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Nov 16, 2006
Kira Cochrane
November 15, 2006

Puritanical diets could be a sign of an extreme eating disorder.

When Janet Hackney is asked when she last went out to a restaurant, there is a long silence. "It must be about five years ago, on my mum's 70th birthday. A group of us went to a restaurant where the owners know me and assured me they would provide food that I could eat, cooked exactly as I wanted. You can't get that very often, though, can you? So I usually don't go out. It's sad how it ruins your social life."

For Hackney, an obsession with eating only specific foods, cooked in certain ways, stretches back more than three decades. At 1.5 metres tall and just 35 kilograms, she was diagnosed with anorexia long ago and concedes that she eats an anorexic diet (with the osteoporosis and chest pains to prove it), but insists her disorder was never about the desire to be thin.

She says her food obsessions were dictated by the pursuit of health, an ache to fill her body only with foods that are good and nutritious and "pure". The roots of it, she says, are more accurately defined by another label: orthorexia nervosa.

Taken from the Greek "ortho" (meaning "correct" or "true"), this term was devised by a Californian doctor, Steven Bratman, in 1997 to describe a "fixation on righteous eating". It refers to people who, while generally not as extreme in their limitations as Hackney, are obsessed with healthy eating, concerned with quality rather than quantity, refining and restricting their diets according to their personal understanding of which foods are pure.

Any foods containing pesticides, herbicides or artificial additives, such as MSG, are often ditched, although regimens can vary wildly, with many orthorexics being raw foodists, vegans, fruitarians or, in one notable case that Bratman came across, committed to eating only yellow foods.

For Hackney, this compulsion began at the age of 10 when she eliminated all the obvious processed foods - fast food snacks, chips and chocolate. Shortly afterwards she gave up fats. This was followed by the exclusion of carbohydrates and a whittling away of proteins that has left her eating primarily chicken and turkey, low-fat yoghurt and low-fat cheese.

In an effort to gain weight, she has begun to eat the occasional sliver of butter again, but can't keep the tub in her own fridge. "Just the thought of having a tub of butter makes me feel awful and dirty. I don't like to touch it, so my mum keeps a tub at her house and brings it over. I put some in a beaker, so that no one could know what it is unless they tasted it."

While orthorexia rarely causes major health problems, it regularly leads to social exclusion and alienation, which, as Bratman has noted, are serious side effects. One of his patients, he says, doesn't have a life: "All she has is a menu."

Most orthorexics would find it difficult, if not impossible, to visit a restaurant. They spend hours each day thinking and talking about food, making meal plans, scanning the latest food research on the internet, visiting organic farms for "perfect" produce and slowly preparing, serving and chewing their food.

It seems that we are living in a uniquely orthorexic moment. There are constantly conflicting messages, particularly on the internet, about the health benefits of specific foods. Anxiety and confusion regarding how best to nourish ourselves are huge, and growing.

Restrictive diets crowd the bookshop shelves (including hundreds of fasting and detoxing programs), and the market in "free-from" foods (products that contain no gluten, say, or wheat) has boomed.

In this environment, where mass consumer choice meets information overload, anyone who commits themselves to healthy eating can find that one dietary refinement leads quickly to another, and the depth of their knowledge jeopardises the breadth of their diets.

In this atmosphere, too, a marked quirkiness around food has become a source of fascination, even admiration.

Where "that quirkiness used to reduce your status", says Deanne Jade, a psychologist and founder of the National Centre for Eating Disorders in Britain, "the attachment to strange eating systems and theories is now supported by a thriving industry and gives people a sense of status. So, for instance, when you go to a dinner party now, it's quite usual for people to say, 'Oh, I don't eat protein and carbs together, or I don't eat anything with the letter R in it, or on Tuesdays I can only eat red things.' And people are tolerant of that. The quirkiness has a seal of approval."

Journalist David McCandless first heard about orthorexia when one of his friends, a health writer, accused him of having it. "She was appalled by the contents of my fridge," he says. "I was into Japanese food so I had lots of organic hemp seeds, miso and fresh seaweed. There was no chocolate, no chips, none of the usual stuff."

McCandless doesn't think he is orthorexic but admits: "I don't know anyone more [concerned] about food than me. I constantly revise and revisit my diet. I've cut out caffeine. I've cut out dairy. I've been a vegetarian for 15 years and I'll probably never eat meat again. I don't eat soya - certainly not industrialised soya. I've just started on non-fat yoghurt again.

"I have all these little rules. Five portions of fruit and veg a day is fine for Joe Public - I aim to eat 10 minimum. I've recently got back into fish again, too, which I had cut out. Then I read an article about fish stocks being polluted and I had a little tremor of anxiety and almost went running straight back to my hemp seeds." He laughs. "Maybe I'm exaggerating slightly."

As McCandless sees it, the rise in orthorexic behaviour is at least partly because "there is no single authority that can tell us what's safe or not".

Among the qualities Bratman has defined as specific to orthorexics are an eagerness to evangelise about their regime and a conviction that their dietary path makes them a more spiritual person. McCandless does recognise these characteristics. "As soon as you start eating healthily there's a smug, self-righteous, judgemental, puritan, religious feeling that descends," McCandless says. "I'm really proud, for instance, when my lacto-ovo vegetarian kosher airline meal is delivered to me first on the plane."

For many of those who start on this path, the adherence to a strict diet masks psychological concerns. Mary Wood, a psychotherapist and chief executive of the charity Foundations UK, which provides information for young people on how to negotiate the "toxic environment" surrounding food, says that for some people orthorexia is the only way they know of asserting themselves, of creating an identity and establishing themselves as someone special. Diet becomes their primary or sole distinguishing factor.

"I think one has to look behind the orthorexic behaviour and ask why they need to assert themselves in this way," she says. There is still confusion over whether orthorexia should be recognised as a specific eating disorder. In 1997 when Bratman devised the term many experts contended that it couldn't be a new disorder because in its less intense forms "orthorexic" behaviour isn't a problem, and many experts felt it was encouraging to see people taking care to eat healthily. Also, in its extreme forms it was simply a variant of other established eating disorders, such as anorexia.

Speaking to British experts almost 10 years later, though, there seems more acceptance that it exists as a separate condition, although no one has done the exacting research that would gain orthorexia recognition by the medical establishment.

In 2004 researchers at the University of Rome carried out the first study to try to determine its prevalence. Out of 400 subjects, 28, or 6.9 per cent, were found to be orthorexic, with the prevalence, interestingly, higher in men than in women.

Steve Bloomfield, spokesman for the UK Eating Disorders Association, sees orthorexia as an obsessive-compulsive disorder. "It is not recognised by the medical profession as a disorder in its own right," he says, "but that doesn't mean it doesn't exist. Just because bulimia nervosa only had the diagnostic criteria specified 26 years ago, that doesn't mean it didn't exist 27 years ago - it plainly has existed for hundreds of years."

The concern about orthorexic behaviour as a gateway to other eating disorders is echoed by others. "Orthorexia can overlap into anorexia quite rapidly and vice versa; an anorexic might try to escape the disorder by adopting an orthorexic approach to eating, which extends that sense of being in control," says Jade. "The personality traits that you see in anorexics and orthorexics are often similar: people who are scared of risks, have perfectionist attitudes, a desire for simplicity and a tendency to live their lives more to avoid harm than anything else."

Jade has also seen many orthorexics who binge-eat between dietary systems, or have a tendency to develop bulimia. Any orthorexic diet, "is very difficult to maintain", she says. By cutting out foods, or even whole food groups, people can end up so nutritionally depleted that bingeing is inevitable. When this happens, orthorexics tend to return wholesale to their former regimen or, in penitence, develop an even more restrictive one.

The orthorexic diet is unbalanced. Jade says: "They have cravings and then they binge. There are orthorexic bulimics, orthorexic binge-eaters and many orthorexic fat people, too, who eat compulsively. I had one person who came to me who was bingeing horrifically on biscuits and cakes and it was obvious to me that she wasn't eating enough protein to sustain her. I tried to address that and she gave every excuse under the sun for why she couldn't include protein in her diet - because I'm vegan, because dairy gives me mucus, because my naturopath told me eggs are very bad for me . . ."

Given all the problems that orthorexia can lead to, is there any way to treat it? The problem seems to be that, even among those orthorexics who recognise that they have the disorder, few see it as a problem. In fact, many consider it a badge of honour. On the internet you find people like Renee who posts pictures of her meals on her personal website. She writes: "Do I have orthorexia? Yeah, probably. Do I care. Nooooo . . . I decided that whole 'recovery' thing is for suckers and weaklings . . . Several months ago I backed off the bodybuilding nutrition and decided I was going to relearn to eat like a normal person. You know what? Normal people are fat and depressed!"

Given that orthorexics are convinced that they are eating healthily and get a great deal of attention as a result of their dietary quirks it seems unlikely that many will seek help. "Rather than doing that they are more likely to say, 'You're the one who should be asking for help, given what you are doing to your insides," Wood says.

Jade agrees. "I think it would be about as alluring for an orthorexic to get help as it is for an anorexic to get help . . . Anorexics have only one system, which is to reject food. Insofar as orthorexics have a number of systems to choose from, and can move from one to another, then it's almost unknown for an orthorexic to say they want to change. It's about the hardest thing in the world to dent someone's system and convince them to eat food that they actually think is going to harm them. I mean, would you?' "

Given that this disorder is so difficult to treat, it is fortunate that it rarely causes severe health problems like Janet Hackney's. But it still seems worth addressing. After all, orthorexia may win you attention and allow you to feel superior when you see someone slobbing down the street eating a McDonald's Happy Meal but, at the very least, it can also leave you feeling extremely lonely on a Saturday night.

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Posted: Nov 16, 2006 8:34am


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