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Orthorexia Nervosa: The Health Food Eating Disorder

by Steven Bratman, M.D.

Because I am a physician who practices alternative medicine, patients who come to me often begin the conversation by asking whether they can be cured through diet. "Regular medical doctors don't know anything about nutrition," they say, believing this will build rapport with me. I feel obligated to nod wisely. I agree that conventional medicine has traditionally paid too little attention to the effects of diet. However, I am no longer the true believer in nutritional medicine I used to be. My attitude has grown cautious where once it was enthusiastic and even evangelical.

I have lost two beliefs that once encouraged me, and that are still widely accepted by others who promote dietary methods of healing. One of these is an assumption that there exists a comprehensive and consistent theory of healing diseases through nutrition. The other is a faith that dietary therapy is a uniformly wholesome, side effect free intervention.

My attitude has not always been so lukewarm. Twenty years ago I was a wholehearted, impassioned advocate of healing through food. My optimism was unbounded as I set forth to cure myself and everyone else. This was long before I became an alternative physician. In those days, I was a cook and organic farmer at a large commune in upstate New York. My experiences there formed the foundation of my early interest in alternative medicine, and continue to give me insight into the ideals, dreams and contradictions that underlie the natural health movement.

All communes attract idealists. Ours attracted food idealists. As a staff cook I was required to prepare several separate meals at once to satisfy the insistent and conflicting demands of the members. The main entree was always vegetarian. However, a small but vocal group insisted on an optional serving of meat. Since many vegetarians would not eat from pots and pans contaminated by fleshly vibrations, this meat had to be cooked in a separate kitchen. The cooks also had to satisfy the Lacto-ovo-vegetarians, or Vegans, who eschewed all milk and egg products. The rights of the non-garlic, non-onion, Hindu-influenced crowd could not be neglected either. They believed onion-family foods provoked sexual desire.

For the raw foodists (and young children) we always laid out trays of sliced raw vegetables. However, a visitor once tried to convince me that chopping a vegetable would destroy its etheric field. I chased him out of the kitchen with a huge Chinese cleaver.

The macrobiotic adherents clamored for cooked vegetables, free, of course, from "deadly nightshade" plants such as tomatoes, potatoes, bell peppers and eggplants. Some also insisted on eating fruits and vegetables only when they were in season, while other communalists intemperately demanded oranges in January.

Besides these opinions on which food to serve, there were as many opinions on the manner in which it should be prepared. Most everyone agreed that nothing could be boiled in aluminum, except the gourmet cooks, who insisted that only aluminum would spread the heat satisfactorily.

By consensus, we always steamed vegetables in the minimum amount of water to avoid throwing away precious vitamins. Certain enthusiasts would even hover around the kitchen and volunteer to drink the darkish liquids left behind. About washing vegetables, however, controversy swirled. Some commune members firmly believed that vital substances clinging just under the skins must be preserved at all costs. Others felt that a host of evil pollutants adhered to the same surfaces that needed to be vigorously scrubbed away. One visitor explained that the best policy was to dip all vegetables in bleach, and gave such a convincing argument for her belief that we would have adopted the principle at once were it not for a fortuitous bleach shortage.

I used to fantasize writing a universal cookbook for eating theorists. Each food would come complete with a citation from one system or authority claiming it the most divine edible ever created, and another, from an opposing view, damning it as the worst pestilence one human being ever fed to another.

This would not be difficult. For example, a famous naturopathic concept proclaims that raw fruits and vegetables are the ideal foods. Some proponents of this school exclaim periodically "the greatest enemy of man is the cooking stove!" However, another popular theory bans raw foods as unhealthy, and attributes to their consumption such illnesses as MS, rheumatoid arthritis and cancer. I am referring to macrobiotics. This influential system of alternative dietary principles insists that all vegetables should be cooked; fruits should not be eaten at all.

Similar discrepancies abound in alternative dietary medicine. The following rules may be found in one or another food theory:

Spicy food is bad.
Cayenne peppers are health promoting.
Fasting on oranges is healthy.
Citrus fruits are too acidic.
Fruits are the ideal food.
Fruit causes candida.
Milk is good only for young cows.
Pasteurized milk is even worse.
Boiled milk "is the food of the gods."
Fermented foods, such as sauerkraut, are essentially rotten.
Fermented foods aid digestion.
Sweets are bad.
Honey is nature's most perfect food.
Vinegar is a poison.
Apple cider vinegar cures most illnesses.
Proteins should not be combined with starches.
Aduki beans and brown rice should always be cooked together.

The discovery that nutritional medicine was so chaotic troubled me. Yet I could always hope that a universal theory of nutrition might eventually be found. What disturbed me more was observing the extremism that so frequently develops among those who propound dietary cures.

I remember a macrobiotic seminar at the commune, led by Mr. L. of the Kushi institute. An audience of at least thirty-five listened with rapt attention as Mr. L. lectured on the evils of milk. It slows the digestion, he explained, clogs the metabolism, plugs the arteries, dampens the digestive fire, and causes mucous, respiratory diseases and cancer.

At that time, a member of the commune by the name of John lived in a small room upstairs from the seminar hall. He was a "recovering" alcoholic who rather frequently failed to abstain. Although only in his fifties, John's face showed the marks of a lifetime of alcohol abuse. But he had been on the wagon for nearly six months when he tiptoed through the class.

John was a shy and private man who would never voluntarily have so exposed himself. But upon returning from the kitchen with a beverage he discovered that there was no way he could reach his room without crossing through the crowded seminar. The leader noticed him immediately.

Pointing to the glass of milk in John's hand, Mr. L. boomed, "Don't you realize what that stuff is doing to your body, sir! Class, look at him! He is a testament to the health destroying properties of milk. Study the puffy skin of his face. Note the bags under his eyes. Look at the stiffness of his walk. Milk, class, milk has done this to him!"

Bewildered, John looked at his glass, then up at the condemning faces, then back to the milk again. His lower lip quivered. "But," he whimpered, "but, this is only milk, isn't it?"

In the alcoholics anonymous meetings with which John was familiar, milk was practically mother's milk, synonymous with rectitude and purity. "I mean," he continued, to the unforgiving students, "I mean, it isn't whiskey, is it?"

By focusing on diet singlemindedly and ignoring all other aspects of life, alternative practitioners like Dr. L. come to practice a form of medicine that lacks a holistic perspective on life. This is ironic, of course, since holism is one of the strongest ideals of alternative medicine, and its most ubiquitous catchphrase (next to "natural").

It would be more holistic to take time to understand the whole person before making dietary recommendations, and occasionally temper those recommendations with an acknowledgment of other elements in that person's life. But too often patient and alternative practitioner work together to create an exaggerated focus on food.

Many of the most unbalanced people I have ever met are those have devoted themselves to healthy eating. In fact, I believe many of them have contracted a novel eating disorder, for which I have coined the name "orthorexia nervosa." The term uses "ortho," in its meaning as straight, correct and true, to modify "anorexia nervosa." Orthorexia nervosa refers to a fixation on eating proper food.

Orthorexia begins innocently enough, as a desire to overcome chronic illness or to improve general health. But because it requires considerable willpower to adopt a diet which differs radically from the food habits of childhood and the surrounding culture, few accomplish the change gracefully. Most must resort to an iron self-discipline bolstered by a hefty sense of superiority over those who eat junk food. Over time, what they eat, how much, and the consequences of dietary indiscretion come to occupy a greater and greater proportion of the orthorexic's day.

The act of eating pure food begins to carry pseudo-spiritual connotations. As orthorexia progresses, a day filled with sprouts, umeboshi plums and amaranth biscuits comes to feel as holy as one spent serving the poor and homeless. When an orthorexic slips up, (which, depending on the pertinent theory, may involve anything from devouring a single raisin in violation of the law to consuming a gallon of Haagen Daz ice cream and a supreme pizza), he experiences a fall from grace, and must take on numerous acts of penitence. These usually involve ever stricter diets and fasts.

Over time, this "kitchen spirituality" begins to override other sources of meaning. An orthorexic will be plunged into gloom by eating a hot dog, even if his team has just won the world series. Conversely, he can redeem any disappointment by extra efforts at dietary purity.

Orthorexia eventually reaches a point where the sufferer spends most of his time planning, purchasing and eating meals. The orthorexic's inner life becomes dominated by efforts to resist temptation, self-condemnation for lapses, self-praise for success at complying with the self-chosen regime, and feelings of superiority over others less pure in their dietary habits.

It is this transference of all life's value into the act of eating which makes orthorexia a true disorder. In this essential characteristic, orthorexia bears many similarities to the two named eating disorders: anorexia and bulemia. Whereas the bulimic and anorexic focus on the quantity of food, the orthorexic fixates on its quality. All three give to food a vastly excessive place in the scheme of life.

It often surprises me how blissfully unaware proponents of nutritional medicine remain of the propensity for their technique to create an obsession. Indeed, popular books on natural medicine seem to actively promote orthorexia in their enthusiasm for sweeping dietary changes. No doubt, this is a compensation for the diet-averse stance of modern medicine. However, when healthy eating becomes a disease in its own right, it is arguably worse than the health problems which began the cycle of fixation.

As often happens, my sensitivity to the problem of orthorexia comes through personal experience. I myself passed through a phase of extreme dietary purity when I lived at the commune. In those days, when I wasn't cooking I managed the organic farm. This gave me constant access to fresh, high-quality produce. Eventually, I became such a snob that I disdained to eat any vegetable that had been plucked from the ground more than fifteen minutes ago. I was a total vegetarian, chewed each mouthful of food fifty times, always ate in a quiet place (which meant alone), and left my stomach partially empty at the end of each meal.

After a year or so of this self imposed regime, I felt light, clear headed, energetic, strong and self-righteous. I regarded the wretched, debauched souls about me downing their chocolate chip cookies and fries as mere animals reduced to satisfying gustatory lusts. But I wasn't complacent in my virtue. Feeling an obligation to enlighten my weaker brethren, I continuously lectured friends and family on the evils of refined, processed food and the dangers of pesticides and artificial fertilizers.

For two years I pursued wellness through healthy eating, as outlined by naturopathic tradition and emphasized with little change in the health food literature of today. Gradually, however, I began to sense that something was wrong.

The need to obtain food free of meat, fat and artificial chemicals put nearly all social forms of eating out of reach. Furthermore, intrusive thoughts of sprouts came between me and good conversation. Perhaps most dismaying of all, I began to sense that the poetry of my life had diminished. All I could think about was food.

But even when I became aware that my scrabbling in the dirt after raw vegetables and wild plants had become an obsession, I found it terribly difficult to free myself. I had been seduced by righteous eating. The problem of my life's meaning had been transferred inexorably to food, and I could not reclaim it.

I was eventually saved from the doom of eternal health food addiction through three fortuitous events. The first occurred when my guru in eating, a lacto-ovo-vegetarian headed on his way toward Fruitarianism, suddenly abandoned his quest. He explained that he had received a sudden revelation. "It came to me last night in a dream," he said. "Rather than eat my sprouts alone, it would be better for me to share a pizza with some friends." I looked at him dubiously, but did not completely disregard his message.

The second event occurred when an elderly gentleman (whom I had been visiting as a volunteer home-health aide) offered me a piece of Kraft Swiss cheese. Normally, I wouldn't have considered accepting. I did not eat cheese, much less pasteurized, processed and artificially flavored cheese. Worse still, I happened to be sick with a head cold that day. According to my belief system at that time, if I fasted on juice I would be over the cold in a day. However, if I allowed great lumps of indigestible dairy products to adhere to my innards I would no doubt remain sick for a week -- if I did not go on to develop pneumonia.

But, Mr. Davis was earnest and persistent in his expression of gratitude, and would have taken as a personal rebuke my refusal of the cheese. Shaking with trepidation, I chewed the dread processed product.

To my great surprise, it seemed to have a healing effect. My cold symptoms disappeared within an hour. It was as if my acceptance of his gratitude healed me.

Nonetheless, even after this miracle I could not let go. I actually quit visiting Davis to avoid further defiling myself. This was a shameful moment, a sign that I was drowning.

The life-ring which finally drew me out was tossed by a Benedictine monk named Brother David Stendal-Rast. I had met him at a seminar he gave on the subject of gratitude. Afterwards, I volunteered to drive him home, for the covert purpose of getting to know him better. (This may be called "opportunistic volunteerism.") On the way to his monastery, although secretly sick of it, I bragged a bit about my oral self-discipline, hoping to impress the monk. I thought that he would respect me for never filling my stomach more than by half, and so on. David's actions over the subsequent days were a marvelous example of teaching through action.

The drive was long. In the late afternoon, we stopped for lunch at one of those out of place Chinese restaurants -- the kind that flourish in small towns where it seems no one of remotely oriental ancestry has ever lived. As expected, all the waiters were Caucasian, but the food was unexpectedly good. The sauces were fragrant and tasty, the vegetables fresh, and the eggrolls crisp. We were both pleasantly surprised.

After I had eaten the small portion which sufficed to fill my stomach halfway, Brother David casually mentioned his belief that it was an offense against God to leave food uneaten on the table. This was particularly the case when such a great restaurant had so clearly been placed in our path as a special grace. David was a slim man and a monk, so I found it hardly credible that he followed this precept generally. But he continued to eat so much that I felt good manners, if not actual spiritual guidance, required me to imitate his example. I filled my belly for the first time in a year.

Then, he upped the ante. "I always think that ice cream goes well with Chinese food, don't you?" he asked, blandly. Ignoring my incoherent reply, Brother David directed us to a Friendly's Ice Cream Parlor, and purchased me a triple scoop cone.

David led me on a two mile walk through the unexceptional town as we ate our ice cream, edifying me with spiritual stories and, in every way, keeping my mind from dwelling on the offense against Health Food I had just committed. Later that evening, Brother David ate an immense dinner in the monastery dining room, all the while urging me to have more of one dish or another. I understood the point. But what mattered more was the fact that this man, for whom I had the greatest respect, was giving me permission to break my Health Food vows. It proved a liberating stroke.

Yet, it was more than a month later that I finally decided to make a decisive break. I was filled with feverish anticipation. Hordes of long suppressed gluttonous desires, their legitimacy restored, clamored to receive their due. On the twenty minute drive into town, I planned and re-planned my junk food menu. Within ten minutes of arriving, I had eaten three tacos, a medium pizza, and a large milkshake. I brought the ice cream sandwich and banana split home, for I was too stuffed to violate my former vows further. My stomach was stretched to my knees.

The next morning I felt guilty and defiled. Only the memory of Brother David kept me from embarking on a five day fast. (I only fasted two days.) It took me at least two more years to attain the ability to follow a middle way in eating easily, without rigid calculation or wild swings.

Anyone who has ever suffered from anorexia or bulimia will recognize classic patterns in this story: the cyclic extremes, the obsession, the separation from others. These are all symptoms of an eating disorder. Having experienced them so vividly in myself twenty years ago, I cannot overlook their presence in others.

For this reason, as a practicing alternative physician I often feel conflicted. I almost always recommend dietary improvements to my patients. How could I not? A low fat, semi-vegetarian diet is potent preventive medicine for nearly all major illnesses, and more focused dietary interventions can often dramatically improve specific health problems. But I do not feel entirely innocent when I make dietary suggestions. Like drug therapy, I have come to regard dietary modification as a treatment with serious potential side effects.

Consider Andrea, a patient of mine who once suffered from chronic asthma. When she first came to see me, she depended on several medications to stay alive, but with my help she managed to free herself from all drugs.

The method we used involved identifying foods to which Andrea was sensitive and removing them from the diet. Milk was the first to go, then wheat, soy and corn. After eliminating those four foods the asthma symptoms decreased so much Andrea was able to cut out one medication. But she wasn't satisfied.

Diligent effort identified other allergens: eggs, avocado, tomatoes, barley, rye, chicken, beef, turkey, salmon and tuna. These too Andrea eliminated, and was soon able to drop another drug entirely. Next went broccoli, lettuce, apples, buckwheat and trout, and the rest of her medications.

Unfortunately, after about three months of feeling well Andrea began to discover that there were now other foods to which she was sensitive. Oranges, peaches, celery and rice didn't suit her, nor potatoes, turkey or amaranth biscuits. The only foods she could definitely tolerate were lamb and (strangely) white sugar. Since she couldn't actually live on those foods alone, Andrea was forced to adopt a complex rotation diet, alternating grains on a meal by meal basis, with an occasional complete abstention to allow her to "clear." She did the same for vegetables, with somewhat more ease since there was a greater variety to choose from.

Last week, Andrea came in for a follow-up visit, and described the present state of her life to me. Wherever she goes, Andrea carries a supply of her own particular foods. She doesn't go many places. Most of the time she stays at home and thinks carefully about what to eat next, because if she slips up the consequences continue for weeks. The asthma doesn't come back, but she develops headaches, nausea and strange moods. She must continuously exert her will against cravings for foods as licentious as tomatoes and and bread.

Andrea is happy with the treatment I've given her, and has referred many of her friends to see me. Yet, I feel ill when I see her name on my schedule. The first rule of medicine is "above all, do no harm." Have I helped Andrea by freeing her from drugs, only to draw her into the bondage of diet? My conscience isn't clear.

If it was cancer she had been cured of, or multiple sclerosis, I suppose the development of an obsession wouldn't be too high a price for physical health. However, all Andrea had was asthma. I have asthma too. When she took her four medications, she had a life. Now, all she has is a menu. Andrea might have been better off had she never heard of dietary medicine.

I am generally lifted out of such melancholy reflections by some substantial success. After Andrea, I saw Bob in follow-up, a man whose rheumatoid arthritis was thrown into full remission by one simple intervention: adding foods high in trace minerals to his diet. Before he met me, he took prednisone, gold shots and high doses of anti-inflammatories. Now he has gone a full year without a problem. Seeing him encourages me not to give up entirely on making dietary recommendations.

But my enthusiasm will remain tempered. Like all other medical interventions -- like all other solutions to difficult problems -- dietary medicine dwells in a grey zone of unclarity and imperfection. It's neither a simple, ideal treatment, as some of its proponents believe, nor the complete waste of time conventional medicine has too long presumed it to be. Diet is an ambiguous and powerful tool, too unclear and emotionally charged for comfort, too powerful to be ignored.