Orthorexia--when Healthy Eating is Taken to an Extreme

My grandfather’s mantra was “everything in moderation.” He drank a small scotch at 5 o’clock six days a week and lived to be 95.

There’s a growing problem in the US with the concept of moderation when it comes to eating and drinking—but not in the way you might guess. This issue isn’t always with people eating too much of food deemed unhealthy, explains Sumathi Reddy in a recent issue of the Wall Street Journal; the problem is with people being overly restrictive in the foods they will eat. The condition she describes is orthorexia nervosa, an unofficial term for when the effort to eat healthy or “clean” becomes extreme and obsessive, affecting either physical health (through weight loss or malnutrition) or mental health (anxiety or avoidance).

What may start out as health-promoting—becoming a vegetarian, going gluten-free or avoiding processed foods—can devolve into something very unhealthy. The condition, says one professional familiar with it, is more akin to an obsessive-compulsive disorder than it is to anorexia nervosa, the eating disorder characterized by overly strict limits on any type of food.

How can you tell if you’ve gone too far? It can be difficult to distinguish between healthy planning and obsessional avoidance. One way is paying attention to how much anxiety you feel. A red flag is when someone's eating habits makes him or her avoid social engagements, according to Marjorie Nolan Cohn, a dietitian quoted in the article.

If you are sacrificing your social life because your need to maintain your diet seems more important, then it may be time to ease up. Similarly, look at how much time you are spending thinking about and preparing food. If other important interests and commitments are getting pushed aside, that may be a signal that you’ve gone overboard.

Boys' Body Image Worries

Eating disorders are usually considered the realm of women and girls. Boys, however, make up a growing share of those with body image concerns and eating disorders.

A recent study of adolescent boys, described at The Atlantic, concludes that boys, in contrast to girls, are usually less worried about thinness and are more worried about being muscular, leading them to fell pressure to gain weight.

Boys are increasingly susceptible to media images of men’s bodies. Like girls, they increasingly seek to emulate unachievable body types; but instead of trying to look like a supermodel, they’re trying to look like a superhero. Their ideal is to be like the Batman or Superman toy from their childhood, but only 1 or 2 percent of men naturally have the body type that is typically represented in action figures, according to Raymond Lemberg, a psychologist specializing in male eating disorders.

So rather than focus on thinness, boys are more likely to try to bulk up with steroids and protein powders, and through overexercise. But just as parents and professionals should be on the alert for signs of eating disorders among girls, they need to do the same with boys—looking for overconcern about weight and shape, as well as high-risk behaviors such as using steroids.

This development among males is disappointing. When people hope for equality of the sexes, I don’t think that the phenomenon of boys and men grappling with unrealistic body image standards is what they have in mind. 

Fat Talk and Body Dissatisfaction

Have you ever said, “I really shouldn’t eat that dessert”? Have you ever deflected a compliment about your appearance by saying, “Oh, I’m nowhere near as thin as you”? This casual banter can be more harmful than you think.

That’s the conclusion of arecent paper, “Is Fat Talking a Causal Risk Factor for Body Dissatisfaction?” “Fat talking” is an expression used to describe the very common dialogue among women (and some men) about how their bodies compare to others, why they shouldn’t eat what they’re eating, and how fearful they are of gaining weight. For this article,  the authors looked at 23 years of studies that measured fat talking. They were trying to understand the link between fat talk and body dissatisfaction. Is it that people who are dissatisfied with their bodies are more likely to engage in fat talking? Or does engaging in fat talking increase the risk people will be dissatisfied with their body? In that case, if you decreased fat talking, you could decrease body dissatisfaction--a worthy goal, since body dissatisfaction is linked to problems such as eating disorders and low self-esteem.

So what did the results show? Fat talking was most strongly correlated with body dissatisfaction for adolescents and adults, as opposed to for younger children. There was some indication of a cause-and-effect relationship between fat talking and unhappiness with one’s own appearance--that fat talking precedes changes in body dissatisfaction. In the one study that directly assessed this, exposure to others’ fat talking led to an immediate increase in body dissatisfaction. In other words, the more you do things such as compare your eating and exercise habits to other people and the more you evaluate other people’s appearance, the more likely you are to be unhappy with your own body. Now, people might know this intuitively. But the article is still a good motivator to be mindful about fat talking and to be conscious of its possible impact on yourself and others.

Overweight and Underweight: What they have in Common

When people are obese, they are often told by their doctor to diet and lose weight. But when  treated for an eating disorder--whether it’s binge eating, anorexia or bulimia--patients are told not to diet. What is the overweight person who binge eats supposed to do? Abby Ellin writes about this conundrum and of the effort of professionals to incorporate knowledge about eating disorders into treatment for obesity. 

Whether they are underweight or overweight, both groups tend to go back and forth between severely restricting their food intake and overeating or bingeing. The treatment for binge eating is geared towards avoiding dieting, not focusing on weight, and on regularizing eating in order to break the restriction-binge cycle. At the same time, a common approach to obesity has been the diet--focus on calories, portion sizes, weight loss. This makes for mixed messages  for the overweight person who also binge eats. Recent changes in the upcoming Diagnostic and Statistical Manual of Mental Disorders includes the diagnosis of Binge Eating Disorder and will hopefully allow for more common ground in the treatment of eating disorders and obesity, according to Ellin’s article.

So where is the common ground? For both underweight and overweight people with eating disorders, low self esteem and body dissatisfaction is common. Both place excessive emphasis on appearance and body size, says one expert quoted in the article. Both groups also suffer from weight stigma and bias. Shifting the focus away from weight and dieting is helpful treatment for both groups.  “The focus should be on behaviors, not weight,” said Dianne Neumark-Sztainer in the article. She is a professor in the School of Public Health at the University of Minnesota. “We know from our research that talking about weight and diets is not effective, and for many leads to weight gain over time.” 

On a societal level, it would help to reduce weight stigma and to lessen cultural pressure to be thin. On an individual level, it helps to resist checking the number on the scale and to focus on changing individual behaviors:eating regularly, learning to respond to feelings of hunger and fullness, and coming up with non-food-related strategies to cope with troubling emotions will help.

Male Anorexia

“20% of Anorexics are Men” is the to-the-point title of an article in the September issue of GQ, which profiles male anorexics and highlights some of their difficulties. Some takeaways:

• The number of male anorexics is rising quickly. One contribution may be the increased focus on hard-to-attain physical attributes like the six-pack

• Risk factors include being overweight as a youth and getting teased for it; a family history of eating disorders or obesity; being gay; and having participated in a sport that emphasizes speed or weight control (distance running, wrestling, etc.).

• Anorexia has the highest mortality rate of any mental illness--between 5 and 10 percent--a result of both suicide and health complications. It lasts longer in men (8 years) than women, in part because men are likely to wait longer to get treated.

• Even with recovery, there are likely to be health complications which can affect life expectancy. The prolonged deprivation can weaken the heart muscles, the bones, and cause cognitive damage which may lead to medical issues long after treatment is completed.

The photos that accompany the article are arresting and disturbing, as are the sad stories of the suffering men profiled. Included are one man on the verge of death, so emaciated that the fat from the pads on his ear that seal his Eustachian tube is gone, leading him to hear a constant rushing of air; and a subclinical anorexic, whose weight is low but not dangerously so, but who tightly controls his exercise and food intake so as to maintain it. What is striking in all of these stories is the amount of focus and energy on food and exercise, and the isolation that accompanies it. Either because of the time and energy devoted to losing or maintaining weight or the need to hide the extent of restriction from others, the men profiled appear lonely, virtually friendless and withdrawn from others. It is truly a sad and moving article.

Technology and Eating Disorders

Technology has changed our lives in ways that we don’t often think about. Remember when the only way to look something up was in a book? Or the only way to access the Internet was on a desktop computer? Now we have uninterrupted access to information that’s always easy to seek out -- even when it may not be good for us.

Information access, for example, is not always such a good thing when it comes to eating disorders. In a recent article at Thefix.com, a website covering addiction and recovery, a colleague, Diana Freed, discusses how technology can be detrimental to people with eating disorders. She describes working with a 24 year-old woman who constantly checks her iPhone -- a phone loaded with apps that count calories, record her weight, and track her body mass index and body fat. Though the patient severely restricts her own food intake, she has also downloaded onto her iPhone recipe apps that she can look at and think about. In other words, at the same time she is seeking treatment to help her alter her preoccupation with weight and food, technology makes it easier for her to constantly retrieve images and information fueling the very impulses she is seeking to change.

Freed’s article raises an array of technology-related issues that I need to consider in my work. It’s important to know how much time a patient is spending on the Internet or engaging in social media, and what he or she believes to be getting from those experiences. Does using a certain app make you feel worse about yourself? Or are there apps you can use in the service of recovery? These are just two of the questions about technology that I and other psychologists must now explore.

Mindful Eating

On the same day that The New York Times published a front-page story about the latest trends in multi-tasking (think multiple computer screens), the newspaper also ran an article about the benefits of something that is almost exactly the opposite of multi-tasking: mindful eating.

Based in Buddhism, mindful eating is the practice of attending closely to how the senses are engaged when one has a meal. When one mindfully eats, one is focusing on nothing but the food. There’s no reading the newspaper, no watching TV -- not even any conversation at the table.

Mindfulness offers a take on food different from the more common view of “good” and “bad” foods. Instead of avoiding a certain food because it’s “bad” to eat too much of it, you slow down the experience of eating the food. You savor it, think about it -- try to really taste it. Mindful eating is a surprisingly challenging thing to do, since we have so many distractions at mealtimes and we’re so used to using food itself to distract ourselves from what we’re feeling, both emotionally and physically. Mindful eating is widely used in treating people with eating disorders because so much of that disordered behavior is about consuming food, not tasting it.

Mindful eating is a difficult practice to master; even the experts quoted can’t do it all the time. But even thinking about the concept and trying it can help us. Compare the difference between really looking, smelling and tasting a piece of chocolate and then just popping it into your mouth without paying attention. It can be a completely different and more pleasurable experience when you taste the chocolatey taste and feel the melting texture of the chocolate. You may find that you feel satisfied with less, and enjoy what you have eaten more.

Recovery from an Eating Disorder

How do you know when you’ve recovered from an eating disorder? The answer is not so simple. The challenge of determining whether someone no longer has an illness such as anorexia or bulimia was explored in a recent New York Times article, “In Fighting Anorexia, Recovery is Elusive” by Abby Ellin. Often — and certainly by insurance companies — recovery is measured simply in terms of a physical condition: restoration of normal-range body weight and, in the case of women, menstruation. But eating disorders are more than just physical symptoms; they’re also a complex mix of sufferers’ thoughts and behaviors. People with anorexia or bulimia can reach a normal body weight yet still have the traits of someone with the disorder: They remain preoccupied with what they eat, restrict certain foods, and have severe body image problems.

Can someone whose weight is stable but who retains these other thoughts and behaviors really be considered fully recovered? I don’t think so. In the wake of the article’s publication, some eating-disorder professionals have commented that they felt the story’s tone was overly negative, leading to the impression that recovery from eating disorders is not possible. Some described patients as reacting to the article with a feeling of hopelessness. Others found it reasonable to anticipate the possibility of a return of eating disorder symptoms during a time of high stress. They agree with the comments of a doctor quoted in the article, Daniel Le Grange, who says he tells patients, “This is your Achilles’ heel.”

I myself did not find the article especially discouraging. When people leave a treatment for any kind of disorder, they often want to believe that they are done with the problem. They feel that any kind of recurrence or a return to therapy is a mark of failure. I disagree. It’s realistic to understand that in times of stress, people tend to fall back on old habits and coping strategies. The depressed person may be vulnerable to a recurrence of depression; the anxious person to a recurrence of anxiety symptoms. Similarly, people with a history of an eating disorder may find themselves returning to their old practice of restricting their calorie intake. But this does nothing to discount the value of all the intervening time in which they lived without their eating disorder. Anticipating a return to old habits, and using it as a signal for intervention, can be helpful and protective.

How Not to Talk About your Child's Weight

This week, Michelle Obama, trying to promote efforts to combat obesity, described taking her kids to the pediatrician and being told that they were overweight. She also mentioned that President Obama had referred to one of their daughters as “chubby.” These remarks caused consternation among eating disorders professionals, because of their apparent overemphasis on weight and dieting, rather than on healthy eating and health in general. Too often, when people talk about the obesity epidemic, it sounds like an attack on the overweight.

There are better ways to promote healthful eating than to call a youngster “chubby.” Those who treat eating disorders strive to help their patients move away from dieting and strict rules about good and bad foods. They aim to help their patients be less rigidly focused on a number and a weight and instead aim for healthy behaviors. One of the challenges in treating people with eating disorders is when the culture at large supports exactly the same attitudes that get in the way of fighting an eating disorder. In this link, Laura Collins, the executive director of FEAST (Families Empowered and Supporting Treatment of Eating Disorders), writes about how some of the First Lady’s comments sound in the eating disorders world. In a later post, she also mentions speaking to a member of the First Lady’s staff and explaining these issues. It will be interesting to see if this will have any effect on the way Michelle Obama talks about her daughters’ eating habits in the future.