A new eating disorder is getting noticed by healthcare providers. Orthorexia refers to an obsession with proper or healthful eating. People with orthorexia become so fixated on healthy eating that they actually do damage to their own well-being.

Orthorexia is not formally recognized in the Diagnostic and Statistical Manual, but awareness is growing.

Dr. Amy Littlefield educates us on orthorexia. She’s a naturopathic physician and acupuncturist with a board certification in integrative oncology. She partners with the University of Vermont Cancer Center to provide treatment of cancer patients during chemotherapy infusion.

What do we know about orthorexia?

Littlefield: What we know is that we need to know a lot more. We know that there are a lot of patients who are suffering a quality of life compromise and sometimes significant health consequences from it. We don’t have a good system to recognize it or to necessarily know how to treat it. It is under-recognized in the medical community, and we need more awareness and support for this.

Do you see it in your patients?

Littlefield: I see it in my integrative oncology practice, frequently.

How does it impact other eating or mental health issues?

Littlefield: It depends. I like to consider that, loosely, there seem to be two categories of people who suffer with orthorexia.

There’s a category of motivated, proactive patients who want to be empowered, who find that they’re lacking information from the medical community, seek it on their own, and then apply it in a way that’s dangerous and inappropriate.

There’s another class or grouping of people who have an underlying anxiety, obsessive compulsive disorder, or anorexia nervosa who also can fit into this category.

What are the warning signs?

Littlefield: I see patients who have a pretty tremendous fixation on foods being proper, eating foods that are healthy, and a sense of being afraid of foods that don’t meet their highest standard. It’s really important for me to figure out how to help the patients by understanding what’s beneath that.

Generally, the telltale sign for me in private practice is a degree of body language representing anxiety that comes up when patients talk about eating and choosing foods. These patients will say to me, “I am afraid of food. I don’t know what choice to make in the grocery store,” or, “I am afraid to go to a party.” It’s not always that dramatic, but the idea of an ‘analysis paralysis’ and wondering what foods are best for them can be very overwhelming.

Sometimes patients will risk social isolation, opting out of social function, opting out of family events because they’re afraid that they won’t have good choices to make. There are patients who manage it much better but still have the anxiety when they show up and participate in social events. All versions of this type of concern deserve support.

What is the mindset of someone with orthorexia?

Littlefield: Orthorexia can be an overly rigid system of eating, but it can also be considered when a patient is eating in a way that may be healthy and appropriate for one person, but for another person creates unreasonable stress and strain.

A vegan diet may be appropriate for some patients and they may be able to apply it in a way where they maintain their nutritional status, they maintain their weight, and they maintain their sense of peacefulness when they’re eating and preparing meals for their family. For other patients, that same diet may lead to nutritional deficiencies and it may lead to extraordinary stress in terms of meal preparation and in terms of sense of a righteousness around eating.

When the risk, and the stress, and the strain, not just a nutritional deficiency risk, but the emotional strain outpaces the benefit of the diet, that also would lead me to consider orthorexia. The vegan diet isn’t inherently a bad diet, but for one given person, the application of the diet may lead to diminishing returns or harm.

What are the health consequences of orthorexia?

Littlefield: The health consequences can be mental, emotional, and physical. Weight loss, nutritional deficiencies, and exacerbations of underlying mental health conditions are the most severe manifestations. A patient who already has an anxiety disorder can amplify that expression and feel much worse if there’s a layer of orthorexia. The nutritional concerns, the anxiety, and eating disorder concerns are prevalent, but it is important to remember that not everyone who has signs of orthorexia has an eating disorder.

There are people who have an underlying eating disorder, and those people will sometimes use the proper eating or dogmatism around foods that are good for them as a way to reinforce their rules about eating for them. And that is really easy to do with so much popular culture talking about good, healthy foods. So, limiting foods allows them to perpetuate this illness in a way that sounds noble.

The group that I see much more often in my practice are people who really just want to do well by themselves. In my practice, it’s usually triggered by a major medical diagnosis. A patient will have a newly diagnosed breast cancer, and she will get excellent care from the care team in terms of treating the cancer. Then, as a way to have agency and a way to help herself feel better, may seek Dr. Google for more advice on how to eat. When they do that, especially if they have been triggered by the stress of a new diagnosis, it’s very hard to stay rooted, grounded, and anchored in evidence. They may not have anxiety disorder but develop a situational anxiety and situational orthorexia.  This is worse if they don’t have a medical training or guidance. So, it’s easy for those patients to be persuaded by nonmedical commentary that’s online. And those are the patients that deserve a lot of help and are suffering and under-recognized.

How do you work with patients when you see the signs?

Littlefield: If I observe evidence suggesting an underlying eating disorder and mental health condition, I work with other providers who can support that portion of the diagnosis.

For the patients who are seeking knowledge and are motivated to enhance their self-care with the intent to improve health, I empower them with more information.  I spend time with them, ask about their sources for information, ask them what their motivations are and curiously learn what their process and journey has been. This process of discovery is so valuable in creating a rapport and creating a trusting therapeutic relationship where they will rely on me instead of google.

The most important and valuable thing that I found in my practice is familiarizing myself with some of the unsafe claims that are made online and in books that promote rigid dogmatic ways of eating. When I already know what those claims are, they’re easier to refute than just a global dismissive ‘food doesn’t matter.’ I’m able to talk with the patients and say, “This is the information you’ve been given about how,” for example, “sugar feeds cancer, and here’s the actual evidence we have. Here’s the nuance that can help you make a healthier decision.” When I’m able to get into that kind of granular perspective with them, they’re able to let go of the dogmatism and really focus on whatisactually the healthiest approach for them.

What are some of the most dangerous food and diet claims out there?

Littlefield: The most dangerous thing is that people are geared to think about what they shouldn’t eat instead of thinking about what they should eat. What we do know is that exercise, good sleep, stress management, and lots of vegetables are really, really good. Our culture is geared to think more about what we shouldn’t do than what you should do. If you had a choice of clicking online to something that said what you shouldn’t do or clicking online to see what you should do, most patients will click online to see what they shouldn’t do. I want the focus to be on the positive.

Lots of books and on-line resources will give versions of scientific evidence that are misconstrued. A common example…Sugar is not really that great for any of us. But, there’s an over-application and a rigidity with the understanding about how sugar feeds cancer. This popular claim is an oversimplification and it’s a misunderstanding that some patients also have. It misses an entire greater metabolic picture that is actually more useful for the patient to understand than the click bait concept of ‘sugar feeds cancer.’

What would you say to somebody who might see these signs in themselves or in somebody they know?

Littlefield: I would say to consider focusing on what is very healthy and fantastically nutritious in your meal. Instead of looking for what’s wrong with your meal, look for what’s right with your meal. If you find that anxiety and concerns prevent you from trusting the nutrition of your meal, you should have more support. That may be talking to someone who’s very well versed in understanding nutrition in terms of their specific diagnosis, or it may mean seeking mental health support. If a patient feels like their meal concern is extreme, to the point that they have weight loss and fear and paralysis about every meal, that patient deserves more support.

You’re a naturopathic physician. Tell us more about your partnership with the UVM Cancer Center.

Littlefield: It’s very exciting. The approach in naturopathic medicine is to lookis to look at a patient’s entire health history and entire holistic system and look for what isworking, and to reinforce those strengths. I want to support patients and allow the patient to really trust where their body is serving them very well, and then look to refine and support the areas where they’re feeling susceptibility or weakness.

In terms of my work with UVM Cancer Center, I’m currently working in the capacity of offering acupuncture to patients in the infusion center and looking forward to participating as they expand their integrative care resources.

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