Today’s question comes via reader Kathy P. in Austin –
I’ve just had a very unsettling interaction with my new internist, a woman physician I’m guessing in her early 40s (new doctor assigned because of insurance change). She was asking me about my diet, and I told her I’ve been eating paleo now for nearly 4 years, dropping 72 pounds the first year, with my weight stable at 138-139 now for three years. My husband and I love to cook, and share meals with friends several days per week.
I intermittent fast 3-4 days per week and try to spend a month in keto sometime in the first quarter of every year. My standard bloodwork has never looked better.
As a matter of background, I’m a college professor, marathoner and wannabe triathlete, am 51, 5’10” tall, weighed 138 in the office, with a calculated BMI of 19.9.
Despite my weight and fitness status, my new doc launched into an angry tirade about “paleo poison”, asked if I ate whole grains and legumes, and pronounced me as suffering from orthorexia nervosa. She basically stormed out after that interaction and sent her PA in to set me up for counseling, which I refused.
Wow, and a Quick Suggestion
Kathy, that’s quite a story, though sadly the second time I’ve heard something very similar in the past two weeks. Your high level function professionally and recreationally, lean body mass, and reported evidence of good general health (blood work mentioned above) all support that you’re doing a lot of things right. Perhaps you caught your new doc on a bad day; more likely, you need to petition the insurance gatekeepers to help you select another doc, and I’d encourage you to be very frank if they ask why.
So What is Orthorexia Nervosa?
The term orthorexia nervosa was coined by Drs. Steven Bratman in either 1996 or 1997; here’s his own introduction to the term written on an eating disorder website –
It is good to eat healthy food. We are encouraged to do so by major medical associations, personal physicians, celebrities, schools, employers, the media and even the US government. However, there are a variety of recommendations available regarding what eating healthy means, and some of these are stricter than others. Some people in their quest to be as healthy as possible begin to choose increasingly restricted diets and develop an obsessive, perfectionistic relationship with eating the right foods. This may go so far as to become psychologically and even physically unhealthy. In other words, it can become an eating disorder.
This unhealthy relationship with healthy foods is referred to as orthorexia nervosa from the Greek orthos, meaning “correct or right” and orexia, meaning “appetite.” While orthorexia nervosa is not listed in the DSM-V (the Diagnostic and Statistical Manual used by mental health practitioners to diagnose mental health problems), it is the subject of growing academic research and has become an accepted diagnosis in the mental health community.
A person with orthorexia nervosa has become so fixated on eating healthy food that this one goal begins to squeeze out and diminish other important dimensions of life. Thinking about what to eat replaces relationships, friendships, career goals, hobbies and most other pleasures of being alive. In extreme cases, the obsession with restricting one’s diet can lead to dangerous malnutrition, a truly ironic consequence of what began as a search for improved health.
The remainder of the article is worth a read, particularly as Dr. Bateman describes the progression of orthorexia nervosa in stages, the first of which is “adopting a theory of healthy eating”.
So What Differentiates Orthorexia Nervosa from Healthy Eating?
Here are several common examples of unhealthy behaviors that typify ON –
Fixation over the quality or purity of food.
Inflexible, rigid eating patterns.
Severe emotional turmoil if “the rules” are broken.
Elimination of entire food groups. (Likely the trap that Kathy fell into in the mind of her internist).
Compulsive checking of ingredient lists and nutritional labels.
Increasing concern about the health of food ingredients.
Unusual interest in the health of what others are eating.
Spending hours per day thinking about food to be eaten in the near future.
Obsessive following of food/healthy lifestyle sites on social media.
High distress if “safe or healthy” foods aren’t available.
Compulsive macronutrient tracking.
A focus on weight loss or body image concerns may or may be present.
Detailed behavioral criteria for the diagnosis of orthorexia have been proposed; here’s an example from 2015.
Back to Kathy’s Question….
Three quick thoughts. One, Kathy, given the thumbnail sketch you’ve provided of yourself and your history, and looking through the typical features of orthorexia nervosa (see other approaches to describing typical symptoms here and here), I’d put money on you being a successful paleo foodie and fitness junkie and not suffering from orthorexia. (My purpose here is purely educational, so that’s not a set-in-stone-diagnosis…)
Two, you may have been caught in what some are beginning to describe as an escalation of hostility from some in establishment medicine toward those choosing what appear to be better alternative nutritional paths. It’s time for another new gatekeeper primary care doc, and may your search be fruitful.
Three, in no way is it my intent to belittle orthorexia nervosa here today. There are people suffering mightily from the condition; I saw them as a physician in practice and see them now, more frequently than you might initially think, now as a health coach. From where I sit, a striking percentage are vegans, though I see them in all walks of life, and following any and all sorts of nutritional program approaches you can imagine. Orthorexia can inflict devastating consequences, and if you know someone teetering on the edge of orthorexic behaviors, reach out a caring, helping hand and help them engage with someone who can help.
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