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Eating Too ‘Clean’ Can Kill You

“Orthorexia,” the eating disorder when people fixate on healthy eating, is moving toward recognition in mainstream medicine

It’s impossible to read Amanda Chantal Bacon’s daily food diary, published in Elle last year, without wondering if, perhaps, the entrepreneur behind L.A.’s Moon Juice brand is taking her passion for healthy eating a bit too far. The day begins with “a copper cup of silver needle and calendula tea,” before she prepares her “morning chi drink” to slurp while driving her son Rohan to school — full of vanilla mushroom proteins, stone-ground almond butter, Brain Dust (a Moon Juice product), “cordyceps, reishi, maca and Shilajit resin,” with some ho shou wu and pearl added for good measure, followed by “three quinton shots for mineralization and two lipospheric vitamin B-complex packets for energy.” And as the day goes on, the meals and their ingredients mount in absurdity: “activated cashews,” mint chip hemp milk, and Chaga mushrooms. For a pre-bedtime snack: raw cacao and chia pudding.

As a lifestyle entrepreneur, Bacon’s job is to make this routine seem aspirational, yet practical and purposeful. The photos that accompany her diary show green juices piled in her lap as she drives her BMW, steering with the few fingers that aren’t wrapped around a smoothie. In a portrait, she’s radiating health, beauty and privilege.

But such effortlessness obscures both the expense and the emotional stress many feel while attempting to maintain a perfectly healthy diet (that is, however they may be defining healthy at the time). What’s not included in this diary — or in general, the wider world of health and fitness blogging — is a look at how someone on such a specific regime might fall to pieces when they “reach for coconut yogurt with cardamom, dried figs, walnuts, and apricots from a weekend farm visit” (as Bacon does in the afternoons) only to find the container empty and the only option a cheeseburger from Postmates. Or how they might survive when venturing out of their rarified bubbles of perfect eating into parts of the world where the only cacao comes in a Hershey’s wrapper, and control over eating must be turned over to the “toxin”-filled pantry of a Midwestern aunt.

“People look at following [healthful diets] as if they are eating virtuously, as if they could get to heaven through making all the right food decisions,” says a spokesperson for the National Eating Disorders Association (NEDA). Furthermore, when these eaters violate their food virtues, they can become anxious, depressed or socially withdrawn — resorting to fasting or cleansing to purify themselves.

If your answer is yes to questions like, “Does it seem beyond your ability to eat a meal prepared with love by someone else — one single meal — and not try to control what is served?” or “Do you ever wish you could spend less time on food and more time living and loving?” then, according to NEDA, it’s possible you might have a form of disordered eating called “orthorexia” — an obsessive focus on healthy eating, that for some people can even be fatal.

The term orthorexia was coined in 1997 by holistic doctor Steven Bratman, and though it has not yet been added to the DSM-5 (the medical world’s official handbook of treatable ailments), a recent paper by Bratman outlining more specific diagnostic criteria is nudging it along in that direction. In the meantime, the unofficial condition has gained increasing visibility over the past two decades as health food has gone mainstream, as eating disorder specialists have attempted to help patients whose symptoms don’t neatly align with anorexia or bulimia, and as researchers have studied what happens to people fixating on diets that suggest cutting out specific foods (whether it’s veganism, paleo, locavorism or something even more niche).

“Whereas the bulimic and anorexic focus on the quantity of food, the orthorexic fixates on its quality,” Bratman wrote in the Yoga Journal essay that introduced the term to world (and became a sort of cult classic in the world of eating disorder research). As he told MEL in December, “Once you start restricting food, for some people, that’s like taking a drug. It just gets under their skin.” Those include the quietly suffering as well as public figures who have spoken up. Jordan Younger, a prominent vegan blogger, gave up that diet after her obsessive eating “almost killed her,” as the Today Show reported. In December, a British TV show host named Carrie Armonstrong revealed that her fixation with raw food (as a means to recover from a virus) made her hair fall out, teeth deteriorate and weight plunge 60 pounds.

Though those more prominent orthorexics share a demographic profile (white, female, professional), Bratman says orthorexia could happen to anyone. “You don’t have to be privileged. You don’t have to be upper middle class.” And you don’t have to be a woman. In 2011, doctors in Korea wrote about treating a 30-year-old man who restricted his daily intake to a few spoonfuls of brown rice and fresh vegetables to treat a health problem caused by a tick bite, and ended up in the hospital for 38 days. Last year, American doctors described the case of a 28-year-old male who mostly ate protein shakes for three years to preserve his body’s status as a “temple” — and ended up severely undernourished at 50 percent of his ideal body weight.

Bratman noticed his own orthorexic tendencies while living as a raw vegan on an organic commune in the late 1970s, where his life began to revolve almost entirely around preparing meals, where people who didn’t subscribe to such “pure” diets were shunned. Working as an alternative medicine practitioner in Colorado in the 1990s, he routinely saw patients developing orthorexic traits as well — like extreme disappointment if they ate the “wrong” thing — often because they wanted to heal medical conditions through diet. “An orthorexic will be plunged into gloom by eating a hot dog, even if his team has just won the World Series,” he wrote in his Yoga Journal essay.

Since Bratman first described the phenomenon, he’s noticed obsessive healthy eating move beyond macrobiotic, raw-vegan and other niche circles, into the mainstream. Today, a hot body, whether it’s Jessica Alba’s or Matthew McConaughey’s, is a fit, healthy body: green-juicing, farmers’-market nourished, full of lean muscle, and probably great at yoga. “There has been an interesting migration of the word fit, which originally meant that you could walk up and down lots of flights of stairs without getting out of breath,” Bratman says. These days, however, it “means more about appearance than a functional thing.” Fasting, cleansing, bulking, detoxing and taking supplements are a routine part of many people’s lifestyles who may become obsessively focused on health or fitness, beauty or weight loss or some combination of all of the above. For some people, this has to do with getting rid of imaginary toxins and eating purely, as Bratman theorized about the original orthorexics, but for others, it could be, in part, about getting skinny, too, similar to more traditional eating disorders.

“I think [orthorexia and anorexia] are different; I think that they overlap,” Bratman says, summarizing his updated perspective, thanks to new research on the topic. In a paper released in November with psychologist Thomas Dunn, Bratman proposed formal diagnostic criteria for the first time, emphasizing the clinical impairments associated with orthorexia, including malnutrition and “intrapersonal distress” (in addition to the type of compulsive dieting he’s been talking about since the 1990s).

Bratman says there still aren’t any great ways to measure orthorexia, nor is the related diagnosis of “Avoidant/Restrictive Food Intake Disorder” (for people who aren’t interested in eating certain foods or any foods at all) capable of completely capturing the state of being orthorexic. Likewise, traditional treatment programs for disorders like anorexia aren’t necessarily a good fit for treating orthorexia either.

As Bratman’s perspectives on orthorexia have changed, so have his opinions on eating more generally. He no longer practices alternative medicine, discouraged by the paucity of double-blind, peer-reviewed studies that could back-up claims that any specific food could accomplish any specific health goal: “You can take any food you want and come up with a theory where it’s the worst food to eat, and where it’s the best.” And recommending specific eating regimes to patients just seemed irresponsible. “I now feel that focused dietary interventions only help specific health problems in rare situations,” he recently wrote on his website.

While Bratman insists that he’s not anti-health food, he considers it to be more like a fun hobby than a science. Moreover, he has no interest in dedicating his life to mythbusting the kind of cleanses offered by Bacon’s Moon Juice or her competitors because he knows people will just tune him out. “It’s a hopeless argument. People desire to believe that they can eat in such a way to make themselves phenomenally healthier and live longer” — and are more than happy to fork over huge amounts of money to do so.

These days his eating advice is completely minimal, in part, to discourage eaters from getting overly fixated on their diets. “The answer is so boring people don’t accept it: Get enough food. Don’t eat too much.”

That’s it?

“Yeah. That’s it.”