Jun 6, 2018When healthy turns harmful
Eliminating junk food might sound great. But an obsession with clean eating has a name — orthorexia — and can have debilitating consequences.
One of your athletes has expressed an interest in eating healthier. Fantastic news, right? They start by making a few dietary swaps, such as changing out white bread for whole wheat bread or selecting carrot sticks with their lunch instead of chips. Pleased by their initiative, you encourage their efforts.
But then you notice the athlete talking excessively about healthy eating or pointing out when others aren’t following an optimal diet. They express shame for even thinking about eating something that they don’t consider “good.” And although they used to love going out for post-practice ice cream, you hear them repeatedly turn down their teammates’ offers.
At this point, you might want to consider that the athlete has developed a pattern of disordered eating called orthorexia. This condition is when an individual becomes obsessed with only eating foods they consider to be “clean” or “healthy.” As a result, they can experience a host of detrimental physical and emotional consequences.
Athletes are particularly at risk for orthorexia. They are often taught to eat healthy by adults whose opinions they respect, and they are under intense pressure to look and perform their best. So for them, following a clean diet can easily be a slippery slope and turn into an issue if not addressed in time.
That’s where athletic trainers, strength coaches, and other performance personnel can help. Although orthorexia is considered a fairly new condition, enough research has been done to provide tips on appropriate diagnosis, treatment, and prevention efforts. With time, even more information will become available to assist athletes who have taken healthy eating too far.
Defining orthorexia
Orthorexia, also referred to as orthorexia nervosa, was first coined in 1996 by Steven Bratman, MD, MPH, co-author of Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating. At the time, Dr. Bratman, who serves as Staff Physician at NorthBay Healthcare in Fairfield, Calif., used the term to describe patients who were overly focused on only eating healthy foods.
Now, although orthorexia is not included as a clinical diagnosis or considered an official eating disorder by the American Psychiatric Association, it is viewed as a disordered eating pattern. It typically manifests similarly to other eating disorders like anorexia or bulimia. The patient may start out with an innocent intention that soon spirals out of control. They may become preoccupied and obsessed with what they are eating, and it could interfere with their lives, health, and interactions with others.
However, with anorexia or bulimia, the goal is often to lose weight or change appearance, and there is a psychological aspect involved. With orthorexia, it typically does not start because of a psychological reason or even for body image, although it may turn into a psychological manifestation, such as anxiety or a way to deal with anxiety. Orthorexia sufferers frequently focus instead on being as healthy as possible. The aim is rarely to restrict calorie intake or the quantity of food consumed.
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In some instances, though, orthorexia can turn into anorexia or bulimia if weight starts to be a motivator. For example, an individual may lose weight without realizing it and receive such positive feedback on their weight loss that they don’t want to stop.
An important thing to note: Some have mistakenly assumed that orthorexia is meant to describe individuals who follow a vegetarian, vegan, gluten-free, or organic diet. However, Dr. Bratman has clarified that it was not his intent to associate these diets with the term.
The reason athletes in particular can struggle with orthorexia is partially because they already face a heightened risk for disordered eating. Many have personalities that trend toward perfectionism or believe their weight is tied to athletic performance. Combine these traits with psychological issues that some young people experience, like low self-esteem, anxiety, feelings of guilt or shame, depression, and mood imbalances, and it’s easy to see how eating healthier to meet a goal can turn into a detrimental obsession.
While any athlete can develop orthorexia, individuals in sports that emphasize a certain body type, including gymnastics, swimming, cross country, dance, and wrestling, tend to be at an increased risk. Male athletes are also especially vulnerable to orthorexia. Often, if they see initial changes in performance from eating healthy, they will think, “More is better,” or “If I eliminate all unhealthy foods, I can be the best on my team.”
What to watch for
Diagnosing orthorexia can be difficult for a number of factors. First, since it is a newly recognized condition, there’s a lack of evidence-based research available in the areas of diagnosis.
Another issue is that orthorexia is easy to miss among health care providers. One reason is because patterns of healthy eating can lie on a spectrum, encapsulating everyone from those who make small changes to their diets to those who cut out certain foods. As a result, medical providers may misinterpret symptoms or simply think it’s great that a patient wants to eat better. Orthorexia can also be accompanied by symptoms of other psychiatric disorders, such as anxiety and preoccupation, that could be more related to behavioral health.
However, these potential challenges don’t mean it’s impossible to recognize orthorexia in athletes. Although these will vary for each individual, there are a number of warning signs to watch out for:
- Avoiding foods that do not fit into very strict guidelines the athlete has set for themselves. This may include foods that they previously loved, though the restricted items will ultimately depend on the athlete’s specific definition of healthy. Most know fruits and vegetables are good for them, but some may classify starchy vegetables as unhealthy or skip certain fruits that contain high amounts of sugar. For example, I recently worked with an athlete who avoided bananas because he read they were high in fat. Dairy and fats are other groups that athletes may eliminate.
- Avoiding social situations in which foods that the athlete doesn’t consider healthy will be present. I have had athletes lie to teammates to get out of going to a birthday party where cake was being served. Others may not want to eat at certain restaurants, at homes where they cannot control the quality of food being served, or on the road with their teams. Collegiate athletes on a meal plan are especially vulnerable if they feel the cafeteria offerings are not up to their standards. As a result, they may avoid the dining halls and become isolated.
- Constantly thinking about food or worrying about what food they will eat next or have to avoid. Athletes may also start to become consumed with researching healthy eating.
- Talking a lot about healthy eating or pointing out when others do not follow a clean diet. Some may start to feel superior over teammates who do not eat as healthy as they do.
- Continuously posting pictures of their meals and snacks on social media. This may start innocently at first with the occasional breakfast photo. But if this behavior extends to posting all foods and snacks, having this digital food log may make it harder for the athlete to embrace social situations. For instance, they may avoid getting ice cream with their teammates for fear that someone will post about it online, thereby showing them eating something considered not healthy in their mind.
- Coming across as overly confident about their diet. Athletes may become especially proud when others notice they are choosing healthy foods or eliminating unhealthy ones.
- Expressing guilt or shame for eating something that doesn’t fit into their food guidelines.
These points should serve as warning signs and merit follow-up. Yet, because of the blurry line between healthy eating and orthorexia, it can be difficult to know when athletes have taken their focus on a clean diet into obsession. One tool that can help is The Bratman Orthorexia Self-Test (below), which includes a series of questions to help determine if healthy eating has turned into a problem.
There may also be physical manifestations that an athlete has gone too far. If they are cutting out certain types of foods or overly consuming others, they may start to show evidence of nutritional deficiencies. I once worked with an athlete who believed sweet potatoes were the only acceptable form of carbohydrate and ate them several times a day. Eventually, this individual developed carotenemia, which is a yellow tone to the skin. Restricting certain nutrients may even cause a noticeable drop in performance, muscle mass, energy level, or weight.
Another serious repercussion is the athlete may start to develop symptoms of anxiety surrounding their obsession with healthy eating. These can include high blood pressure, an asthma attack, or rapid heart rate.
Further, some athletes get so preoccupied with what they will eat that they can’t think about anything else. The consequences could include poor focus in school, a drop in grades, lack of concentration in their sport, or withdrawal from social activities.
Getting help
Athletic trainers and strength coaches can be the first to recognize orthorexia. Since they spend so much time with athletes, they may notice an individual eating differently, talking more about food, or experiencing a performance drop due to inadequate fueling.
If you suspect an athlete has developed orthorexia, communication is key-with the athlete, their teammates, their coaches, and other important people in their life. Meet with these groups to determine if the athlete only talks about healthy eating with one person or if it’s a larger trend seen by many people.
If it’s the latter, it’s appropriate to explore the issue before it gets worse. One way to do this is by having a conversation with the athlete about their eating habits. Do they think their fueling approach has changed recently? Have they been trying to alter their diet? If so, what is their motivation? Maybe they are trying to eat healthier because they learned about a family member’s high cholesterol, or they could be learning about the benefits of healthy fats from a nutrition class. But if the athletes’ answers raise further suspicion, a physician can typically determine if there is a problem.
Once orthorexia has been identified in an athlete, it’s best to intervene and start treatment. Because orthorexia is not recognized as an official eating disorder, treatment may be difficult to initiate.
To start, it may be challenging to find a local medical professional who has experience dealing with orthorexia. Some may not even accept it or incorrectly assume it is strictly a mental health issue. Even when a supportive health care professional is available, treatment can be costly if not covered by health insurance.
Despite these potential obstacles, a good first step is setting up a treatment team to assist you. Ideally, it should include a medical provider who is familiar with orthorexia, a psychologist, and a registered dietitian.
Once that’s established, cater treatment to the needs of the individual athlete. Due to the varying symptoms of orthorexia, there is not a standardized treatment plan. Outpatient therapy may work well for some, while others may need an in-patient approach at a clinic or hospital. In addition, some may struggle more with anxiety and need psychological counseling, while others may require more intense medical management for their eating disorder symptoms.
My approach is to build a relationship with the athlete first before beginning any kind of treatment. This helps develop trust. Many times, the individual will not recognize they have a problem. They may think about food a lot but not feel it is an obsession. Even when others point it out, they may still not understand how it is negatively impacting them or their team.
When this is the case, it can be beneficial to get involvement and support from parents or teammates. Other strategies I use include reflective listening, having athletes summarize their thoughts about food, and having athletes keep a food/thought journal. It can be helpful to include the expertise of a counselor to get athletes to this point.
Another element of building trust is not coming across as the food police. Although I have extensive knowledge of current health trends, it is not effective to quote research articles or attack the validity of a patient’s eating patterns. That will only make them raise a defensive wall. Instead, I like to take on the role of the nutrition detective.
A good way to attempt this is by asking the athlete if they have any concerns regarding their diet. Some point out that they think about food a lot, or they eat differently than teammates.
Next, it is important to examine whether their eating habits are actually healthy. Explain that maybe they are doing too much of an initially good thing, and it’s creating a lab value deficiency or impacting their performance.
If the progression of the behavior is not too advanced, small steps can restore balance to the athlete’s diet. A counselor can help deal with any anxiety the athlete may feel about making these changes. Here are some examples to try:
- Have the athlete add in one “banned” food item to a meal each week, even if it’s just a bite.
- Encourage the athlete to go with teammates to get ice cream, even if they do not indulge in a treat.
- Have the athlete eat a snack on campus or add dressing to their salad.
As you embark on treatment, keep in mind that there is no recovery checklist for orthorexia. It is difficult to determine if an athlete has fully recovered or if they will have relapse symptoms or thoughts. My approach is to decrease the number or frequency of appointments if the athlete feels they are starting to have a healthier relationship with food.
Future prevention
With proper intervention, athletes with orthorexia can go on to have fully functional lives. To keep orthorexia from reappearing in the future, athletic trainers and strength coaches can be part of a prevention game plan.
This starts by setting a positive example of healthy eating. Athletes, especially younger ones, will want to copy the eating patterns of those they look up to. Educate them that having a good relationship with food means it’s okay to eat high-fat foods in moderation or have celebratory treats on occasion.
Along the same lines, avoid judgmental statements, such as, “You are letting your team down if you eat an unhealthy diet.” Athletic trainers and strength coaches may not realize how much of an impact offhand comments like this can have on athletes.
In addition, you might want to encourage athletes to limit their social media use, if you believe they could be vulnerable to online influences. This could keep them from comparing themselves and their diets to what others’ “perfect” lives look like online.
In the end, it is important to recognize that there is nothing inherently wrong with athletes wanting to eat healthier foods. But when it becomes all-consuming orthorexia and begins to interfere with their everyday life, it’s best to step in and provide the appropriate help.
Case study
A marathon runner recently came to see me at the urging of her boyfriend. He believed her training and diet plan was causing unhappiness in their relationship.
One of the main issues centered on the runner being so focused on healthy eating that she no longer wanted to eat out. Her boyfriend felt they used to enjoy going out to dinner and ate healthy overall but splurged on enjoyable food items from time to time. Now, the runner wanted to pack all meals, even when traveling to a different state for a race. Further, she was inflexible about where she would grocery shop.
When asked about her boyfriend’s concerns, the runner expressed she thought he was just jealous of her diet. She had lost a bit of weight but did not consider it a problem and still had a healthy Body Mass Index (BMI). In her mind, there was no issue with her eating habits.
At our session, we discussed what it was like to go out to eat with her boyfriend. We made a pro/con chart of the experience, and the runner was able to recall some of the positive elements, such as laughing over dinner together.
I also had her make a list of foods she had cut out of her diet because she did not feel they were healthy. After some coaxing, we came up with some ways she could add those foods back into her eating plan when she felt comfortable doing so.
Because the runner’s weight was in a normal range, she did not need specific intervention to address her weight loss. However, I did mention that she would face an increased risk for stress fracture if she dropped below the healthy BMI threshold.
Finally, I brought up the idea of attending counseling to work on developing a healthy relationship with food. Although the runner was not interested in this solution, she did consider couples’ counseling to work on the issues with her boyfriend.
The Bratman Orthorexia Self-Test
After he coined the term “orthorexia” in 1996, Steven Bratman, MD, MPH, co-author of Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating and current Staff Physician at NorthBay Healthcare in Fairfield, Calif., developed the following “Bratman Orthorexia Self-Test.” It includes a number of questions to help individuals identify if they have gone too far with healthy eating.
If you are a healthy-diet enthusiast, and you answer yes to any of the following questions, you may be developing orthorexia nervosa:
- I spend so much of my life thinking about, choosing, and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work, and school.
- When I eat any food I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods.
- My personal sense of peace, happiness, joy, safety, and self-esteem is excessively dependent on the purity and rightness of what I eat.
- Sometimes I would like to relax my self-imposed “good food” rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make any exception to your diet, then this item does not apply.)
- Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own.
- Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me or has caused other signs of malnutrition, such as hair loss, loss of menstruation, or skin problems.
The Bratman Orthorexia Self-Test is printed with permission from Dr. Bratman. More information about the test can be found at www.orthorexia.com.
