As so often happens in my practice, in the last week or so the same topic of concern has arisen in conversation with several of my clients: “How can I tell if I’ve crossed the line between a rational, healthy level of interest in my own well-being, and an unhealthy obsession with eating ‘right’ at all times?”
I cordially despise the diagnostic labels that the medical profession – and especially psychiatrists – loves to pin on any form of behaviour that deviates from the supposed norm. (“Social anxiety disorder” and “Disruptive Behavior Disorder Not Otherwise Specified” are two of my personal bêtes noires; once upon a time these ‘disorders’ would have been called being shy and bored/troubled/disengaged kid acting out – or perhaps annoying out-of-control brat if you were a teacher stuck with one of these kids in your class.)
But there’s one diagnostic label that is of particular interest to me, given that my job is to teach people how to improve their health, which by necessity means that I spend a lot of time talking about why and how to eat a health-promoting diet. That label is orthorexia.
Orthorexia missed out on inclusion in the latest (2013) revision of the psychiatrists’ ‘bible’, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), because of limited research and uncertainty about proper diagnostic criteria. The main concern about this label, which I share, is that mentally healthy people who simply adhere to a non-orthodox but wholesome diet out of a rational concern with their well-being, may be inadvertently classified as having a psychological disorder because they shun foods that are considered ‘normal’ and even ‘necessary’ by most people in our society, including most nutrition professionals.
Here are two examples:
- In typical eating disorder clinics and inpatient facilities, patients are not permitted to follow a vegan diet for ethical reasons because veganism is defined as part of their eating disorder. I’ve seen many girls and young women whose sensitive natures predispose them both to eating disorders, and to deep empathy for animals. Being forced to eat flesh and dairy products before they can be declared ‘recovered’ is simply torture to them.Furthermore, ‘recovery’ from an eating disorder in such clinics is defined as being able to eat junk food such as chips and ice cream without restraint. This results in many former anorexics becoming overweight and unhealthy, as described by Sandy, a client of mine who ‘survived’ treatment in such a clinic. (You can hear the story in Sandy’s own words, right here.)
- The mother of a child client of mine who suffers from a form of autoimmune disease that causes massively swollen and painful joints, having found that the medical therapies she was offered did not resolve the condition, began researching dietary approaches. She found that removing dairy products, red meat and gluten-containing grains from her daughter’s diet brought about rapid relief from the pain and swelling, but was told by hospital dietitians that she was starving her child, and threatened by child protection authorities with removal of her child if she did not feed her ‘normally’.
Now, I’ll grant you, there are some people who take the desire to eat a healthy diet to extremes, resulting in significant psychological distress and even physical harm to themselves through excessive dietary restriction. I’m in quite a unique position to differentiate between these people, and those who are happily following a health-promoting diet, for two reasons:
Firstly, over the more than 20 years I’ve been in clinical practice, I’ve seen far more than my fair share of clients with eating disorders of various descriptions – anorexia nervosa, bulimia, binge eating, compulsive overeating and so on; and
Secondly, I battled an eating disorder for 10 years myself, from my mid-teens into my mid-twenties, which resulted in me losing my menstrual period for 3 years and developing osteoporosis (now, thankfully, completely reversed thanks to a healthy diet and strength exercise program).
My personal experience with recovering from an eating disorder equips me to identify the patterns of thinking, feeling and behaving that differentiate between these two categories and, most importantly, how to restore a healthy relationship with food in those who have crossed the line.
If you have a healthy relationship with food and your own health, you:
Classify foods as either health-promoting or health-sabotaging based on your understanding of nutrition science.
Feel sadness, disappointment or regret when observing other people who aren’t make healthy dietary choices, but are mindful of your own journey toward healthy eating and content to let them be on theirs.
Choose healthy foods most or almost all of the time, but are comfortable with eating less-healthy foods in special circumstances e.g. when at a restaurant with friends, or on a long plane flight with nothing else to eat.
Feel pleased with yourself when you choose healthy foods, and chalk unhealthy choices up to experience.
Find that you’re eating and enjoying a wider range of foods than before, when you were eating ‘normally’.
Plan your meals for the sake of ease and convenience, and can adapt your plans easily to a change in circumstance.
Think about food only when hungry, when actually eating it, or when searching for new recipes and planning meals.
Track your food intake either not at all, or only occasionally out of curiosity, or when preparing for a specific event e.g. athletic competition.
Read food labels so that you can choose the healthiest option.
Adhere to a healthy diet to maximise your capacity to enjoy time with loved ones, engage in enjoyable activities, contribute to your community and achieve career goals.
If you’re in an unhealthy relationship with food and your own health, you:
Classify foods as ‘good’ or ‘bad’, and yourself as being either ‘good’ or ‘bad’ depending on what you’ve been eating.
Judge other people who make unhealthy dietary choices, and judge yourself if you experience any temptation to follow suit.
Feel deeply uncomfortable, anxious and conflicted when the only foods available are those you define as unhealthy.
Feel compelled by fear of adverse consequences to make healthy food choices, and experience guilt, shame, anxiety and even a sense of impurity or defilement when you make unhealthy choices.
Find that the list of foods you define as ‘healthy’ is getting smaller and smaller, and that you’ve lost all enjoyment in eating.
Plan your meals so that you can control what you’re eating, and you feel anxious if those plans are disrupted.
Think about food practically all the time, even having intrusive thoughts about what you’ve eaten or are planning to eat during conversations with friends, or during sex.
Track your food intake consistently, recording everything you eat and drink and obsessing about whether you’re properly adhering to a healthy diet.
Read food labels so that you can be sure of completely avoiding any food or additive that’s on your ‘bad’ list.
Find that your obsession with healthy eating is interfering with relationships and work, preventing you from engaging with your community and detracting from your enjoyment of leisure time.
The bottom line, as I tell my clients who are struggling with this issue, is your ‘come-from’ – the psychological stance that you’re coming from when you think about your dietary choices (and other behaviours that influence your health):
Psychologically healthy people come from the stance that their health is the means to an end – the end being maximum enjoyment of life for the longest possible time – and investing in their health is an investment in that current and future enjoyment. In other words, the desire to live a full life is what motivates the decision to make healthy eating choices.
Psychologically unhealthy people come from the stance that their health is an end in itself – something that defines their personal worth or moral virtue, and also something that’s fragile and can be severely disrupted by even the most minor dietary indiscretion (which simply isn’t true for the vast majority of people). Fear of being ‘contaminated’ or becoming sick is what motivates their eating choices.
So what can you do if you’ve identified thoughts, feelings and behaviours that might indicate orthorexia? The first step is to begin paying close attention to the thoughts you have about food and eating. I encourage my clients to write down these thoughts, along with the feelings and physical sensations associated with them, and the behaviours that these thoughts make you feel compelled to engage in.
For example, you might notice that if you open the fridge at work to take out your healthy lunch, and a junk food-munching colleague has put a bag of greasy takeaway food right on top of it, you:
- THINK “Yuck, I bet that grease has seeped into my food, even though I had a lid on it. If I eat my meal, I’ll be eating that grease.”
- FEEL disgusted, anxious, even nauseated; and
- Feel COMPELLED to throw your meal out rather than risk being ‘contaminated’ by the unhealthy food, even if you have nothing else to eat.
Rather than simply use cognitive techniques such as thought disputation, I teach my clients to use Emotional Freedom Techniques (EFT) to calm their emotional distress before engaging with their thoughts, beliefs and perceptions in order to reshape them into rational and health-supporting ones.
EFT is also invaluable for resolving the underlying drivers of those dysfunctional cognitions; more often than not, the roots of them lie in early-life experiences that caused you to systematically undervalue yourself, so that you feel you must be ‘perfect’ in order to be worthy and lovable.
The other crucial element of recovery relates to the ‘come-from’ that I discussed previously. In order to see your health as the means to an end, you have to figure out what that ‘end’ is for you. What gives you satisfaction and fulfillment? In what ways can you make a meaningful contribution – to friends and family, to your community, to the environment, to the sum of human knowledge? What unique abilities, talents and interests were you put on this planet to develop and share with others? Keeping your eye firmly fixed on this bigger picture is crucial to pull you out of the morass of dietary nit-picking that characterises orthorexia.
As someone who has emerged from the stifling tunnel of an eating disorder into the light of a life packed with fulfilling relationships, a satisfying career and engaging interests, I can tell you that it’s worth it to do this work.