Sunday, February 3, 2013

Orthorexia in the Paleo/Primal Community: Further Considerations

I knew Friday's post on orthorexia would hit a nerve, but didn't anticipate it would gather steam quite as fast as it did…and (for my moderated blog) a bit of a lively discussion has developed in the comments, raising some important questions and concerns. Thus worthy of a Part Deux. There will be (maybe somewhat irreverent) digressions based on my personal and clinical experiences rather than a Pubmed literature review. So here we go.

Citizens True Romance

1) What about the kids? Are we raising a bunch of gluten-free dairy-free peanut-free neurotic orthorexics?

A subject close to my heart, as the mother of three and five year old little girls, who mercifully have (knock on wood) no health problems or body image issues. In fact, the three year old, who lives life with gusto, invariably runs around the room with her arms upraised giggling whenever she is naked (at least twice a day, with changing back and forth into PJs and clothes and tubby and spilled things, etc.) because being naked and free is clearly just so awesome. Now I know several adult men who still think this way (you know who you are), but I don't know any women who do. Which is sad. Someday soon my kids will start worrying about their thighs. Ugh.

I don't want my children to grow up neurotic about food. On the other hand, when you look at the advertisements and the grocery stores and the incentives out there, popular kid food is pretty wretched, processed, sugary, blue gooey crap. Kids have growing brains and bodies and need appropriate nutrition to fuel that growth.

(Speaking of incentives, one of the things that really bugs me about my daughter's pre-school is that they require than lunches and snacks be brought in recyclable containers. That sounds all good and responsible on the face, but "real food" is bulky, requires more prep, and my little girl has a good appetite. If I try to cram some orange slices in a plastic baggie into the top little space left in her lunch box, I get a supercilious little paper reminder of the rules that comes back in her empty lunchbox. Meanwhile, pre-wrapped convenience food is allowed (I suppose it would be ridiculous to tear the goldfish crackers out of the snack pack and pour it into a little bowl with a plastic top). So, parents being busy and kids being kids and no one liking to get obnoxious notes, most of the kids get pre-wrapped convenience foods like juice and gogurt and little packages of goldfish crackers for snacks because its easy and it fits.)

So all thoughtful parents have to find a line between running after little Jimmie and ripping the cupcake out of his hand as he sobs at the birthday party (unless there is particularly good reason) and raising little sugarized zombies who only eat rice krispie treats, lunchables, and dinosaur shaped fried chicken nuggets. I tend to have my kids eat what I eat when I'm cooking and not make a big fuss about it. But they have cookies and whatever at parties and on play dates and when their father brings one home, and I also don't make a big fuss about it. If the five year old asks me why I don't drink milk, I just tell her it upsets my stomach or something of that nature. I do make it clear that we should eat mostly "healthy food" and that the sugary candy and processed stuff doesn't nourish our bodies and brains like we need, but it can be happily enjoyed as an occasional treat. Now there are many tales of kids with behavioral and health issues that respond to taking some major players (like gluten, for example) completely out of the diet, and those parents have to draw the line a little further than I do.

Bratman's book, Health Food Junkies has some horror stories about moms with food allergies diagnosed with some sort of naturopathic test using electric voltage changes in the skin (or the IgG tests) who put their kids on crazy restricted diets too, and little four year old Jane babbles about not eating chocolate, oysters,  tomatoes and yak meat because it gives her migraines. I think we need to be very careful about restricting diets too much and putting too much importance on every molecule of food that goes into our mouth or those of our kids. That's also why I tend to prefer the Paleo 2.0 ancestral "real food" approach which includes dairy (particularly fermented) and cooked legumes (except most soy and peanuts), potatoes, and rice for everyday eating and things like 80/20 rules so we can enjoy anything we want from time to time and not wig out about it.

2) Orthorexia is just a BS problem for bored yuppies and everyone should just get a new hobby already.

I've been advised by some to completely ban Itsthewoo from my blog because she can be quite aggressive, and frankly I have to steel myself whenever I see the email pop up that she has commented, but she can be entertaining and has some penetrating observations. Her original comment was a bit beyond the pale, but fortunately she allowed me to moderate it for "public consumption." I didn't moderate it that much. This comment is a bit of a poke at psychiatry in general and the explosion of diagnoses and are we just trying to medicate and treat everyone to be a brave new world sort of useful worker for their mismatched sock disorder and weird goth teenager disorder and most of mental illness doesn't actually exist.  My response is that orthorexia is a popular term for kind of food/health anxiety that can be very debilitating and, in some rare cases, fatal (Bratman's book, which is very good and has some hilarious statements such as "tofu is healthy" details several such cases). I would also say that just being a little anxious about what you eat or paying attention to what you eat or trying to eat healthfully is NOT orthorexia. It's when healthy eating crosses the line and becomes the entire focus of your life, and that focus disrupts your life or your relationship with your loved ones. Life is short, and there is more to life than food, and food should be enjoyable and sometimes fun, not a always penance or a purification ritual. Orthorexia is almost never as dangerous as anorexia or bulimia nervosa, and I don't think anyone would argue that.

3) Should eating disordered people be handing out advice about eating disorders?

Actively eating disordered folks could give out some pretty bad advice (consider the ana and mia forums, and if you don't know what that is, you are better off and the world is a brighter place for you, though if you are a health care professional or the loved one of someone with eating disorders you should know what that is). I can't get all bent out of shape about people who are in recovery from eating disorders counseling others, because in treatment settings it is often people who have had eating disorders or relatives with eating disorders who dedicate their lives to treating them. Eating disorders are tough, heartbreaking, and difficult to treat, and it takes a special sort of motivation and energy. In general these settings are supervised and work along standard lines, and there are some treatment models quite similar to AA, with peer counselors and sponsors. Should random bloggers be doling out advice about eating disorders and should be people be getting medical/nutritional advice from random bloggers? Random bloggers can and will say whatever they care to, for the most part, and people ought to consider what they take as fact or wisdom from the internet, obviously.

4) Is low carb dieting (and, particularly, the mythos behind low carb dieting, that carbs=insulin=burnt out pancreas and diabetes and foot ulcers) a fast lane pass to an eating disorder?

I'm reminded of the "Ask the Paleo Experts" panel at PaleoFx12 where I suddenly became a "Paleo Expert" because Chris Kresser hadn't been told (apparently) that he was supposed to be on this 8:20am panel, had slept in a little, and I was around and available. This incident occured at the height of the carb wars (sigh) and I put in my little push for bananas and starches as most bodies can very efficiently and happily process glucose with little to no problems, and being metabolically flexible (being able to process both fats and glucose with pleasantly clean and efficient mitochondria) is associated with the healthiest people. Nora Gedgaudus, Jack Kruse, and Ron Rosedale sort of cluck-clucked that very young sorts of people (and I do look very young) could unwisely consume the poisonous glucose that obviously ages you and kills you dead…but that the wise elders would never consume starch (in the winter for one, pretty much at all for the others). Yes, I think that sort of view can instill some unwarranted anxiety and fear in people. On the other hand, low carb and ketogenic diets can be very helpful and useful for certain conditions. In my practice I've seen some people get pretty anxious and overly burnt out and and troubled who came in on essentially zero carb diets who tend to be happier and healthier eating starch. I don't know if it was the carbs that made them better or the lack of worrying about carbs that made them feel better. I tend to favor higher-end low carb diets (like perfect health diet) and higher-carb end ketogenic diets (with MCT oil/coconut oil supplements to allow for more carb consumption) because they tend to be more flexible, easier, and less restrictive of a wide variety of foods.

5) Does Paleo dieting put you at particular risk for something like orthorexia?
I'm running out of time this morning! I feel like Robb Wolf and his carbohydrate manifesto. This one has a lot of interesting bits so I will wait to address it in Part Three.


  1. It's so good to have serious non-fanatic doctors in the paleo community. :-)

    I did eat 3 sugar and vegetable oil loaded brownies yesterday with friends, it was too sweet for my taste, but it was OK :-)

    Although I did feel a bit bloated and my sleep was a bit worse than normal, but without further consequences.

    So considering that I avoid sweets and eat healthy on an everyday basis, eating unhealthy sometimes is like a sanity check to myself and a reminder of why I eat what I eat.

  2. Emily, i'd like to commend you for not banning Wooo! she has an immense amount of experience, which i've found very valuable on many occasions. upon observation, my body behaves differently on different foods/supplements than hers does, but that doesn't minimize her wisdom. she can react over-strongly, but ... she's from New Joisy, fer gawdsake! ;-) not to mention the fact that when one's experience is CONTINUALLY ignored by conventional-thinkers, one gets angry -- i know, because i've been THERE too.

  3. Fantastic. A couple of general observations:
    1) I was born in 1958 and most kids of my generation were forced to eat our veges, such as they were, and had little choice but to eat the same food as adults at any meal. We were often told snacking was bad for us, sweets would rot our teeth, and that various products had poison in them (as they did from time to time in those days - I can't remember when tonka bean flavourings disappeared, but I think it might be one of my nostalgic cravings.)
    We were also bullied into exercise at school to an extent that wouldn't be allowed today.
    That general background of good childcare might have some relevance. A degree of orthorexia, albeit one held in common to some extent by a whole community, may be the norm.

    2) a rule-of-thumb in genomics is that 50% of behaviour is determined genetically, 25% is learned from our parents, and 25% is learned from our peers as we grow up.

  4. Emily, I love how you think. You have turned the orthorexia gimmick into a launching point for something much more interesting. Because, imho, in most of paleoland, "orthorexia" is simply an escalation of the safe starch wars.

    Stage I:
    Starches are Paleo too!

    Stage II:
    If you're not eating starches, you're not eating real Paleo!

    Stage III:
    If you're not eating starches, you're mentally ill!

    The wider "Orthorexia" campaign has some familiar faces in it. You kind of wonder how they get anything else done.

    1. Not actually disagreeing with you, Robert, but I see orthorexia in far broader swaths of the paleosphere. "Gluten will kill us all!" "The 5x10^-14 g of soy isoflavones in this coconut ice cream will kill us all!" "Two tablespoons of milk in your mashed potatoes will kill us all!" Or, from the LC camp, "Mashed potatoes will kill us all!" Paying attention to the food you eat is one thing, hyper-vigilance that interferes with your daily life is another, and it's the latter I see popping up all over paleoland.

      I do understand that vegans and macrobiotic dieters and suchlike are even worse, but I don't actually know any, so.

    2. Hi, Sarra, thanks for your reply.

      Yes, there's definitely all flavors of silliness out there. But bothers me is that the commenters here who attempt to paint this supposed "orthorexia" as a threat to health seem to be only on the warpath against low-carb bloggers.

      I'm not aware that low-carb eating has been proven particularly dangerous, though I've seen that some people who try zero-carb/ketogenic can feel sluggish (others don't, and the sluggishness apparently resolves upon returning to a more conventional low-carb diet.) For other people, cutting out sugars and starches is nothing less than a Godsend.

      But what IS definitely dangerous is telling undiagnosed diabetics that starch is not a problem. Or, worse, that they can get thin fast by eating NOTHING BUT POTATOES (actually quite common advice the past two months.) This is inarguably risky advice for people with poor BG control, yet this behavior is NOT what these commenters are lobbying against!

      This makes me question if they're really so concerned about people's health, or if they're more interested in landing blows in the starch wars.

    3. I think the fact of life that all sort of advise, good or bad, is being available on the internet is just the unchangeable reality nowadays. For better or for worse it is left for people to decide which advise to follow. There is a downside in that, but also an enormous advantage. Freedom always comes at a price. There is a downside in the freedom of speech, freedom to own a weapon, freedom to choose any life-style.

    4. "I see orthorexia in far broader swaths of the paleosphere. "Gluten will kill us all!" "The 5x10^-14 g of soy isoflavones in this coconut ice cream will kill us all!""

      That's not 'orthorexia' that's a rational response to limited information: namely knowing that gluten and soy are very bad for many people, but not knowing precisely how large a dose is required to cause said harm.

  5. On parenting: it's what you model that makes all the difference in the long run. If you have a half-decent relationship with your children and you set an example, one or two birthday parties with blue cookies isn't going to ruin them any more than running around in urban air will.

  6. "This makes me question if they're really so concerned about people's health, or if they're more interested in landing blows in the starch wars."

    I think bloggers are mostly concerned with attracting readers, the people who are concerned with people's health spend years studying and training and become medical professionals.

  7. "I've been advised by some to completely ban Itsthewoo from my blog because she can be quite aggressive, and frankly I have to steel myself whenever I see the email pop up that she has commented, but she can be entertaining and has some penetrating observations."

    Laf. Me too. And sometimes there will be 3 or 4 comments.

    I just can't help myself but like her, even when she goes after me and perhaps even more then.

    Good for you, Emily.

    Later today I'm doing a Skype interview for a nice guy who's started a blog, whatever, and one of the advance questions is "what would you advise the Paleo community to do.?" After thinking about it, it came down to one word: BREATHE!

  8. I just can't help myself but like her, even when she goes after me and perhaps even more then.

    Wooo? Watch out, she's got a knife! She'll get ya! She'll cut ya!

    Worst of all, she'll refute ya!

    Erm, those were jokes. I like Wooo. I'm also partial to attacks from the front, rather than the rear.

    I would love it if Emily would publish some of the back-channel emails she's been getting (the way you did, Richard. When you did it, it sure cleaned out the stables in a hurry.)

    I have a feeling the emails Emily's getting are from the usual suspects.

    1. Emails to me will always remain private except at the explicit permission of the mailer. Secrets are my business.

  9. Wooo is unique, smart, honest,and amazingly insightful. Is social grace so valuable that it outweighs the rest?

    1. Woo spends a lot of her time tilting eloquently and dramatically at imagined windmills of interpretations she has created. Confidence doesn't always equal wisdom. She also applies her personal experience like a scythe against all other experience… which is often enlightening, but not always accurate. I don't mind aggression, as it can be important. But my blog is my little totalitarian regime corner of the internet, and I've been at this game too long to allow the comments to fall apart into sniping. See below...

    2. Wooo's interpretations could be quite interesting. Due to the reading about her take on Taurine, I successfully experimented with adding that supplement to my migraine preventing and management routine. The only sane approach to the blog reading is treating the information there as a food for thoughts. It is almost like an art, we normally don't try to model our lives according to what we read in a novel, but often such reading helps us to look at our life from a different angle. According to what I remember from the reading the Wooo's blog, she doesn't claim everybody would need the same level of carbohydrate restriction like she does, but if she did she wouldn't be alone. Applying personal experience too widely probably is the main reasons for Carbs Wars. It is possible in a few years we will remember current situation with a smile. Mileage may vary. I limit my carbs intake, but my family members are just fine eating mostly junk-free.

      I guess Wooo's experience during the leptine trail left quite a few people in similar situation (body resisting massive fat loss) guessing, what if it would be helpful for them too?

      Dose of totalitarian approach could be healthy. As we know from the history, totalitarianism indeed provides order and security. Freedom could be messy.

  10. If I were to pick a therapeutic nutrient to try to treat these conditions, it would be Vitamin K2 as MK-4. Big doses are anhedonic and depressing, but steady food-like doses seem to dampen compulsive behavior without denying pleasure.

  11. Have you read this Emily?

    Sure the recoverED eating disordered are in a position to help others, even those in recovERY that is working, but Stefani is/was neither.

    She writes from time to time about women eating carbs and how important that is. Did she utter a peep in podcasts? Rarely. When she does she sounds wicked timid as if to be afraid of upsetting her carbophobic benefactors.

    1. Evelyn, "carbophobic" is as much a word as "sugarophobic", and makes exactly as much sense.

    2. carbo = short for carbohydrate
      phobic = suffering from irrational fears

      I'll use one definition irrational to be unsubstantiated. Sounds about right to me Robert! OK, sarcasm aside, why does Ruper go on LC podcasts? Is it to discuss her experiences and issues when she was VLC? How she believes women should eat carbs? Why not I wonder ...

    3. I don't actually know anything about her. But for your jihad, I doubt I'd ever have heard about her. I do know that there are pro-carb people no better qualified that you and Melissa go to the ramparts for. So IMHO you're not being fully authentic about your reasons for your war.

      Also, Evelyn, you endlessly give advice to the clinically obese on your blog. Which makes me curious: where did you go to medical school, and in which states are you a licensed nutritionist and/or M.D.?

    4. @Robert, be nice. I'm not going to post your latest comment. @Evelyn, I'm not cool with these comments being a bashing forum for Stefani Ruper, either. She has very little to with the anti-carb spin the paleosphere went for a while.
      @Everyone, are we really going to replay the carb wars here? On the orthorexia post?

    5. But that's the thing, Emily. For most of those throwing the term around, "orthorexia" is just an attempt to conflate dietary carbohydrate control and mental illness. The term is being used in a fundamentally unserious way. It's an attempt at frame control.

      You are IMHO the first blogger I've seen who took it seriously. And in the process, you've made the discussion far more interesting and subtle than its proponents ever intended.

      And I'm not sure they're happy about it. :-)

    6. @Robert, I've made a an attempt to figure out the carb thing from an academic perspective.

      The two positions are fundamentally opposed. I tend to hang out on the carb friendly side because that seems the most likely ancestral paradigm and the home of the metabolically flexible.

  12. Any chance you have a topics tag list for all your posts?

  13. "So, parents being busy and kids being kids and no one liking to get obnoxious notes, most of the kids get pre-wrapped convenience foods like juice and gogurt and little packages of goldfish crackers for snacks because its easy and it fits."

    Uh oh, you're starting to see the Matrix. You'll be flying any day now.

    I vote for not banning Woo, she has pros as well as cons.

  14. Most Americans have an insane way of thinking about nutrition:

    Some foods are Good, and remain Good no matter how much you eat (carbs are in this category).

    Other foods are Bad, and less is always better ad infitum (dietary fat).

    When some people say that excess carbs make most people fat, that violates the belief system of carbs being Good, so they must defend the tatoes against this blasphemy. It is not science.

    However, some LC'ers retain the insane way of thinking, and just switch the categories. I have read some websites using the phrase "evil carbs".

    I think most people need to restrict calorie carbs to less than half of total cals. I am imagining a bell-shaped curve with "the avg person" doing best on 40% carb/40% fat/20% protein. This would have some people needing - biologically needing - VLC, and some well tolerating a high carb/low fat diet.

  15. Oh, FFS. Is it possible to discuss anything in the paleosphere right now without it devolving into the carb wars? There are other things at issue, people.

    (That's not directed at your post, Emily, that's directed at the comment thread.)

  16. Oh, please.

    Serra, avoiding wheat and sugar is a simple habit. It's not "extremely stressful", nor does it require "hyper-vigilance" or is it "downright dangerous" as you put it in another comment.

    The attempts to clinicalize simple low carb eating are so transparent. The benefits of low carb for some populations are established.

    Give it a rest, will you?

  17. Please.

    Serra, avoiding wheat and sugar is a simple habit. It's not "extremely stressful", nor does it require "hyper-vigilance" or is it "downright dangerous" as you put it in another comment.

    The attempts to clinicalize simple low carb eating are so transparent. The benefits of low carb for some populations are established.

    Give it a rest, will you?

  18. "Ban" Me? I post very infrequently. It's a bad habit.

    There is next to zero discussion on this blog anyway which is why I stopped commenting; however, you're free to leave it to the 3 MDs who post and you can all congratulate each others brilliance etc, I will *volunteer* to stop polluting your comment section every 2 weeks or so, lol.

  19. Dr. Deans, Any thoughts on personality disorders and orthorexia and eating disorders in general...seems like group B? ones like narcissism and border-line seem to 'feed the beast' so to speak...I guess that was a pun?

  20. So bold Dr. Deans, as always. I do miss those heady days when we would facebook message thoughts about eating and the emergence of your excellent blog. Back when archevore was PaleoNu and things were pretty chill. I've just gone back through your recent posts, which are as good as ever. Admittedly I haven't been on a paleo blog, or any other such site in months now, just couldn't take it anymore. I've been dealing with my sons issues (as you know) and getting really intensively back into work (pun intended :) ). The carb wars and subsequent disasters on many blogs were just all too much for me. I'm now sticking to Alan Aragon's research review, my own reading and the occasional review or your's and Richard's blog (he just kills me, even when he's being "angry"). I've been whole hog on the carbs for awhile, included tons of wine and things seem fine. Following the Martin Berkhan theme of lower carbs on non-workout days, higher on big lifting plus the 8-10 hour eating window (with a little of Anthony Colpo's wisdom thrown in) seems to be great. I gain muscle, don't gain fat and feel great. Since I have celiac the gluten isn't much of a debate for me, increasingly people at work are seeing the wisdom of what I've been saying and incorporating a little bit of paleo plus some high intensity exercise into their lives and into the recommendations they give their patients. Take a look into "Post ICU Syndrome". it's long been an area of interest for me and is starting to gain traction amongst the society of critical care. I think that good nutrition and well-structured exercise such as I've been advocating, starting in the ICU, will make a huge difference for these folks (and there will be sooooo many more in the coming years).

    well, off to get the eldest from gymnastics. shoot me a FB message or gmail if you are interested in the follow-up details on my son. Amazing what a well structured diet, slightly adjusted point of view and good psychiatric guidance can do for a little man who struggles. Plus, i hired a lawyer for school stuff, which as I tell everyone, is what we do as adults because we can't actually punch other adults in the mouth :). She's giving to the school pretty good.

    as always, keep up the good work and best of luck with the snow.


  21. Why are people still debating about starches? Take Jimmy Moore's lead and measure yourself and take the guess work out of it.

    BloodSugar101: What is a Normal Blood Sugar?

  22. Emily - I happily cooked and ate mostly LA farmers market faire for the past 25 years. Which did include lots of fruit - as well as veggies, wild fish, pastured eggs, buffalo. I just called it eating. Since my husband was diagnosed Type 2 a few years ago, we've been researching and eating paleo variations but I've given up gluten and non-fermented dairy. I must confess to thinking orthorexian thoughts whereas before I just happily prowled the farmers market and made great food. I think I am going to go back to happily making food. Thanks for the post! This is really good. And, if your kids help you cook, this may help engage them with healthy eating. My mom let me cook and bake with her beginning when I was about 3. The creative engagement with food taught me tons - especially about the pleasure of experiencing vibrant foods and creating great meals and experiences.

  23. Thanks, agreed, the neurosis about food gets overdone. I get it myself, too long on lowcarb in the past, too worried about the profound asthma I get if I ingest any gluten (wheat or rice), too concerned about whether I might be eating something that'd crash my blood sugar when I have to be working, and I end up eating nothing. For me, not-eating is the worst and most chronic thing, so anything that makes me wander the kitchen, feel guilt for 14 reasons everywhere I look and wander out again is bad, sigh.


    I hope you don't bow to pressure from others to ban commenters (only to own your own choices, of course).

    I have only returned to the blogosphere after several years away and (having recently found my google reader backup file so I got my RSS feeds back) have been catching up the last few weeks. I am stunned at some of the behavior and comments in it. Woo's a drama but holy cats she is way, way down the list if we're looking at people who deserve to have their kazoo taken away.

    It's one thing to be slicing or dramatic. It's another thing to be so crassly, trashily crudely insulting like an "-ism" (against race, sex, weight, or anything else like that, I consider them all equal in that regard). Insults and epithets and derogatory and sexist refs about women and about fat I've seen when reading backlogs recently have made me feel (as a woman with lipedema) pretty unwelcome in the online world -- by proxy, where I never did before. I used to enjoy reading in this genre more, as I recall, which is kind of sad.

    It's not so much the battle of certain personalities; it's more that the initial spark only seemed to be discussion about nutrition or health, which brought inappropriate personal insult response, which brought complaint about that kind of response (personal/sexual insult is never an ok response to a simple complaint that one lacks any science backing for a claim), which brought 10x the same response again, which brought complaint to everyone else as they allegedly "should" be themselves commenting on or distancing from such behavior, which just brought more of it all over and then everyone felt like a victim of someone, apparently. But it all really tracked back to was a primary source that was so escalatingly abusive. I used to know someone like that but the person eventually got help for substance abuse issues. I've never actually seen that kind of behavior online in this field before. Now it feels like the whole bloody paleo-ish blogosphere needs therapy.

    Well I guess you're well placed, haha!


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