Friday, November 13, 2015

Analyzing Healthy Eating vs. Eating Disorders (including Orthorexia), and The Need to Get Out

Whoa long title... but lot's to follow up on in regard to my last post.

Among all the lovely comments, emails and replies to the anorexia post (btw, thank you!), a couple stood out, which makes me want to dive deeper into this very important conversation. Basically the jist of those comments was, "But, Tawnee, it is OK to 'fear' today's food, ingredients and restaurants!"

The folks who said this, folks whom I highly respect for the record, suggested that it's better to prepare your own food (aka cook at home), be seriously skeptical of the restaurant industry and what really goes on in their kitchens (especially in the U.S.), and find ways to socialize or go on dates that don't center around food and dining out.

Valid points.

However, I said, "Yeah, but it's different if you've had an eating disorder (ED). In fact, it's really complicated...."

Letting Go of Control and Loneliness
For one, I've had to work my ass off to overcome some serious fears over food, control issues with food, body dysmorphia, and self-imposed social isolation. When you're suffering from an ED, you are lonely--extremely lonely no matter how many people love you and how many friends you have. And loneliness is not fun. In fact, the latest NBT podcast with Dr. Bryan Walsh explains how loneliness has very negative impact on gut health and overall health. I had to step up and stop isolating myself. There where times where I'd go hide in my car at SDSU (while it was parked in a hot parking structure) to eat my "lunch" for fear of people seeing what I actually ate, and what they may think of me. Those were sad times. I've had to overcome anxiety eating in groups (even with family!), anxiety over dining out, and anxiety over what my body looks like to the world. Thus, it is incredibly important that I continue to GET OUT and make sure I don't get "stuck" in my safe place at home, eating my "safe" meals. Not only physically get out the door to sit at a restaurant but also build up the comfort and confidence to enjoy the company of others--and not feel isolated but rather feel engaged, connected and truly part of a group. (And this isn't just specific to those with ED's either; think about how often we're lonely when we're around others; in or cubicle or social media are good examples too....)

Not to mention I love the experiences and life-lasting memories that often come from dining out--even at the risk of a few less-than-perfect ingredients. John and I have had some amazing times, amazing meals, and guess what? I survived, and he and I thrive as a couple. Plus, since 80 to 90 percent of the time I am cooking at home and eat an incredibly clean diet (even when we travel we do VRBO to get places with kitchens so that we can home-cook some of our meals) I think that extra 10 to 20 percent of the time I'm perfectly ok stepping outside into the world and take risks--and so are you.

My risks don't include "extreme eating" like sketchy hole-in-the-wall buffets, questionable hot dog stands, Outback Steakhouse-type fare or fast-food joints, etc. Hell no! I'll sit out on eating truly bad stuff, and/or go there to be social but not eat--then before (or after) eat something better quality. When we dine out, I am usually very conscious of choosing good restaurants, for health reasons above all--not for the need to control/restrict calories or lose weight. Ok maybe I am too conscious at times of searching for "the perfect" restaurants (getting a little obsessed with Yelp), but I truly care about fueling my body with the best quality foods possible--organic produce, free-range/grass-fed meats, wild fish, healthy fats, locally sourced fare, etc. Especially since I have knowledge (maybe too much knowledge) on nutrition and today's food supply--it is a scary world out there if you're not careful--and because I want to fuel for performance in sport and life. I'm the first to agree, and recommend, that we should give a lot of thought and concern into the the quality of food we eat, the restaurants we choose, and the meals we cook at home.

Happy times at a random restaurant in DC...
...trying creamy, buttery escargot--worry free!

New-Age Eating Disorders
This begs the question.... what's the healthiest approach? Does it always have to be about adhering to the best-quality ingredients, or should we let go more often--let go of the associated stress that comes with seeking perfect food--and be more free and go-with-the-flow. If you get too wrapped up in always trying to eat a perfect, pure, healthy diet, you go down a scary road--one that's lonely and isolated--and risk developing a new-age eating disorder known as orthorexia, the obsession with eating healthy food to the point where it disrupts your life, behavior and happiness.

I've thought about it in my own case: Has my ED past manifested into some form of orthorexia? Are my aforementioned friends who told me I should fear the food and only cook at home also orthorexics? (They both work in the functional health field, after all.) There's plenty of reason to believe, as you'll see below, why a former anorexic could easily fall become orthorexic. I don't want to think that's the case with me... and I'll argue why I don't think I'm orthorexic. But at the same time I don't think you'll ever catch me eating McDonald's or even the salad at Chuck E Cheese's, ever.

So now to the meat of the post. I've got some 'splaining to do. 

Breaking it Down
Gets confusing though, right? You're telling me. There are multiple situations going on, and they can't be lumped together. What the former anorexic feels--often irrational fears--is very different than what a non-pathological human feels when going to a restaurant with intent to eat healthy--which is different but similar to the orthorexic. Thus, my friends who promote cooking at home have a fair, valid point, but they have to understand there are reasons why I choose to eat out that are more important to me than ingredients alone. Below I'll attempt to distinguish the differences among the types of people we're talking about:

Person 1: 
Those who strive to eat quality/healthy food but are flexible with no disorder

Person 2: 
Those who've suffered from an eating disorder such as 
anorexia nervosa ("AN") and/or bulimia nervosa ("BN")

Person 3: 
Those who've developed Orthorexia Nervosa ("ON") by taking healthy eating too far

Person 4: 
Those who are all or some of the above

It could be a good practice to find out where you fall on the spectrum in your quest to develop a healthy relationship with food, your body, your mind, and stress levels--and to avoid any loneliness or isolation caused by fear over food.

Person 1Health-Conscious but Non-Pathological 
This is the person who seeks healthy food and clean ingredients for smart reasons, with no underlying pathology. Their reasoning to eat healthy may include achieving and maintaining good health status, avoiding harmful substances (i.e. pesticides, GMOs, chemicals, additives, hormones, etc), disease prevention, and building a well-functioning body that's not overloaded with sugar, gluten and other disruptive forms of food. Or it's the person who wants to eat healthy and clean as part of their health and fitness routine--perhaps they're in high training mode and need/want to feel their best, or they achieved great weight loss and don't want a setback. Or it's the person who's doing it for more ethical and moral reasons. With the increase of documentaries, books and articles exposing what really goes on behind the scenes in the food industry--from poor treatment of animals to GMO crops--some folks will not support these poor practices and avoid conventional foods for better alternatives--they consciously seek labels that say "organic" or "free range" or "grass-fed" (hint: labeling something "natural" doesn't count--that term is total BS with no governing regulations). Person 1 may develop a sense of pride in choosing quality over the "evil"' stuff, as well as realize how much better quality food in terms of its nutrient density, nourishing properties and superior taste*. Or maybe Person 1 doesn't even care so much about health-food per se, but simply realizes that junk food and empty calories make her feel like crap--and she chooses not to feel like crap.

That said, Person 1 is not overly obsessed with only eating healthy, quality, pure food. She likely has no pathological condition surrounding food or her body and its size/shape. She allows for balance--realizing we can't all be perfect--and sometimes living life means the occasional situation where the food may not be the best, so she adapts, doesn't freak out and understands that the 80-20 rule (or some variation) will ensure she'll be okay. For example, she's flexible and willing to eat most things at holiday gatherings or parties, she can find something to eat at most restaurants or during travel without any food-related stress, she's okay having the occasional "conventional" piece of birthday cake or pizza. Person 1 has good intentions to eat well, but realizes we can't be perfect so we can just do our best, and the idea or reality of a "bad" meal or "bad" day of eating won't shatter her world or have lasting psychological implications like anxiety, fear, doubt, and obsessive thoughts.

Bottom line, she's not eating the Standard America Diet ("SAD") by any means, and rather is much healthier and making conscious decisions for clean, quality food the majority of the time, but she is flexible and doesn't see food, or control over food, as a source of stress.

Btw: I think my fiance, John, is person 1, and I admire him. He definitely makes efforts to eat as healthy as possible but realizes it'll never be perfect, so he doesn't stress it and instead lives a balanced, happy life and goes with the flow. Could he be healthier in his meal choices at times, sure. Does he know that? Yes. But at what price? Maybe more stress that then makes him less healthy?


Person 2: Healthy-Eating-Turned-Orthorexia
For argument sake, let's assume Person 2 does not have a history of an eating disorder nor a per-existing condition. It started out innocently enough: She got on a health kick, liked how it felt, saw results, and even liked how it felt to be part of an "elite" community of fellow healthy-eaters. She spent free time reading/following blogs and websites on nutrition, clean eating and healthy recipes. She started obsessing more over "pure" eating, eliminating anything that was not deemed healthy, and even letting her obsession with healthy food cut into her social life by declining invites if she knew there's be unhealthy options. She'd get angry if she couldn't stick to her healthy routine, fussy if ingredients weren't up to par. It snowballed, and healthy eating went too far turning into the latest of eating disorders: orthorexia.

Orthorexia was coined by Steven Bratman, MD, in 1996 and literally means "the fixation on righteous eating." Although it's not listed as a disorder in the DSM-5, it is an increasingly growing REAL eating disorder in today's population, and happens when people who let a once-innocent desire to eat clean, quality, and pure go too far. The quest for quality food dominates their life. How does it differ from healthy eating? According to Dr. Bratman, "healthy eating is a conscious choice. Orthorexia is an obsession with healthy food that involves other emotional factors and has become psychologically and perhaps even physically unhealthy. It is an eating disorder."

I can certainly see this being the case for many athletes, especially endurance athletes, who are very in tune with their bodies and very particular about the food they allow in order to look and perform a certain way. In fact it took two seconds to find research validating that theory. On one hand, I think it's fair for an athlete to be strict with diet--or any human, it doesn't have to be athlete--but how do you know that strict approach has gone too far?

When it invades your life and "creates psychological distress and impairs various life dimensions, but does not present a physical danger," says Dr. Bratman (who recovered from orthorexia). Dr. Bratman was also quoted on saying, “I pursued wellness through healthy eating for years, but gradually I began to sense that something was going wrong. The poetry of my life was disappearing. My ability to carry on normal conversations was hindered by intrusive thoughts of food. The need to obtain meals free of meat, fat, and artificial chemicals had put nearly all social forms of eating beyond my reach. I was lonely and obsessed. … I found it terribly difficult to free myself. I had been seduced by righteous eating. The problem of my life's meaning had been transferred inexorably to food, and I could not reclaim it.”

Still, there are some who think it's silly that healthy eating could be considered a terrible thing, but in my eyes--as someone who's lived through an ED--I don't think it's too silly at all. Those addictions and obsessions can go too far, I think. However, I would NOT consider ON on the level of AN or BN.... I just wouldn't...

More on healthy eating vs. ON - and don't be a "wannabe orthorexic."
Here's a test used to assess ON
Here's a critical look at ON.


Person 3: The Recovered ED
I don't want to take the space here to define an ED other than they are mental disorders, often life-threatening; read more here. What I do want to distinguish is the difference between ON and other EDs: AN/BN are more related more to the quantity of food, while ON is more about quality. AN/BN patients seek an ideal body image, while ONs seek a pure body. Usually there are strong biological roots in AN/BN cases (my story supports this), whereas I would argue that ON may be more of a phenomenon of our modern world (and the person with the "right" traits falls victim). ON often has roots in obsession to look good and fit in, including on social media--AN/BN not so much. Not too many ANs want to post full-body selfies. Instead, AN/BN often reach a level where they knowingly don't take care of their bodies--they realize the harm but still continue on. TO complicate it further, as you will read in Person 4, it seems that these days the lines are often blurred between ON and AN/BN.

So for the Recovered ED (aka Recovered AN/BN), it's complicated... there are stages to get through. Let's assume we're talking about someone in a maintenance and relapse-prevention stage, or beyond. Whether you finished rehab yesterday or 20 years ago, it doesn't just shrivel up and die as soon as treatment is over. If you've never experienced an ED don't assume that this illness can be expelled from the mind and body once and for all.

There's a lot of shit that can still surface, those unwelcome inner "demons" that rear their ugly heads:

1) Sometimes food choices may or may not not have pure intentions about healthy, clean eating. Perhaps eating healthy is just another manifestation of restriction or quantity control. Research supports that some Recovered ED's still have a strong urge to control food, ingredients and/or weight even in the management post-ED phases, and healthy eating or having dietary restrictions (i.e. vegan, gluten free) is the perfect excuse; for more see Person 4.

2) Maybe exercise addiction is still present along with body dysmorphia and the need to control weight. The Recovered ED may be a normal weight but inside feels strong impulses to keep strict control over bodyweight, fears getting fat, and maybe even feels fat or obese even if that's not the case. An "easy solution" is to take up a sport that requires a lot of training, or some highly-regimented fitness routine. There's a bit of comfort found in the calories-in, calories-out equation.

3) Speaking of punishment, it's hard for the Recovered ED  to let go of feelings of guilt and self-hate. For example, say she over-indulged--not binged--but simply enjoyed eating whatever food was present and let go of that damn voice telling her to control. It felt so good for a second--free and liberating--but then... then the guilt set in. The desire for self-punishment and future restrictions started brewing... 

4) Or, there is some presence of obsessions, the need for control, and anxiety issues. There are still "pizza stories" that pop up. Perhaps these obsessions manifest into a new issue. Enter Person 4.

I could go on... keep in mind I'm highlighting the problematic behavior for a Recovered ED (for the purpose of this post) not the positive gains they've made. Whatever the problem is, it's all about self-management and belief in one's self that they are better than the ED.


Person 4: The Recovered-ED-Turned-Othrorexic
Yikes. Person 4 is not just someone I made up, there is strong evidence in the research of this being and actual person. This study, for example, had a small sample size, but it showed how "easy" it is to develop ON if there's a history of AN or BN. ON symptoms are highly prevalent among patients with, or recovering from, AN and BN. ON tends to increase after treatment of and improvement from AN/BN--it's migration toward a "less severe" form of an ED.

I see how this can be. Coming off AN/BN it seems very logical that one would develop a new obsession for eating healthy--the obsession for quality, to some degree, replaces an obsession over quantity. Let's assume that she even lets go of obsessing over weight loss and calorie control. Now the obsessions are about organic, gluten-free, chemical-free, etc--all those distinguishing variables I listed with Person 1 (oh, Person 1, it was so simple then lol). Again, seems innocent enough, right? But not so fast...

Since there are biological roots in someone who develops AN/BN, the new ON obsessions may trigger the same old anxiety or irrational fears over food, and bring back the same old habits, rituals and tricks. More and more food is "off the table" for being considered edible, dining out once again becomes a problem (god forbid eating non-organic), there's more secrecy and seclusion surrounding food. The fun is taking out of food, anxiety comes back, and the quest for healthy food is no longer pure. All of a sudden it appears a worse relapse may be occurring: social isolation, psychological disturbance and even treating the body maliciously again.

Perhaps even the desire to control weight and calories comes back. Dr. Bratman says there are "covert anorexics" who use healthy food as an excuse for low calorie. Even the diagnosis of "anorexia" now includes one's desire to eat healthy food--not just restriction. Equally confusing, there's research to support that some orthorexics start to take on AN/BN behaviors like binge/purge or severe restriction and weight loss obsessions. It gets to a point where you have to question what really is going on here? What's the diagnosis?! It's complicated!

"Today, the majority of people with orthorexia may best described as having orthorexia with anorexic features, and a large percentage of those with anorexia as having anorexia with orthorexic features," says Bratman.


Final Thoughts
I can't help but think about where I fall.... I wish I was Person 1. I'm not quite there. I'm likely some hybrid of a Recovered ED with ON tendencies--but I certainly don't consider myself to be ON. If I weren't careful, I probably could go down that road. I won't go down that road. I don't want to be lonely and isolated due to food ever again. So I have to be proactive. How so? Keep it real. Go outside my comfort zone. Face situations that will allow me to toughen up and manage it. I don't like going out of my way to introduce stress (like the pizza episode), but sometimes risking a little potential stress up front ends up saving a lot of big stress down the line--and could even promote better health going back to the Bryan Walsh/NBT podcast. It's the same with sport, the podcast, entrepreneurship, even backpacking--none of these things are "easy" and there are definitely associated stresses and fears at times, but that doesn't mean I hide from them by quitting or getting a "safe" desk job instead. I step up to the challenge--and I also become a part of some great communities as a result, making life-long friends and lasting relationships in the process. Just look at lucho and I--he's my BFF! All because I got over myself and public speaking fear to do the podcast AND bring on a co-host who at first intimidated me due to his amazing race resume/reputation.

So with food, hell yea, I will proudly eat healthy and clean, and hell yea, there are still certain unhealthy foods that I'll absolutely refuse to eat for health reasons. But I'm equally set on branching out and maintaining balance and quality relationships--let me say that again QUALITY RELATIONSHIPS. I do my best to maintain an open mind and a flexible approach and attitude. I don't want to go down a path of stress, isolation, loneliness and misery just because of food... 
Sometimes that means facing those very stressors to stand up to them, and sometimes I have to fight really hard to overcome the old demons. But I got it. I can and will stay strong. Attitude prevails.

ED or not, maybe we can all take this as a lesson to ease up a bit... don't always stress... think deeply if you are feeling lonely or isolated (for food reasons or otherwise), and know that we won't be perfect, but there are tools to have a damn fulfilling, fun life--pizza included.

What do you think: 
How far should we take our healthy habits? How far is too far?
Have you ever felt lonely or isolated because of your eating habits/dietary needs?


  1. I think I have a "righteous fixation" on all of it. The diet, getting enough sleep, appropriate training, stress reduction and management. After 35 years of not giving a fig and feeling like crap I'm pretty much OK with that label. Righteous makes me feel good!

    Great article though, thank you for being so honest.

    1. This comment has been removed by the author.

    2. Chris,

      Thanks for your comment! You and I are both so passionate about helping others find good health through nutrition and lifestyle--so passionate that we've centered our careers around it!

      We each bring such a different background to this situation--you not giving a crap for 35 years, and me giving too much of a crap! Now we're at a point where we each share a similar philosophy on what goes into good, healthy living. In your case, I think it's incredible that you've turned around poor diet habits and are now so dedicated to clean eating--and a righteous fixation is totally fair and appropriate! I've worked with plenty of athletes who are similar to you--they too come from a background of generally poor eating habits and can certainly afford to clean it up, eat out less, plus implement all the other lifestyle tweaks.

      Even with our different backgrounds, look where we are now--great friends, colleagues, health geeks, etc., and it's safe to say I think we generally agree on what goes into achieving optimal health, wellness and performance--for ourselves and our clients. We have the right tools for success (and we each built up that "toolbox" for different reasons to some degree). Powerful stuff. I believe what we promote can and WILL work for others. Meanwhile, we can't ignore that each of us has our own unique journey, and unique needs, which brings me to....

      Hopefully all of us can now understand, even more, the importance of individualization for each case! Additionally, the importance of the mind and psychology of it all... We all bring something unique to the table, and the practitioner/coach needs to take the time to dig into the mind--not just food logs and lab reports, which I know you do having worked with you so closely--and that's how we make progress!

      Thanks again, Chris, I'm glad we're letting this conversation go even deeper!

  2. The fear of gaining weight seems to have a permanent spot in my thinking though my eating is pretty normal. The ideals that seem appropriate in my mind in terms of body shape, weight, appearance, composition need to be challenged and adjusted. This seems to be the issue. Would be nice to be able to let it all go.

  3. A friend sent this to me via email and I thought it'd be good to add to comments:

    I think you have a person 5 - people with food allergies (like peanut, which can be life-threatening) or conditions like celiac or even severe gluten intolerance. The issues of not knowing what you’re getting to eat unless you make it yourself, and the risk of cross-contamination, make eating out a nerve-wracking and frightening experience. I’ve been served gluten-containing items at restaurants that had been fine on other visits and where the owner/manager touted it being safe because he had a sister who was celiac.

    Being afraid isn’t a fun way to live around food - but some of us have reason too. The pain from mistakes - ours or other folks’ - is quite real.