Friday, February 1, 2013

Orthorexia in the Paleo/Primal Community

Far be it from me to steer entirely clear of the paleo drama when it pops up, despite my best intentions. An issue and question has been put forth that I feel I should address as the resident psychiatrist around these parts. Bear with me as I trace the trail of drama…it all began with Dr. McGuff, Dr. Davis, and Jimmy Moore going on former KKK Grand Wizard David Duke's podcast over the past couple years, which led to some outspoken criticism on Evelyn's blog and elsewhere. Then Jimmy Moore put out a post about 10 things the "paleo community" should address as I suppose he felt put-upon by the criticism and needed to fire off a salvo of his own.

In the comments of that post, Angelo Coppola was critical of Jimmy's premise but, amidst all that, came up with something very important that I don't know has been discussed all that rigorously in the "paleo community:"

"Recognizing and addressing eating disorders among those who are trying Paleo approaches" 

Angelo went on to say: As far as eating disorders, this is an extremely important topic to start talking about. And if we're going to talk about it honestly, we'll have to talk about how low-carb and Paleo can lead to or contribute to disordered eating. I have 4 daughters being raised in a home with some pretty strong ideas about food, so this is a very real issue for me."

Stacey also commented: "That said your point is extremely well taken on eating disorders. After being on the front-side of this paleo movement I've learned that QUITE a few of us have had eating disorders in the past. I believe some continue to use Paleo as an orthorexic approach to eating, which of course is unhealthy and off-putting for the general public."

Let's begin by more precisely defining Orthorexia, a term originally coined by Steven Bratman, MD* in a 1997 edition of Yoga Journal. Dr. Bratman is a very interesting fellow who served as a chef and organic farmer in a largely vegetarian commune in upstate New York, then trained as an alternative medicine practitioner, then as an allopathic MD. Originally he subscribed whole-heartedly to the idea of "let food be your medicine." He tinkered with vegetarianism and macrobiotic diets, and noticed that he could make a lot of very positive changes in his patients. However, in the process of living in the commune and working as a clinician, he came across many folks who were obsessed with the purity of their food. The following is from his book, Health Food Junkies, which is out of print but still available at Amazon.com if you are interested (and I think makes the point rather well that being a chef in a commune can be a thankless position):

Like all communes in those days, ours attracted food idealists.I had to prepare several separate meals at once to satisfy the unyielding and contradictory dietary demads…The main entree was invariably vegetarian. However, to placate a small but very insistent group, on an end table placed at some distance there could always be found a meat-based alternative…Since…30 percent of our vegetarians refused to contemplate food cooked in pots and pans contaminated by fleshly vibrations, our burgers had to be prepared in a separate kitchen…

…For the raw-foodists we laid out sliced raw vegetables in endless rows. Once, when a particularly enthusiastic visitor tried to convince me that slicing a vegetable would destroy its energy field, I felt so hassled I ran at him wildly with a flat Chinese cleaver until he fled. Meanwhile, the macrobiotic dieters condemned the raw vegetables for different theoretical reasons.

"Ortho" is the Greek term for straight, correct, and true, and Dr. Bratman created the term "orthorexia nervosa" to mean a problematic fixation on eating healthy food. He also developed a questionnaire to help diagnose it, and recognized that by prescribing diets to patients in order to fix health problems, he could cause patients to develop anxieties and obsessions with food. A major side effect of using diet as medicine. Orthorexia is not an official DSM-IV eating disorder, and there is no "validated" research questionnaire to use to study it, so the articles in Pubmed are few and far between (they tend to use Bratman's questionnaire as it is the only one available). In fact, orthorexia nervosa might be most properly considered a subset of obsessive compulsive disorder rather than an eating disorder per se (the whole eating disorders category in the DSM is a hot mess anyway, so I hate to quibble over the semantics).

So what is a "problematic fixation" with eating healthy food? For some folks, it has a meaning similar to too much masturbation… someone who thinks about it or practices it more than you do. But like all psychiatric conditions the cardinal issue is that the obsession interferes with normal functioning or relationships or causes pathology, such as anxiety. If you don't have celiac disease or a serious gluten intolerance and going to a family party causes you great anxiety because you are worried that Uncle Brad cut the cucumbers with the same knife he used to slice the bread, you might have a problem.

Orthorexia can have a number of different forms…for some it involves what they eat (eg only certain foods), sometimes it involves the preparation or creation (no eating food cooked in aluminum pans or any food ever exposed to pesticides). While orthorexia is not as immediately dangerous as anorexia or bulimia, there are cases where it has been fatal. It can also be very disruptive to life, for example among those who cannot consume anything they did not prepare themselves, so can never eat at parties or restaurants and have to carry food everywhere. Those who proselytize about healthy eating can also find themselves losing friends and even jeopardizing family relationships.

Are folks in the paleo/primal community more at risk for orthorexia? Well, obviously. Here we have a pre-selected population of folks who tend to be on the obsessive side who care a great deal about food, and many of them have had great health benefits from some dietary changes. It's very tempting to look to solve the next health problem with a tweak in diet or supplements. Unfortunately, one could tweak forever, with additional restrictions in diet leading to smaller and smaller benefits, no benefits at all, or even health problems derived from the diet. One can easily eat too little and intermittent fast too much on a strict paleo/primal diet, causing hormonal problems as the starvation response kicks in. One can also develop nutritional deficiencies from a very restricted diet. And some folks will delay going to the doctor for a serious medical problem, trying to find a solution by surfing the internet and eating zero carb (or only raw food, or cutting out every last molecule of fructose, or eating only this or that…).

Last year, Lindsay wrote a great post about her struggle with paleo-inspired orthorexia, and she has very graciously allowed me to interview her for my upcoming book about eating disorders. Her cautionary tale details exactly how trying to tweak her diet to cure some niggling health problems led to a problematic fixation on food and "pure" eating.

Is just eating paleo/primal "orthorexia" on its own? Absolutely not. Nowadays pretty much everyone has to care at least a little bit about what he or she eats. For example, if I don't pay some attention, I tend to gain fat, and I have two choices, to be fairly aggressive about calorie counting and portion control, or to restrict the kinds of foods I eat. Calorie counting annoys me and makes me think too much about food. If I stick to mostly paleo-style eating, I don't have to worry too much about counting, and I can go out to eat and "cheat" every once in a while without having to diligently make up for it. Whether or not you believe me, seeing as how I write a blog dedicated primarily to looking at nutrition and mental health, eating "paleo" allows me to think a lot less about food and my personal diet.

Should people with previous eating disorders be eating "paleo" or "primal" or in any sort of restrictive way? For some eating disordered folks (check out the Friday success stories at Mark's Daily Apple), eating paleo/primal has freed them from food obsessions and health problems. For others, an overly strict paleo approach might be a ticket back to majorly disordered behavior.

And there are certainly some very good reasons to obsess about what goes into your mouth,  for example life-threatening allergies or celiac disease.

If paleo or primal-style eating takes up a disruptive amount of time, makes you unduly anxious or is causing major problems in your life, you might want to consider some professional help. Most therapists are adept at dealing with anxieties, and there are also many phobia or OCD specialists who can help, particularly in larger metropolitan areas.

Dr. Bratman runs a very interesting and informative website, Orthorexia.com

65 comments:

  1. I admit I go through stages. I get really strict and really focused on every aspect. What ends up happening is it becomes habit and the attention I was paying becomes part of the background and I enjoy the food. If I am making tweaks (for example, starting the autoimmunity protocol for specific reasons) I am bringing the specifics back into the foreground until I find a path that feels natural again. Then it takes care of itself. Right now, I'm learning fermentation and I am also avoiding raw veggies entirely. As my technique improves, I think about it less and it just becomes tasty food that I look forward to.

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  2. I don't mean to bring religion into what's already a somewhat heated debate, but based on your description the thought I had was: "One person's orthorexia is another person's kosher/halal."

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    1. I've seen people get very anxious about consuming something they thought was halal or kosher and finding out later it wasn't. However, with entire households and stores and everything geared toward the eating style, it is perhaps not as disruptive to life. Its not really about the type of eating, it is about the amount of disruption and whether the disruption is worth the dietary change (sometimes it is).

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    2. I don't know if this is true, because eating kosher/halal doesn't involve eliminating entire food groups from your diet and so doesn't seem as disruptive.

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  3. I feel especially critical about parents being too concerned about their children diet to be super-clean paleo.(OMG, my child was given an evil birthday cup-cake at school) It could led to numerous social complications.
    I think we should first of all listen to out bodes and base out food restriction and preferences on that rather then surfing internet in order to find how "Paleo" is a chocolate or a cream-cheese. Restricting food for ideological reasons is a religion.

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    1. I think a healthy diet should be the least restrictive one can do but get the most benefit. I tend to like Mark Sisson's 80/20 rule a lot, though personally I do better with 90/10 or so...

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  4. Thank you for bringing this up. I see a lot of ortho & ideology in paleo/primal as well as other diets (vegan, etc). It's disturbing when parents give it to kids -- as well as paleo/primal gurus with ED/ortho promoting the ideas of micro managing and unsubstantiated food phobias. Eat the carbs people, you'll be less moody. And paleo/primal people really need to stop saying 'sugar a drug, more addictive than cocaine' <-- that is ludicrous and dangerous.

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    1. @Unknown,
      You have no way to know how many or little carbs should another person eat in order to be in a stable mood. For example, I have to eat a VLC diet, even my physician approves the result, and my diet is a part of my medical history. As I understand, the people with Orthorexia mistake imaginary need for a real one, or treat sub-optional food as a poison.

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    2. "Eat the carbs" may not be good advice to people with diabetes and metabolic syndrome.

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  5. Whenever I read anything anyone says in defence of someone like Jimmy Moore, I feel acutely aware of the religiosity of the whole bro-scientific movement. It's supposed to be about the objective pursuit of health, and when you defy fundamental logic to defend someone, it's no longer about the food. It's what keeps me well clear of becoming the kind of person Galina alluded to. That and the whole shill-based economy behind it all.

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  6. I do eat strictly - last time I inadvertently ate what must have been a very small amount of gluten, I was surprisingly sick for more days than I'd have believed. I'd like not to experience that again.

    I find a Paleo-ish approach makes it really simple. I don't identify myself, or my diet, as Paleo (or any other label). I spend much less time thinking about food now than I have in the past. And buffet tables are a breeze - there's an off chance there'll be something there that I can eat... but if I can't spot it quickly, I spend my event time talking to people - it's actually *good* for my social skills. I try not to arrive ravenous, and it all works out.

    I do drink wine, in a non-Paleo frequency. And I'll occasionally eat a few corn chips or GF crunchy thing, if someone has gone out of their way to read every label in their own pantry to find the one thing they're confident is perfect for me (and if I'm in the mood - otherwise, I'll thank them profusely and never get around to eating any).

    I eat very few 'products' - we cook a lot, and enjoy it, and I enjoy the time I'd otherwise spend reading labels :)

    It saddens me to hear adults talk about "cheating"... I have always hated that vocabulary, in any dietary context. Eat it. Or don't. Don't make it into a rule - and certainly don't make it sound as though it's someone else's rule.

    For me, the Great Gluten Crash of 2011 was an unexpected line in the sand - it does seem strange that I could become so extremely sensitive to gluten at such a late date in my life, but things work till they don't. I might have struggled more, in an orthorexic way, if there had been ambiguity about it.

    I also think middle age helps. I've eaten a lot of baked goods over the decades, so being "post-pastry" doesn't feel like a big loss.

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  7. @Sara, I think it is easy to guess that human body has an ability to get adjusted to some regularly consumed unhealthy substances. Wheat also contains nutrients, and gluten itself is a protein, even a problematic one. During your break from eating gluten, your got more sensitive to it. I think an alcohol tolerance could be a good analogy. I almost never drunk alcohol for about 10 years after my allergies got worse at 35 years old, now, after my allergies got better due to changes in my diet, I can drink again without experiencing symptoms of asthma, but I get drunk extremely quickly and it takes much longer for me to stop feeling "under the influence" than before.
    For that reason my husband thinks that avoiding gluten completely(what I do together with most carbs because I feel better then) is unwise for people who are not totally got sickened by it because it renders them from developed tolerance. People are resilient enough to tolerate some toxins and live on less than perfect food, like there are numerous babies were and are raised on artificial mixes, while breast milk would be the perfect food for them. I disagree, but he has a point, that people who live on less than perfectly healthy food could have an advantage if some food shortages occur as a result of a disaster.

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  8. Thank you for talking about this. As I've begun to read more and more in the online Paleosphere/WAPF, I've noticed that orthorexia is a serious problem among many people involved. I think orthorexia, specifically, as a kind of eating disorder should be talked about more. Eating disorders are becoming talked about more in the Paleosphere, especially thanks to people like you and Stephanie, but it often appears to be focused on the more commonly recognized eating disorders like anorexia and associated body image issues. I am aware that orthorexia is not an official eating disorder according to the DSM-IV (and I doubt it will appear in the DSM-V, if the DSM-V itself ever appears), but based on my observations, it appears to be a real disorder, and quite common among those who have already self-selected as food-conscious.

    Becoming extremely hyper-vigilant about every thing that enters your mouth (unless you have a very severe food allergy or intolerance) is not only foolish, it is counter-productive. The increased stress that goes along with such hyper-vigilance is likely to be worse than the 2 mg of gluten you accidentally got while eating out. And informing everyone you meet that they could solve all their problems if they just ate like you did -- including telling them that they shouldn't go to the doctor for whatever condition because "it's completely a dietary issue" -- can be downright dangerous.

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    1. So can keeping one's opinions quiet and inactively allowing big pharma to profit off what could simply be a basic gluten intolerance which eventually leads to cancer or something. Not saying it *would*, just sayin'.

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    2. @Unknown, there is a difference between "maybe you should consider whether your symptoms are a result of a food intolerant" and "don't go to a doctor, they're just pill pushers for Big Pharma; you should cut out XYZ from your diet and it will cure you!". There is unfortunately not enough of the former and too much of the latter on the internet.

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  9. Hi Emily,

    In my time at PaleoHacks, there were sadly too many posts/questions about eating disorders that disappeared. It is not only a topic that is not discussed openly, but is actively shoved under the rug.

    I was mostly over my ED when I first tried LC, but I always credited Atkins with the last step -- being able to eat ad libitum. I used to think that had I gone LC (and now paleo/primal owns that as well) back at age 17 I'd never have developed ED. Now I'm pretty sure that would not be true.

    Also, an amazing number of people with active eating disorders are doling out diet and fitness advice in this community. And when called on it they often retort "find what works for you". This is difficult when these people frequently accuse those eating carbs of feeding their addictions, or equate carbs with poison, or deride diabetics who take insulin, or perpetuate myths about carbohydrates. I am grateful to possess the knowledge base and background to see past all of this which was and remains the primary reason for my blog.

    As I'm sure you are aware, the best way to instill disordered eating into an animal is to restrict its food arbitrarily. This is what all of these popular challenges in the paleo community do. These one week, two week, one month, etc. hacks, challenges, detoxes, etc. are all prime triggers for ED in those susceptible, as is the obsession with fasting.

    I hope this post of yours will reach a few minds and hopefully hearts. Well done.

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    1. Thanks Evelyn. It's a tough call, because an elimination diet is the gold standard for figuring out food intolerances, the key being that one adds back in foods at the end of the time period to test the intolerance… but there is a reason that Dallas and Melissa recommend that folks with eating disorders NOT do a Whole30. And there are some processed "foods" that do seem to be "addictive" (soda and diet soda are good examples), where a period of abstinence (as long as it is long enough) is a great way to halt the addictive cycle (soda rehab?). I don't think carbs are addictive. Most humans crave sugary/fat foods, chocolate, or salty processed snacks. There is a bit of literature on sugar addiction. But starch on its own? I don't think so.

      Intermittent fasting is also a mixed bag. There are folks who are literally afraid to be hungry (this situation is probably more common than we think), and intermittent fasting is a perfect desensitization tool when undertaken with care and support. On the other hand, for some people with binge eating problems, fasting is the perfect trigger for a binge. Personally, I don't tolerate fasting well when I'm exercising regularly.

      I think the main point is to recognize when eating is beocming problematic in someone's life, even if it is disguised as virtuous eating. On the other end, junk food probably causes more distress, anxiety, and health problems on that end of the spectrum than a few paleo or vegan orthorexics on this end.

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  10. What about all the self-taught folks marketing themselves as eating disorder counselors?

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    1. I'm glad "MD" has a fairly specific meaning as opposed to "counselor" or "nutritionist." However, there are many able peer counselors in specific areas without much formal training, and some great nutritionists with PhDs, etc, and some very bad formally trained counselors with masters degrees or PhDs (or MDs) and licenses...

      I know you both are alluding to Stefani Ruper. For all the controversy, she is pretty much the person who started the discussion about eating disorders and questioning the utility of intermittent fasting in women. I haven't followed her blog other than a few posts.

      There's a lot of nonsense of all kinds in the "paleo community," to its detriment. But focusing on ditching most of the processed foods, good sleep, (hopefully) responsible exercise in general will cause more good than harm, I would think.

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    2. The problem with Stefani is anyone getting counseled by her for eating disorders when she is admittedly eating disordered herself. Check that, she claims to have conquered them, but she was a peer ED counselor -- her first "work" in the arena -- in college smack dab in the middle of developing her own. This is harmful.

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    3. I like to ask, "Who taught the first person about---?"
      Also: "How is it taught now, if not through books, that can be acquired through a library, or purchased?" Why do we need to "be taught" by another so-called expert? Whether it's from a book, or a person (maybe the person who wrote the book), it's still the passing down of information.

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    4. If someone is actively engaging in eating disordered behaviors, then that person counseling another would be a bad idea. If someone is in recovery, there are some peer models very similar to AA. When sponsors relapse in AA, they have to tell their pigeons.

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    5. Great point, Emily. I think transparency is key.

      This community is full of people giving diet advice and critiquing others even though they're overweight themselves. I don't think there's a problem as long as they're open about it, but some aren't.

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    6. I shudder to think of anyone I cared about getting treatment from a random blogger on their eating disorder. They are serious and I would think you would recommend people seek more professional help.

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    7. @Melissa, to be clear on my end, I'm thinking of very specific settings when it comes to peer counseling for eating disorders, for example established groups in a university setting, or in an intensive outpatient program (or as the step down from one). Typically these are supervised by a social worker or someone else. But even on the inpatient setting, particularly in the substance abuse and eating disorders arena it is not uncommon for the nurses, mental health workers, etc. to be folks in recovery from eating disorders or substance abuse (or have close relatives who have the disorders). I mean, there's a reason they are drawn to help people with the condition. Just like many nutritionists and dietitians have or are in recovery from eating disorders.

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    8. Also, there are all kinds of random bloggers telling people who may have insulin resistance or undiagnosed diabetes that eating potatoes is just fine.

      But potatoes seem to be the fad at the moment, so less shuddering seems to be happening.

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  11. It's easy to spot a person experiencing Orthorexia, they say things like "When I eat X the result is Y."

    With X being a very common food item and Y being a wildly improbable response.

    "Last night I ate an Oreo and I bled from my toenails for nine hours straight"

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    1. That's an exaggeration, but maybe not as much as you think.

      If I eat a bunch of Oreos it's not unlikely that a hangnail will start bleeding a bit.

      Does that mean it's orthorexia if I now avoid Oreos?

      I think it's just intelligent.

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  12. if you know what your body does best on, i think eating any OTHER way is disordered! gluten-grains, some dairy and certain vegetables make my intestines and joints feel like hell, even though i'm not celiac or lactose-intolerant. WHERE is the virtue in ignoring my discomfort eating this stuff anyway?

    great work, Emily! i think you made the distinction between being "careful about diet" and being OBSESSSSIVVVVE! :-)

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  13. Good post Emily, as always.

    If eating something makes you sick, eating it in public is not the best way to prove the robustness of your mental health.
    If it's a case where eating too much of something long-term is reasonably thought to be harmful - fructose, seed oils - then avoiding the smallest dose on every occasion may not make much difference.


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  14. Thank you so much for writing this, it's a topic that's been on my mind lately as well as it seems quite common the paleo world.

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  15. I think it is important to note that orthorexia is an ad hoc term like workaholism except with a fancier Latin name. This is not to say that orthorexics and workaholics don't exist, but to acknowledge the difference between a generic term like workaholism and schizophrenia or a generic term like orthorexia and anorexia. Not that I think workaholics tend to be schizophrenics. Or that I even comprehend schizophrenia in general.

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    1. There's actually a peer reviewed paper about canvassing MDs and psychologists as to whether they thought orthorexia was a real thing or one more BS internet diagnosis. Most of the professionals felt it was a "real" and troublesome condition (though many felt it would be overkill to pull it out from OCD as a separate diagnosis.)

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    2. That's exactly what I didn't say, but feel free to re-read.

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    3. This comment has been removed by the author.

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    4. Science by consensus!!! ;)

      I'm no Szaszian, lest I wouldn't be reading this blog, but let's face it, the incentive for the psych establishment is for ever more inclusion when it comes to diagnoses.

      Anyway, why can't workaholism and orthorexia both be real yet outside the dichotomy of recognized disorder or BS internet diagnosis? I remember seeing anti-workaholism PSAs back when I was a kid, but that whole thing seems to have quietly gone away in the 80s for some reason. Hard work and healthy eating are both encouraged by society, but turning them into unhealthy obsessions could have its roots for a number of different clinically recognized phenomena like OCD, deep insecurity, mental truama, watching Dr Oz, but I repeat myself...

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    5. Most psychiatrists I know (including me) use a tiny fraction of the multitudes of diagnostic codes available. The codes are for research and billing. The real question is does the problem cause major life disruption. Does it prevent you from working (if you want to or need to) or having relationships (if you want them) or driving or going over bridges or whatever it is you need to do. If it causes that problem, in psych it tends to fall under the general rubrics of personality disorders/attachment disorders, anxiety, depression, mania, psychosis, attention deficit and executive function, dementia, substance abuse…and that's pretty much it. There are other considerations obviously, and people do better when met at a very personliazed level. One day we will trace the limbic or frontal lobe or whatever connections that are arwy to meet those basic phenotypes but until then...

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    6. here is that paper: http://www.ncbi.nlm.nih.gov/pubmed/21360365

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  16. Is it possible that a person with OCD who is obsessed with color-coordinating of underwear, germs fighting or arranging of items in drawers in a very particular way would be more concerned about his/her diet being more "paleo" or whatever? I knew a lady who was obsessed with having at least 3 different food colors in every meal, because back then everybody was talking about antioxidants.
    Who knows, may be if they get obsessed with staying in ketosis, it would be beneficial for their anxiety http://evolutionarypsychiatry.blogspot.com/2010/08/your-brain-on-ketones.html

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  17. Evolutionary psychiatry suggests, in part, that every disorder has an adaptive basis, that in some form or variant it aided survival or fertility in the past.
    Maybe orthorexia is the adaptive version of OCD at this point in evolution.

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  18. ItstheWoo your comment had some good points but I can't publish the full comment due to some of the content that is too personally insulting to some people. I can take out a paragraph and publish it, or you can reformulate, or put it up on your own blog, whatever. Let me know.

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  19. Hi Emily,

    Great post. Im looking forward to your upcoming book.

    As a longtime follower but seldom contributor to the paleosphere, this is a touchy issue. If someone is suffering from the host of problems we would call the "diseases of civilization" then coming across this blog -- or any blog in the paleosphere -- might be an enlightening moment for them. They will realize that their diet high in linoleic acid, fructose, and immune stimulating grains are the cause of much suffering.

    However, for the people that have been aware of this for a long time and have tweaked and tweaked until they eventually found a comfortable millieu -- where they are healthy yet not obsessive -- the marginal benefit from further research is low. Its just a matter of implementation of the knowledge they already have. Further perusing through blog entries that are just variants of the same theme wont solve any problems.

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  20. Yes, my reply was ranty/dramatic per usual. You may edit as you see fit for public view.

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  21. Dr. Deans, I'm so glad you've chimed in on this. The areas I've been especially thinking about recently, relative to the Paleo community, are:

    1) Whether orthorexia in parents leads to more severe eating disorders in children. If true, this could be the most dangerous aspect of orthorexia. It seems to me that parents who are overly strict about what their (healthy) children eat are at risk of introducing an entirely new set of problems with unintended consequences.

    2) Whether (otherwise healthy) people who religiously avoid carbs have traded one set of unhealthy, overly simplistic, overly dogmatic ideas about food (obsessively low-fat, calorie counting, etc.) for another. The Paleo community's alliance with low-carb marketing avenues has hindered its objectivity with regards to real-food carbs (like fruit, nutrient dense starches, etc.). Robb Wolf has recently reassessed his position on carbs. Hopefully, Sisson and other leaders will do the same — 150 to 300g of carbs per day (600 to 1200 calories), simply is not an 'insidious weight-gain zone,' for most people in the world.

    3) Whether the Paleo community's disregard for calories is leading to over acceptance of empty-calorie Paleo desserts and processed foods, which in turn promote binge eating and/or excess caloric intake.

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  22. It looks like Steve Jobs is a good example of a driven to perfection person who also tried to make his diet "perfect" and himself more perfect through his strange eating practices. http://www.westonaprice.org/blogs/kdaniel/2011/12/27/ivegetarian2-the-eating-disorders-of-steve-jobs/

    In his case it looks more like a particular type of personality then just a pattern of an orthorexic dieter when the diet is not the cause but rather one of manifestations of a very unusual and even dangerous behavior.

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  23. Thanks for the link to the Bratman website. His book Holistic Harry is hilarious! And the appendix and footnotes are well worth a read. I loved the example of cough syrup. Most parents know that cold meds in general work because they let kids sleep, and then the parents get some sleep, and everybody feels better in the morning. Those "non-drowsy" cough and cold meds? Worthless waste of money. Sleep is the cure all.

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    1. Too bad we can't use brandy like in the old days ;-)

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  24. Here is Woo's comment with the personal attacks edited out (with her permission):

    "Orthorexia is entirely a nonsense condition.

    When orthorexia becomes a problem it is typically redundant with anorexia nervosa. Anorexia nervosa itself is a specific syndrome involving compulsive food restriction, obsessive compulsive rumination regarding aforementioned food restriction to the point where physical health is jeopardized. It is only in modern times anoretics confabulate weight concern as a motivation - the original anoretics were obsessed with purity. In a way, clinically real "orthorexics" are much more like the original anoretics, than are modern anoretics who play out purification concerns via obesity fears. The mental machinery concerned with purification (a common theme to religious, weight, and food purity forms of restriction) seems to be related to obsessive compulsive thought/behavior/mental processes. This is why people with pure OCD often have rituals pertaining to organization as well as hygiene - all purification/cleaning rituals.

    The eating disorders are OCD like mental illnesses in general, not just "orthorexia". Restrictive anorexia highly comorbid with anxiety, depression, and OCD.
    Bulimia of course would be something different, almost entirely opposite brain pathology more related to behavioral disinhibition and is found more with borderline personality and bipolar mania. The personalities vulnerable are often polar opposite as well. But then again bulimia (pure builimia nervosa) has nothing in common with anorexia at all, other than it involves food, they are lumped together merely out of convenience.

    Point I'm making is that orthorexia is a nonsense, meaningless diagnosis, and the only time it is a real diagnosis is when it overlaps with anorexia nervosa or milder subclinical forms of it. It is basically anorexia when it is a real diagnosable psychiatric problem, and when it's not, it's just a fake yuppie disease.

    That's why people can get a hobby/life, and magically their eating "problem" goes away. Because for them, it's not a real eating disorder... it's a very temporary, transient mental preoccupation, vs an entrenched enduring mental illness that takes months and years to recover from no matter how much you would like to be free of your fears, obsessions, compulsions, and thought loops. You can't just get a hobby and make an eating disorder go away... it takes yeeeears of "getting better" until you are better, if one ever does recover. Indeed, many anoretics stay permanently locked in an OCD cycle of fear and punishment and rituals their whole life until they die usually of complications related to starvation or alternatively suicide because they can't take it anymore.

    Orthorexia? A joke. It is a yuppie disease, basically. Too comfortable, too few problems, so why not play with your food like a toddler? This will be done until something more interesting comes along (new boyfriend, new hobby, and paleo food purification = so passe now). That's why these food fads have a natural life course where a person will be like frutarian or macrobiotic for a year or two only to stop when it is no longer "fun" distraction. That's orthorexia.

    Real eating disorders don't work like that because they're in your brain and your entire life is whittled away as it's the one thing that matters black or white life or death ... real eating disorders MAKE YOU only care about your repetitive thoughts and rituals, it's not like you choose to do it out of boredom. You become a completely different person.

    IMO orthorexia is almost insulting to real people with eating disorders. It would be like calling the monday blues similar/related to psychotic depression or something. There is absolutely nothing in common, one is a disease, one is a very brief mild product of lifestyle. "

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    1. I don't think anyone is arguing that orthorexia is generally as serious as anorexia or bulimia, which, while being fundamentally different (generally) in style of personality from each other, also overlap a great deal. Anorexia can be argued to be OCD, body dysmorphia, even delusional if one is broad in defining those terms. So far as being a "yuppie disease," historically anorexia was also seemingly confined to the upper classes until the most recent decades.

      As to whether it insults people with "real people" with eating disorders, I guess you can pick your things to be insulted by. I've met people with awful food phobias, folks who have screwed up their hormones, people who have no life because they spend every moment thinking about food. Do they not deserve help just because they aren't on death's door? There are people who fast for two days to undo the sin of eating a tomato or M&M or whatever is on the do not list, and double up on restrictions and purity. The main difference from anorexia is the lack of overriding concern about body image and weight.

      Bratman gives a good example at the beginning of his book about a woman whose asthma he cured by changing her diet. She started out on four medicines and inhalers (and felt well), and by eliminating most foods she was on no medicines, but she had to do a rotating, carefully planned diet in order to not develop new intolerances to the few things she could eat. Before she was on four medicines, but before she had a life. Afterward her entire life revolved around food. Bratman felt guilty about that patient, that he had violated the premise of "first do no harm."

      I think the trickiest thing about orthorexia is that it can be disguised as a self-deluding virtue, whereas self-starvation in anorexia and bingeing and purging cannot be.

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  25. As a person with allergies I can relate to the asthma case. I guess the doctor should not feel guilty from informing patient about diet options to treat her condition and leave it for her to decide what she would prefer - watching her diet or living on 4 medications. I used 2 to control my asthma, and still I can tell avoiding certain foods it better than compensating with meds effect of allergens in one's diet. It is the same as hiding the information from a patient that his pet is causing his/her asthma and prescribing him/her antyhistamine and couple inhalers instead. I don't think it is ethical for a doctor to even considering keeping his patients in a dark and applying himself a prime decision-maker of behalf of not mentally-disabled person!

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  26. I'm unsure whether this is a Paleo-specific issue to be addressed. Having been under the Paleo umbrella for over two years now, I've seen plenty of folks come and go, and they will continue to waft through whatever faddy trend they latch on to in their quest for...what? Some people are always seeking something. My point being that by sheer numbers and probability, some folks who find Paleo will also have orthorexic tendencies.
    I do think it's wise for people in Paleo to say that this is not a system for hiding eating disorders. I appreciate Dallas and Melissa's stance on that with their Whole30 program.
    I also appreciate Angelo's perspective, and as the mother to a daughter, I will face this as well. I was fortunate enough to never have a body-image issue and I hope that whatever physiological foundation for that was passed on to my daughter. She is 3, and I am currently gluten-elimination-trialing her and when she asks for foods she can't have right now, I tell her that she needs to eat real food that makes her happy, healthy, and strong. At this, she raises her arms and makes big muscles and growls. :) Happy. Healthy. Strong. With an emphasis on these things, I can't see how we can go wrong. Also, as she gets older, I'm perfectly happy to let her experiment and I'll ask her the age-old Wolfian question: "How does it make you feel when you eat XXX?" I think kids get that some foods will just make them feel like crap, or that sugary foods won't actually fill them up, and I don't think we should worry about driving them into eating disorderville with it. Of course, how that's done will matter, but only if they're predisposed in the first place.
    Also, orthorexia is definitely in the eye of the beholder. My in-laws would probably say they think I'm orthorexic due to all the "restrictions" and crazy ideas I have about food. So be it.

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    1. In reading about the raw foodists and macrobiotic dieters, etc, "paleo" is a bit lightweight in the orthorexic arena. However…not all health problems can be solved with food. Food should augment life, not consume it. Having kids myself, I do not swat the cupcake out of their little hands at birthday parties. But I do keep them mostly gluten-free and they eat "real food" most of the time. They don't have health problems (knock on wood). Life is short.

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  27. Coming from an eating disordered background, I've found a 'paleo (ish)' diet to be great because it really is easy to do anywhere, even when eating out, and I don't need to think too hard about it. I have also mastered the VERY tricky 'art' of eating off plan now and then without it being a big deal. This is very hard for an ex fatty/bulimic to do, because my brain wants to be 'on the diet' or 'off the diet'. Food is just food. It makes me sad when I read blogs or visit groups where people are on the religion of vegan, or raw food, or paleo, or anything and get anxious if they can't do it (because it's really impractical) or are faced with a situation that doesn't fit their plan.

    Nearly everyone, even those that have never had a health or weight problem, eat to a set of internal rules but don't think of it as such. My sister never eats dessert, she just 'isn't a dessert person', and this is ok with everyone. But, I imagine if she started with 'I never eat sugar after 6pm' (technically true), people might think it was disordered.

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  28. From my nutrition training, it was well-known that those with eating disorders would hide behind the likes of vegetarianism or veganism in order to legitimise their food avoidance... it is an easy way to eliminate a boat-load of energy in one "legitimate" hit. "I don't eat meat".

    There has been much talk behind the scenes about similar things occuring within the paleo community, especially with its increasing popularity and (unfortunately) links to the LC community (you just want to Hulk-smash those links, don't ya?). Paleo has the benefit of being the diet de jour, of allowing people to avoid large chunks of energy ("I don't eat carbs, I'm paleo" or "I'm on an autoimmune protocol... Oh I don't have an autoimmune disease, but I feel better this way"), and for being fantastic at lowering appetite - you can dodge whatever food group you are OCD about and not be penalised by feeling hungry.

    Strangely enough, I think many of these people are the same ones who absolutely freak out about feeling fat at AHS and who write posts on their fear and anxiety around such social gatherings.

    The difficulty in reaching out to these sorts of people, or calling others out, is that you get a mouthful of abuse for doing so, get told you don't understand, get called a perfectionist, and so on.

    It's tough, but hopefully this post, coming from someone with some authority in this area, might make people sit up and take a bit more notice (albeit with a few axe-grinders already coming along for the ride).

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    1. I read your comment four times and I still can't figure out what you're trying to communicate.

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    2. Robert, seems pretty clear to me. People with existent, or perhaps a propensity for, eating disorders will gravitate towards a restrictive dietary régime like veganism or perhaps VLC that act as a cover for their disorder.

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    3. Hmm. Thanks. I read it two more times & I still don't see where he says that.

      I'm not trying to pick nits; I really can't parse the comment.

      It's a good point if he meant what you said. :-)

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    4. Oh, Robert, I heard the message loud and clear. It is another example of people in the paleo community exercising their hatred towards fat people who do well on low carb. I do not think it is a universal feeling that we should hulk-smash low carb links, but thank goodness those poor people are spared from being reached-out-to by others with this attitude.

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  29. Great post Dr. Deans. As with a lot of the diagnoses du jour, I'm on the fence about orthorexia as a Real True Thing. What is real, though, is that I am contacted every day by women (and sometimes men) who have restricted themselves into a corner they can't see to get out of. They are terrified of eating anything other than a few 'safe' foods, and their restrictive eating has started to have deleterious effects on their health (reduced fertility, depression, anxiety, insomnia, thyroid issues, crushing fatigue, etc). As you said, paleo and other dietary dogmas tend to attract people who already have some disordered thought processes regarding food and body image, and dietary restrictions have been shown over and over to trigger eating disorders in people with the biological predisposition. These are real people with real disorders suffering with the real health consequences of their restrictive dieting. This topic deserves much more attention, and I'm so glad people like you are bringing it up.

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  30. It is clear for most people that following a very strict diet just for the reason that it is a chosen life-style is looking as ortorexia, but it is also a wide-spread sentiment in US that even for diabetics following the diet very low in carbohydrates could be unnecessary and spirit-damaging. "They deserve to eat like everybody else," but should not forget to cover it with insulin.

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  31. This was a good post on a difficult topic. I admit I'm troubled by the ease with which dietary partisans of whatever stripe can hurl the accusation "you're eating disordered!" at people who follow diets they dislike. Maybe practicing clinicians have clearer vision about who is truly eating disordered (or maybe not).

    The National Weight Loss Registry has a lot of stories of weight-reduced, formerly obese people who very strictly monitor the amounts and kinds of foods they eat, and who track meticulously. All of these people say that such monitoring and restriction is necessary, and when they don't do it, the pounds start to pile back on. By some of the standards applied in the blogosphere, this behavior could look eating-disordered, especially to people who don't need to be this strict to maintain their weights (or who simply refuse to, consequences be damned).

    And yet, strangely, the bloggers and forum owners who are quick to denounce Paleo, LC, VLC and ZC eaters as "eating disordered" (even those of us who find it necessary to restrict carbohydrates to maintain massive weight losses) don't seem to have the same kind of venom about CICO dieters and the "extreme" measures they need to take. This tells me the accusation is more likely to be ideologically rather than factually driven.

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  32. Yes, "orthorexic" seems to be a bit circular and self-congratulatory when looked at closely.

    It's another way of saying "My way of eating is EXACTLY picky enough to be healthy. So if you don't eat as I do, you're either unhealthy or obsessive."

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