Orthorexia Nervosa: When 'Healthy' Eating Turns Dangerous

Deborah Brauser

May 31, 2017

SAN DIEGO, California – Today's ever-growing focus on fitness and "clean living" may lead to an increase in cases of a condition known as orthorexia nervosa, according to two presentations here at the American Psychiatric Association (APA) 2017 Annual Meeting.

Orthorexia has been defined as a "pathologic obsession with proper nutrition," including a strict avoidance of food believed to be unhealthy or impure, that can have serious nutritional and medical consequences.

Unlike anorexia nervosa, body image is usually not a focus for patients with this condition -- which is not currently recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

A poster presentation here described the case of a 54-year-old man who presented at the emergency department following a 3-day water fast, which he underwent because of a belief in "health stuff, herbs, and a super-healthy diet." The patient was experiencing anion gap metabolic acidosis and severe nausea.

In a full workshop devoted to orthorexia, more case reports were presented, and a discussion was held about possible diagnostic criteria, overlapping symptoms, and the fact there have been no studies into effective treatment.

Dr Steven Crawford

"Clearly there is more interest in this diagnosis and more case reports coming forward," session moderator Steven Crawford, MD, codirector of the Center for Eating Disorders at Sheppard Pratt, Towson, Maryland, told Medscape Medical News.

"And as there's more of a societal focus on healthy eating, the more people who are biologically vulnerable to go in the direction of eating disorders will fall into it."


Spiritual Purity and "Miraculous Maids"

Although the term "orthorexia nervosa" first appeared in the literature in 1997, its leading symptoms have been around for much longer, according to three residents from the University of Maryland/Sheppard Pratt Psychiatry Program.

During the Middle Ages, self-starvation was employed as a way to achieve spiritual purity, and during the Renaissance, "miraculous maids" were said to have uncommon abilities to starve themselves.

Today, "we are faced with updates on the latest food diet, warnings about certain foods and products, and an ever-changing set of guidelines on how to live a healthier life," write the investigators. "In this complicated cultural environment, many individuals find it difficult to not worry about their eating habits."

During her presentation, Yon Park, MD, said that although there has been a significant decline in the popularity of diet pills and the diet industry as a whole, it has been replaced by a movement of "eating clean" and practicing a holistic lifestyle.

"Sugar-free, gluten-free, non-GMO, no pesticides, grass-fed – companies are bombarding consumers with these labels. And they're adding new lines of products to appeal to this ideology," said Dr Park, adding that sales of organic foods doubled between 1994 and 2014.

An obsessive focus on all of this can lead to orthorexia nervosa, which is characterized by a restrictive diet and ritualized eating patterns.

"Simply put, orthorexia is a fixation on food quality as opposed to food quantity," said Dr Park. "The social and cultural context could promote certain types of food intake management that ultimately becomes pathological in a person genetically predisposed to [eating] disorders."

"I Was Afraid to Do Anything"

Copresenter Rebecca Sokal, MD, noted that the condition would likely fit between anorexia nervosa and avoidant restrictive food intake disorder (ARFID), which are both currently in the DSM-5. However, "ARFID doesn't address the complexity of motivations and behaviors in those with symptoms of orthorexia, and it makes research difficult."

Although orthorexia is often misdiagnosed as anorexia, patients with the former often flaunt their eating habits instead of hiding them, especially on Instagram, said Dr Sokal. She added that the condition also overlaps with obsessive compulsive disorder, obsessive compulsive personality disorder, and somatoform disorders.

During the session, two case reports were presented. The first patient was a 72-year-old white Buddhist nun who presented with extreme weight loss. "You get afraid of eating because you don't know what it'll do to you," said the patient in a video clip. "Eventually I was afraid to do anything, so I did nothing."

This patient's mother had unusual beliefs about eating and started eliminating certain foods herself when she was in her 20s.

In later years, the patient met with a holistic medicine specialist, who diagnosed her as having multiple food allergies and recommended that she increase her use of food supplements and that she follow the paleo diet.

Treatment for the patient, who had no history of concern regarding body image, included a gradual reintroduction of all types of food into her diet and discussions to help her recognize her obsessive thoughts.

She starting eating a wide variety of food, including those she once thought would hurt her. She reported being happy with her new curves and became involved in Eating Disorders Anonymous. However, "She is struggling to find additional resources regarding orthorexia specifically," said Dr Sokal.

Only Request: Coconut Water

Copresenter Michael Cannon, MD, discussed the second case: a black woman in her 30s who was severely underweight, hypokalemic, and dehydrated upon presentation. After a psychiatric evaluation, she was prescribed olanzapine 5 mg once nightly and lorazepam 0.5 mg three times per day and was involuntarily admitted to the University of Maryland Medical Center.

During early treatment, she only wanted organic coconut water because she believed she had parasites in her gut. She had previously been diagnosed with "leaky gut syndrome" by a naturopathic physician. Total parenteral nutrition was initiated to maintain her health.

Psychotic symptoms included paranoia as to whether her food had been contaminated, fear of mistreatment by staff, performance of several rituals regarding eating and food preparation, and what appeared to be hallucinations.

Her dose of olanzapine was titrated to 20 mg. After several weeks, it was deemed ineffective. Haldol, titrated up to 20 mg, was then substituted. Soon after, the patient started eating more foods and eventually consumed full meals.

The patient was transitioned to therapy with haldol decanoate and was discharged after 4 months. She continues monthly treatments. However, "she intends to return to the care of a naturopath as soon as she has enough money," reported Dr Cannon.

"Unlike the first case, which sounded like a pure form of this eating disorder, I'm wondering if this was driven more by psychosis," said an audience member after the presentations.

"Where do you draw the line for orthorexia, especially in the culture that we're living in?" asked another meeting attendee. "We all know people who have certain preferences. Even in here I'm sure some colleagues would say a plant-based diet is a healthy way to go. So at what point would you say this is a problem?"

Dr Crawford said clinical impairment from these concerns is what is important, whether such impairment is in the form of high levels of distress, deficits in functioning, severe malnutrition, or unintentional weight loss.

He later told Medscape Medical News that orthorexia has not yet been included in the DSM-5 because there has not been enough research about it. "A first step would be to try to get it recognized at least within the ARFID category, so more people can do research and then more details can be fleshed out."

Eating Disorders and Men

In her poster presentation earlier in the week, Rebecca Olufade, MD, psychiatry resident at the University of Massachusetts, Springfield, noted the case of a male patient with a history of major depressive disorder and suicide attempts. The patient underwent an extreme fast, which he reported was undertaken in the hope it would decrease his chronic pain and constipation.

Dr Rebecca Olufade

"Although uncommon for males to present with eating disorders, it is something to be cognizant of," Dr Olufade and colleagues write. They add that, given the patient's psychiatric history, his symptoms could have been seen as an intentional suicide attempt only.

"Psychiatrists need to be aware of newer types of eating disorders in order to provide proper assessment and treatment."

Dr Olufade said that because there is such a high degree of overlap with symptoms of other conditions, she is unsure whether orthorexia should be a distinct diagnosis or whether it should be lumped under something else.

"Is this just part of societal norms and images at this time? Is it a fad? We're not sure," she said, adding that collecting more data is extremely important.

Another Form of Anorexia?

Commenting on the presentations, Evelyn Attia, MD, director of the Center for Eating Disorders at New York–Presbyterian Hospital and professor of psychiatry at Columbia University Medical Center, New York City, told Medscape Medical News that eating disorders "fall pretty neatly" into the six diagnostic categories outlined in the DSM-5.

Dr Evelyn Attia

"Anorexia nervosa is a very interesting eating disorder in that it has, over the centuries, looked quite similar yet taken on questions that had to do with the social context of the time," said Dr Attia. "It's not uncommon for people with anorexia to adopt popular eating patterns and popular diets."

She noted that individuals who insist that health is the reason for greatly restricting their diet may stress that their condition is different from anorexia "when in actuality, when we think of the criteria, what they're describing isn't that different at all."

For the case reports presented at the APA meeting, "we have some real questions," said Dr Attia. "For those pursuing health to a very stringent extent, are we really talking about some new condition with a name clinicians are less familiar with? Or are we talking about good, old-fashioned anorexia nervosa?"

She added that she does not think orthorexia "is ready for prime time," in the sense of being represented as a diagnosis.

"And I would urge clinicians to think carefully about when weight gets to a dangerous place for these individuals. Does the condition fall more easily under one of the existing eating disorders, making it less likely that we need to come up with yet another one?"

None of the presenters or commenters have disclosed any relevant financial relationships.

American Psychiatric Association (APA) 2017 Annual Meeting. Poster abstract P4-106, presented May 21, 2017; and Afternoon Workshop 5, presented May 23, 2017.

Follow Deborah Brauser on Twitter: @MedscapeDeb .


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