The Wall Street Journal has reawakened the topic of orthorexia with an alarmist article titled, "When Healthy Eating Calls for Treatment."
Some doctors and registered dietitians say they are increasingly seeing people whose desire to eat pure or "clean" food -- from raw vegans to those who cut out multiple major food sources such as gluten, dairy and sugar -- becomes an all-consuming obsession and leads to ill health. In extreme cases, people will end up becoming malnourished.
Let's begin with one important detail: Orthorexia is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Dr. Steven Bratman, who coined the term, even writes that he "do[es] not claim that orthorexia nervosa is or should be a DSM diagnosis."
The Wall Street Journal reports that some researchers are now calling for a series of criteria to help suss out orthorexia. One criteria would be:
... an obsession with the quality and composition of meals to the extent that people may spend excessive amounts of time, say three or more hours a day, reading about and preparing specific types of food; and having feelings of guilt after eating unhealthy food. The preoccupation with such eating would have to either lead to nutritional imbalances or interfere with daily functional living to be considered orthorexia.
As a dietitian, I believe it's important for people to establish healthy relationships with food. Food should be pleasurable and nourishing, not a source of unnecessary stress, anxiety, or judgment. And any situation that leads to nutritional imbalances or interference with daily life requires assistance.
However, these are extreme circumstances. The average person can only benefit from encouragement to become more health conscious and aware of what they eat.
The Wall Street Journal article cites different examples of supposedly problematic diets that shun food groups, among them a dairy-free diet. Readers are notified that one challenge that results from shunning dairy products is that one must "make sure to get calcium, phosphorus, and potassium from other foods."
This comes across as fear-mongering, especially since those three minerals are abundant in the food supply. The fact that the average American only consumes 60 percent of the recommended daily intake of potassium is not because potassium is hard to find, it's because the American diet is high in processed foods (processing drastically reduces a food's potassium content).
When it comes to calcium, certain foods like kale, broccoli, mustard greens and bok choy offer highly absorbable calcium (greens like spinach and beet greens are high in oxalates, which inhibit calcium absorption). And, unlike milk, they offer vitamin K, which is crucial for strong bones. Dairy alternatives like soy, almond, and coconut milk are all fortified with calcium, too.
In some cases, I encourage clients of mine to shun certain foods and beverages. I think of the 50 or so clients in the past year alone who chose to stop drinking sugar-sweetened beverages (mainly soda, along with sugary coffee drinks). They all lost weight and improved their blood work (e.g., lower triglycerides, increased HDL cholesterol). They wouldn't feel guilt or self-loathing if they had a few sips of soda at a social event, but they also don't see the need to drink something that doesn't align with their health goals.
What about moderation, some may ask? The problem is that "moderation" is a rather meaningless -- and completely subjective -- term. Ask 10 different people what it means and you'll get 10 different responses. For some, moderation may mean enjoying a bowl of ice cream every two weeks. For others, moderation may mean drinking soda with lunch every other day.
"Everything in moderation," when doled out as blanket advice, unnecessarily and inaccurately equalizes all foods. It operates on the silly notion that peaches, Pop-Tarts, muffins, soda, lentils and tomatoes should all be approached the same way.
Three cups of mixed greens as part of a salad are not the same thing as three cups of chocolate pudding. A large Dunkin' Donuts Mountain Dew Coolatta should not be consumed with the same frequency as unsweetened green tea. Eating a pint of blueberries in one sitting is very different from eating a pint of Häagen-Dazs.
In reality, certain foods belong in the "eat always" category, others in the "eat sometimes" category, and others in the "eat rarely, if at all" category. This type of thinking lessens guilt and recognizes the fact that foods have different impacts on our health.
Some argue that if we do not preach moderation, we are setting the stage for unreachable perfectionism and eating disorders such as orthorexia, an argument I find hyperbolic. Recommending that people shy away from fast food whenever possible and instead make more homemade meals is not about perfection. It's healthful and helpful advice that empowers.
There is a world of difference between someone who inherently fears and mistrusts food to the point where they jeopardize their health and someone who is well-informed and aware of what they put into their body.
The average American eats 20 teaspoons of added sugar a day and only gets half of the recommended daily intake of fiber.
Many college students eat no more than one serving of fruits and vegetables each day, and almost one quarter of American teenagers drink more than 26 ounces of soda every day.
There will always be cases of extreme preoccupation with eating that lead to troubling physical and emotional consequences. And, certainly, it is important to let people know that our bodies already rid themselves of toxins via the kidneys, liver, and lungs, so subsisting on juice for three days doesn't make physiological sense. Let's also, however, recognize that a 500-calorie salad made up of vegetables, chickpeas, avocado, and sunflower seeds is not nutritionally equal to a 500-calorie fast food hamburger.
Healthful and informed eating should be supported, not stigmatized, even more so in a society where unhealthy options are so ubiquitous.
If you're struggling with an eating disorder, call the National Eating Disorder Association hotline at 1-800-931-2237.