Orthorexia Nervosa

[Guest guest]

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.