In a vegan cafe in New York City, Nisha Moodley pushes a glass crusted with the remnants of a berry-acai-almond milk smoothie across the table and begins listing the foods she excised from her diet six years ago.
"Factory-farmed meats; hormone-laden dairy; conventional nonorganic fruits and vegetables; anything hydrogenated; anything microwaved," the slender 32-year-old health coach says. "I would not eat irradiated food; charred or blackened foods; artificial coloring, flavoring, or sweetener; MSG; white rice; sugar; table salt; or anything canned."
Back then, a typical breakfast for Moodley consisted of buckwheat mixed with seaweed, raw cacao powder, flax oil, and flax seeds. Lunch was usually homemade brown rice with lentils, fresh vegetables, and kale, followed by a midafternoon snack of homemade flax-seed-and-buckwheat crackers. And for dinner, a salad with garbanzo beans, avocado, carrots, beets, and mushrooms.
Moodley initially adopted this diet to address recurring bad digestion. But her commitment to healthy eatingsomething to be commended, ordinarilyturned into an obsession that took over her life. "I was terrified of food that didn't fit within my idea of what was healthy," Moodley says. "I was terrified of cancer, of dying."
She couldn't eat out with friends, attend dinner parties, or shop at certain grocery stores because of her intense phobia. Her anxiety was so overwhelming that her stomach problems worsened.
Moodley knew she had a problem, but she didn't view it as an eating disorder. Although she had been a self-described "emotional overeater" for most of her life, the naturally slim Moodley had never been concerned about her weight, nor had she ever purged after her binges. Her unhealthy fixation with healthy food was something else, and it was years before she realized it had a name: orthorexia.
Orthorexia is not an official diagnosis. The American Psychiatric Association (APA) does not recognize it, and some eating-disorder clinics aren't even aware of it. But orthorexiawhich seems to include elements of other disorders, such as anorexia and obsessive-compulsive disordercan be a serious problem. Left untreated, experts say, it can lead to malnourishment, anorexia, or disabling anxiety.
A murky diagnosis
Steven Bratman, MD, coined the term orthorexia in a 1997 essay for Yoga Journal in which he described the disorder as a "fixation on eating proper food." Bratman, who himself had a food fixation while living on a commune in upstate New York, chose the prefix "ortho"which in Greek means straight, correct, trueto reflect the obsession with maintaining a perfect diet. Dr. Bratman described orthorexia in greater detail in the 2001 book Health Food Junkies, but it remains largely unrecognized and poorly understood.
It doesn't help that people with orthorexia can get positive feedback for behavior that appears healthy. For many people, strict diets such as veganism, locavorism, and fruitarianism (exactly what it sounds like) have become a way to eat healthier and also address their concerns about how food ends up on our tables.
"One of the things that's tricky about our culture is that orthorexia is socially acceptable and often even heralded as a great statement of self-control and doing the right thing for your health," says Amanda Mellowspring, a registered dietician in Miami who specializes in eating disorders.
The key difference between orthorexia and simply following a strict diet, Mellowspring says, is that orthorexia causes distress and interferes with everyday life. "What it boils down to is, how much does it negatively affect their life?" she says. "How much does it affect their social life? How much time do they spend thinking about food?"
Although orthorexia shares characteristics with anorexia, orthorexics don't always lose weight since they fixate on the quality (as opposed to quantity) of food. And they usually lack the distorted, negative self-imageknown as body dysmorphiathat causes some anorexics to look in the mirror and see oodles of fat when in fact they're severely underweight. "Body dysmorphia will make you miserable, and those with orthorexia tend not to have that," says Alan Kaufman, a licensed clinical social worker who works with patients with eating disorders at Alta Bates Summit Medical Center, in Berkeley, Calif.
That's not to say orthorexia doesn't pose health risks. Some patients do become malnourished and dangerously underweight, and dietitians and therapists say orthorexia can become a gateway to anorexia or bulimia.
In fact, orthorexia may in some cases serve to disguise anorexia. Because it's more socially acceptable to say, "I want to be healthy," than to say, "I want to fit into these skinny jeans," some anorexics may use orthorexia as a cover for their behavior. "[This is a] very common hidden agenda behind orthorexia," Dr. Bratman writes in Health Food Junkies. "A dietary theory can allow women to seek the culturally accepted norms of beauty without admitting it to themselves. … You can 'accidentally' live up to the Barbie image without admitting you believe in doing so."
Similarly, recovering anorexics or bulimics sometimes latch on to orthorexia. Elizabeth Dear, a therapist based in Reno, Nev., who works with eating-disorder patients, says she does not consider anorexics fully recovered if they judge themselves according to the quality of the foods they eat. "This so-called healthy eating can easily develop into eating-disorder thinking," she says.
How orthorexia starts
Orthorexic tendencies often begin as a result of health problems. Alena's obsession with healthy eating started in 12th grade, when she found out she had Candida (a type of yeast infection) and a homeopathic doctor asked her to stop eating yeast, wheat, sugar, and dairy for several weeks as part of her treatment. She was already a vegetarian, so she mainly ate rice and vegetables. (Alena did not want her last name published.)Then, when she was 19, she went to a naturopathic doctor with a collection of stomach symptoms, including nausea, constipation, and indigestion, and was again instructed to avoid processed grains, sugar, soy, dairy, and nuts. "And that's when I went crazy," says Alena, now a 22-year-old student at NYU. "I basically cut out everything from my diet. I convinced my mind that food made me sick."
Alena still goes through bouts where she swears off those food groups, and her forbidden list now includes carbohydrates, beans, tropical fruit, sugar, farmed fish, and potatoes that aren't from her own garden. Meat, nonlocal produce (such as bananas), juice, beer, and dairy are all "evil," she says. "What I do eat are a lot of vegetables. I have to have vegetables in every meal or I feel sick," she says. "I eat whole grains like barley, whole-grain kasha. Not rice, because it really hurts my stomach and for political reasons, because it is shipped from too far away. I eat seasonal fruits, fish, and eggs."
For Alenawho has never been to a therapist or nutritionist to discuss her behavioranorexia and orthorexia go hand in hand. She has experienced bouts of body dysmorphia and sometimes exercises excessively to make up for minor eating binges, such as overindulging on dessert. She also exhibits other traits common among those with eating disorders, such as living vicariously through the diets of others. She often bakes for her family and roommates, and urges her sister to order hamburgers at restaurants so she can watch her enjoy them.
"The distinction for me is, anorexia is about what I look like and orthorexia is about my lifestyle," Alena says. "I want to feel good about what I'm eating. I want to feel cleansed and detoxified. And at times it is related to image. But I worry that if I start eating in an unhealthy way I'm going to start having stomach issues."
It may not be a coincidence that Alena studies food and agricultural policy in school. Few studies have been done on orthorexia, but some researchers have speculated that restrictive diets and orthorexic tendencies may be more common in dietitians and nutrition students.
Moodley's interest in nutrition and career choice certainly influenced her diet. Her burgeoning orthorexia seemed to worsen when she began studying at a nutrition school in New York City. (She stopped eating frozen vegetables, for instance, when she was taught that plant cell walls expand and break down from low temperatures, sometimes resulting in lost nutrients.) "If I had to draw a line, I'd say that my interest in nutrition spurred orthorexia," she says.
How to get help
Therapists, nutritionists, and eating-disorder experts have slowly begun to take orthorexia more seriously. Anorexia and bulimia were similarly slow to be recognized: Anorexia was long considered a symptom of hysteria, while bulimia was regarded as a type of anorexia and was not considered a disease in its own right until 1980.
There are no plans to add orthorexia to the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM), a new edition of which is scheduled to be released in 2013, in part because of the dearth of research. "The problem is, we don't know enough about it," says B. Timothy Walsh, MD, a psychiatrist at Columbia University, in New York City, who chairs the Eating Disorders Workgroup for the new edition. The workgroup does, however, recommend adding to the DSM something called Avoidant/Restrictive Food Intake Disorder, which pertains mainly to children and preteens who are excessively picky eaters, to the point that they become undernourished.
Dear, who has been working with patients with eating disorders for 11 years, says adding orthorexia to the DSM could benefit people with the disorder by making clinicians more likely to recognize it. She says inclusion in the DSM could also be "counterproductive," however, if the diagnostic criteria are too narrow and leave some cases undetected and untreated.
If you suspect that you or someone you know may be orthorexic, Kaufman suggests approaching with care. "When you have a full-blown eating disorder there is a strong degree of denial [about] the extent of the condition," he says.
Recognizing orthorexia can be difficult if a person does not yet show outward signs of malnutrition, Kaufman says, but if the disorder has become medically compromising then they may need treatment to help them change their eating patterns and their thoughts that go along with eating. (Directories of eating-disorder experts can be found on the website of the International Association of Eating Disorder Professionals.)
The ultimate recovery from an eating disorder is to get beyond labeling foods good or bad, Dear says. "You have to reach a self-loving place, not a virtuous place. It would be helpful [for] clinicians to have their radar out for orthorexia because it is easily misread as just healthy eating when it can be a major problem."
Moodley no longer considers herself orthorexic. Her work with clients made her realize that the correct diet is different for each individual and helped her overcome her orthorexia. But when she discusses her diet today, a sense of pride still lingers in her voice. To some, her diet was the epitome of healthy perfection. She said she still maintains a healthy diet, but now it is a preference as opposed to an obsession. She prefers fresh vegetables, but isn't opposed to eating them frozen and she doesn't think of all sweets as junk anymore. She says her fears of "bad" food are gone.
But it still takes Moodley several moments of silent reflection before she can recall the latest treat she ate. Finally, after some deep thought on the matter, she remembers: "Two days ago. I had a cookie. An organic cookie."