Being healthy has
always been trendy. Diets and exercise regimens have been popular for decades.
With the prevalent use of social media, a person can find an online community
from which they can find inspiration for their personal lifestyle goals. The culture
of dieting is pervasive, common, and perhaps most importantly, dangerously
acceptable. Think about the last time you heard someone say they wanted to lose
“x” amount of pounds, or the last time someone mentioned they were trying a new
pattern of eating for their health. It has become quite common in every day
conversation, from “today is my cheat day” to “no thanks, I’m on a diet.”
Intentionally choosing to eat vegetables over hot dogs every day is not
inherently bad. In fact, we should encourage patients to make conscious efforts
in eating delicious, nutritious foods. But what happens when we take it too
far?
In the past few years, orthorexia
nervosa, a pathologically disordered healthy eating disorder, has gained quite
the spotlight in media coverage. It is not recognized by the Diagnostic and
Statistical Manual of the American Psychiatric Association (DSM-5), and not
very well documented or understood. Orthorexia nervosa is not body dysmorphia
nor is it necessarily always driven by pure desire for thinness. It is an
eating disorder that evolves from only eating what the individual perceives is
to promote good health, whether that be mainstream acceptable healthy foods, or
dangerously restrictive diets. Dr. Steven Bratman, a physician who practices alternative
medicine, first described orthorexia nervosa in an article in the 1997 Yoga
Journal. It would not be until 2004 when orthorexia was described in the
peer-reviewed journal of Eating and Weight Disorders—Studies on Anorexia,
Bulimia and Obesity. Since then, there have been multiple propositions for
diagnostic criteria, although none that is formally or officially used.
In the primary
care setting, patients are often encouraged to lose weight, told that they are
overweight, and advised to change their eating patterns. More often than not,
patients are praised when they inform their clinician about their behavioral
changes in eating a perceivable healthy diet. In a case study of a 28 year old
woman who presented with severe malnutrition and BMI of 10.7, the patient was
14 years old when told by a nutritionist to cut fats from her to diet to
control her acne refractory to treatments. When the patient was 16 years old,
she began to eat extremely restrictive diet, having no desire to be thin nor
poor body image, she began only eating uncooked vegetables and socially
isolated herself as these radical changes were not conducive to social
environments. She simply held to the belief that certain foods were toxic and
needed to be avoided. While weight changes may result from orthorexic behaviors
or may be peripherally desired, thinness is not the main reason.
Simply desiring to
eat healthily in itself is not orthorexia. According to the literature review,
“one widely accepted practice to determine pathological behavior or clinical
significance is whether the behavior is interpersonally distressing or causes
impairment in important areas of functioning: occupational, social, or
educational. While some patients may present themselves all too readily for
further evaluation (belief that they should only have 3 tablespoons of brown
rice and spinach daily), some patients may evolve to develop orthorexia nervosa
from an innocent desire to simply be healthy. Care should be taken by
clinicians when conversing with their patients about their eating habits.
Below are the
diagnostic criteria proposed in a literature review by
Thomas Dunn and Dr. Steven Bratman himself.
Chelsea Salas DUCOM 2020
