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When healthy eating runs afoul: orthorexia nervosa explained

While many Americans could benefit from dietary habits that include consuming more unprocessed foods, healthy eating styles can be taken to an extreme, and the impact on health can be detrimental.

Coined in 1997, orthorexia nervosa (ON) describes a condition that can arise from an extreme fixation on maintaining a strict diet that initially is selected for health benefits, but becomes overwhelmingly difficult to maintain and can lead to malnutrition. Thomas M. Dunn, PhD, a research psychologist at the University of Northern Colorado, said the condition can be difficult to detect, unlike other more commonly known eating disorders such as anorexia nervosa.

How it begins

Dunn told Healio.com/Psychiatry that friends of a person with anorexia nervosa may notice that the person appears to be very thin and often disappears after meals, which can signal that something may be wrong. Persons with ON, however, may have a peer group of like-minded individuals who are focused on health and “clean eating” such as avoiding processed foods or artificial sweeteners. Or they may seek out certain other foods with perceived benefits. A person with ON takes the lifestyle to an unhealthy extreme and to the exclusion of a balanced diet.

“They kind of fly under the radar,” Dunn said. “They get caught up into peer groups and some may see the behavior as a little weird, but maybe not as much as someone else might think. They start having problems. People don’t want to go out to eat with them anymore. It’s like being picky to an extreme.”

Dunn said the obsession also can involve how the person with ON prepares food, or they may take extreme measures such as driving long distances to procure certain food items. They may find that a typical lunch break at work isn’t long enough because of the overwhelming urge to prepare things in certain ways. Or they may go to specific stores and buy ingredients perceived to be fresher or more nutritious than others, or they perform other ritualistic behaviors related to the food they are eating.

“If you have to get on a plane [and travel] to get your food, something is wrong,” Dunn said, but added that not all ON patients take such extreme actions. The condition can become problematic when it affects a person’s ability to hold a job, interact socially or manage family relationships.

Identifying ON

Unlike anorexia nervosa or bulimia nervosa, body image is rarely part of the motivation for a person with ON.

“It isn’t about being fat or getting fat, it’s about getting as healthy as possible. They don’t necessarily get caught up in body image; it’s about treating the body as a temple,” Dunn said, mentioning that an ON patient may not be underweight.

A patient beginning to have problems with ON may visit their PCP with vague symptoms, such as fatigue. Dunn said these are symptoms of malnutrition due to the patient’s focus on a limited diet.

In a research paper to be published in Psychosomatics (vol 55 issue 6; Nov/Dec 2014 cover date), Dunn and colleagues propose diagnostic criteria for ON. These include an “obsessional preoccupation” with perceived healthy foods, worries about eating perceived “impure” foods, intolerance of other people’s food beliefs, spending excessive time preparing, obtaining or reading about food, and feelings of guilt after consuming something not perceived as healthy.

Dunn said if a physician suspects a patient may be experiencing ON, the patient should be asked how much time they spend on food preparation.

Treatment includes talk therapy

Dunn said treatment for ON should be similar to therapy for other eating disorders, OCD and psychotic disorders. CBT and possibly medications, such as an atypical antipsychotic like olanzapine, can be effective in altering patient behavior.

“We have to have a multipronged approach,” Dunn said. “Some will benefit from medicine, some from a CBT approach. Talk therapy is an essential pillar for all eating disorders to change the way patients think about food, then they can change their behavior. They need to be able to say that it’s OK to have some of those [perceived unhealthy] foods in moderation, not to the extreme.”

Prevalence may grow

The condition is more common among affluent and educated adults who are often from high-achieving families, Dunn said. He expects the condition to become more prevalent as awareness of food supply issues increase.

“There will always be people who kind of go off the deep end, who are going to get carried away with something,” he said. “We may see this condition increase as more and more people become aware and have better access to places like Whole Foods and Trader Joe’s.” --By Shirley Pulawski

Disclosure: Dunn and colleagues report no financial disclosures.