Orthorexia: What this eating disorder is, and why it's easily misunderstood

Recognizing and then working through recovery from an eating disorder is challenging enough. But when people don't believe your eating disorder exists in the first place, the recovery process could stop before it even starts.

That's why Maddy Moon is so fired up in her videos about orthorexia, an eating disorder in which people have an unhealthy obsession with eating only foods they perceive to be healthy, pure or detoxifying. Those with orthorexia might restrict themselves more and more until they are eating only a few foods, to the point of causing a health issue, like malnutrition. Or they might alter their lives because of those restrictions -- for example, never eating out with friends or coworkers out of fear of the menu choices at a restaurant.

Moon, who lives in Boulder and works as a life coach, is trying to get the word out about orthorexia because she has experienced it. She has also seen the reproach that social media posts about orthorexia, which is sometimes described (incompletely) as the "healthy eating disorder," can generate. Moon said she hates the idea that someone might be suffering but -- because of "that's not a real disease" comments -- backs away from seeking help.

"You wouldn't roll your eyes at someone that said that they have anorexia or bulimia, so why roll your eyes at someone who says they have orthorexia?" she says into the camera in one of her videos.

"For those of you who say orthorexia's not real -- 'That's not a real thing; get over it' -- it's real."

Moon began obsessing over her diet when she was training for fitness competitions. Her coach gave her a nutrition plan and said, "if you eat these seven foods, and nothing but those seven foods, for 18 weeks ... you'll be ready for this competition," she said. Anything that wasn't those seven foods became "bad." (She knows people with eating disorders search for new ways to follow their obsession, so she doesn't reveal what those seven foods were, on her blog or to the media.)

Orthorexia nervosa was first coined by Dr. Steven Bratman in 1997, but when popular health blogger Jordan Younger told her followers in 2014 that she was battling orthorexia, it gained broader attention from traditional media outlets.

However, orthorexia is not listed on the current Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, a listing health care practitioners use for diagnosis and researchers use for data collection.

There's been little research in North America on orthorexia, said Thom Dunn, an associate professor in psychological sciences at the University of Northern Colorado. Dunn is one of just a handful of U.S. researchers and clinicians working toward a definition, diagnostic guidelines and broader research.

One of the reasons there's some controversy over orthorexia, he said, is that "there are people who take great offense that there is pathological healthy eating," especially at a time when obesity is such a widespread and far-reaching health issue.

"We're not saying healthy eating is bad for you," he said. "We're saying there are some people who go overboard." And that's a small segment of the population. Due to the lack of research, it's unclear just how prevalent orthorexia is, but Dunn suspects it's less than 1 percent.

Dunn clarified that by "going overboard," he's not talking about just adopting a particular diet, like paleo or vegan or even one that seems a little extreme. Rather: "When it crosses the line is when it starts affecting your health and your daily life."

He believes orthorexia exists, he said. "There are people whose lives are being ruined, and people are dying because of this condition."

Evolving eating disorders

The best way to understand orthorexia's emergence as a "new" eating disorder might be in terms of evolution.

Eating disorders change over time, said Dr. Ovidio Bermudez, of the Eating Recovery Center in Denver. Each new version of the DSM includes new disorders: Bulimia was recognized as a syndrome in 1979 and included in the DMS in 1980; not long after that, clinicians started seeing clients who would binge and purge, or just binge, Bermudez said. But binge eating disorder wasn't added to the DSM until the most recent, the DSM-5, in 2013.

"The reality is that there's a whole evolution of eating-pathology-related symptoms," Bermudez said. "So we're not just talking about the eating disorders or typical presentations of them but different manifestations of eating-related pathology."

Of orthorexia, he said, "It's clearly not made up. It's a reality in the clinical world."

The "ortho" part of orthorexia means correct or straight. "Rexia" is appetite. "So orthorexia really implies that same concept of righteousness or correctness but applied to food and eating-related issues," Bermudez said.

Emily Richter, a licensed psychologist at La Luna Center, an eating-disorder treatment center in Fort Collins and Boulder, said that even orthorexia has evolved since Bratman, who coined the term, wrote about it in the late '90s, when cleanses were popular.

"Now we're not seeing so much cleanses as we're seeing the dietary restrictions," Richter said.

"Orthorexia usually starts out with really good intentions to be healthy and lead a nutritionally sound lifestyle," she said. Those who get obsessive about it -- by eliminating one food, then one group of foods, then other whole groups of foods -- no longer have a nutritionally sound diet, though. Yet they keep doing it, she said, because "they're so afraid of those (impurities) being in their body."

Although Richter works in Fort Collins now, she spent three years working with the eating disorders program at the University of Colorado, where "we know that eating disorders are two to three times the national average," she said. There, she said, students would come in for something else, like depression. But after asking a few questions (Do you go out with friends? Why won't you meet them for dinner?), she might uncover an eating disorder, such as orthorexia.

Richter stressed that because of the lack of research on orthorexia in the U.S., she doesn't have prevalence numbers, but anecdotally, as someone who works with people recovering from eating disorders on the Front Range, she sees it often. "I saw a ton of it from people who had grown up in Boulder and also students who had moved to Boulder who maybe didn't have full-blown orthorexia but orthorexic tendencies," she said. "And I think we're seeing more and more," she said, noting that she's seeing more cases of orthorexia now in Fort Collins, too.

She also stressed that this isn't about demonizing healthy lifestyles or one city or state; orthorexia isn't a healthy lifestyle. It's restriction that leads to distress: "malnutrition, extreme weight loss, interpersonal distress."

Moon, the life coach in Boulder, expressed frustration over that misunderstanding. "We're not saying healthy eating is a disorder," Moon said. "It's when you have panic attacks, when your self-worth is conditional upon what you ate today."

Regardless of where you live, orthorexia might be tough to spot in a loved one, said Carmen Cool, a psychotherapist in Boulder. It might just look like disciplined healthy eating.

"The fact that it's so culturally supported makes it really hard to recognize when it crosses the line into something that's a problem."

Jenn Fields: 303-954-1599, jfields@denverpost.com or @jennfields

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How to talk about food, dieting and body image, and how to help

Although orthorexia is about food, it can be tied to body image, said Maddy Moon, who shares her experience with orthorexia at maddymoon.com and mindbodygreen.com. It was in her case; she said it's still a challenge when people comment on her photos from her fitness-competition days, when she perhaps looked healthy to some but was struggling. They'll say, "You look so fit! But for me, that's an opportunity to educate them," Moon said.

"People who are complementing people on their weight loss success, you have to be careful. What's not healthy is when you say, 'You look better than you've ever looked.' Because then you say, 'What did you think I looked like before?' "

Before you comment, remember that you probably don't know why someone has lost weight, said Boulder psychotherapist Carmen Cool. It could be a health issue, from depression to flu to cancer.

Cool, who primarily works in the field of binge eating and chronic dieting, said "I wish we would stop feeling free to comment on each other's bodies."

She advocates for eliminating a few phrases that have to do with food and body image from our lexicon:

* "The term 'clean eating' really bothers me, a lot, because obviously, what is the opposite of that? Because I'm not eating 'dirty' if I'm eating something that's processed," she said.

* Good vs. bad: Evaluating one's diet or exercise habits with phrases like "I was good today" isn't helpful, Cool said. "Murder is bad. Cake is not."

HOW TO HELP: If you're worried about a friend or loved one, "don't disregard your concern," said Dr. Ovidio Bermudez of the Eating Recovery Center in Denver. "Because a lot of people talk themselves out of it -- 'she's OK; he's all right.' Express your concern. Don't make a diagnosis. The right approach is, 'Look, I've noticed some changes.' "

Your friend or family member might get mad, Cool said. "I expect defensiveness. That's OK." Just "communicate what you're noticing, from a place of love, and not from a place of blame or shame."