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