remedies, or probiotics," is also considered to be a sign of orthorexia. However, as mentioned above, it's important to note that what she's referring to is a significant increase in the number of supplements taken as well as an uptick in the obsessive thoughts that feed into drastic behavioral changes such as these. Adding a turmeric capsule to your routine doesn't mean you have an eating disorder, but relying on supplements alone for the nutrients you need may be a sign it's time to talk to your doctor.
6. Feelings of superiority about your diet
All four experts agree that orthorexia can be tricky to both self-identify and treat in others, for one specific reason: A person with orthorexia tends to feel convinced that their way of eating is correct or even superior to other diets. "People who do this truly believe they're doing the right thing, they really do," says James. "That's where the psychology has gone haywire." To gauge whether or not your own mindset might signify an issue, Dr. Bakshi asks, "Have you put yourself on a nutritional pedestal and wonder how others can possibly eat the foods they eat?"
Dr. Bakshi asks, "Have you put yourself on a nutritional pedestal?"
When trying to help someone else who exhibits this sign—or any others on this list—James suggests approaching them with compassion, from a non-judgmental place. "You might say, 'I noticed that there seems to be some fear around eating food that isn’t within your current diet philosophy. Do you want to talk about it?'" she suggests. She doesn't, however, advise use of the label in these discussions (she doesn't use it in her practice, either). "When you’re a healthy eater, there’s a lot of pride in that," she says. "No one is going to like the term orthorexia."
If you think you or someone you know may be experiencing disordered eating, reach out to family or friends, connect with your doctor or a treatment facility such as the Eating Recovery Center for a free evaluation, or call/text the helpline of the National Eating Disorders Association at 800-931-2237.
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