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What Is Orthorexia?mdtrs“

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ith the obesity epidemic mak-ing headlines in the UnitedStates, it is difficult to imagine

hat a person who is vigilant aboutis or her diet would be a cause foroncern. But a new term used to de-cribe those who become obsessedith a perfect diet has recentlyained attention in the mainstreamress.Although there is still a debate as

o if this is a real, unique disorder andorthy of its own categorization in

he Diagnostic and Statistical Man-al of Mental Disorders (DSM) along-ide such eating disorders as anorexiaervosa and bulimia nervosa, manyxperts interviewed for this articlegree that the most important pointo be made is that the faces of extrem-sm in dietary habits can varyreatly. They also agree that dieteticsrofessionals are often the first line ofefense in spotting these obsessiveabits and getting the patient appro-riate help.Steven Bratman, MD, coined the

erm orthorexia nervosa (meaningxation on righteous eating) for anrticle that appeared in the October997 issue of Yoga Journal. Sincehat time, he says he has been inun-ated with e-mails and phone callsrom men and women of all ageslaiming to suffer from the symptomse described. The term has alsoained attention in women’s maga-ines including Cosmopolitan and onopular Web sites such as WebMD1). Unlike anorexics or bulimics,ratman claims that the motivationf the people who contact him is not toose weight but to achieve a feeling oferfection or purity.Bratman says the people who haveritten or called him tend to followiets that are tied to a philosophy orheory (eg, macrobiotic diets or dietsreated for a specific blood type). The

This article was written byJennifer Mathieu, a freelancewriter in Houston, TX.

edoi: 10.1016/j.jada.2005.08.021

510 Journal of the AMERICAN DIETETIC ASSOCIATI

ore restrictive and complicated theiet, the more the person is attractedo it, Bratman claims. There is also aedemptive quality to these diets, heays, that involves denying oneselfbad” or “wrong” foods.

“They have a need to punish them-elves,” says Bratman, who acknowl-dges that his research sample is100% unscientific.” “If they violatene of their food rules they might fastr become even stricter with them-elves.”

The problem, likewith other

obsessions, is whenthe behavior beginsto hinder a person’sability to take part in

everyday society.

Bratman says those he has spokeno often gravitate toward other peopleho share their philosophies about

ood, and many find that their obses-ion prevents them from enjoyingeals with friends and relatives who

o not share their dietary habits.hey sometimes hold a morally supe-ior attitude about what they do (oro not) eat, and by obsessing over ev-ry meal they have socially isolatedhemselves. Finally, Bratman sayshere is sometimes a spiritual or reli-ious element that many of these peo-le have in common, with the beliefhat a perfect diet will help the personchieve purity.While he admits that most peopleho exhibit these symptoms are

arely in any real physical dangerunlike those who suffer from an-rexia or bulimia), Bratman says heas in contact with one woman whose

trict diet eventually led to starva-ion-induced heart failure and subse-uently death. The woman said sheas repeatedly told she was anorexic

ven though she said her obsession w

ON © 2005

as not with losing weight but witheeling pure, healthy, and natural.

Ironically, Bratman says he nevereant for his term to attract so much

ttention. “It started out as a veryongue in cheek thing,” says Bratman,hose major field of study is alterna-

ive medicine. “[But] it touched aerve.” He says the idea for the article

n Yoga Journal came from his experi-nce as a staff cook at a commune inpstate New York during the late970s, where he himself started exhib-ting symptoms similar to those of theeople who now contact him.“For the raw-foodists we always

aid out trays of sliced raw vegetables,ut the macrobiotic adherents lookedt these offerings with disgust,” wroteratman in his original article. “Theyould only eat cooked vegetables.urthermore, they believed that only

ocal, in-season vegetables should beaten, which led to frequent and vio-ent arguments about whether theommune should spend its money onettuce in January (2).”

The article eventually turned intohe book Health Food Junkies, whichs no longer in print. Bratman re-eived so many inquiries after hisork was published that he created

he Web site www.orthorexia.com. Heas also been invited to speak on theopic at conferences in the Unitedtates and Europe. Bratman says heopes researchers show an interest inhe term and there are more formaltudies carried out about it. [At theime of this writing, there were onlyix references to orthorexia found in aearch on the PubMed Web site. Thenly known scientific study on orth-rexia was performed in Italy at Uni-ersita degli Studi di Roma La Sapi-nza. The researchers studied theehavioral characteristics of 28 peo-le who exhibited orthorexic symp-oms (3)].

Bratman says he prefers to focus onis work in alternative medicine andopes that the attention his term iseceiving in the mainstream press

ill prompt dietetics professionals

by the American Dietetic Association

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BEYOND THE HEADLINES

nd others who work with eating-isorder patients to take his theoryeriously. He also hopes they find aay to work with those who say theyave these kinds of symptoms, be-ause he freely admits that he is reg-larly contacted by people he does notnow how to help.“I’m not a therapist,” he says. “Peo-

le are sure I’m getting rich off this,nd I’m not. I’m not trying to be therthorexia guy.”

ATEGORIZING ORTHOREXIAn the current edition of the DSM,ating disorders fall into three cate-ories: anorexia nervosa, bulimia ner-osa, and eating disorder not other-ise specified (4). The latter categoryften includes those suffering frominge eating disorder. It is in this cat-gory that Kathy Kater, a Minnesota-ased psychotherapist who has spe-ialized in the treatment of image,ating, and weight concerns for al-ost 10 years, would place someoneho exhibits symptoms like those de-

cribed by Bratman.Kater, who has seen some clientsho exhibit behavior in line withratman’s definition and believes his

heory may have some merit, sayshese people may share several com-on behaviors with those battling

ther eating disorders. One such sim-larity is a genetic predisposition toerfectionism and a need for control.These people tend to be anxious, per-ectionists, looking for ways to soothehemselves,” says Kater. “The dietay have a calming effect.”Kater says that those obsessed withperfect diet, and anorexics in partic-lar, may share other similarities, in-luding the need to follow strict rulesnd the longing to feel pure. Unlikehe people who have contacted Brat-an, however, anorexics (and bulim-

cs) rarely form communities, withhe exception being the controversialpro-ana” and “pro-mia” Web siteshat encourage such behavior. “Whennorexics get together, it can actuallyecome competitive,” says Kater.According to Kater and others in-

erviewed for this article, the biggestifference between someone who isriven by a goal of a perfect diet andomeone who is battling anorexia orulimia is that anorexics and bulim-cs are motivated by weight loss.

ater says a good therapist will al- e

ays create a safe space for a persono discuss their real feelings no mat-er what they are. “[Motivation] isomething that can only be deter-ined through a trusting relation-

hip with the patient,” says Kater,ho adds that when given enough

ime, the majority of good, trainedherapists will usually be able to de-ect the reasons behind a patient’siet.Kater says she doubts Bratman’s

erm will earn its own diagnostic cat-gory in the DSM anytime soon, stat-ng that if any disorder receives a newategorization, it will be binge eatingisorder. “I think it has enough dis-inctive criteria to pull it out of thatating disorder not otherwise speci-ed category,” she says. “Personally, Ion’t think there would be a need forwhole different classification [for or-

horexia].”

ATING DISORDER OR SOMETHING ELSE?ould it be possible that someone ob-essed with achieving the perfect dietoes not even belong in the categoryf eating disorders, but should in-tead be classified as having obses-ive compulsive disorder (OCD)?“Lots of people have argued that all

ating disorders really belong in thebsessive compulsive category [of theSM],” says Richard Pesikoff, MD, arofessor of psychiatric and behav-oral sciences at Baylor College of

edicine in Houston, TX, who alsoas his own practice. But the termsnorexia and bulimia are so wellnown that Pesikoff predicts they willrobably always stay separate.Pesikoff, who has seen patients who

ave various obsessions surroundingood, echoes Kater’s thoughts that un-erlying predispositions to anxiety anderfectionism are often found in peopleho develop a compulsion to create theerfect diet. The same holds true forhose who develop other obsessiveompulsive behaviors such as repeti-ive hand washing. “There is a heavyenetic element,” says Pesikoff. “Butbsessions are as varied as the cre-tivity of the human mind.”Society plays a part in determining

hose obsessions, says Pesikoff. Whilenorexics and bulimics often developisorders in response to society’sressure to be thin, those who haveontacted Bratman about their di-

tary obsessions might also be pick- s

October 2005 ● Journal

ng up societal triggers even if theirotivation is not to lose weight. “Eat-

ng well is something positive in ourociety. There’s a reason Whole Foodstock has gone up,” he says, referringo a national chain of grocery storeshat stock organic foods. Society alsollows for a certain amount of restric-ion in diet, he says. For example, theact that airlines offer vegetarian orosher meals supports the idea that aertain amount of limitations in whatperson eats is normal.The problem, like with other obses-

ions, is when the behavior begins toinder a person’s ability to take part

n everyday society. “It can spill intoreas of functioning,” says Pesikoff.They might start bringing their ownood to restaurants or dinner parties.”

Pesikoff also argues that this be-avior probably has an economic com-onent to it. Someone who cannot af-ord to shop at an organic health foodtore would most likely not be able tondulge obsessions surrounding high-nd specialty foods. “It is expensive toat the kinds of foods you would clas-ify as healthy foods,” he says.Richard Kaye, DO, a physician in

uffolk, VA who treats patients withbsessive compulsive disorder, agreeshat society often dictates obsessions.or example, when news about theuman immunodeficiency virus startedaking headlines, Kaye soon began

eeing patients who had developed anrrational, obsessive fear of contract-ng it.

Like Pesikoff, Kaye has treated cli-nts who have obsessions surround-ng food, including those with an-rexia. He has also treated patientsho are so terrified of pesticides that

hey cannot handle fruit and vegeta-les until someone else washes theood for them.

Kaye concurs with Pesikoff andater that obsessions are a combina-

ion of a societal trigger or object ofxation and being “genetically wired”o develop obsessive compulsive be-avior. Kaye explains that a predis-osition to OCD might be the result ofehavior that was at one time benefi-ial. Early humans depended on thoseho repeatedly checked for danger or

hreats to the tribe. “OCD is a goodhing, up to a point,” says Kaye.Sometimes you want someone who isn a constant state of alert.”

But what is the best way to treat

omeone whose obsession with a per-

of the AMERICAN DIETETIC ASSOCIATION 1511

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BEYOND THE HEADLINES

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ect diet has begun to inhibit theirbility to exist in today’s society?hose interviewed for this article say

abels are not as important as provid-ng solutions for the patient with theroblem.Pesikoff, Kaye, and Kater all agree

hat cognitive behavioral therapyombined with selective serotonin re-ptake inhibitors such as ZoloftPfizer Inc, New York, NY), ProzacEli Lilly and Co, Indianapolis, IN),nd Paxil (GlaxoSmithKline, Re-earch Triangle Park, NC) can be use-ul in treatment. “The effectiveness ofedication in those with OCD is veryigh,” says Kaye.However, there is a unique chal-

enge in treating certain patientsith medication. If someone is ob-

essed with purity or a natural diet,hey might be terrified with the pros-ect of putting prescription drugs in-ide their body. “There seems to be auilt-in bias that if it’s natural itust be fine, but if a doctor prescribes

t, it isn’t,” says Kaye. “It’s commonnd it’s an unfortunate thing.”While the resistance to medicationight be a challenge in treating those

bsessed with a perfect diet, Kateruggests that these patients might beore open to receiving treatment

han those with other eating disor-ers. “People who are attached to or-horexic behavior might be a bit moreesponsive to treatment because theyre actually concerned about theirealth,” she says. “With anorexicshere is often so much denial thathere is even something unhealthyoing on.”For more information on OCD, go toww.nimh.nih.gov/HealthInformation/cdmenu.cfm.

MPLICATIONS FOR DIETETICSROFESSIONALSondra Kronberg, MS, RD, whoerves on the board of the Nationalating Disorders Association (www.ationaleatingdisorders.org), concursith what other professionals inter-iewed for this article have to saybout Bratman’s theory, in terms ofauses and treatments. She adds thatehaviors as well as symptoms ofther eating disorders are being seenore and more in men because of the

ncreasing importance society is plac-ng on healthfulness and body image.

“Adolescent males and adult males “

512 October 2005 Volume 105 Number 10

re buying into the fitness and healthessage,” says Kronberg. “We’re see-

ng boys as young as eight or ninealking about protein. Men are nowoining the circuit women have beenn forever.”When it comes to those overly con-

erned with a specific diet, Kronberglso believes that dietetics profession-ls are in a unique position to spotroblems, because the patient’s moti-ation is a healthful or perfect diet.he person will often go to a dieteticsrofessional seeking more informa-ion on how to create an ideal way ofating. “They seek a nutritionist be-ause it’s in alignment with their dis-rder,” says Kronberg. “They’re notoing to go to a social worker. Regis-ered dietitians need to be properlyrained about when this crosses theine.”

Instead of beingoverly concernedwith terminology,

dieteticsprofessionals can

instead be the firstperson to triage these

patients fortreatment, whether

that is a referral to amental health

professional, primarycare physician, or acombination of such

referrals.

While Kronberg also agrees thatating disorders and obsessive com-ulsive behavior are closely linked,he says the focus should not be souch on labels as it should be aboutorking with all people who suffer

rom obsessions surrounding food.hether the term orthorexia is ever

iven its own diagnostic category inhe DSM is not as important as as-isting those who need help.“The new model of thinking is that

hose with eating disorders are oftenransdiagnostic,” says Kronberg.

We’re finding people don’t stay in one

pot. They move back and forth withifferent methods of coping, buthey’re still suffering from the samenderlying pathology. It’s all abouthallenging a belief system that isistorted and about being able to tapnto that belief system and changingt.”

Although the jury is still out as tohether this emerging term is a dis-

rder in and of itself, Kronberg ad-ises dietetics professionals to beware of the growing public aware-ess of extremism in diets. Instead ofeing overly concerned with terminol-gy, dietetics professionals can in-tead be the first person to triagehese patients for treatment, whetherhat is a referral to a mental healthrofessional, primary care physician,r a combination of such referrals.

eferences. WebMD. Orthorexia: Good diets

gone bad. Available at: http://my.webmd.com/content/article/29/1728_64424. Accessed July 10, 2005.

. Orthorexia Web site. Original es-say on orthorexia. Available at:http://www.orthorexia.com/index.php?page�essay. Accessed July10, 2005.

. Donini LM, Marsili D, GrazianiMP, Imbriale M, Cannella C. Or-thorexia nervosa: A preliminarystudy with a proposal for diagnosisand an attempt to measure the di-mension of the phenomenon. EatWeight Disord. 2004;9:151-157.Available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd�Retrieve&db�pubmed&dopt�Abstract&list_uids�15330084.Accessed July 10, 2005.

. PSYweb. Available at: http://www.psyweb.com/Mdisord/DSM_IV/jsp/Axis_I.jsp. Accessed July 10, 2005.