Do You Have Orthorexia?

There is a lot of information out there about the best foods to help us lose weight, prevent cancer, fight inflammation – the list goes on. In fact, for everything about our health we try and improve, there’s someone with a new theory on how to do it. But what does the science say?

Welcome to the Nutrition Facts Podcast. I’m your host Dr. Michael Greger. And I’m here to give you the evidence-based approach to take the mystery out of the best way to live a healthier, longer life.

Orthorexia.  You may have heard of it.  And no it’s not a way to straighten your teeth.  It’s described as an “unhealthy obsession with healthy eating.”In our first story we trace the source and legitimacy of orthorexia.

Orthorexia has been styled as a type of ‘self-righteous eating’ or as ‘clean eating’” by “sufferers” of the disorder. Wait, let’s take a step back here. First of all, though this “phenomenon has been described in the scientific literature, it is not formally recognized as an official psychiatric diagnosis.” Furthermore, orthorexia doesn’t even have “an accepted definition,” nor “validated diagnostic criteria.” And, if you can’t validly diagnose it, or even define it, what good is it? Okay, well, first off: where did this concept even come from? Not from some scholarly source, but from a popular press article called “Confessions of a Health Food Junkie” in a magazine called Yoga Journal.

Let’s explore its “scientific legitimacy.” Evidently, it looks like “orthorexics obsessively avoid processed foods, unhealthy fats, and foods containing too much salt or too much sugar.” But wait; by definition, we should avoid unhealthy fats, they’re unhealthy! And anything that has too much salt or sugar has too much salt and sugar. Is someone who’s a nonsmoker “obsessively” avoiding cigarettes orthospirexic? Obsessed with “right” breathing? “In many cases, parents try to “strictly limit their children’s sugar intake.” No! Off to the loony bin they go.

Orthorexics make the “nutritional value of a meal more important than the pleasure of eating it.” Uh, but if you didn’t just a little, wouldn’t you just eat doughnuts all day? If pleasure trumps health, maybe we should all just start shooting heroin.

One of the proposed criteria is “an unusual concern about one’s health.” What does that mean? Do you have a mental illness if you decide to hold the bacon on your double cheeseburger? I mean that could be seen as an unusual level of concern in a standard American diet.

“People with orthorexia pay excessive attention to the quality of consumed food,” so much so they’d rather not eat unhealthy food. I bet they put their seatbelts on too! We better reprogram their unhealthy healthy thoughts with “cognitive behavioral therapy combined of course with” drugs (SSRIs such as Zoloft, Prozac, and Paxil.) Hey, that’s what the “experts recommend.”

“With regard to psychotropic medication,” yeah SSRIs may help, but you may have to dip into the atypical “antipsychotics” as well. Now, often there will be a concession like: “Of course, from a clinical and public health perspective it would not be reasonable to suggest that individuals who follow a strict healthy diet are endangering their health.” It only reaches “clinical significance” when “health-directed eating” starts causing problems in relationships, or impairs an individual’s social life. But, like, if someone asks their spouse not to smoke around them and the kids, that “health-directed” behavior could cause “interpersonal distress” in the relationship. Should you just keep quiet? Or should you yourself keep smoking just to not cause waves with your smoking spouse? And social-life-wise, do you have mental illness if you tell your date you’d rather not go to the steak house or the smoking lounge?

“The problem is when the behavior begins to hinder a person’s ability to take part in everyday society.” Like what if you start bringing food to dinner parties? Maybe I’ve just gone to too many potlucks, but bringing a healthy dish to share doesn’t sound like a druggable psychiatric offense to me.

And then, there’s Instagram. Think of “the implications social media can have on the psychological well-being” of hundreds of thousands of individuals. Did you know that “healthy food posts tend to receive more support from users than less healthy images, indicating a positive attitude towards healthy foods and healthy eating”?!? Soon, everyone might be taking pictures of broccoli. Quick, get out the straitjackets!

In his decades of medical practice, Dr. Dean Ornish says he’s “never seen” a case of orthorexia. “Most people,” he says, “have the opposite problem; they don’t care enough about what they eat.”

In our next story we examine how an eating “disorder” can save your life.

“Orthorexia Nervosa” is an “unrecognized eating disorder in which the person becomes obsessed with eating healthy foods.” “Whereas recognized eating disorders,” like anorexia, deal with the quantity of the food, orthorexics care about “the quality“ of their food. “Many researchers have raised questions about the validity of orthorexia as an entity,” but I always try to give the benefit of the doubt. A medical case report was published on orthorexia in a critical care journal about eating disorder emergencies. Okay, I’m listening. So, they’re talking about cases of bona fide eating disorders, like this woman with anorexia collapsing after self-induced vomiting and laxatives after years of throat and rectal bleeding. I mean, that is indeed a tragic eating disorder emergency. Okay, so what’s their orthorexic case like?

A 53-year-old man who had a triple bypass two years ago comes in for a check-up. His physician recommends seeing a dietitian, since his BMI is down to like 18.5, which is right on the cut-off for being underweight. He’s evidently been eating so healthy he’s “lost a significant amount of weight. He states that since his diagnosis of coronary heart disease and high cholesterol, he only eats ‘natural and organic foods.’” Therefore he probably has a psychiatric illness. “He clearly is preoccupied with food and judges others based on their food choices,” when in fact, he very well may be saving his own life. To me, the craziest thing this guy did was get a triple bypass. I mean, imagine lying on a psychiatrist’s couch and being like, “Yeah, I know I could switch to bean burritos, but I’d rather pay someone to slice my chest open with a knife, maybe saw my breastbone in half, put me at risk for stroking out, ya know, instead of dealing with the underlying cause, what do ya think, doc?”

Then, we could see some orthorexics becoming “evangelical as they share their feelings of disgust or disappointment towards their family, friends, and even children for their quote on quote normal food choices.” I mean, it’s bad enough they care about their own health, but caring about their family and friends, their children? Off to the funny farm you go. I mean, it’s not like what we eat is the #1 cause of death in the United States or anything, killing hundreds of thousands more Americans every year than cigarettes. Oh wait, it is. And also the #1 cause of disability, but you may have a mental illness if you’re disappointed that your kids are eating multi-colored marshmallows for breakfast.

If you recognize these warning signs, what should you do? You should confront the person. I know it’s not easy, but if you see someone obsessively trying to avoid unhealthy foods and worse, trying to get others to do the same, then confront them. “The possibility of helping them save their own life far outweighs uncomfortable emotions.” The irony, of course, is that they’re trying to save your life. Imagine if you were able to talk Mr. Triple Bypass out of his healthy eating obsession. You’d probably kill him.

To his credit, even Steven Bratman, the guy who “coined the term orthorexia”, has backed off, saying that he never “intended to propose a new eating disorder.” As an “alternative medicine practitioner,” he just wanted his patients to “relax their dietary corset and live a little.” I mean, where did people get this idea that he was trying to coin the name for a novel eating disorder? I mean, if you go back to his original article he just said he was trying to coin the name for “a novel eating disorder.” An eating disorder he saved himself from: “saved from the doom of his eternal health food addiction” with the help of “tacos, pizza, and a milkshake.”

One of the directors of the Yale Center for Eating Disorders is “skeptical.” “We’ve never had anybody come into our clinic with orthorexia, and I’ve been working in this field for at least 20 years.” “Without research to back his theory, Bratman is simply another guy trying to make a buck off the health-conscious public.” “They invent some new term, a new diet, a solution to a problem that doesn’t even exist. The burden should fall to the authors to prove what they’re saying is correct, before they start unleashing advice on the public.”

Finally today, let’s see how you score on the orthorexia “diagnostic” test.

“Orthorexia is defined as an unhealthy obsession with eating healthy food.” Want to know if you’re orthorexic? “The ORTO-15 is the most widely accepted assessment tool used to screen for orthorexic tendencies.” A score of 40 or lower was considered the best threshold for an orthorexia diagnosis. There are 15 questions, each scored from 1 to 4, so you can end up with a score of 15 to 60, with a score under 40 denoting orthorexia. So getting 1s and 2s and even an occasional 3 on your answers would mean you may have it, so lower scores are worse. Okay, let’s check it out. The first question: “When eating, do you pay attention to the calories of the food?” Always, Often, Sometimes, or Never. According to the test, the healthiest answer is Often, with the orthorexic answers being Always or Never. I can see how always obsessively worrying about calories could hint at a problem, but if you’re eating healthy enough, a diet centered around whole plant foods, you don’t need to worry about calorie counts or portion control. And the healthiest foods, fruits and vegetables don’t even have a nutrition label. But, apparently, if you’re never Googling the calories of every apple you eat, you may have a problem.

“When you go to the grocery store do you feel confused?” Supposedly, the healthiest answer is Always. You should always be confused, and if you’re not at least often confused, we may end up having to drug you.

Question 3: “In the last 3 months, did the thought of food worry you?” The supposed healthiest answer? Never. The thought of what you’re putting into your body didn’t worry you once. According to the test, it would be healthier if your eating choices were “conditioned” worries about your health, and of course taste should always be “more important than the quality” of your food. I mean, if you think the quality of food is even “sometimes” more important, you may have a mental illness. And if you’re often “willing to spend more money to have healthier food?” Crazy! Are you so delusional that “you think that consuming healthy food might improve your appearance?” My favorite, though, has to be question 14. Do you think that supermarkets also sell “unhealthy food?” You’ve got to be kidding. And then, they like penalize people who live alone. 

If you scored under 40, you are not alone. Using this test, about 50 percent of registered dietitians in the United States are supposedly suffering from a mental illness. “The prevalence of orthorexia nervosa presents as being impossibly high.” I mean, “anorexia and bulimia are estimated to be no higher than about 2 percent.” And so, it’s kind of “counterintuitive to believe that” there’s some eating disorder out there that has rates as high as nearly 90 percent. No wonder the DSM, the psychiatry profession’s official diagnostic manual, does not include orthorexia “as a psychiatric diagnosis” and they love turning things into mental illnesses. The latest edition can turn kindergarten temper tantrums into a disorder, too much coffee or even bad PMS into a mental illness, but they’re still not going to go there with orthorexia. For example: “Researchers had a tendency to pick and choose which questions of the ORTO-15 they used and come up with their own cut off scores for diagnosis,” resulting in “an alarmingly erratic use of the ORTO-15 tool that was designed to measure orthorexia.” The bottom line is that the ORTO-15 test “is likely unable to distinguish between healthy eating and pathologically healthful eating,” whatever that is.

Now, more recently, new criteria have been introduced. Given “the impossibly high prevalence rates,” new emphasis is placed on health problems because of diet, such as malnutrition, or medical complications that would, by definition, make it an unhealthy diet. Like this tragic case in which someone had tried to live off a few spoonfuls of rice and vegetables, and ended up bedridden. If that is what you want to call orthorexia, fine, but one wonders if it might have been clouded by some actual psychiatric diagnosis, like OCD, obsessive-compulsive disorder.

If you add in those adverse health criteria, then the prevalence drops to “less than one half of 1%,” which seems a little more reasonable. Interestingly, those eating “vegan” diets had the least pathological scores in the sample though this may reflect them just being less serious about healthy eating, reaching for the vegan doughnut rather than the lentil soup.

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