When you actually jeopardize your health by wanting to eat healthy, you’ve crossed the line into orthorexia – the “in” eating disorder. But the concept gets more space in the tabloid press than in scientific reviews. A look back at the unusual beginning of a not-so-medical term.
When Steven Bratman coined the term “orthorexia,” he had no idea it would garner so much attention. Flash back to the 1990s. A few of the young American doctor’s patients were very worried about the quality of their food. Perhaps too worried. For some, the questions were never-ending: with or without gluten, vegetarian or raw food, too much or not enough fiber and protein, combine certain nutrients or not? “I wanted to provoke them, get them to think about it, so they’d take themselves a little less seriously and relax a little. So I started calling it orthorexia. But I wasn’t really trying to turn it into a disorder.”
Orthorexia – from the Greek orthos for “correct” and orexis for “appetite” – is an eating problem that is not defined by a poor body image, as with anorexia, but by an obsession with eating healthy food. Dr. Bratman says that before researchers seized on the term and the media ran with it, it was only meant to be a useful way of discussing the issue with patients and the general public.
A real disorder or a useful concept?
Twenty years later, the term has been featured in a few scientific publications and a lot of articles in the mainstream press. When some star admits to suffering from orthorexia, this gives women’s magazines material for yet another column in their diet pages. But the line between trend and reality has become increasingly blurred. Already in 2011, the Huffington Post was questioning whether orthorexia was the “real thing” or “just another annoying attempt to medicalize and pathologize everything in the world.”
In the meantime, Dr. Bratman has been swarmed by journalists. “I get at least one request a day for an interview. I’m a little tired. Plus, what I read in the news is often muddled and depressing.”
Over the phone, he sighed at certain questions – the ones he gets all the time – and gave his stock answers. “You want to know if orthorexia is a real disorder, if it’s an actual scientific concept. That’s not the right question. You should be asking if the concept can help doctors better treat their patients. Personally, I’m not convinced it can.”
Dr. Bratman is sure of one thing though – he has managed to make people aware of the issue. At a time when food and health topics are being pushed more and more, some people have become obsessed. “If what I’ve read and heard are true, and people are saying ‘I want to eat healthy, but not be orthorexic,’ then the term is useful. But again, it’s useful for the general public. For doctors and experts on eating disorders, it’s a whole other story.”
When grocery shopping makes you anxious
Sandra Gebhard, a psychiatrist and chief of medicine at CHUV/eHnv’s Vaud Center for Anorexia and Bulimia, agrees with Dr. Bratman. “Clinicians don’t quite know what to do with orthorexia, or even if the concept can be useful. To be honest, we’re not even sure what it is exactly. What we do know is that Dr. Bratman was right to pick up on this evolution in our relationship with food, a form of anxiety that is characteristic of this day and age, given that increasingly complex decisions lay on the shoulders of individuals.”
Eating disorders are by no means a new discovery – accounts dating back to the Renaissance contain detailed descriptions of anorexia as we know it today. We have not, however, seen a single trace of orthorexia, at least until Dr. Bratman gave it a name.
Dr. Gebhard thus believes we need to look at more recent history to find the causes of orthorexia. Industrialization and productivity-driven farming have made a wide range of foods available to us. Eating has gone from being part of our normal social behavior – sitting around the table with our family to eat local, seasonal food – to becoming a matter of individual responsibility.
“Medicalizing everything left, right and center has added another layer to our plethora of choices,” says Dr. Gebhard. “Everyone is responsible for having an eternally young and healthy body, which you control in part through nutrition.”
So is orthorexia a technical term to describe the anxiety we feel nowadays when we look at our plates or walk through the supermarket? That’s how Dr. Bratman sees it. “I think of orthorexia above all as a cultural phenomenon. We’re still far from including it in mental illness catalogues, and I don’t even know if it’s worth fighting for that.”
A new concept’s unusual journey from a yoga magazine to scientific reviews
How did orthorexia go from a doctor’s office to scientific articles and tabloids? The term’s history is anything but ordinary. It all started with Dr. Bratman’s first article, which was in a yoga magazine. He believes he targeted the right audience – people concerned about their well-being, at times to a fault, and very likely to be receptive to arguments supporting healthy diets (detoxing wasn’t a thing yet).
In 2000, he published a book for the general public entitled Health Food Junkies: Orthorexia Nervosa – the Health Food Eating Disorder.1 A second edition came out, but in the end the book was not a huge success. Tired of the subject, Dr. Bratman happily moved on to other things.
Then in 2001, it caught the attention of researcher Adriane Fugh-Berman, who published a critique of the book in the internationally renowned Journal of the American Medical Association. While she did not formally support the concept of orthorexia, Dr. Fugh-Berman did encourage colleagues to explore it further. And thus she got the ball rolling, slowly but surely, as is often the case in the scientific world.
Less-than-convincing preliminary studies
It wasn’t until 2004 that an article3 on orthorexia appeared in a peer-reviewed scientific journal, i.e., whose content is evaluated by a committee of experts. In it, a team of Italian researchers attempted to provide a succinct definition of the disorder. A year later, the team published another article in which they introduced their test to diagnose orthorexia, ORTO-15.4
“Without telling me, they published a modified version of the test I had suggested in my book,” said Dr. Bratman. “My questionnaire was meant to raise the reader’s self-awareness and get them thinking, not be a medical diagnosis!”
There were numerous issues. For starters, Dr. Bratman and Dr. Gebhard note that the test is based on a very basic definition of orthorexia. “It doesn’t make sense: how are you supposed to measure something you haven’t clearly defined?” said Dr. Gebhard.
When applied to certain populations, the ORTO-15 test produced noticeably absurd results. According to a study5 from 2014, when a group of Brazilian nutritionists took the test, it was found that 88.8% of them presented orthorexic behavior. “What does a disorder that affects almost 90% of the population tell us? Absolutely nothing!” says Dr. Bratman. Dr. Gebhard agreed: “Some really pitiful things get published. With results like that, people can’t help but think it’s a bunch of baloney!”
What’s worse, the test does not measure the degree to which people supposedly with orthorexia are suffering, which is the whole point of psychiatry. Dr. Gebhard said, “The amount of suffering is what makes something a disease; it’s what differentiates normal behavior, although perhaps eccentric, from a mental illness. Anorexia, for example, leads to major physical health problems, psychological distress, and social isolation.”
The unconvincing results have not stopped several teams of researchers from using ORTO-15. Their articles, which are few and far between, tend to pass unnoticed and are often published in less-reputable sources.
Uncooked vegetables and amino acids: the first unbelievable case studies
The majority of scientific articles sought to establish the prevalence of orthorexia in different population samples. But at the same time, researchers started publishing the first case studies, in which they had carefully analyzed a particular patient’s case.
In 2005, Spanish researchers published an article6 about a 28-year-old patient who only ate raw vegetables. She had also convinced herself that mixing different types of nutrients in the same meal produced toxins. The patient had socially isolated herself and, although she did not aim to lose weight, she had dropped below 28 kilos (62lbs).
Ten years later, American scientists described the case7 of a young man whose diet consisted solely of amino acid powder – the supplement often used by body builders – which he would make himself in order to avoid the additives used in commercial products. He developed an obsession with “pure” food following an episode of severe constipation and believed his diet of “pure building blocks” was the only way for him to be healthy. He also was not aiming to lose weight, but at the time he was hospitalized for severe malnutrition, he only weighed 43 kilos (95lbs).
The blogger who threw orthorexia into the limelight
These rare and unbelievable cases did not catch the public’s attention. Then in 2013 American blogger Jordan Younger, known as “The Blonde Vegan,” confessed to her then 70,000 plus Instagram followers that she suffered from malnutrition due to “her obsession with eating healthy.” And thus orthorexia became the “in” eating disorder.
Younger’s story went viral, as major television channels and papers spread word of her confession. Orthorexia was now a thing. Many medical professionals learned about the disease at the same time as the general public – which is not normally the case. From one day to the next, Dr. Bratman’s phone began ringing off the hook.
The resulting media storm has been a far cry from the insulated atmosphere of consultations and careful consideration that doctors hold so dear. For Dr. Gebhard, it is time for the medical community to have a serious look at the concept, even if it ends up rejecting it. “In my opinion, orthorexia got off on the wrong foot. We have to make up for that through a concerted effort to publish quality work on the subject.”
And when will it become an official diagnosis?
As orthorexia has appeared in only a limited number of scientific publications (and those being of questionable quality), it is safe to assume that it will not be added to the American Psychiatric Association’s famous Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) anytime soon – if ever.
“Psychiatrists aren’t as lucky as astrophysicists,” says Dr. Bratman. “Psychiatric disorders do not exist in the same way that Jupiter and the Andromeda Galaxy exist. Ours are descriptions that have to be agreed upon before they’re included in the manual.”
In general, for a disorder to be officially recognized, hundreds of articles have to be published on it, data must be compiled, and researchers and clinicians have to come to a clear consensus on the quality of that data. To date, just over 30 studies have been carried out on orthorexia.
The criteria are complex and often incomprehensible to the average person. According to Dr. Gebhard, “We don’t compile the classifications just for the fun of it. They’re there so we can provide accurate diagnoses and appropriate treatments. Take binge eating, which was recently added to the DSM-5. The treatment isn’t the same as bulimia – binging and purging – which justifies its inclusion in the manual. It took dozens of years of studies to prove that. To be classified, orthorexia needs to require a special treatment, different from how we treat anorexia, for example. And based on our current knowledge on the matter, that need isn’t obvious.”
In addition, Dr. Gebhard has yet to meet a patient who is truly orthorexic; most are “patients with a classic eating disorder who exhibit orthorexic behavior.” She says this may be because potential patients go to see a dietician instead of a psychiatrist. “However, I think it’s more likely that it’s just a rare profile.”
Using orthorexia to demean others defeats the purpose
For Dr. Bratman, this experience has had other consequences besides unwelcome phone calls from journalists. He regrets that orthorexia has started being used as a way of denigrating others, even though he originally came up with the word as a kind of “tease therapy.”
“Orthorexia is being used to attack people with special diets. Needless to say, that doesn’t work. Groups like vegans or raw food vegans are quite particular. They display a certain pride in being privy to the real truth and aren’t immune to conspiracy theories. So any attacks from the Establishment further anchor their beliefs. That’s the exact opposite of what I wanted. And, given everything we don’t yet know about nutrition, these attacks are frankly quite arrogant.”
Dr. Bratman says he feels responsible for the term he invented. In 2015, he co-published a scientific article in which he proposed diagnostic criteria to advance further research on orthorexia8. He often attends seminars he is invited to and accepts most interview requests, despite his weariness. He did, however, just decline a request from the BBC so that he could get ready for a weekend hiking trip in an area where he is guaranteed to have no cell phone service. “Honestly, I’ve had enough of the press and this whole subject. Please don’t take it wrong if I’m a bit grumpy. I’m just not interested in it anymore.”
- Steven Bratman & David Knight (2004, 2nd edition) Health Food Junkies: Orthorexia Nervosa – the Health Food Eating Disorder, Harmony.
- Adriane Fugh-Berman (2001), “Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating,” The Journal of the American Medical Association (JAMA), 285 (May), 2255-56.
- Donini, D. Marsili, M. Graziani, M. Imbriale & C. Cannella (2004). Orthorexia nervosa: A preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesity, 9(2), 151–157.
- Donini, D. Marsili, M. Graziani, M. Imbriale & C. Cannella (2005). Orthorexia nervosa: Validation of a diagnosis questionnaire. Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesity, 10(2), e28–e32.
- J. O. V. de Souza & A. M. Rodrigues (2014). Risk behavior for orthorexia nervosa in nutrition students. Revista Chilena de Nutricion, 63(3), 200–204.
- L. C. Zamora, B. B. Bonaechea, F. G. Sánchez & B. R. Rial (2005). Orthorexia nervosa. A new eating behavior disorder? Actas Españolas de Psiquiatría, 33(1), 66–68.
- M. Moroze, T. M. Dunn, J. C. Holland, J. Yager, & P. Weintraub (2015). Microthinking about micronutrients: A case of transition from obsessions about healthy eating to near-fatal “orthorexia nervosa” and proposed diagnostic criteria. Psychosomatics, 56(4), 397–403.
- Thomas M. Dunn & Steven Bratman (2015). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 2016 Apr;21:11-7.