I'm often asked why I decided to become a dietitian after years of teaching. I tend to gravitate towards discussing a need for change and how nutrition made the most sense since I spent years ingesting all kinds of information about nutrition as a hobby. And while all of that is true, there's a few more layers that I've really only shared with peers, people who understand orthorexia and are familiar with the behaviors commonly associated with it.
To say it simply, I was hyper-focused on eating clean. I was consumed with the concept of "proper" nutrition and eating the "right" foods. I wanted to understand every single aspect of nutrition's impact on the body and mind, and embarrassingly, my goal at the time was to share that understanding with others so that I could "help" them too.
I spent most of my late twenties and early thirties obsessing over the idea that eating foods that aren't providing a cache of nutrients are not only pointless, they're bad. I gave up sugars (including honey and maple syrup) and alcohol for whole years at a time. I reduced my intake of store-bought "processed" foods. I didn't eat any kind of white breads. I didn't keep foods I deemed to be "bad" in my house. At varying times, I was vegetarian. I was vegan. I was pescatarian. [Diet Disclaimer] I regularly said no to celebratory desserts, restaurant meet-ups, and shared meals because I couldn't control what ingredients were used. I found myself cutting out types of foods and food groups believing they impacted my body and mind negatively. No dairy. No wheat. No meat, etc.
I had some favorite encyclopedia style books that discussed "good" foods, broken down to their most basic components, filled with explicit instructions of how best to prepare and/or cook the foods to either avoid nutrient loss or enhance their benefits. I was fully invested in my world revolving around what I ate and what I planned to eat next. I pushed myself through detoxes and cleanses, over and over again, even though there were times I readily recall not being able to stand up without being lightheaded due to a lack of nutrition.
Ironic.
One experience with a particular cleanse stands out. It was organized by the days in which foods were allowed to be "added back in" to my diet. After days of minimal caloric intake, basically just clear liquids from what I can recall, I was "permitted" to physically eat a select group of vegetables. My excitement was palpable. I had been daydreaming about this huge head of broccoli in the fridge and was all set to get it ready; but when I opened up the bag it was covered in aphids. Seemingly hundreds of tiny insects were blocking me from reaching some degree of satisfaction. The defeat I experienced in that moment would have been tangible to any observer. I tried to wash the bugs off, but they were all over and I was left barely balancing at the edge of a precipice, hungry with no options.
I slid onto the floor and cried way harder than the situation suggested. But to be clear, it wasn't just disappointment and sadness that there were hundreds of bugs on the food I was trying to eat; I could not think clearly. There was an inability for me to consider another food option that would be a reasonable replacement. I remember feeling like there was absolutely nothing in my house that I could eat to fit the rules I had created for myself. That's why I was crying. And what really bothers me now is...I had food. I was restricting myself through these cleanses and detoxes....and rules because I had immersed myself in distorted beliefs that some foods weren't good enough.
I was exhausted. Living like that is exhausting. It's the exact opposite of health.
Unfortunately for me, that particular moment (nor the many other similar moments where I found myself frozen and fraught with indecision over finding something that was "good enough" to eat) didn't cause me to rethink my choices about how I viewed food. I actually shared that "crying over bug-filled broccoli" for years after as a funny little anecdote.
I don't really see it that way anymore.
It wasn't until years later when I even started recognizing my own habits and behaviors. I took an eating disorder course after finishing my dietetic degree. It was in this class where all of the nutrition information I'd gained during my coursework was put into authentic human context. For me, any practicing dietitian or medical professional who focuses solely on food group or food restriction as "healthy eating" (usually with the goal of weight loss) - has lost all validity. You should feel this way too.
There is clearly so much more that goes into our overall health, outside of the calories in/calories out concept and outside of eating solely for nutrient value. Eating can fulfill many needs. Yes, it can absolutely provide the nutrients our cells need to function and that is important for our overall health and well-being. Eating can also elicit joy and happiness. Eating can be connected to taste and pleasure. Eating can physically bring people together. I was missing out on a lot of these aspects for a quite a while.
[Diet Disclaimer]: I noted some types of diets/lifestyle choices that are not inherently problematic (vegetarian, vegan, pescatarian). Individuals can absolutely commit to these options as "healthy" alternatives. As discussed below, it's when an individual's food choices become a pathological fixation that problems can arise.
Orthorexia Nervosa
So, what exactly is Orthorexia?
"Orthorexia Nervosa is a pattern of disordered eating behaviors characterized by excessive preoccupation with overvalued ideas about healthy eating" whereas "Healthy Orthorexia refers to a non-pathological interest in healthy eating and nutrition" (Zickgraf, 2021).
This distinction is important as there is nothing wrong with choosing foods that make you feel better, think better, and just generally provide the levels of energy your body craves. The basic concept/lifestyle of choosing foods that provide nutritional benefit has been around for years with clear, marked success when it comes to mitigating chronic disease risk. So, you might be wondering if your version of "eating clean" is a problem? And, the quickest identifier is similar to other disordered eating behaviors - is it a pathological fixation?
"Although being aware of and concerned with the nutritional quality of the food you eat isn’t a problem in and of itself, people with orthorexia become so fixated on so-called ‘healthy eating’ that they actually damage their own well-being." - National Eating Disorder Association
Some research additionally describes the behaviors consistent with orthorexia nervosa (OrNe) to be guided by maladaptive eating to achieve weight loss where healthy orthorexia (HeOr) is more focused on obtaining health. With OrNe, the diet can become "more rigid, and eating foods categorized as “unhealthy” can cause feelings of guilt, fear of becoming ill, and encourage the individual to follow an even more restricted diet (Depa, 2019) and in some cases, "detrimental health consequences occur due to self-imposed dietary rules intended to promote health" (Cena, 2019).
Orthorexia Signs & Symptoms (NEDA)
Compulsive checking of ingredient lists and nutritional labels
Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products)
An increase in concern about the health of ingredients
An inability to eat anything but a narrow group of foods that are deemed ‘healthy’ or ‘pure’
Spending hours per day thinking about meals or what food might be served at an event
Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available
Refusal to eat food for which an individual is unclear about preparation methods or ingredients
Refusal to eat food an individual has not prepared themselves
Refusal to eat foods that weren’t produced, prepared in a specific way or includes ingredients an individual considers pure (organic, farm to table, etc.)
Mindset of "health" over weight loss
Truth About Detoxes and Cleanses (MD Anderson Cancer Center)
Our bodies don't need to detox. They are designed to do that all on their own. Sure, it's not a great idea to repeatedly overindulge in some types of foods (high added sugar foods, alcohol, fatty foods, etc.), but on those occasions where we have had a little too much, our bodies can usually take care of themselves. [Note: There are exceptions this. When behaviors have caused liver or kidney damage, a body's ability to restore itself to health is impacted.
Detoxes and cleanses can be unsafe. Most are based on high intensity food restriction, high intake of certain fruits and veggies, and high intake of liquids (not too mention whatever other random ingredients used as "fixes") which mostly cause an increase in time spent on the toilet, nausea, cramping, and even electrolyte imbalances (that can be dangerous). Plus, it is essential to consider that many "programs" haven't even been checked for efficacy or safety before they are marketed.
Weight loss "results" are unsustainable. Just like most "diet" programs, any weight loss achieved during a detox or cleanse is connected to liquid loss and food restriction. As soon as normal eating behaviors return, so will the weight (often with even more pounds).
Detoxes and cleanses don't fix serious problems. As noted in the first point, when behaviors have caused liver or kidney damage for example, a body's ability to restore itself to health is impacted. Some problems become irreversible and no detox or cleanse will fix the associated problems.
Watch Companion Video Here!
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Nutrition Through The Ages: Special Edition - Orthorexia (Clean Eating)
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Looking For More Information? Check out these videos!
Resources
Alexander, Heather. “4 Detox Myths: Get the Facts.” MD Anderson Cancer Center, https://www.mdanderson.org/cancerwise/the-facts-behind-4-detox-myths-should-you-detox-your-body.h00-159385890.html. Accessed 13 Feb. 2023.
Cena, Hellas, et al. “Definition and Diagnostic Criteria for Orthorexia Nervosa: A Narrative Review of the Literature.” Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, vol. 24, no. 2, Apr. 2019, pp. 209–46. DOI.org (Crossref), https://doi.org/10.1007/s40519-018-0606-y.
Depa, Julia, et al. “Are the Motives for Food Choices Different in Orthorexia Nervosa and Healthy Orthorexia?” Nutrients, vol. 11, no. 3, Mar. 2019, p. 697. DOI.org (Crossref), https://doi.org/10.3390/nu11030697.
Esposito, Susan, and Dana Fierstein. “When Does Healthy Eating Become Dangerous.” National Eating Disorder Association, https://www.nationaleatingdisorders.org/blog/when-does-healthy-eating-become-dangerous.
Gkiouleka, Maria, et al. “Orthorexia Nervosa in Adolescents and Young Adults: A Literature Review.” Children, vol. 9, no. 3, Mar. 2022, p. 365. DOI.org (Crossref), https://doi.org/10.3390/children9030365.
Hornberger, Laurie L., et al. “Identification and Management of Eating Disorders in Children and Adolescents.” Pediatrics, vol. 147, no. 1, Jan. 2021, p. e2020040279. DOI.org (Crossref), https://doi.org/10.1542/peds.2020-040279.
Hyrnik, Joanna, et al. “Orthorexia – Current Approach. A Review.” Psychiatria Polska, vol. 55, no. 2, Apr. 2021, pp. 405–20. DOI.org (Crossref), https://doi.org/10.12740/PP/115149.
“Orthorexia.” National Eating Disorders Association, https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia.
Pontillo, Maria, et al. “Orthorexia Nervosa, Eating Disorders, and Obsessive-Compulsive Disorder: A Selective Review of the Last Seven Years.” Journal of Clinical Medicine, vol. 11, no. 20, Oct. 2022, p. 6134. DOI.org (Crossref), https://doi.org/10.3390/jcm11206134.
Ryman, Frida V. M., et al. “Orthorexia Nervosa: Disorder or Not? Opinions of Dutch Health Professionals.” Frontiers in Psychology, vol. 10, Mar. 2019, p. 555. DOI.org (Crossref), https://doi.org/10.3389/fpsyg.2019.00555.
Simpson, Courtney C., and Suzanne E. Mazzeo. “Attitudes toward Orthorexia Nervosa Relative to DSM - 5 Eating Disorders: SIMPSON and MAZZEO.” International Journal of Eating Disorders, vol. 50, no. 7, July 2017, pp. 781–92. DOI.org (Crossref), https://doi.org/10.1002/eat.22710.
Skella, Panagiota, et al. “Orthorexia and Eating Disorders in Adolescents and Young Adults: A Systematic Review.” Children, vol. 9, no. 4, Apr. 2022, p. 514. DOI.org (Crossref), https://doi.org/10.3390/children9040514.
Zickgraf, H.F., Barrada, J.R. Orthorexia nervosa vs. healthy orthorexia: relationships with disordered eating, eating behavior, and healthy lifestyle choices. Eat Weight Disord27, 1313–1325 (2022). https://doi.org/10.1007/s40519-021-01263-9
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