Orthorexia Nervosa

From Virtuous to Vicious

By Ruth Werner
[Pathology Perspectives]

This article is a bit of a departure from the typical Pathology Perspectives column. It is focused on a phenomenon, not yet fully accepted as a freestanding disorder, called orthorexia: a pathologic obsession with eating healthfully. The obsession is so extreme that people with this condition can literally “health themselves to death.” I offer it partly because massage therapy may have a role to play for clients dealing with orthorexia, but mainly because health-care providers—that’s us—turn out to be unusually susceptible to some of the problems this condition can bring about. And because our clients look to us as role models for wellness, it is worth taking a close look at our attitudes about food, eating, and health.

The Challenge of Food
Food is a glorious necessity. We need food—a wide variety, with the right ratios of all the essential ingredients, or we get sick and die. Somehow in the process of our evolution, humans have figured out how to derive a usable balance of nutrients, minerals, and vitamins from our surroundings. Our haphazard intake of calories allows us to grow, fight disease, reproduce, and engage in all the activities that characterize being alive.
It would seem that in our millennia of experience as food-consuming organisms, our nutritional intake would become less haphazard, and we would develop a reasonably solid, widely applicable, predictable, and functional recommendation for eating that people would be willing to follow. Nothing fancy, just some simple guidelines about what to eat, where to get it, how to prepare it, and how much to have. But as we all know, diet science is far from fixed, and human appetites don’t always follow best practices.
A brief look at food culture in the United States dating from the 1950s shows distinctive cycles in our approach to food. We have swung from a primarily farm-and-garden culture of the ’40s and ’50s to the drive-through restaurants, artificial sweeteners, processed cheese food slices, and never-stale snack cakes of the ’60s. The ’70s brought us macrobiotics and the natural foods movement, where we rediscovered the virtues of brown rice, soaked beans, and the use of carob as a sad, sad substitute for chocolate. The ’80s brought us Pritiken, and the ’90s delivered Atkins, super low-carb diets (and clients with truly awesome flatulence), and—my personal favorite—the cabbage soup regimen. The ’00s were all about South Beach and the Mediterranean diet. Now we are bombarded with messages about going gluten-free, the advantages of the paleo diet, and the dangers of nonorganic, GMO-enhanced “Frankenfoods.”
Today’s eater has a harder task than ever before. How is it possible to make sense of all the messaging we receive about food and health? Where, in the bombardment of our senses through television, the Internet, and even billboards on the streets, can we find some kind of truth about healthy eating? This is an especially challenging issue for massage therapists and other health-care professionals. We are better educated than many about nutrition and healthful eating, and we want to take responsibility for being good examples. But with so many conflicting messages being hurled around us through every medium, how do we settle on the “right” diet? Does such a thing even exist?

History of Orthorexia Nervosa
In 1997, after having been an organic farmer, a cook at a commune, and a holistic medical specialist in nutritional healing, Stephen Bratman, MD, coined the term orthorexia nervosa to describe a pathologic pattern of “righteous appetite.” He based this description partly on his observations with his patients, but also on his own experiences as he struggled with the challenges of eating healthfully. He wrote a book on the topic: Health Food Junkies: Overcoming the Obsession with Healthful Eating.1 Bratman reflects on his experience with orthorexia:
“After a year or so of this self-imposed regime, I felt light, clear headed, energetic, strong, and self-righteous. I regarded the wretched, debauched souls about me downing their chocolate chip cookies and fries as mere animals reduced to satisfying gustatory lusts …
… Gradually, however, I began to sense that something was wrong. The need to obtain food free of meat, fat, and artificial chemicals put nearly all social forms of eating out of reach. Furthermore, intrusive thoughts of sprouts came between me and good conversation. Perhaps most dismaying of all, I began to sense that the poetry of my life had diminished. All I could think about was food.”2
Bratman developed a set of criteria whose purpose was to determine whether a patient might show orthorexic tendencies. The criteria include these features:
•    Investing three hours or more each day in planning, finding, preparing, eating, and concentrating on food (this is for people who don’t work in the food industry).
•    Feeling superior to others whose diets are not as “pure.”
•    Rigid adherence to an eating regime; any faults or shortcomings are followed with compensatory action (usually fasting and additional restrictions).
•    Associating self-esteem with adherence, and the converse: associating lack of adherence with self-loathing, disgust, and guilt.
•    Being centrally focused not on weight or appearance, but on eating properly.

In addition, Bratman developed a questionnaire of 15 items called the ORTHO-15, in which people are asked to rate on a 4-point Likert scale their feelings or behaviors about food. A sample question might read, “I spend hours every day thinking about food safety,” with the instruction to choose “Always,” “Often,” “Sometimes,” or “Never.” The higher the score, the fewer orthorexic tendencies are identified, and a score of 40 or under is proposed as the diagnostic marker for the condition.3
While it has been useful to have these benchmarks, the diagnostic criteria and questionnaire developed by Bratman have not been fully validated in clinical research. As of this writing, the bulk of research into orthorexia nervosa has been done in Europe. Several items on the original ORTHO-15 have no cultural reference for some of the studied populations, so other versions of the questionnaire have been developed. In addition, because the Bratman survey doesn’t account for food-related obsessive-compulsive behaviors, some specialists recommend combining the ORTHO-15 tool with another survey that is sensitive to obsessive-compulsive disorder (OCD) issues, the Minnesota Multiphasic Personality Inventory.
As the study of this phenomenon has evolved, other specialists have proposed alternate diagnostic criteria, using many of Bratman’s concepts but adding others, including:
•    Intolerance for others’ food beliefs.
•    Spending excessive amounts of money relative to one’s income on foods because of their perceived quality and composition.
And they go further to identify when the habits that start out as virtuous turn vicious:
•    Health becomes impaired because of nutritional imbalance or malnutrition.
•    Severe distress and social impairment interfere with function in social, academic, and vocational settings, because of the patient’s beliefs about healthy eating.
And a final nuance:
•    The disturbance is specifically not due to another disorder like OCD or schizophrenia.
•    The behavior is not accounted for by religious food observance or in relation to professionally diagnosed needs for a special diet.4

Orthorexia: Compare and Contrast
Many eating-disorder specialists agree that Bratman’s description is a real phenomenon. Having a set of clear and validated diagnostic criteria for this condition is important; otherwise, health-care providers or researchers can’t know that they’re talking about and trying to identify and treat the same condition.
This all boils down to a central question: what is orthorexia? Is it an eating disorder? Or is it an anxiety disorder? Or both—or neither? The lack of a clear answer is problematic because the characteristics of orthorexia overlap substantially with characteristics of other psychiatric issues, especially anorexia and OCD. This muddies the water both for clear diagnosis and for finding the best possible treatment options.
Here is one researcher’s definition of orthorexia:

A pathological obsession with proper nutrition that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure.5

This description includes aspects of both anorexia and OCD. Indeed, as scientists look more closely at orthorexia, the areas of overlap with these other disorders, along with the areas where they definitely do not overlap, yield some fascinating information.
The following diagram is a simplified version of a chart found in the cited articles that highlight the relationships between orthorexia and similar conditions (see below).
It is clear that areas of overlap are substantial, but one of the most important distinctions is in the sense of motivation behind these behaviors. People with orthorexia are not trying to be thin or fit, nor are they motivated by physical appearance; they are simply trying to be healthy. This may also speak to why people involved in health care seem to be more vulnerable than many other populations: we are all trying to be healthy for our own sakes, but also as examples for our clients and patients.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the reference most commonly used in the United States to categorize mental disorders. The fifth edition was recently published, and it lists a new heading under eating disorders: avoidant/restrictive food intake disorder, or ARFID. Orthorexia may fit under this heading, and in subsequent editions this condition may appear as an ARFID subtype.

The Controversy
At this point some readers may be experiencing signs of hypertension. Maybe your stomach is roiling, and your teeth are grinding, as you draft your letter to the editor. “Are you seriously suggesting that it’s an illness for people to be concerned about food safety?” Or, “Really, Massage & Bodywork? Now we are pathologizing the idea of healthy eating? I expected better.”
No one is making the argument that most Americans are trying too hard to eat healthily. But for some, the goal of eating right actually creates disease. Patients can become so consumed with “doing it right” that the variety of foods they find acceptable becomes narrower and narrower. Any deviation leads to guilt, self-loathing, and compensatory activities that can range from extended fasting to extra exercise, often followed by a commitment to an even more limited diet.
Those who go through treatment for standard eating disorders like anorexia or bulimia may eventually find themselves on the orthorexia merry-go-round. They replace one food-related goal (being thin) with another (being healthy), but it doesn’t necessarily improve their well-being.6
To make things even more difficult, many people start down this path because they begin with some kind of digestive upset or other health problem that can be addressed with nutritional changes. Sometimes it’s because a loved one is battling a disease and they are making dietary adjustments for their sake. But for reasons that aren’t clear, the range of foods they can consume without pain or negative reactions becomes restricted to the point that it is impossible to access the range of nutrients, vitamins, and minerals that are necessary for even baseline function. People can make themselves sick; people can even die from complications related to this disorder. Anecdotes from caregivers include the development of anemia, acidosis, osteopenia, and dangerous changes to blood chemistry and heart function.

What Can Be Done?
As researchers Nancy Koven and Alexandra Abry put it, “Asking severely orthorexic patients to abandon false food beliefs is really a request to discard a deeply held ideology.”7
Treatment for orthorexia is a largely undeveloped field. Even experts in anxiety disorders and eating disorders are often at a loss. Some recommend low-dose antidepressants, which can also act as anti-anxiety medication. Antipsychotic medication may be prescribed to interrupt the delusional thinking about food that orthorexic patients experience.
Psychotherapy that focuses on control issues, similar to that used with anorexia, is often called for. The goal of treatment isn’t primarily to change how someone eats; it is to change how that person feels about preparing and eating food, which can require imaginative and personally customized treatment. Many people in recovery find their way to wellness with the help of medical professionals and loved ones, but always with the fear of the damage they will do to themselves by reverting to their former, “impure,” eating habits.
Massage Therapists, Massage Therapy
Regardless of whether orthorexia is ever recognized as a disorder in the DSM, it is clear that a certain population of people experience deep unhappiness and physical illness paradoxically caused by their efforts to be healthy. Whether this should be considered an eating disorder, an anxiety disorder, or some combination of the two, the research supports massage therapy as a relaxation-inducing coping mechanism for people who can receive it well. In addition, massage therapy provides a way to connect with another human being on a profound, if nonverbal, level. This can serve to gently alter the isolation that many people feel when they are forced by their condition to separate themselves from many social situations.
As people who are aware of healthy nutrition, massage therapists are vulnerable to orthorexic tendencies. And, like it or not, we serve as role models for our clients. Clients may follow the examples we set—rather than the advice we provide—about exercise, getting massage, smoking, getting enough sleep, and also about our relationships with food. This isn’t to suggest that every massage therapist needs to be perfect in all things. But it does suggest—strongly—that we can serve our clients best when we are models of optimism, of conscientiousness about taking care of ourselves, and perhaps above all, of forgiving ourselves with good humor when we fall short of our goals.

1. Steven Bratman and David Knight, Health Food Junkies: Overcoming the Obsession with Healthful Eating (New York: Broadway, 2001).  
2. Steven Bratman, “The Health Food Eating Disorder,” Yoga Journal, October 1997, accessed May 2015, www.orthorexia.com/original-orthorexia-essay.
3. Anna Brytek-Matera et al., “Orthorexia Nervosa and Self-Attitudinal Aspects of Body Image in Female and Male University Students,” Journal of Eating Disorders 3, no. 2 (2015).
4. Ryan M. Moroze et al., “Microthinking About Micronutrients: A Case of Transition From Obsessions About Healthy Eating to Near-Fatal ‘Orthorexia Nervosa’ and Proposed Diagnostic Criteria,” Psychosomatics, March 19, 2014.
5. Nancy S. Koven and Alexandra W. Abry, “The Clinical Basis of Orthorexia Nervosa: Emerging Perspectives,” Neuropsychiatric Diseases and Treatment 11 (2015): 385–94.
6. Cristina Segura-Garcia et al., “The Prevalence of Orthorexia Nervosa Among Eating Disorder Patients After Treatment,” Eating and Weight Disorders, December 28, 2014, accessed May 2015, www.ncbi.nlm.nih.gov/pubmed/25543324.
7. Nancy S. Koven and Alexandra W. Abry, “The Clinical Basis of Orthorexia Nervosa: Emerging Perspectives.”

Ruth Werner, BCTMB is a former massage therapist, a writer, and an NCTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.