By Wendy Sterling, MS, RD, CSSD
This post is an adapted excerpt from Wendy Sterling’s book in progress, “PlateED: A Parent’s Guide to Refeeding Your Teen with an Eating Disorder.” PlateED is co-written by Casey Crosbie, RD, CSSD, Lead Dietitian at the Healthy Teen Project.
“I cut out gluten and dairy, I don’t eat meat, I don’t eat fried foods, I don’t eat processed foods, and I definitely don’t eat foods that have sugar.” Um, so what do you eat? “Orthorexia,” term coined by Stephen Bratman, MD in his popular book, “Health Food Junkies,” refers to an obsession with health and nutrition that becomes all-compassing. Though not a formal eating disorder diagnosis, orthorexia refers to those who have become excessively preoccupied with “eating healthy” and “eating clean,” to the point it disturbs the flow of one’s life. Orthorexia refers to someone who will “only eat” brown rice and not white rice, or only eat organic, cage-free, grass-fed, free-range foods. Someone with orthorexia may have an eating disorder or may not; there tends to be a focus on “quality” vs. “quantity” and a focus on “health” vs. “losing weight.” And in a world of quinoa and soba noodles, it’s easy to blend in. But there is a difference between someone who has an allergy or a “preference” vs. someone who is hiding behind those things because they are actually scared to step out of their comfort zone.
“It took a long time for me to be able to see how debilitating orthorexia was, and how it was just not a sustainable lifestyle. It’s seems so obvious and irrational from the outside, but the feeling is so powerful that when you’re stuck that deep and you’ve convinced yourself for so long of your ways, it takes many “wake up calls” to undo all the layers of denial.” – Current client working on orthorexia
With the influx of health messaging, orthorexia has become increasingly common but can be very debilitating, especially for teenagers. Kids who are looking to “become healthy” are attracted to this messaging yet an extreme adherence to these messages can, ironically, cause kids to become unhealthy both physically or psychologically. Consequences of orthorexia include increased irritability, depression, anxiety, poor relationships with others, social avoidance, feelings of guilt, and an excessive amount of time spent thinking about and/or preparing meals, taking time away from other activities.
Teens who are restrictive and maintain strict guidelines for what they will or will not eat continue to be restrictive years later. They struggle to eat pizza with friends, eat in restaurants, and attend even basic social events like football games or concerts because “there is nothing for me to eat there.” I have worked with kids who have packed measuring cups with them when traveling (highly discouraged, and in fact, is sign that the person is not ready to travel). I have had clients bring “their food” to birthday parties and other events. This immediately makes you seem different and becomes just another way that eating remains difficult and “front and center” in your life.
Below are some characteristics typically seen with orthorexia. Some people may have 1 or 2 of these behaviors/beliefs around food, but with orthorexia, a person usually exhibits most, if not all, of the behaviors below.
Do you sort foods into good foods and bad foods?
Someone with orthorexia (or even a chronic dieter) categorizes foods as “good” and “bad.” “Good foods,” also known as “safe foods,” are typically foods a person considers to be “good” or “healthy.” Examples of safe foods may be fruit, yogurt, vegetables, chicken, and fish (and will vary per person). Conversely, fear foods are foods that feel “scary” to eat. You may label a food as “fattening” or “disgusting,” “unhealthy,” “gross,” or “too high in sugar.” Fear foods might include potato chips, ice cream, cookies, cake, brownies, and candy.
How varied is your diet?
Typically, those with orthorexia, show a lack of variety at meals and snacks, not only throughout the day, but also throughout the week. If you keep a seven day food record, logging all meals and all snacks, how good is your variety? Are you eating the same thing for breakfast most days? For snacks? Is the format of your meals the same? If so, it is time to brainstorm how you can expand your variety. This not only helps to ensure flexibility, but also helps your body get a variety of different nutrients from different foods. For example, chicken is low in iron. If you ate chicken every day, you would be missing out on getting enough iron. Similarly, if you ate an orange every day, you would be missing out on getting the potassium found in bananas.
How flexible are you when it comes to food?
Due to firmly held beliefs around food or how food should be prepared, someone with orthorexia may struggle to find something to eat when out of their home environment. This mostly plays out in restaurants, on the road, in college, when traveling, at a friends house, at a birthday party etc.
One of my clients refused to eat at In and Out Burger on the way home from his soccer game. “I would rather not eat than have fast food,” he said at the time. But it was four hours later until he was able to eat at home. He missed the recovery window post workout, which arguably would harm him more than having In and Out. In fact, sports nutritionists (myself included) would likely agree that given the choice between eating fast food or skipping the post workout meal and eating nothing, it is better for you to eat fast food post workout.
Flexibility around food is important. For example, if you run out of quinoa, are you able to eat the white pasta your parents are serving at night? Or if you go to your friend’s house for dinner, and she serves mashed potatoes, are you able to eat it? If you find yourself bobbing and weaving when it comes to food, it is a sign that your flexibility around food might need a tune up.
Can you eat spontaneously?
All of your friends are going out for ice cream. Are you able to join them? What if they’re going for ice cream at an odd time that you normally wouldn’t expect to eat? Can you join them anyway? The ability to be spontaneous is a gateway to freedom from rigidity around food.
Can you have a bite of food out of turn?
OK, you ordered your own entrée but your boyfriend looks over and says, “Yum, this is amazing, try it.” He is eating a Sizzling Beef dish, with a horseradish cream sauce. Can you try it? Does it bother you that it’s an extra bite outside of your entrée? Similarly, can you try your grandmother’s homemade soup when she offers you a spoonful, rather than say no because it’s not officially part of your meal plan? You may have heard that it’s not good to pick and graze throughout the day. But that is not what we are talking about here. We are talking about the ability to try something new, to have fun with food, to try something you might not order, and to be able to have a random bite of food, out of turn, just because you feel like it.
Do you have a million specific requests and instructions for the waiter?
“Steam the vegetables, put the sauce on the side, no bacon, no butter, a side of lemon, and please add 3 ice cubes in my water with a straw.” Be honest. Do people find it really annoying to eat in a restaurant with you? Usually with orthorexia, a person may have specific food requests about what they want, how they want it prepared, and which ingredients to omit from their order.
Can you eat other people’s cooking?
You’re running late, have a lot of homework, and your mother offers to cook dinner. Will you let that happen? Or will you insist on being in the kitchen overlooking how she is making it? Do you complain that she is using too much oil? Too much cream? Adding too much cheese? Are you able to attend Thanksgiving without feeling like you need to bring along your own food? Unless you have a food allergy, bringing your own food is a sign that something may be wrong. If fear wasn’t a factor, most people would be excited to have someone else cook for them.
Is your food plain and dry?
Typically, those with orthorexia, eat a very plain diet. They will say it’s “clean ” but others may say it’s “boring.” A typical meal might be a plain breast of chicken, sweet potato, and a salad without dressing. There is no stir-fry sauce, seasoning, flavor, or herbs. Food is meant to be enjoyed, the combination of spices and flavors bring out the tastes of different ingredients in the dish. For some reason, those with orthorexia may think that sauces are unhealthy and should be avoided. Or that you should skip the salad dressing when eating salad. Really? That sounds like a torturous way to eat. The best way to expand what you eat and how you make foods is to find new recipes. In some cases, using a meal service like Blue Apron, Hello Fresh, Gobble or Home Chef, can push you out of your comfort zone in this area, in a good a way.
The primary goal of reducing orthorexic behaviors is to be able to eat anything without a heightened state of anxiety present – cake on your birthday without an intense fear around it, eat in restaurants, travel, and go out for ice cream with friends. It takes repeated exposure and practice to make these experiences less scary. Though fearful initially, I have found my clients to be highly responsive in working on this. A current client shared with me the following, “Introducing new foods again is scary, but there comes a point when you realize how freeing it is to not be so bound by your rules, and that outweighs any scared and negative feels associated with it. It’s not to say I don’t still cringe at eating certain things, and still overanalyze things, but that voice slowly becomes quieter and my rational mind is able to win out more often than not.”
If you or someone you know is struggling with orthorexia, below are some suggestions to consider. This work is best done with the help of a Registered Dietitian or Therapist who specializes in Eating Disorders.
Things to Consider to Fight Orthorexia:
- Watch out for this common pitfall. “I don’t like bread, but I would have quinoa.” This might make sense – trading a grain for a grain, right? But this perpetuates the fear of bread. Unless you are not actually scared of bread, in which case, then it might just be a you have a preference for something else. But if it is a preference, you should be “able” to have bread if that’s the only thing being served.
- Sometimes a person may avoid the bread, but then eat more chicken and broccoli to make up for it. This unfortunately reinforces the fear that something is wrong with eating whichever food you avoided that night.
- One food is not capable of “making someone fat.”
- The goal of reducing the orthorexia is not weight gain. The goal is a more expanded palate, more variety, and less anxiety around food. Many people can work on the orthorexic component of their diet while keeping their weight stable.
- Make a list of your “Safe Foods” and “Fear foods.” What foods scare you? Frequent exposure to that which scares you helps minimize fear. Begin to practice trying some of the foods on your Fear Foods list. Start by making a “food hierarchy” ranking the foods that scare you from least to most. Start with the easier fear foods and gradually work towards more scary foods. Once in trying-new-foods-mode, you will be amazed at how free you feel. If you are a parent, help your child practice exposure by asking him/her to practice eat a variety of foods.