Orthorexia Nervosa I: Women Laughing Alone with Salad

Please note: this post has now been updated [August 8, 2015] to reflect correspondence from Dr. Steven Bratman as I had misrepresented his self-quiz to be limited to two questions, when it comprises 10 questions.

Additionally, there is now much more clinical trial data on the prevalence of restrictive eating disorders within health provider communities and I have added other pertinent material as well.

Like all good internet memes, you go to Know Your Meme to learn that an ironic appreciation for stock photography includes a lot of photos of women laughing alone with salad as well as women struggling to drink water and men laughing alone with fruit salad.

Meme is a term originally coined by Richard Dawkins to attempt to define cultural thoughts and concepts that seem to reproduce in ways that mimic what genes do in a biological sense. Internet memes are cultural ideas or concepts that get snapped up and reproduced electronically.

Of course the ironic shift in revealing the absurdity of many stock photos is what makes these images internet memes. But before that, these photos were originally posed and generated because our society actually has a completely non-ironic and earnest belief that healthy food makes us ebulliently happy.

If you check out women eating ice cream in stock photo albums, by comparison, you’ll find well over 75% of the images are sexualized (read: sinful); the remainder involve a few “double-girl-happy fun ice cream” shots and then the obligatory “woman pensively trying to decide whether to eat the ice cream” photos that are used for all those endless articles on the evils of ‘emotional eating’.

It is our general misunderstanding that food is either good or bad for us. This misconception is why orthorexia is an easy facet of the restrictive eating disorder spectrum to maintain in the face of concern from family and friends for your wellbeing, because “I’m just being healthy” shuts down the argument.

Is Orthorexia a real eating disorder?

As I have probably mentioned in other posts, orthorexia is not recognized in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV, now DSM-5). However, you also know that I have little use for the DSM as it is a laundry list of observable symptoms that usually obfuscates rather than clarifies underlying genetic predispositions for various neural conditions.

I also don’t really have much interest in mental disorders as a classification in any case as all of the neural spectrum conditions have some level of value from both an individual and population perspective. If the expression of these conditions has either individual or population survival value then it cannot be a disorder of human function.

Schizophrenia? Mild cases are well suited to shamanistic roles in tribal societies. Obsessive-compulsive disorder? Mild cases are well suited to applying religious orthodoxies to maintain societal structure in the face of an uncertain future. Restrictive-eating disorders? Mild cases are well suited to foraging further for longer thereby enhancing overall survival of the tribe in times of famine. Depression? Mild cases appear to provide a more accurate sense of self and others; more empathetic interactions; and an increased neural focus to address complex problems by shutting out the rest of the world. i

Additionally the complexity of all these neural conditions is further entrenched because they all exist on very broad spectrums. As such, the medicalization of these conditions creates arbitrary markers that distinguish someone as either having the condition or not. Our current predilection for the medicalization of mental states also completely overrules the environmental conditions in which the condition might present itself.

What this means is that in one environmental condition, having a severe case of depression (as one example) may not only be harmless for the individual involved and harmless to others, but also it may be beneficial to self and others as well. In another circumstance having even a mild case of depression may be extremely harmful to self and others.

The subjectivity of the individual’s experience with the condition, within the context of the society and the individual’s own observations, should determine whether intervention is indicated or not. And that approach does not fit within the framework of the DSM at all.

Certainly there have been plenty of examples on this site of those with restrictive eating behaviors who have clearly outlined to their health care providers the numerous negative impacts they and their loved ones are experiencing due to those behaviors, only to be told they do not have an eating disorder.

Although I do use the term restrictive eating disorder spectrum, I do so only to make it identifiable to a broad audience familiar with “eating disorders”. A descriptor such as: a neural condition that is genetic in origin and expressed through sociocultural memes, is not recognizable to almost everyone.

To answer the headline at the beginning of the section, yes orthorexia, or orthorexia nervosa, is part and parcel of the neural condition I call the restrictive eating disorder spectrum.

Later in this post I’ll talk about if and when intervention is a good idea but first let’s look in more detail at what orthorexia is, as well as its signs and symptoms.

Orthorexia Nervosa Defined

Physician Steven Bratman coined the term orthorexia: “orth”, meaning right or correct and “orexia” meaning appetite. ii

He identified orthorexia in patients as those who pursue “healthy eating” to a point of thinness and ill health. He distinguishes orthorexia nervosa (ON) from anorexia nervosa (AN) by suggesting that an orthorexic is not pursuing thinness but rather a pure, healthy and natural existence.

We know that anorexics are not pursuing thinness any more than orthorexics; rather post-onset of the condition, they attempt to consciously frame and define their anxious state and avoidant behaviors in terms that are culturally relevant.

Of course there is a universal pursuit of thinness in our society and that is why everyone attempts that first diet. However, the pursuit of thinness does not drive the anorexic to continue restricting. The pursuit of thinness certainly may drive him or her to begin dieting, but the compulsion to continue dieting is due to distinct biological underpinnings found within the restrictive eating disorder spectrum that are not present within the non-affected population at large.

And this is why it is possible to be anorexic/bulimic/orthorexic and have anorexia athletica all at once or in succession or back and forth—the avoidant behaviors are not rigid because the underlying neural condition to adopt restrictive eating behaviors is not created by the sociocultural inputs, it is framed by them.

In 1997 Dr. Bratman developed an initial 10-question self quiz as a way to determine the presence of orthorexia in a patient:

  • Do you spend more than 3 hours a day thinking about your diet?
  • Do you plan your meals several days ahead?
  • Is the nutritional value of your meal more important than the pleasure of eating it?
  • Has the quality of your life decreased as the quality of your diet has increased?
  • Have you become stricter with yourself lately?
  • Does your self-esteem get a boost from eating healthily?
  • Have you given up foods you used to enjoy in order to eat the ‘right’ foods
  • Does your diet make it difficult for you to eat out, distancing you from family and friends?
  • Do you feel guilty when you stray from your diet?
  • Do you feel at peace with yourself and in total control when you eat healthily? iii

Since that time, Dr. Lorenzo Donini and his colleagues have expanded on this initial self-quiz to develop the ORTO-15 test. iv There are, as far as I can determine, now five empirical studies assessing (and modifying) the psychometric properties of the ORTO-15: an Italian, Turkish, Portuguese, Hungarian and Polish paper. v, vi, vii, viii, ix Understandably, the validity of the ORTO-15 is still under review.

However, these psychometric machinations are the requisite compulsory hoops associated with research that must eventually funnel into the DSM. The delineation of normalcy vs. pathology is arbitrary in mental health and does not reflect anything more than consensus-based wrangling by interested parties. That still leaves those with questions about whether their eating behaviors are concerning or not, dependent on checklists rather than a self-assessment on whether those behaviors are harming quality of life or not.

Signs and Symptoms of Orthorexia

As with anorexia athletica the society-wide obsessions with increasing our activity levels and improving our “healthy” food intakes allow the signs and symptoms of orthorexia to go undetected by the sufferer, their loved ones and their health care professionals.

Here are common symptoms that reflect that quality of life is negatively impacted:

You will not eat certain foods under any circumstance despite the fact that you once enjoyed them.

You weigh your food when preparing your meals.

You look-up and tally (either mentally or with actual food logs) macronutrients in your foods. If the results are not exact, then you cannot shake the feeling that you have done damage to yourself, or that you risk imminent ill health or disease.

You equate processed foods, additives, chemical residues, GMO as well as unbalanced micro and macronutrients as dangerous and the cause of disease and ill health (eg. sugars, all processed and packaged foods, sodium, saturated fats).

You are vegan or a raw-foodist (these choices do not automatically indicate orthorexia, however they are markers alongside the other signs in this list).

You adhere to diets that are suitable for those with existing disease states believing they have disease prevention capabilities (eg. Paleo-diet, low-fat diets, no-dairy diets, low-carb diets, low-protein diets, etc.).

You will not go to restaurants if you cannot confirm ingredients, calories and macro and micro nutrient contents of menu items in advance of going there.

You tend to avoid having meals at other people’s homes because you have no way to measure and identify all of the ingredients, nutrients and caloric value of the food served.

If you do eat anything that you consider unhealthy, you experience anxiety and you compensate by applying any number of behaviors to try to re-balance yourself: fasting, juicing, cleanses, additional exercise (to sweat out the impurities), supplements purported to detoxify, home-remedy enemas, etc.

Your mood is dependent on how successful you are at any given point in reaching or failing to reach your nutrient and healthful eating goals.

If you can say “yes” to at least 4 of the items above, then there is cause for concern and above 5, intervention is strongly advised.

There is a current Activia® commercial in rotation on TV right now where the woman speaks of eating multiple turkey dinners and the challenge of getting through the holidays. I believe she says on two separate occasions “It’s just not normal.” A variation on this ad can be found here: Activia: Get Back on Track.

Given that we now live in a society where over-indulgence during the holidays is “not normal”, and eating yogurt with patented cultures is somehow preferable to spending time enjoying the company of family and friends, it’s easy to understand how orthorexic behaviors are almost indistinguishable from a society-wide obsession with “healthy eating”. And in the ironic vein of Woman Laughing Alone With Salad, it’s about selling product and not health in any case.

Prevalence of Restrictive Eating Disorders within Health Provider Communities

The challenge with clinical data looking at restrictive eating disorder prevalence within health provider communities is two-fold: there is not always a control group identified within the studies in question and it is questionable that a differentiated control group could ever be dependably identified within our healthist and fattist cultures in any case.

In this study a majority (68.55%) of female students and large minority (43.18%) of male counterparts reported met criteria for high levels of orthorexic (healthy eating) behaviours. This may have been because the study selected students who were mostly studying psychology or dietetics and thus already were knowledgeable and interested in nutrition, health and well-being.”  x

Again, it is not that these groups are more vulnerable to orthorexia, rather it is more likely that those on the restrictive eating disorder spectrum who are physicians or dieticians etc., may develop orthorectic restrictive patterns because they are acceptable and re-enforceable within the current social and cultural contexts in which these groups of people work and live.

Dr. Johann F. Kinzl, Department of Psychiatry, Insbruck Medical University, and his colleagues distributed a questionnaire to 500 female dietitians, where 283 completed the questionnaire, to identify prevalence of orthorexia.

“More than one third (n=102) of the dieticians had changed eating behavior in recent years, 60% of them to a generally more healthy eating pattern and about 10% to healthy foods only. The change to health eating was prompted by a diminished physical ability to cope with stress, emotional crisis, a serious physical or emotional disorder. Of the entire sample, 13 (4.6%) dieticians reported having had anorexia nervosa, 10 (3.5%) bulimia nervosa and 3 (1.1%) a binge eating disorder in the past.” xi

We can clearly see within the responses above, that the dieticians who responded to the survey have a history of anorexia nervosa at 15 times the rate found within the population at large. xii Now keep in mind, we are carefully comparing apples to apples. The prevalence of restrictive eating disorders is arbitrarily very small when applying psychometric tests and DSM checklists that do not reflect a spectrum disorder but rather a binary classification that means you either have or do not have the condition in question. But of course Dr. Kinzl and his colleagues would be applying those binary classifications and not the eating disorder spectrum that is more accurately represented by the work of Dr. Catherine Shisslak and her colleagues. xiii

Generally speaking, the prevalence of orthorexia within the health provider student and practitioner communities is very high (around 70% xiv) and that likely suggests that the ORTO-15 (and its modified versions) is not yet a viable method for identifying the presence of orthorexia, within the framework of the DSM of course.

When it comes to students within nutritional science programs, they have higher scores of dietary restraint than students from other programs:

While healthy food choices are done in a less obsessive fashion by higher semester nutrition students, their food choices themselves become slightly, but significantly more healthy. This has been in contrast to the control group; there, the food choices became slightly less healthy in higher semesters. Therefore, the increasing knowledge of nutrition students is paralleled by a more healthy food choice and eating behaviour.” xv

You’ll likely note the “white-hat bias" xvi within that last sentence— a series of assumptions that there is a) healthy food choices to be made and b) that it is the educational input generating such a shift in eating behavior.

It is also just as feasible to conclude that the control group’s food choices are not “less healthy” but rather “less rigid and restrictive” reflecting maturation and individuation that will occur naturally as students reach their final years of study. And therefore, nutritional science students in higher semesters are applying ever-increasing levels of restrictive food choice behaviors in stark contrast to their peers spared the pressures of a nutritional science program.

As for the prevalence of orthorexia within medical student and doctor communities, two studies indicate a high prevalence, xvii, xviii however control groups are lacking in those studies. However a review of eleven studies suggests the prevalence rate for orthorexia is 6.9% in the general population and 35-57.8% for high-risk professions (healthcare professionals (including physicians) and artists). But it should be noted that the review indicates that the definition and diagnostic criteria of orthorexia nervosa remains unclear. xix

Is there a higher prevalence of restrictive eating disorder behaviors and pathology to be found in those pursuing health care provision careers when compared to the population at large? Certainly we need more investigation, but I am comfortable saying that the data so far suggest prevalence rates are higher within the health care provision environments.

Neurobiological Underpinnings

A restrictive eating disorder is an inherited neurobiological condition.

The genetic markers are not fully identified, but the condition usually lies dormant and is triggered by innumerable environmental factors. The genetic predisposition for the condition is present in all human populations and even exists in some animals. xx, xxi It has persisted within the human gene pool because it likely has, or had, beneficial implications for survival.

There was a push to pursue a transdiagnostic approach to merge the currently distinct classifications of restrictive eating disorders from the DSM-IV to 5 into one broad classification of restrictive eating disorder. As I had anticipated, the appropriate merger did not occur. Had it happened, it would have accurately reflected the clinical evidence that anorexia and bulimia are not two distinct conditions, and that several other restrictive facets are all part of the same neurobiological condition as well. xxii, xxiii, xxiv

As best as we can understand the condition at this point, there appears to be various functional neural anomalies that appear with the onset of the restrictive eating disorder within the various centers distributed across the brain, and these anomalies persist whether weight restoration and cessation of restrictive behaviors are achieved or not. xxv, xxvi

Orthorexia’s Place Within the Neural Condition of Restrictive Eating Behaviors

Unfortunately there are no studies as yet on the progression of symptoms from anorexia nervosa to orthorexia, or the presentation of both symptom suites at the same time, and this is largely due to the fact that orthorexia as a distinct symptom suite was only identified this century.

We can however extrapolate from the much larger body of clinical work on the presentation of both anorexia nervosa and anorexia athletica in patients that I discuss in more detail in my blog posts on exercise and restrictive eating disorders.

Given that anorexia athletica can be defined as the combined presence of restrictive eating behaviors alongside excessive exercise, orthorexia nervosa might likely be defined as the combined presence of restrictive eating behaviors alongside excessive focus on health as it relates to food. In fact, one recent study suggests that prevalence of orthorexia is high in athletes, xxvii confirming the significant overlap of restrictive behaviors and so-called pursuits of health and wellness.

Often the earliest signs of the progression into clinical levels of anorexia nervosa are the cutting out of desserts, sugars, etc. xxviii And that often progresses to vegetarianism, veganism or other diets that place significant macronutrients off limits. So in many cases, orthorexic behaviors are embedded in the progression to full-blown anorexia nervosa.

Orthorexia’s Distinctiveness Within the Neural Condition of Restrictive Eating Behaviors

Generally it is assumed by both experts in the field and those with only passing knowledge of the subject, that those with restrictive eating disorders are exquisitely capable of enduring massive pain and discomfort in their quest to reinforce their restrictive behaviors. How else can they suffer through starvation, purging, running despite fractures and injuries, and so on?

That’s not an accurate reflection of their entire experience, in my estimation. It is true they are aware of hunger and pain and yet they do experience a greatly improved mood when resisting the urge to succumb to those signals. But perversely, as they continue to feel good when they are successful in resisting the need to eat and rest, they also become increasingly terrified of the ultimate outcome of these behaviors.

No matter whether the patient expresses more anxiety or obsessive-compulsive traits, more attention to the goal of thinness or the goal of purity or virtuousness, more unabated low-calorie intake or more cycles of restriction with reactive eating, none has an overwhelming desire to die and they have no particular affinity for pain or tolerance of it either.

My anecdotal experience with alcoholics is that they have a propensity to drink green tea. And their reason for doing so is to try to negate the deleterious effects of alcohol on their bodies. Unable to reduce or cease drinking, the green tea becomes a distracting totem that will protect them from the ultimate health catastrophe that awaits them from a lifetime of alcohol abuse.

Orthorexia holds a somewhat equivalent space in the onset and progression of restrictive eating behaviors—to a lesser extent, so too does anorexia athletica.

Orthorexia in its application within the restrictive eating behaviors spectrum is a distracting totem meant to protect the patient. It is meant to bolster the patient’s health such that she might somehow avoid the damaging consequences of restrictive eating behaviors.

Focusing on measurements, percentages, the possible benefits of biodynamic food when compared to organic food, or the need to increase or decrease certain supplements based on the latest health articles…all create distraction through ritual—the sense that, if applied correctly and perfectly without flaw, both sickness and perhaps even death are avoidable.

Death is Not the Issue

Of course death really is a serious issue when it comes to the restrictive eating disorder spectrum, but patients are generally not inordinately afraid of death.

What they do fear, with some reason, is the helplessness and horror of being very sick in our modern societies. It is no surprise to me that orthorexia appears in higher numbers with medical students and physicians than in the population at large (see above section on the discussion of prevalence within health provision careers)—they get to see first hand what awaits.

Obsessive-compulsive behaviors do not tend to appear in the absence of underlying anxiety. The OC-behaviors develop as a way to try to lessen anxiety.

Anxiety is a physically uncomfortable state. Useful for survival in more nomadic existences, it becomes quite a burden to have an anxious set point in modern, complex urban societies.

Orthorexia is often likened to obsessive-compulsive disorder—things are fine as long as the rituals for pure and virtuous food consumption are successfully applied, but massive anxiety ensues when the rituals are either incompletely or insufficiently applied. xxix

But in fact, the development of those rituals is in response to anxiety. The source of that anxiety is the neurobiological drive to restrict but the “why” eludes the patient’s conscious mind and so he or she applies appropriate sociocultural memes as a way to conjure up explanation.

The Presence or Absence of the Restrictive Eating Disorder Spectrum

Here is a good diagram xxx that I have subsequently modified to provide a flow chart of the onset and progression of the restrictive eating disorder spectrum as I envision it:

Figure 1: Cycles of Eating Disorders and Disordered Eating

Looking at Figure 1, we can see that the amalgamation of both the genetic predisposition with sociocultural, familial and personal factors lies in wait for a precipitating factor. The precipitating factor is presumed to activate or kindle the neurological alterations within the brain (pre-determined by the genotype).

The patient is now driven to apply restrictive eating behaviors but while she may be able to identify the precipitating factor, she cannot frame in thoughts or words why it drives the need to restrict. In other words the entire top line of Figure 1 essentially resides below conscious comprehension or communication.

The perpetuating factors, brilliantly identified by Dr. Ramacciotti and colleagues, entrench the drive to restrict. The starvation-impacted brain is now paranoid and highly anxious. Food becomes the enemy. Explanations for continuing to restrict are often framed as “excuses” by others, but they are more a reflection of the biological adjustments to starvation: gastroparesis, reduction of digestive enzyme production (leading to secondary food intolerances), gastrointestinal motility issues due to bacterial colony collapse, and issues with swallowing often associated with reduction in saliva production and throat irritation due to regurgitation and vomiting.

And we arrive at the patient now expressing some or all of the facets associated with how the drive to restrict is applied on a day-to-day basis: AN (anorexia nervosa), non-purge BN (restrict/reactive eating cycles), BN (bulimia nervosa, ON (orthorexia nervosa) and AA (anorexia athletica).

Now let’s turn our attention to the left side of Figure 1. When is a diet just a diet and not a progression into anorexia? The answer would be that there is an absence of any underlying genetic predisposition to restrict. With only the influences of sociocultural inputs, a person can certainly do damage, but will likely reverse her course as a result of such damage appearing.

Someone who diets because social and cultural inputs alone suggest she should, will not be successful at maintaining the damaging weight loss. Someone who is “good on her diet” on the weekdays and splurges with food and drink on weekends will eventually even out the cycle as she gets older and finds the restriction too onerous during the work week and the weekend partying too exhausting to maintain as well.

I have specifically shaded the boxes from green to red to indicate that, in the absence of genetic testing, we cannot know for certain whether someone who only consumes raw food (as an example) is suffering from restrictive eating behaviors, or is going through a phase of being particularly responsive to the sociocultural emphasis on healthy eating.

And that is why Dr. Bratman’s 10-question quiz is useful— the marker of a restrictive eating disorder being present or absent in any individual is best identified by having the individual honestly assess whether the behaviors negatively impact her life or the lives of those who are close to her.

What’s the Difference Between Healthful Eating and Orthorexia, or Is There a Difference?

Essentially there are very few observable differences between someone eagerly pursuing a healthy lifestyle and someone in the clutches of orthorexia nervosa.

Likely the most dependable way to identify orthorexia nervosa is to take a detailed history of the patient in question. Many with orthorexia nervosa will have a history of applying other restrictive behaviors. “I had a bout of anorexia when I was 11, but I recovered,” is often a telltale sign of the continuation of active restrictive eating behaviors rather than a stable and complete remission and an interest in healthy foods unrelated to restrictive eating.

As already mentioned, the negative impacts on self and others are a very strong marker of the presence of orthorexia. Those who pursue healthy eating habits in response to purely sociocultural pressure will regularly modify their food choices to suit others and lessen social tension.

A visit to the in-laws for someone temporarily applying “clean” or “healthy” eating behaviors will inevitably mean she will eat foods she usually eschews and she will feel no anxiety in doing so. By comparison, someone on the restrictive eating disorder spectrum who expresses the condition with orthorexic behaviors will perhaps not go to the in-laws because the familial tension that her absence causes is preferable to the unmanageable anxiety she has at having to graciously accept unacceptable food. Or, she might attend but feign intolerances, illnesses, lack of hunger to explain her disinterest in partaking in the food prepared.

It should be noted that Dr. Bratman would disagree with framing the expression of orthorexia in these ways and that it risks pathologizing those who pursue healthy and clean eating who do not have orthorexia nervosa. Those who pursue healthy and clean eating in the absence of a restrictive eating disorder cannot and do not maintain the behaviors. The dropout rates for all types of restrictive diets for remediation of either fatness or chronic illness range between 35-55% within the first two months of applying the restriction. xxxi, xxxii, xxxiii

At the core of the healthy-eating craze is the misunderstanding that restrictive diets that provide health improvements for those with existing disease states will somehow also have preventative and protective value for those who are currently healthy.

Obviously a patient with celiac disease must remove gluten-based foods from her diet. However, she is in a diseased state. And while celiac disease may confer other survival benefits, essentially her restrictive diet is an unfortunate outcome of her existing disease state. Her disease will worsen with the continued consumption of gluten. But a healthy person who removes gluten from her diet will at best experience absolutely no health benefit and at worst will alter the bacterial balance in her gut in ways that might even be harmful.xxxiv, xxxv She also adds a reasonable risk of nutritional deficiency and poor vitamin status over time. xxxvi, xxxvii, xxxviii

There is a world of difference between the improvements in health from a diseased state that a restrictive diet may provide, to the bold mental leap that those specific foods caused the diseased state in the first place. Gluten does not cause celiac disease. Dieting does not cause anorexia. Dietary fat does not cause heart disease.

And most importantly, even with genetic predispositions in place, disease states are not foregone conclusions with either the presence or absence of particular foods.

Even for patients with the genetic predisposition to develop celiac disease, gluten in the diet does not activate the disease state.

But what about a controlled randomized trial that confirms a gluten-free diet improves diarrhea in patients “diagnosed” with irritable bowel syndrome?

You have to read the trial data. They did not screen for celiac disease prior to randomization. Well, they did and they didn’t. They did in the sense that they certainly did not include already confirmed or likely celiac patients into the trial, but they did not actually apply the IgA antibody test or biopsy confirmation for all subjects prior to admission. They relied on a history of such tests having been applied or a history of the subject having applied a gluten-free diet in the past.

And in fact, they had 50% of their subjects in both the control and experimental groups positive for genotype HLA-DQ2/8. Given that those genotypes are markers for the possible onset of celiac disease, all of the subjects should have been HLA-DQ2/8 negative to absolutely rule out the possibility that any improvements on a gluten-free diet were not actually reflecting the expected improvements for a confirmed celiac disease subject who adopts a 100% gluten-free diet. They are at least forthcoming in indicating that those with the HLA-DQ2/8 genotypes had greater improvements and I expect the statistical relevance of which they speak would disappear entirely were those individuals properly screened out at the beginning of the trial. xxxix

When and How to Intervene

If you (or a loved one) have any history of restrictive eating disorders, then early and complete intervention is wise. Treat the presence of orthorexic behaviors as a relapse of the restrictive eating disorder (the same is true for anorexia athletica behaviors).

Real healthy eating and activities are not reflected at all in today’s sociocultural drive to sell product as a path to an illness-free, immortal and deeply fulfilling existence.

Remember, the woman who is laughing alone with her salad is alone. Few human beings experience health and fulfillment by being alone in real life. And, ironically, the photo at the beginning of this post does indeed portray one outcome of orthorexia that is accurate: social isolation.

For those on the restrictive eating disorder spectrum, healthy eating is unrestricted at all times and healthy activity is the equivalent of no more than 30 minutes’ brisk walking each day (once fully weight restored).

One barrier to receiving adequate support from a relapse that involves orthorexia is that it’s not out of the question that your medical and dietetic professionals will have orthorexia themselves. When this happens then you are likely to be told that your concerns are not well founded and that there is nothing remiss in your focus on healthful pursuits.

Unless you already have in place a support team whose members are not struggling with their own issues with the restrictive eating disorder spectrum, then consider turning to those in your life who clearly do not have restrictive eating behaviors—perhaps some friends, or a spouse or partner, or a family member. Although they are hard to come by, we all know people who still enjoy food and are not wracked with guilt over food choice decisions. They should be your compass for guiding you to non-restrictive behaviors, rather than expert advice that may lead you astray.

Attach Yourself to Those Who Love to Live Within Their Own Bodies

We can choose to some extent the sociocultural influences that shape us. If you, or someone you love, are struggling with a restrictive eating disorder (orthorexia included) then intervention cannot overlook the necessity of the sociocultural inputs.

You can attend all the group therapy sessions and cognitive behavioral training you want, but if your day-to-day influences counteract the need to live through your body (not alongside it, or in spite of it, or even to spite it) then everything ends up a wash.

I am going to end by quoting just one of so many insightful and intelligent men and women who pass through this site (I would like to quote them all!):

I managed to hurl myself out of my apartment before I spun into a black hole of misery, went to the farmer's market with my best friend, then went for a margarita and loads of guacamole and chips at our favourite Mexican place. I was sitting there, laughing my butt off, gossiping about a bad date I went on last night, when it hit me: if I relapsed...if I never made the choice to get better, I would absolutely never be sitting there having a great time and enjoying myself. I never would have gone on the date (my first in a year!) and I never would be drinking or eating whatever I wanted while laughing with my best friend. I decided right then and there that if thinness/sickness is what I have to give up to find these moments of happiness again, then it's absolutely worth it." xl

And that, my dears, is a Woman Not Alone Laughing With Guacamole and Margaritas!

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i Lecture Series on Religion Dissected, R.M. Sapolsky, 2011; N. Ghaemi, A First Rate Madness: Uncovering the Links Between Leadership and Mental Illness, 2011.

ii S Bratman, Original Orthorexia Essay, retrieved from: http://www.orthorexia.com/original-orthorexia-essay/

iii S Bratman, D. Knight, Health Food Junkies: Orthorexia Nervosa—Overcoming the Obsession With Healthful Eating, New York, Broadway Books, 2000.

iv Donini, L. M., D. Marsili, M. P. Graziani, M. Imbriale, and C. Cannella. "Orthorexia nervosa: Validation of a diagnosis questionnaire." (2005).

v Donini, L. M., D. Marsili, M. P. Graziani, M. Imbriale, and C. Cannella. "Orthorexia nervosa: validation of a diagnosis questionnaire." Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 10, no. 2 (2005): e28-e32.

vi Ramacciotti, C. E., P. Perrone, E. Coli, A. Burgalassi, C. Conversano, G. Massimetti, and L. Dell’Osso. "Orthorexia nervosa in the general population: a preliminary screening using a self-administered questionnaire (ORTO-15)." Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 16, no. 2 (2011): e127-e130.

vii Alvarenga, M. S., M. C. T. Martins, K. S. C. J. Sato, S. V. A. Vargas, Sonia Tucunduva Philippi, and F. B. Scagliusi. "Orthorexia nervosa behavior in a sample of Brazilian dietitians assessed by the Portuguese version of ORTO-15." Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 17, no. 1 (2012): e29-e35.

viii Varga, Márta, Barna K. Thege, Szilvia Dukay-Szabó, Ferenc Túry, and Eric F. van Furth. "When eating healthy is not healthy: orthorexia nervosa and its measurement with the ORTO-15 in Hungary." BMC psychiatry 14, no. 1 (2014): 59.

ix Brytek-Matera, Anna, Magdalena Krupa, Eleonora Poggiogalle, and Lorenzo Maria Donini. "Adaptation of the ORTHO-15 test to Polish women and men." Eat Weight Disord 19 (2014): 69-76.

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xl Torontogirl, Forum Post 2012, Your Eatopia.