Dec. 1, 2018

When healthy eating becomes unhealthy: A look at orthorexia nervosa

Most people are familiar with common eating disorders such as bulimia or anorexia nervosa, which are characterized by unhealthy relationships with food. But what happens when someone becomes obsessed with eating well?

It’s one thing to ask for your Hollandaise sauce on the side of your eggs benedict at brunch or to prefer fruit over French fries at lunch. But if you become so concerned with healthy eating habits that they start to rule what and with whom you eat, you may have an emerging problem called orthorexia nervosa.

First named about 20 years ago, orthorexia nervosa has yet to be thoroughly researched or fully defined. And so far, it’s not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the American Psychiatric Association’s classification of mental disorders and the agreed-upon guide for psychiatrists, psychologists and other mental health-care professionals.

“There isn't one definition for orthorexia nervosa where everyone has agreed ‘this is the best way to diagnose this problem,’” says Dr. Kristin von Ranson, PhD, a professor in the Department of Psychology in UCalgary's Faculty of Arts and director of the Eating Behaviours Laboratory. “But the gist is that it describes people who get really obsessed with healthy, clean eating and carry it too far. For example, someone who has such strict rules about what they can eat that they're not able to go to a restaurant or to someone’s house and eat something there because it would not suffice for them.”

At this stage, orthorexia nervosa is mentioned more in the media than in the scientific literature. It’s hard to know whether further research will determine that it's its own distinct eating disorder or a subtype of some other mental disorder. It may be classified as a type of obsessive-compulsive disorder. Or it may be determined that it’s more about eating, shape and weight, which means it may be classified as an eating disorder like anorexia nervosa.

“It’s not clear how distinct it is from anorexia nervosa,” says von Ranson. “In anorexia nervosa, people purposely eat less than their body needs to become underweight and feel better about themselves. It’s a complicated disorder that involves being underweight, even starving, but orthorexia is not centred on a person’s weight.” While people diagnosed with anorexia nervosa are concerned with their body image, that may not be the case with people who show symptoms of orthorexia nervosa.

Yet another eating disorder may be relevant to the emerging discussion around orthorexia nervosa — avoidance and restrictive food intake disorder, or ARFID. “Regular people call it picky eating, but people can do it to such a degree that it causes them problems. It’s pretty extreme,” she says. ARFID, where people limit their food intake — because of lack of interest, how foods look, smell, taste, feel or appear, or concern over aversive consequences of eating — was just added to the DSM in 2013.

It can take decades to gather enough research about a disorder that it can be recognized in the DSM. “First, what is it?” says von Ranson. "Are we all talking about the same thing? And second, are we sure that it really is a problem that is distinct from other things that we already know about? It has to be demonstrated that it matters that someone has one problem rather than the other.”

Too-clean eating in high-performance athletes

In one of the first studies of its kind in Canada, Georgia Ens, who just graduated from UCalgary's Faculty of Kinesiology, did her Masters’ thesis on orthorexia nervosa in high-performance athletes. “It looks different for athletes,” she says. “With sports, the whole idea of sport performance gets added into the mix. This individual needs to fuel their body for this particular sport so their eating attitudes are going to be based around their sport performance demands.”

She recruited 72 elite athletes competing in different sports at the national or international level, and asked them to fill out two surveys to share their thoughts about food and eating. She found that about 14 per cent of them expressed “some sort of disordered eating attitude.” That’s more than triple what we see in a “normal” population. “I wasn’t shocked,” says Ens. In fact, 75 per cent of the athletes she surveyed experienced some symptoms of orthorexia nervosa.

High-performance athletes are always looking for that extra edge that will set them apart, and diet is one of the factors they can control. “Even though it’s not an officially recognized category, there are athletes that fall into this pattern of eating,” says Dr. Dave Paskevich, PhD, an associate professor and associate dean in the Faculty of Kinesiology, and Ens’ supervisor. “They're so focused on how they prepare their food and how they want to fuel their body that they start making comments to others. ‘How could you eat that?’ Because of that, they become socially isolated or they don’t want others to see what they’re eating.”

The athletes may also suffer anxiety when they can’t follow their strict diets while competing in foreign countries — for example, wanting to have broccoli for breakfast in South America. “But also from a health perspective you can start becoming so concerned about what you eat that maybe without good nutritional advice you start to cut out things that could actually be beneficial to your performance,” says Paskevich.

Aesthetic athletes — such as divers, gymnasts and figure skaters — are concerned about their body image because competition judges rate them in part on how their bodies look. For this reason, it’s known that these athletes are at risk for eating disorders. “But we don’t know whether hockey players or soccer players are at risk,” says Ens. “The research for my thesis started to uncover what’s going on across all sport types and I want to take a deeper look at other sports to see what’s going on there.” She is planning to do more research into orthorexia nervosa in a PhD.

The field could certainly use a lot more research to help high-performance athletes understand their extreme eating habits may be hurting, not helping, their performance. “There are so many different ways to eat and there is no one right way,” says Paskevich. “We want to make sure that at the end of the day you’re fueling your body properly.”

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Dr. Kristin von Ranson, PhD, is a professor in the Department of Psychology in UCalgary's Faculty of Arts and director of the Eating Behaviours Laboratory. Her research focuses on eating disorders, specifically questions related to etiology, classification, and assessment of eating problems and body image. Read more about Kristin

Dr. David Paskevich, PhD, is an associate professor and associate dean (academic) in UCalgary's Faculty of Kinesiology. His interests center on the integration of the science-practitioner model, bringing the science of sport psychology into practical/applied settings. His current research interests include coping, group dynamics, leadership, mental toughness, psychological hardiness and performance on demand. Read more about Dave

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