Obsession with healthy eating complicates work with some eating disorder clients

Phrases such as “locally sourced” and “farm to table” have become significant selling points in the food industry. Yet similar concepts can be taken to extremes in a subset of individuals with eating disorders, and this can result in devastating consequences for some patients and families.

The term “orthorexia” is not officially recognized as a disorder in the Diagnostic and Statistical Manual of Mental Disorders, but it has been identified in the eating disorders treatment community since the late 1990s and is treated as an accompanying issue for some patients at Castlewood Treatment Center in St. Louis, says lead eating disorders therapist Katie Thompson. Orthorexia refers to an excessive focus on a righteous relationship with food, Thompson says, which becomes an obsession with procuring and consuming pure, whole foods.

“You see people who to some degree would prefer to grow their own,” says Thompson, who facilitates Castlewood's eating disorder groups. She thinks that possibly around 10% of her program's clients have orthorexia, an issue that she says is more common in patients with anorexia nervosa but that also can be seen in patients with bulimia or an eating disorder not otherwise specified.

These individuals might take hours to accomplish a grocery store visit that for most people would take 30 minutes, as they furiously read labels and aggressively avoid purchasing any foods that they consider toxins. “Everything in their cart will be organic or whole grain,” says Thompson. “The first time they go through our food line, they might say something like, 'That's cooked in butter; I will not eat anything unless it's cooked in grapeseed oil.'”

Thompson adds that it becomes clear that in the most extreme cases, “Something else deeply seated is amiss.”

Harms to self, others

For some of these patients, the obsession with healthy eating eventually becomes physically unhealthy, as they begin to pull needed nutrients out of a diet that is too rigid. “They see all fat as a bad item, and fat is a necessity of the diet,” Thompson says.

She adds that it is easy to see how this behavior can negatively affect others, particularly if the patient is a parent. Thompson herself is an athlete and remains very conscious of what she feeds herself and her children, but she also can visit a street festival on the weekend and be OK with purchasing a hot dog. That would not be possible for a person with orthorexia, who would shield his/her children from anything perceived as unhealthy.

This issue also can create relational challenges in the treatment setting, because these individuals in their perspectives on food can project an air of superiority over others, whom they see as making less informed decisions around food.

Comorbid anxiety disorders are common in the subpopulation with orthorexia, Thompson says. Some of these individuals might feel that while they cannot solve their relationships with others, they can control their relationship with food.

Clinical strategies

Treatment therefore becomes about assisting the patient in creating a new relationship with food and a sense of balance. “We do a lot of work around the beliefs,” says Thompson.

She finds that schema therapy, a technique that integrates elements of cognitive therapy, behavior therapy and other strategies, can be effective in this population. Yet it can be a long road, she says. Some patients with comorbid anxiety might benefit from medication, but some of them might see medications in the same light in which they perceive “toxic” foods, she says.

Thompson says she has not noticed any increase in the prevalence of orthorexia in her patients since the phenomenon was originally described by Steven Bratman, MD, in 1997, but she definitely sees how some individuals with eating disorders can latch on to messages prevalent in today's food-focused society. “Our culture has obsessive pressures on both men and women in terms of what we are expected to feed ourselves and our families,” she says.