Ex­perts weigh adding ‘clean eat­ing’ fix­a­tion to DSM

National Post (National Edition) - - Front Page - SHARON KIRKEY

Is an ob­ses­sion with “clean eat­ing” a bona fide men­tal dis­or­der de­serv­ing of its own di­ag­no­sis in psy­chi­a­try’s of­fi­cial man­ual of men­tal ill­ness?

A flurry of new stud­ies and re­views is breath­ing new life into so-called or­thorexia ner­vosa, loosely defined as a patho­log­i­cal fix­a­tion on eat­ing “pure” foods. At its ex­treme, ad­her­ents shun all sugar, all carbs, all dairy, all meat and an­i­mal prod­ucts, gluten, starch, pes­ti­cides, her­bi­cides — any­thing that isn’t nat­u­ral, or­ganic or “clean.”

Ac­cord­ing to one new pa­per, or­thorexia is a “cy­ber­pa­thy,” a dig­i­tally trans­mit­ted con­di­tion of priv­i­lege. Whether it’s a “real” men­tal dis­ease or an imag­i­nary one, the be­hav­iours and con­se­quences are certainly real, ac­cord­ing to the author.

“Phenomeno­log­i­cally, or­thorexia seems real enough, even though it may be cul­tur­ally bound and may have an up­com­ing ex­pi­ra­tion date,” Cristina Han­ganu-Bresch, an as­so­ci­ate pro­fes­sor at the Univer­sity of the Sciences wrote in the jour­nal Med­i­cal Hu­man­i­ties.

“As a cy­ber­pa­thy, or­thorexia lures the dig­i­tal flâneurs in search of non-con­ven­tional health ad­vice and colonises their imag­i­na­tion with prom­ises and ca­jol­ing, mi­cronu­tri­ent for­mu­las and ‘bio­hacks,’ and as­pi­ra­tion/in­spi­ra­tion con­tent,” she wrote.

In­sta­gram and other so­cial me­dia chan­nels have be­come the “vec­tors” of both trans­mis­sion, and re­cov­ery, said Han­ganu-Bresch, who de­scribed or­thorexia as a most un­healthy man­i­fes­ta­tion of “health­ism” — the idea that peo­ple are en­tirely re­spon­si­ble for their own health and that in­di­vid­u­als who don’t scrupu­lously stick to healthy be­hav­iours have only them­selves to blame if they get sick.

“The or­thorexic will elim­i­nate harm­ful or po­ten­tially un­suit­able sub­stances from the diet ac­cord­ing to a logic that shifts with the winds of the food fad­dism du jour,” she wrote, “hence, the ob­ses­sion with cleanses, juices, ve­g­an­ism, or raw and or­ganic food.”

Gwyneth Paltrow’s 2019 book, The Clean Plate: Eat, Re­set, Heal, for ex­am­ple pro­motes “su­per-clean eat­ing.” For the Goop god­dess, that means no al­co­hol, caffeine, dairy, night­shades (to­ma­toes,


egg­plant, mush­rooms), pro­cessed foods, red meat or other “toxic trig­gers.”

There’s an el­e­ment of self-right­eous­ness to or­thorexia, although Han­ganu-Bresch is wary about mak­ing moral judg­ments. Pa­tient “zero,” Han­guna-Bresch writes, was holistic med­i­cal prac­ti­tioner Steve Brat­man, who, in a piece he pub­lished in a yoga jour­nal in 1997, de­scribed his own ob­ses­sion with eat­ing pure and clean. “Most (or­thorex­ics) must re­sort to an iron self-dis­ci­pline bol­stered by a hefty sense of su­pe­ri­or­ity over those who eat junk food,” he wrote. Brat­man wrote 20 years later that when he coined the term “or­thorexia ner­vosa” he had not in­tended to pro­pose a new eat­ing dis­or­der.

“The con­cept went from a bon mot, a pun in a yoga mag­a­zine,” Han­ganu-Bresch said, and then slowly spread via web­sites and blog­gers un­til re­searchers (mostly Euro­pean) picked it up.

To­day, although it’s not for­mally recognized, or­thorexia is vy­ing for a place in the Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders, or DSM, an in­flu­en­tial guide­book used by doc­tors the world over.

How­ever, much of the re­search is still anec­do­tal or based on case stud­ies, there’s no uni­ver­sally shared def­i­ni­tion of or­thorexia ner­vosa, and no con­sen­sus on how to di­ag­nose it.

“We don’t yet know what it is,” said clin­i­cal psy­chol­o­gist Dr. Jen­nifer Mills, an as­so­ci­ate pro­fes­sor at York Univer­sity and co-author of a pa­per on or­thorexia in the Septem­ber is­sue of the jour­nal Ap­petite.

With­out for­mal di­ag­nos­tic cri­te­ria, it’s dif­fi­cult to get a han­dle on its preva­lence. Es­ti­mates “are all over the place,” Mills said, from less than five per cent, to 80 per cent or higher.

For their study, Mills and Sarah McComb, a grad­u­ate stu­dent in Mills’ lab and first author of the study, re­viewed peer-re­viewed ar­ti­cles pub­lished up un­til the end of 2018. Gen­der and self-esteem were gen­er­ally un­re­lated to or­thorexia ner­vosa. Sur­pris­ingly, they found equal rates of men and women strug­gled with symp­toms, even though eat­ing dis­or­ders tra­di­tion­ally tend to be 10 times more com­mon in fe­males.

Be­ing a veg­e­tar­ian or ve­gan put peo­ple at higher risk of de­vel­op­ing or­thorexia. The con­di­tion also has over­laps with anorexia ner­vosa, even though the em­pha­sis is of­ten on “health,” and not thin­ness or body dis­sat­is­fac­tion. But even then, the line can be blurry, Mills said.

“If some­body has this ap­par­ent ob­ses­sion with eat­ing ‘clean’ or healthy food, what’s the mo­tive behind that be­hav­iour?” she asked. “Are they try­ing to re­duce their fear that they’re go­ing to get sick? Is it more of a so­cially sanc­tioned eat­ing dis­or­der, where it be­comes a so­cially ac­cept­able way to re­strict what you’re eat­ing to try to lose weight. Or is it some other mo­tive en­tirely?”

It could be a form of OCD (obsessive com­pul­sive dis­or­der). Or­thorex­ics, the re­view by Mills and McComb found, tend to have cer­tain per­son­al­ity traits, such as per­fec­tion­ism, anx­i­ety, poor body im­age and a history of dis­or­dered eat­ing. Still, it’s hard to de­fine what’s “nor­mal” and “ab­nor­mal” eat­ing, said Mills, who is not con­vinced or­thorexia needs its own sep­a­rate, stand-alone di­ag­no­sis in the DSM.

“The re­sults of our re­view sug­gested there might be different types of peo­ple who show th­ese types of be­hav­iours and that they may al­ready fit into es­tab­lished cat­e­gories of psy­chopathol­ogy,” she said.

While there may be sig­nif­i­cant num­bers of peo­ple who show signs of the prob­lem, what’s im­por­tant is whether it’s caus­ing se­ri­ous dis­tress or phys­i­cal con­se­quences, like mal­nu­tri­tion.

“I think we should have a very high thresh­old for call­ing this truly ab­nor­mal, or a men­tal dis­or­der,” Mills said.

What she does hope is that health pro­fes­sion­als will be­come more aware of the be­hav­iours.

“When they ask some­one, ‘How do you eat?’ and the per­son says, ‘I eat re­ally healthy,’ maybe you should ask a few more ques­tions,” she said.

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