Good news - "Health Food Junkie" will soon be a book! The following
was recently posted on rn newsgroups, and is cross-posted here with
permission of Dr. Bratman. Inquiries/stories should be sent to the
address below. / Tom Billings
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In the fall of 1999 Doubleday will release the book Eating for
Perfection (working title), by David Michael Knight CHT and Steven
Bratman MD. In this book David and Steven will illustrate Orthorexia
Nervosa, an eating disorder which until now has not been described.
The purpose of this letter is to ask for your assistance. We have
accumulated many stories from our own practices but we would like to
include more. Attached you will find a copy of Steven's article which
prompted the original interest in writing a book. If you feel you
have a story to offer us please email it to us. You must include your
name, address, and phone number. Please rest assured that it will be
kept in the strictest confidence and not used in our book unless a
release is signed by you.
Thank you,
David Knight CHT
Steven Bratman MD
[log in to unmask]
david knight <[log in to unmask]>
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Orthorexia Nervosa -- The Health Food Eating Disorder
by Steven Bratman, MD
[Note: an edited version of this was published in "Yoga Journal"
magazine (Oct 97 issue) under the title "Health Food Junkie". It
was reprinted in "Utne Reader" earlier this year, as well. It also
was reprinted (with the author's permission) in the SF-LiFE newsletter
(Dec. 97 issue, with comment articles by me).]
Because I am a physician who practices alternative medicine, patients
who come to me often begin the conversation by asking whether they can
be cured through diet. "Regular medical doctors don't know anything
about nutrition," they say, believing this will build rapport with me.
I feel obligated to nod wisely. I agree that conventional medicine
has traditionally paid too little attention to the effects of diet.
However, I am no longer the true believer in nutritional medicine I
used to be. My attitude has grown cautious where once it was
enthusiastic and even evangelical.
I have lost two beliefs that once encouraged me, and that are still
widely accepted by others who promote dietary methods of healing.
One of these is an assumption that there exists a comprehensive and
consistent theory of healing diseases through nutrition. The other
is a faith that dietary therapy is a uniformly wholesome, side effect
free intervention.
My attitude has not always been so lukewarm. Twenty years ago I was
a wholehearted, impassioned advocate of healing through food. My
optimism was unbounded as I set forth to cure myself and everyone else.
This was long before I became an alternative physician. In those days,
I was a cook and organic farmer at a large commune in upstate New York.
My experiences there formed the foundation of my early interest in
alternative medicine, and continue to give me insight into the ideals,
dreams and contradictions that underlie the natural health movement.
All communes attract idealists. Ours attracted food idealists. As a
staff cook I was required to prepare several separate meals at once
to satisfy the insistent and conflicting demands of the members. The
main entree was always vegetarian. However, a small but vocal group
insisted on an optional serving of meat. Since many vegetarians would
not eat from pots and pans contaminated by fleshly vibrations, this meat
had to be cooked in a separate kitchen. The cooks also had to satisfy
the Lacto-ovo-vegetarians, or Vegans, who eschewed all milk and egg
products. The rights of the non-garlic non-onion Hindu-influenced crowd
could not be neglected either. They believed onion-family foods provoked
sexual desire.
For the raw foodists (and young children) we always laid out trays of
sliced raw vegetables. However, a visitor once tried to convince me
that chopping a vegetable would destroy its etheric field. I chased him
out of the kitchen with a huge Chinese cleaver.
The macrobiotic adherents clamored for cooked vegetables, free, of
course, from "deadly nightshade" plants such as tomatoes, potatoes,
bell peppers and eggplants. Some also insisted on eating fruits and
vegetables only when they were in season, while other communalists
intemperately demanded oranges in January.
Besides these opinions on which food to serve, there were as many
opinions on the manner in which it should be prepared. Most everyone
agreed that nothing could be boiled in aluminum, except the gourmet cooks,
who insisted that only aluminum would spread the heat satisfactorily.
By consensus, we always steamed vegetables in the minimum amount of
water to avoid throwing away precious vitamins. Certain enthusiasts
would even hover around the kitchen and volunteer to drink the darkish
liquids left behind. About washing vegetables, however, controversy
swirled. Some commune members firmly believed that vital substances
clinging just under the skins must be preserved at all costs. Others
felt that a host of evil pollutants adhered to the same surfaces that
needed to be vigorously scrubbed away. One visitor explained that the
best policy was to dip all vegetables in bleach, and gave such a
convincing argument for her belief that we would have adopted the
principle at once were it not for a fortuitous bleach shortage.
I used to fantasize writing a universal cookbook for eating theorists.
Each food would come complete with a citation from one system or
authority claiming it the most divine edible ever created, and another,
from an opposing view, damning it as the worst pestilence one human
being ever fed to another.
This would not be difficult. For example, a famous naturopathic concept
proclaims that raw fruits and vegetables are the ideal foods. Some
proponents of this school exclaim periodically "the greatest enemy of man
is the cooking stove!" However, another popular theory bans raw foods
as unhealthy, and attributes to their consumption such illnesses as MS,
rheumatoid arthritis and cancer. I am referring to macrobiotics. This
influential system of alternative dietary principles insists that all
vegetables should be cooked; fruits should not be eaten at all.
Similar discrepancies abound in alternative dietary medicine. The
following rules may be found in one or another food theory: Spicy food
is bad. Cayenne peppers are health promoting. Fasting on oranges is
healthy. Citrus fruits are too acidic. Fruits are the ideal food.
Fruit causes candida. Milk is good only for young cows. Pasteurized
milk is even worse. Boiled milk "is the food of the gods." Fermented
foods, such as sauerkraut, are essentially rotten. Fermented foods
aid digestion. Sweets are bad. Honey is nature's most perfect food.
Vinegar is a poison. Apple cider vinegar cures most illnesses. Proteins
should not be combined with starches. Aduki beans and brown rice should
always be cooked together.
The discovery that nutritional medicine was so chaotic troubled me.
Yet I could always hope that a universal theory of nutrition might
eventually be found. What disturbed me more observing the extremism
that so frequently develops among those who propound dietary cures.
I remember a macrobiotic seminar at the commune, led by Mr. L. of the
Kushi institute. An audience of at least thirty-five listened with rapt
attention as Mr. L. lectured on the evils of milk. It slows the
digestion, he explained, clogs the metabolism, plugs the arteries,
dampens the digestive fire, and causes mucous, respiratory diseases
and cancer.
At that time, a member of the commune by the name of John lived in a
small room upstairs from the seminar hall. He was a "recovering"
alcoholic who rather frequently failed to abstain. Although only in
his fifties, John's face showed the marks of a lifetime of alcohol
abuse. But he had been on the wagon for nearly six months when he
tiptoed through the class.
John was a shy and private man who would never voluntarily have so
exposed himself. But upon returning from the kitchen with a beverage
he discovered that there was no way he could reach his room without
crossing through the crowded seminar. The leader noticed him immediately.
Pointing to the glass of milk in John's hand, Mr. L. boomed, "don't
you realize what that stuff is doing to your body, sir! Class, look
at him! He is a testament to the health destroying properties of milk.
Study the puffy skin of his face. Note the bags under his eyes. Look
at the stiffness of his walk. Milk, class, milk has done this to him!"
Bewildered, John looked at his glass, then up at the condemning faces,
then back to the milk again. His lower lip quivered. "But," he
whimpered, "but, this is only milk, isn't it?"
In the alcoholics anonymous meetings with which John was familiar,
milk was practically mother's milk, synonymous with rectitude and purity.
"I mean," he continued, to the unforgiving students, "I mean, it isn't
whiskey, is it?"
By focusing on diet singlemindedly and ignoring all other aspects of
life, alternative practitioners like Dr. L. come to practice a form
of medicine that lacks a holistic perspective on life. This is ironic,
of course, since holism is one of the strongest ideals of alternative
medicine, and its most ubiquitous catchphrase (next to "natural").
It would be more holistic to take time to understand the whole person
before making dietary recommendations, and occasionally temper those
recommendation with an acknowledgment of other elements in that person's
life. But too often patient and alternative practitioner work together
to create an exaggerated focus on food.
Many of the most unbalanced people I have ever met are those have devoted
themselves to healthy eating. In fact, I believe many of them have
contracted a novel eating disorder, for which I have coined the name
"orthorexia nervosa." The term uses "ortho," in its meaning as straight,
correct and true, to modify "anorexia nervosa." Orthorexia nervosa
refers to a fixation on eating proper food.
Orthorexia begins innocently enough, as a desire to overcome chronic
illness or to improve general health. But because it requires
considerable willpower to adopt a diet which differs radically from the
food habits of childhood and the surrounding culture, few accomplish
the change gracefully. Most must resort to an iron self-discipline
bolstered by a hefty sense of superiority over those who eat junk
food. Over time, what they eat, how much, and the consequences of
dietary indiscretion come to occupy a greater and greater proportion
of the orthorexic's day.
The act of eating pure food begins to carry pseudo-spiritual
connotations. As orthorexia progresses, a day filled with sprouts,
umeboshi plums and amaranth biscuits comes to feel as holy as one
spent serving the poor and homeless. When an orthorexic slips up,
(which, depending on the pertinent theory, may involve anything from
devouring a single raisin in violation of the law to consuming a gallon
of Haagen Daz ice cream and a supreme pizza), he experiences a fall
from grace, and must take on numerous acts of penitence. These usually
involve ever stricter diets and fasts.
Over time, this "kitchen spirituality" begins to override other sources
of meaning. An orthorexic will be plunged into gloom by eating a hot
dog, even if his team has just won the world series. Conversely, he
can redeem any disappointment by extra efforts at dietary purity.
Orthorexia eventually reaches a point where the sufferer spends most
of his time planning, purchasing and eating meals. The orthorexic's
inner life becomes dominated by efforts to resist temptation, self-
condemnation for lapses, self-praise for success at complying with
the self-chosen regime, and feelings of superiority over others less
pure in their dietary habits.
It is this transference of all life's value into the act of eating
which makes orthorexia a true disorder. In this essential
characteristic, orthorexia bears many similarities to the two named
eating disorders: anorexia and bulemia. Whereas the bulimic and
anorexic focus on the quantity of food, the orthorexic fixates on
its quality. All three give to food a vastly excessive place in the
scheme of life.
It often surprises me how blissfully unaware proponents of nutritional
medicine remain of the propensity for their technique to create an
obsession. Indeed, popular books on natural medicine seem to actively
promote orthorexia in their enthusiasm for sweeping dietary changes.
No doubt, this is a compensation for the diet-averse stance of modern
medicine. However, when healthy eating becomes a disease in its own
right, it is arguably worse than the health problems which began the
cycle of fixation.
As often happens, my sensitivity to the problem of orthorexia comes
through personal experience. I myself passed through a phase of
extreme dietary purity when I lived at the commune. In those days,
when I wasn't cooking I managed the organic farm. This gave me
constant access to fresh, high-quality produce. Eventually, I became
such a snob that I disdained to eat any vegetable that had been plucked
from the ground more than fifteen minutes ago. I was a total vegetarian,
chewed each mouthful of food fifty times, always ate in a quiet place
(which meant alone), and left my stomach partially empty at the end
of each meal.
After a year or so of this self imposed regime, I felt light, clear
headed, energetic, strong and self-righteous. I regarded the wretched,
debauched souls about me downing their chocolate chip cookies and fries
as mere animals reduced to satisfying gustatory lusts. But I wasn't
complacent in my virtue. Feeling an obligation to enlighten my weaker
brethren, I continuously lectured friends and family on the evils of
refined, processed food and the dangers of pesticides and artificial
fertilizers.
For two years I pursued wellness through healthy eating, as outlined
by naturopathic tradition and emphasized with little change in the
health food literature of today. Gradually, however, I began to sense
that something was wrong.
The need to obtain food free of meat, fat and artificial chemicals put
nearly all social forms of eating out of reach. Furthermore,
intrusive thoughts of sprouts came between me and good conversation.
Perhaps most dismaying of all, I began to sense that the poetry of my
life had diminished. All I could think about was food.
But even when I became aware that my scrabbling in the dirt after raw
vegetables and wild plants had become an obsession, I found it terribly
difficult to free myself. I had been seduced by righteous eating.
The problem of my life's meaning had been transferred inexorably to
food, and I could not reclaim it.
I was eventually saved from the doom of eternal health food addiction
through three fortuitous events. The first occurred when my guru in
eating, a lacto-ovo-vegetarian headed on his way toward Fruitarianism,
suddenly abandoned his quest. He explained that he had received a
sudden revelation. "It came to me last night in a dream," he said.
"Rather than eat my sprouts alone, it would be better for me to
share a pizza with some friends." I looked at him dubiously, but did
not completely disregard his message.
The second event occurred when an elderly gentleman (whom I had
been visiting as a volunteer home-health aide) offered me a piece of
Kraft Swiss cheese. Normally, I wouldn't have considered accepting.
I did not eat cheese, much less pasteurized, processed and artificially
flavored cheese. Worse still, I happened to be sick with a head
cold that day. According to my belief system at that time, if I
fasted on juice I would be over the cold in a day. However, if I
allowed great lumps of indigestible dairy products to adhere to my
innards I would no doubt remain sick for a week -- if I did not go
on to develop pneumonia.
But, Mr. Davis was earnest and persistent in his expression of
gratitude, and would have taken as a personal rebuke my refusal of
the cheese. Shaking with trepidation, I chewed the dread processed
product.
To my great surprise, it seemed to have a healing effect. My cold
symptoms disappeared within an hour. It was as if my acceptance of
his gratitude healed me.
Nonetheless, even after this miracle I could not let go. I actually
quit visiting Davis to avoid further defiling myself. This was a
shameful moment, a sign that I was drowning.
The life-ring which finally drew me out was tossed by a Benedictine
monk named Brother David Stendal-Rast. I had met him at a seminar he
gave on the subject of gratitude. Afterwards, I volunteered to drive
him home, for the covert purpose of getting to know him better.
(This may be called "opportunistic volunteerism.") On the way to
his monastery, although secretly sick of it, I bragged a bit about
my oral self-discipline, hoping to impress the monk. I thought that
he would respect me for never filling my stomach more than by half,
and so on. David's actions over the subsequent days were a marvelous
example of teaching through action.
The drive was long. In the late afternoon, we stopped for lunch at
one of those out of place Chinese restaurants -- the kind that
flourish in small towns where it seems no one of remotely oriental
ancestry has ever lived. As expected, all the waiters were Caucasian,
but the food was unexpectedly good. The sauces were fragrant and
tasty, the vegetables fresh, and the eggrolls crisp. We were both
pleasantly surprised.
After I had eaten the small portion which sufficed to fill my stomach
halfway, Brother David casually mentioned his belief that it was an
offense against God to leave food uneaten on the table. This was
particularly the case when such a great restaurant had so clearly
been placed in our path as a special grace. David was a slim man and
a monk, so I found it hardly credible that he followed this precept
generally. But he continued to eat so much that I felt good manners,
if not actual spiritual guidance, required me to imitate his example.
I filled my belly for the first time in a year.
Then, he upped the ante. "I always think that ice cream goes well
with Chinese food, don't you?" he asked, blandly. Ignoring my
incoherent reply, Brother David directed us to a Friendly's Ice
Cream Parlor, and purchased me a triple scoop cone.
David led me on a two mile walk through the unexceptional town as we
ate our ice cream, edifying me with spiritual stories and, in every
way, keeping my mind from dwelling on the offense against Health Food
I had just committed. Later that evening, Brother David ate an
immense dinner in the monastery dining room, all the while urging me
to have more of one dish or another. I understood the point. But
what mattered more was the fact that this man, for whom I had the
greatest respect, was giving me permission to break my Health Food
vows. It proved a liberating stroke.
Yet, it was more than a month later that I finally decided to make
a decisive break. I was filled with feverish anticipation. Hordes
of long suppressed gluttonous desires, their legitimacy restored,
clamored to receive their due. On the twenty minute drive into town,
I planned and re-planned my junk food menu. Within ten minutes of
arriving, I had eaten three tacos, a medium pizza, and a large
milkshake. I brought the ice cream sandwich and banana split home,
for I was too stuffed to violate my former vows further. My stomach
was stretched to my knees.
The next morning I felt guilty and defiled. Only the memory of
Brother David kept me from embarking on a five day fast. (I only
fasted two days.) It took me at least two more years to attain the
ability to follow a middle way in eating easily, without rigid
calculation or wild swings.
Anyone who has ever suffered from anorexia or bulimia will recognize
classic patterns in this story: the cyclic extremes, the obsession,
the separation from others. These are all symptoms of an eating
disorder. Having experienced them so vividly in myself twenty years
ago, I cannot overlook their presence in others.
For this reason, as a practicing alternative physician I often feel
conflicted. I almost always recommend dietary improvements to my
patients. How could I not? A low fat, semi-vegetarian diet is
potent preventive medicine for nearly all major illnesses, and more
focused dietary interventions can often dramatically improve specific
health problems. But I do not feel entirely innocent when I make
dietary suggestions. Like drug therapy, I have come to regard dietary
modification as a treatment with serious potential side effects.
Consider Andrea, a patient of mine who once suffered from chronic
asthma. When she first came to see me, she depended on several
medications to stay alive, but with my help she managed to free herself
from all drugs.
The method we used involved identifying foods to which Andrea was
sensitive and removing them from the diet. Milk was the first to
go, then wheat, soy and corn. After eliminating those four foods
the asthma symptoms decreased so much Andrea was able to cut out
one medication. But she wasn't satisfied.
Diligent effort identified other allergens: eggs, avocado, tomatoes,
barley, rye, chicken, beef, turkey, salmon and tuna. These too
Andrea eliminated, and was soon able to drop another drug entirely.
Next went broccoli, lettuce, apples, buckwheat and trout, and the
rest of her medications.
Unfortunately, after about three months of feeling well Andrea
began to discover that there were now other foods to which she was
sensitive. Oranges, peaches, celery and rice didn't suit her, nor
potatoes, turkey or amaranth biscuits. The only foods she could
definitely tolerate were lamb and (strangely) white sugar. Since
she couldn't actually live on those foods alone, Andrea was forced
to adopt a complex rotation diet, alternating grains on a meal by
meal basis, with an occasional complete abstention to allow her to
"clear." She did the same for vegetables, with somewhat more ease
since there was a greater variety to choose from.
Last week, Andrea came in for a follow-up visit, and described the
present state of her life to me. Wherever she goes, Andrea carries
a supply of her own particular foods. She doesn't go many places.
Most of the time she stays at home and thinks carefully about what
to eat next, because if she slips up the consequences continue for
weeks. The asthma doesn't come back, but she develops headaches,
nausea and strange moods. She must continuously exert her will
against cravings for foods as licentious as tomatoes and and bread.
Andrea is happy with the treatment I've given her, and has referred
many of her friends to see me. Yet, I feel ill when I see her name
on my schedule. The first rule of medicine is "above all, do no harm."
Have I helped Andrea by freeing her from drugs, only to draw her
into the bondage of diet? My conscience isn't clear.
If it was cancer she had been cured of, or multiple sclerosis, I
suppose the development of an obsession wouldn't be too high a price
for physical health. However, all Andrea had was asthma. I have
asthma too. When she took her four medications, she had a life.
Now, all she has is a menu. Andrea might have been better off had
she never heard of dietary medicine.
I am generally lifted out of such melancholy reflections by some
substantial success. After Andrea, I saw Bob in follow-up, a man
whose rheumatoid arthritis was thrown into full remission by one
simple intervention: adding foods high in trace minerals to his diet.
Before he met me, he took prednisone, gold shots and high doses of
anti-inflammatories. Now he has gone a full year without a problem.
Seeing him encourages me not to give up entirely on making dietary
recommendations.
But my enthusiasm will remain tempered. Like all other medical
interventions -- like all other solutions to difficult problems --
dietary medicine dwells in a grey zone of unclarity and imperfection.
It's neither a simple, ideal treatment, as some of its proponents
believe, nor the complete waste of time conventional medicine has
too long presumed it to be. Diet is an ambiguous and powerful tool,
too unclear and emotionally charged for comfort, too powerful to be
ignored.
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