What is Orthorexia Nervosa?

Warning Signs Your Obsession With Healthy Eating Has Gone Too Far


K was dedicated to her diet - organic produce, mostly vegan with occasional fish, no alcohol, no added sugar. She was running 60 miles per week and hoped to complete an ultramarathon next year. She had lost a substantial amount of weight and reduced her cholesterol after changing her diet, and she felt like she was nailing nutrition. On the other hand, food consumed most of K's daily thoughts. She spent hours planning what she'd eat and how she would prepare it to make it as healthy as possible. Her period had recently stopped coming regularly. She wasn't much fun at parties, often bringing her own meal with her to others' homes and scheduling her vacations around her eating and running routine. She was afraid to eat cake for her daughter's birthday - "If I eat that once, I know I'm not going to be able to stop," she told me. She had a bite at the party and hastily threw the rest in the trash. She knew athletes need a lot of fuel - she tried to eat more, but always felt full before she finished her meals. She often felt bloated and tired all the time, which she attributed to eating too many carbs.


Friends and family praised K's dedication. "I wish I could be as healthy as you," they'd say. But K was frustrated. She was trying so hard to have a perfect diet, and she still didn't feel good. What's more, she was constantly getting dropped by her training partners in workouts, and she never executed in a race the way she should have. There must be more she could do.


If K's story sounds familiar, keep reading.


Diet and exercise have always gone hand-in-hand. You can't outrun a bad diet, after all. Abs are made in the kitchen. And whatever other catchphrase you've heard.


There's certainly some truth to this. What an athlete eats can affect performance, health, and energy levels throughout training. Nutritional deficiencies can contribute to injuries. Meanwhile, fueling correctly can make a huge difference in training gains and race performances, which means it's not something to be overlooked when it comes to optimizing for your biggest goals.


However, there's always two sides to the coin. Athletes may love to talk about eating virtuously, but just like a lot of "healthy" behaviors, it can spiral into something more sinister. K's diet might look perfect to the casual observer, but was it? Or was her obsession with healthy eating backfiring?


What is Orthorexia Nervosa?


Orthorexia Nervosa is the term for healthy eating that has gone too far - into an obsession with "pure" or "clean" nutrition. The term was coined in 1998, though it's not an official diagnosis in the Diagnostic and Statistical Manual. Unlike other commonly known eating disorders where there is a preoccupation with weight or thinness, those with orthorexia aren't necessarily concerned about weight (although weight loss can occur). Instead, they have an obsession with healthy eating to the point it becomes harmful.


Some of the red flags of an individual with orthorexia nervosa may include:

  1. Cutting out increasing numbers of foods or food groups.

  2. Anxiety around eating things with unknown ingredients or outside of a narrow range of foods

  3. Obsessively checking nutrition or ingredient labels.

  4. Preoccupation with the impact of individual foods or food groups on health outcomes

  5. Avoidance of social situations where there is a lack of control over foods served and preparation of foods.

  6. Desire for control over food preparation and ingredients.

  7. Linking of self-esteem to adherence to "clean" or "pure" diet and/or judgement of others who do not adhere to the same dietary restrictions

  8. Spending an unusual amount of time thinking about and preparing for meals relative to daily life.

  9. Increasing reliance on supplements.

  10. Rigid food rules (i.e., no eating after 8 pm, no added sugars, no white foods, no drive-throughs, no snacking in between meals, must have a vegetable at every meal, etc)

Now, you may be reading that list and thinking to yourself, "that's just what life looks like for a dedicated athlete!" And it's true that not every athlete who eats salads and uses a supplement has an eating disorder! However, dedication can also be a slippery slope into obsession. Orthorexia Nervosa can develop when these types of behaviors become more of a compulsion than a choice.


The Danger of "Eating Clean"


Ironically, this fixation on "health" can actually leading to negative health consequences. The nutritional quality of one's diet can be compromised by cutting out too many foods, leading to weight loss and symptoms of malnutrition.


A restrictive diet can also lead to Relative Energy Deficiency in Sport (RED-S), which is comprised of a constellation of symptoms ranging from increased anxiety and difficulty sleeping to a missing menstrual cycle, compromised bone health, digestive issues and cardiovascular dysfunction. This arises when athletes' fuel intake is not adequate to keep up with the demands of training, causing a chronic energy deficit. If you think you may have symptoms of RED-S, consider talking with a sports medicine doctor or a dietitian who works with athletes to navigate the recovery process.


Orthorexia Nervosa can also have a severe impact on athletes' mental health as anxiety around unknown ingredients and perceived health concerns escalates. Inadequate nutrition also triggers the body's stress response, which can lead to heightened anxiety. Individuals who are under-fueled can have difficulty sleeping and feel on edge all the time. Challenging situations like eating at a restaurant or going to dinner at a friend's house can be overwhelming. An individual with orthorexia may find excuses to avoid eating with others, skip social occasions where food is involved, or try to plan his or her meals and exercise obsessively while traveling away from home.


Separating Wellness Fads From Science


Our culture's interest in wellness, from organic foods to pricey supplements, buoys this type of attitude. There are many influencers, professional athletes, and celebrities selling so-called "cures" for a variety of ailments, encouraging people to cut out gluten for hormonal health, or avoid conventional produce because of pesticides. Many of these individuals look the part, using their chiseled abs and weight loss before-and-after shots to sell their products and their advice. But just because something worked for one person doesn't mean it will work for others. Furthermore, what is shown on social media is rarely the full story. Someone may promote their diet while leaving out their recent string of injuries or that their period is missing. They might show their salads and smoothie bowls but not photograph their late-night McDonald's run or weekend binge routine for their "what I eat in a day" posts. You can't tell how healthy someone is by looking at them, so treat these posts with extreme skepticism, and get your advice from qualified individuals who don't use their body or their race times to sell a product.


Media outlets, meanwhile, often cover nutrition research in clickbait-style headlines that grab attention but fall short on accuracy. In reality, nutrition is a notoriously difficult field of research. It's hard to pinpoint the impact of a specific nutrient or food on a health outcome, not only because chronic illnesses tend to have many underlying variables affecting them (including big ones like socioeconomic status, availability of preventative medical care, and health literacy) but also because it's nearly impossible to accurately calculate the nutritional intakes of subjects in a free-living environment. People also don't eat nutrients - we eat food. There are multiple nutritional components in every food, which leads to confounding variables in research. The reality is that as far as we know, unless you have a food allergy, there is not evidence to link any specific health outcome to consuming or avoiding a specific food. For example, there are links between consuming red meat and cancer (there is not evidence that red meat consumption causes cancer). You're not guaranteed a cancer-free life if you cut out red meat, and you're not guaranteed a cancer diagnosis if you eat it. Red meat is an important source of protein, zinc, and iron (a nutrient which many endurance athletes need to consume!) and there are also negative health outcomes associated with consuming too little of those nutrients.


A Better Way


The best thing most athletes can do for their nutrition is to maintain a focus on balance. It's not realistic to cut out so many food groups, and it can be expensive, isolating, and frustrating to try to do so. Yes, fruits and vegetables are rich in nutrients, but all foods have nutritional benefits. Separating food choices from morality (i.e., thinking of yourself as "better" or "worse" depending on what you eat) and specific health outcomes is important to moving past disordered tendencies. I encourage the athletes I work with to include plenty of foods that contribute to nutritional adequacy and also enjoy the foods that they love.


Food should enhance life, bringing enjoyment and allowing athletes to perform better through adequate fueling. If food is consuming your thoughts and causing anxiety, it's time to think about getting help. An eating disorder therapist or a dietitian who works with RED-S clients or eating disorders and understands athletes (like me!) is a good place to start.


It's possible to overcome Orthorexia Nervosa (and subclinical disordered eating habits) with patience and commitment. And you'll probably find that your training and performance improves the more foods you let back into your life.



References:

  1. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia

  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370446/

  3. https://www.eatingdisorderhope.com/information/what-is-orthorexia-nervosa

  4. https://bjsm.bmj.com/content/51/21/1570

  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228817/#:~:text=Nutrition%20research%20conducted%20to%20examine,that%20are%20largely%20self%2Dreported.


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