the PDF of the presentation

Orthorexia Nervosa: When “Eating Healthy”

becomes Self-Destructive

Steven Bratman, MD, MPH

creator of “Orthorexia Nervosa”

Amanda Mellowspring, MS, RD/N, CEDRD

Eat from the Earth Nutrition Counseling, LLC

www.eatfromtheearth.com

Origin of the term

What Foods Should I Cut

Out?

Practicing alternative medicine in

1990s

Patients: “Doc, what foods should I

cut out?”

Primarily related to theories of

improving health via diet

Began to recognize that for some

patients more important to relax

about eating than to improve diet

Popular Alternative Diets

Macrobiotics

Vegan/Raw Food Vegan Ayurvedic

Elimination Diet

Candida

Zone

Blood Type

Paleo v.1.

Supplements-only

Miscellaneous Naturopathic:

No pesticides, preservatives, food

coloring, coffee, tea,

sugar, spicy foods, wheat,

dairy, red meat; food

combination;

acid/alkaline

In the 1990s, common alternative

medicine diets:

Side Effects of “Healthy” Diet

In alternative medicine, “healthy”

diet touted as side-effect

alternative to medications

Recognized numerous side effects:

Cannot share food with other

people

Cannot eat things one enjoys

Must pay intense attention to

food

Identity wrapped up in food

Guilt, shame fear when err

Disease Disguised as a Virtue

From holistic perspective, more important to

relax about food rather than restrict further

Had personally gone through something

very similar in 1970s while living on organic

farm

Recognized would be difficult to explain:

Patients thought they were being virtuous.

To recommend loosening up would be like

saying, “Drive drunk a little. Commit a little

larceny.”

Invented Term

Ortho = right

Orexia = hunger

Nervosa = fixation / obsession

Analogy to anorexia nervosa

Orthorexia nervosa: Obsession with

eating the right food

Publications

Published term in 1997 Yoga

Journal article

Reprinted in Utne reader

Immediately taken up by popular

magazines

Book Health Food Junkies, 2000

“Tease Therapy” to Eating

Disorder

Intended term as “tease therapy” to help people loosen up

Only later recognized as eating disorder

Kate Finn, person who had contributed to book, died of orthorexia in 2003

Cause of death was protein-calorie malnutrition, but was not trying to lose weight.

(Detailed story on orthorexia.com, “Fatal Orthorexia”)

Disconnect

Patients (like Kate Finn) would present for help, and would be told “you want to be thin”

Patient with orthorexia would say they don’t want to be thin; want to be pure, healthy, clean

Created disconnect and possible treatment failure

Suggests benefit for distinct diagnosis

Published Case Histories

28 y.o. female raw vegan 12 years, severe malnutrition. No desire to be thin; no typical anorexic behaviors. Zamora et al. (2005)

30 y.o. male restricted diet to brown rice and unsalted vegetables leading to hospitalization. No concern about weight Park, et al. (2011)

Macrobiotics?

33 y.o. female 8 year history of raw fruits, raw vegetables and raw eggs; social isolation and undesired weight loss. BMI 14.5 Saddichha et al. (2012)

28 y.o. male, eating protein shakes and supplements. “My body is my temple, and these are the pure building blocks I need to be healthy.” BMI 12.3 Moroze, et al. (2014)

Research

Health Food Junkies proposed a self help quiz.

Misinterpreted as formal “test,” and referenced in the literature as the Bratman Orthorexia Test (BOT)

Inadequate for research

BOT converted to the ORTO-15, used for research in Turkey, Italy, Eastern Europe, Portuguese speaking countries

Problems with ORTO-15

Extraordinarily high “prevalence” rates

81.9% Brazilian dieticians (Alvarenga, et al 2012)

86% Spanish Yoga practitioners (Valera et al, 2014)

40% Turkish medical students (Fidan et al, 2010)

Can reduce rates by adjusting cutoff

Nonetheless, ORTO-15 pathologizes interest in healthy eating rather than identifying an eating disorder related to healthy eating

Lacks other standard requirements of test construction

Was developed without the logically prior step of proposing formal criteria

Orthorexia: Descriptive Analysis

External causes

Large, overt social support for “the healthier you eat

the better.”

Educational programs in schools

Healthfoodist parents

Governmental programs (“Ministry of Orthorexia”)

Active evangelizing by others (flaunting instead of

hiding)

Buy-in from professionals (both alternative and

conventional medicine)

Social Media

“It’s just true!”

Transformation

Begins as exuberant interest in healthy food

This is NOT an ED

No matter how irrational the theory, adoption of a dietary theory is NOT in itself a disorder!

Should not pathologize disagreement

In susceptible individuals, transforms into an ED

INDIVIDUAL Risk Factors

Adoption of a highly restrictive dietary theory

Health-foodism in parent (undue importance assigned to food)

Childhood illness involving diet and/or digestive issues

Medical problems that can’t be addressed by medical science

Traits of perfectionism, OCD, extremism

Fear of disease

Movement Toward Excess

Certain foods are idealized as semi-magical superfoods (kale!)

Other foods demonized as evil

Subjective benefits initially experienced with restrictions fade; progressively stricter diets needed to produce same effect

Escalating restrictions, decreased food variety

Entire food groups may be cut out; progressively more severe cleanses may be utilized

Violation of dietary rules causes fear of disease and sense of impurity accompanied by anxiety and shame

Food becomes primary source of self-worth, happiness, meaning

Characteristics

Obsessive focus on food choice, planning,

purchase, preparation, and consumption

Food regarded primarily as source of health

rather than pleasure

Distress or disgust when in proximity to

prohibited foods

Exaggerated faith that inclusion or elimination

of particular kinds of food can prevent or cure

disease or affect daily well-being

Periodic shifts in dietary beliefs while other

processes persist unchanged

Moral judgment of others based on dietary

choices

Characteristics, ctd

Body image distortion around sense of physical "impurity" (can never become pure enough)

Persistent belief that dietary practices are health-promoting despite evidence of malnutrition

May include marked or excessive focus on exercise as part of health seeking behaviors, and/or utilize exercise capacity as a means to self-evaluate health

May use body appearance and maintenance of ideal weight as indicator of optimum health (looking fit)

Becomes a Compulsion

What was initially a choice becomes a

compulsive behavior

Individual may attempt to relax rules, but

cannot

May experience health problems such as

malnutrition

More commonly, psychological problems

such as social isolation and inability to focus

attention on anything other than food

At this point help may be sought, either by the

individual or by others around them

Proposed

Criteria

Why not ARFID

ARFID Characteristics do not match typical orthorexia

Apparent lack of interest in eating or food, often

called “selective eating” or “picky eating.”

Aversion based on the sensory characteristics of food, often color, shape or texture.

Conditioned negative response to food, such

as due to an anticipatory anxiety about

aversive experience while eating, usually a choking phobia or fear of vomiting.

First attempts

Jessica Setnick proposed sample criteria in her self-

published Eating Disorders Clinical Pocket guide

Thom Dunn proposed related criteria in 2014 paper:

Microthinking about Micronutrients: A Case of

Transition From Obsessions About Healthy Eating to

Near-Fatal “Orthorexia Nervosa” and Proposed

Diagnostic Criteria. (Moroze et al, 2014)

After reading these, I decided to jump in

Need somewhere to start, and if I authored the criteria,

would have greater chance of being accepted

Important that criteria do not demonize any specific

dietary theories

Proposed Formal Definition

of Orthorexia Nervosa

Two Criteria

Must satisfy ALL of Criteria A

Must satisfy ONE of Criteria B

Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17.

Criteria A

All of the following:

1. Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices* believed by the individual to promote optimum health**

2. Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.

3. Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe "cleanses" (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy food.

*Dietary practices may include use of concentrated "food supplements."

**Exercise performance and/or fit body image may be regarded as an aspect or indicator of health.

Criteria B

Any of the following:

1. Malnutrition, severe weight loss or other medical

complications from restricted diet

2. Intrapersonal distress or impairment of social,

academic or vocational functioning secondary to

beliefs or behaviors about healthy diet.

3. Positive body image, self-worth, identity and/or

satisfaction excessively dependent on compliance

with self-defined "healthy" eating behavior

Recent

trends

Evolution of “Healthy”

The concept of “healthy” and “low calorie” have begun to merge in popular conception Not in initial cases, nor through multi-century

history of healthfood-ism. Dietary theories are now most often presented

as a means of losing weight AND becoming healthier

Has led to convergence of weight loss and “eating healthy”

Similar transformation of exercise: previously separate concepts of exercise for health, weight loss and appearance have merged

Other evolving

characteristics

Elements of ON often present along with those of other eating disorders

May develop after treatment of standard EDs

Exercise dependence more frequently present even in cases of “pure” orthorexia

Orthorexia merging with concepts of life extension; biohacking.

Future steps In Process

In development (Thom Dunn): 100

question survey tool to identify

orthorexia nervosa

Use of that tool in research

Discover whether there is value in

defining ON as a separate

syndrome

Case Histories Eat from the Earth Nutrition Counseling, LLC

Not just another form of

Anorexia…

Anorexia Nervosa?

Bulimia Nervosa?

Binge Eating Disorder?

Avoidant Restrictive Food Intake Disorder?

Client #1

63yo Female

AN, purging type

69”

81.8#, BMI 12.4

11 month f/u:

Highest 90.0#

85.0#, BMI 12.6;

refused wts d/t laxative use

Goal wt: 120-145

Typical wt 108-118; preg 135

Labs WNL, except TG 31 initially,

no MD concern throughout, despite referrals for fluids, etc.

24HR DIET RECALL

Upon waking

½ c OJ

½ c Coffee, black

(strong)

1 c Coffee, black

(weak)

Drip of Soymilk

Sprinkle of Raw Sugar

¼ of half English muffin,

Ezekial

1.5hrs after waking snack

½ c OJ with bio-silica

mix

½ c Water with Hijiki &

Arame, boiled

Breakfast

1 shredded wheat biscuit

½ c Soymilk

¼ tsp Raw Sugar

1 Walnut

Sprinkle Sunflower/Pumpkin seeds

40g Whey protein pwdr (2tsp)

Sprinkle lecithin granules

1 slice Hemp bread, small

1 Tbsp Flax Oil

2 tsp Cashew/Almond butter

Pudding snack

Pudding

2 Tbsp Rice powder

Sprinkle lecithin granules

Sprinkle Raw Sugar

1-2 drips Chocolate sauce

Soymilk to consistency

Or,

2-3 Crackers

Flax Oil

Almond butter

Lunch

½ c Adzuki beans, cooked

1/3 c Winter squash + Onions + Carrots, cooked

1 slice, Ezekial or Hemp bread

3 oz turkey burger with cheese, before cooking (from WF counter – ½)

1 small ear, Corn

*Not always completed*

“Nibbles”

2tsp Protein powder +

choc sauce

1-2 Crackers + almond

butter

Pieces of Dates

½ slices Apple

Dinner

4-5oz White Fish, before

cooking

10 chips, dried Root

veggies

1 small ear Corn

1 Tbsp Flax Oil

Or,

1/3 c Sweet potato/Squash

+ Carrots + Onion

1 Tbsp Flax Oil + lecithin

2am snack

½ c Soymilk

¼ slice Toast, Ezekial or

Hemp

Or,

½ c Oats, drinkable

Soymilk to consistency

Water Intake

2 qts Water

2c Ionic Trace Minerals

18.95/8oz = $37.90/day

* Water intake spread

throughout day and

included medications and

supplement intake

#1, Proposed criteria met

CRITERION A 1. Goal to prevent

disease & increase vitality

2. Reported food rxns & aversions (increased pain, only organic, whole foods, fresh)

3. Coffee enemas, senna, detox suppl & throwing food out d/t imperfections

CRITERION B

1. 12bmi, severe state

2. Unable to tolerate

others “lack of

knowledge”, visited

suppl ‘specialist’ qd,

unable to work

3. Strict pentinence with

altruism, cat rescue,

cleaning, feeding

others

Client #2

20yo, Female

BN

College student

Appropriate body weight range

Documentation - samples


CRITERION A

1. 13pg document with

no review by allergist

2. Craved foods, ate

them secretively, then

purged 2/fear for

health

3. Increased beliefs that

there were reactions

to foods with

behaviors

CRITERION B

1. No, aside from obvious

consequences of

purging bx

2. Would not eat with

peers 2/ “cravings” &

limitations/judgements

3. Self-worth – “weak”,

“non-compliant”, self-

disgust developed

Client #3

16yo, Female

BED

“Food Addiction”

67”

Appropriate body weight range

Food reaction “testing”

Muscle testing /

applied

kinesiology Voice testing


CRITERION A

1. Focus on food as fuel and health rules

2. Inability to tolerate foods not required for fuel unless in binge state; shame; somatic reactions

3. Tricky for BED cts.; some crossover with food ideals and avoidances in standard diet; increased bingeing bx & somatic reactions

CRITERION B

1. Somatic reactions create

true physical pain, etc.

2. Severe social anxiety, fear

of trusting self with peers,

satellite school

3. Self-worth fully engaged in

beliefs r/t food as fuel limits

and self-doubt with food

“addiction”

Client #4

33yo, Male

ARFID / AN

73” (6’1”)

131.0#, BMI 17.25

8month f/u:

168.4#, BMI 22.25

Goal wt range = 155-175#

Interpretations


CRITERION A

1. Health as spiritual

expectation, altruism

2. Physical pain, aches;

fear of disease

3. Religious fasting,

cleanses, goal to

“need” less

CRITERION B

1. 17bmi, severe state

with rapid weight loss

of 27%BW

2. Psychotic features,

paranoia;

acceptance within

faith center

3. Self-worth

Historical Context

Ancient Theories

of Healthy Eating

Pre-modern medicine used diet as primary method of healing

Complex theories of healthy eating in ancient China, India, Greece

(Theories contradict one another)

In 16th century, French writer Montaigne satirized contradictory nature of diet theories in essay

Becomes clear that some people among the wealthy became obsessive about diet very long ago

Healthy Eating in 19th

Century Europe

Medicine continued to have numerous dietary theories of health: Low diet, cooling diet, warming diet

Back to Nature (Rousseau)

Early 19th century in spas of Germany: Avoid canned food, eat raw vegetables, vegetarianism, walk barefoot in nature (Sebastian Kniepp)

In mid and late 19th century US, theories involving fiber and whole grains. (Kellogg, Post and Graham) Muesli

In Japan, reaction against western diet led to “macrobiotic diet”

Traditional Japanese diet plus theories of acid/base, sodium/potassium, yin/yang balance

Early 20th Century US

1918 Benedict Lust (disciple of Sebastian Kniepp)

created First Health Food store, and founded

Naturopathy (Natural Medicine)

1920s: Gaylord Hauser in Hollywood emphasized

wheat germ, blackstrap molasses, yogurt, brewers

yeast (Disciples: Greta Garbo, Paulette Goddard,

Marlene Dietrich, Ingrid Bergmann)

1935 Jack LaLanne founded first fitness gym, San

Francisco Bay Area

(My grandmother was a follower of Gaylord Hauser,

my mother of Jack LaLanne)

1950 – 1970 US

Chemical dietary supplements (vitamins)

Large increase in popularity of “natural medicine” concepts

Eliminate pesticides, preservatives, food coloring, coffee, tea, sugar, spicy foods, wheat, dairy, red meat

Food combination theory

Acid/alkaline

Food sensitivity

Asian dietary ideas (macrobiotics)

Beginning of inventive period: Single diet guru invents theory out of nowhere

Kale becomes magical food

1980 to 2000

Numerous dietary theories flourish

Low carb becomes new dogma

Older idea “wheat is bad” becomes “gluten is bad”

Idea of going back to Eden (the name of a 1920 diet book) gives birth to Paleo. Initially involved raw meat (Cave Man

Candida

Zone

Blood Type

Supplements-only

Kale remains magical

Post 2000

Mainstreaming of some basic naturopathic diet ideas

as “Clean Eating”

Dietary theories becoming less alternative and more

mainstream

Currently dominated by Clean Eating, Paleo (v.2),

Veganism, Raw Foods

Exercise now included

Kale is still magical!

What it feels like The inner side of dietary theories

Understanding the interior

Dietary theories are ideologies: ideas tied to an urge

to believe

Self-defending against argument from non-believers

Opponents perceived as living in error, whether

innocently or maliciously

Monsanto!!

To address an ideology must understand ideas and

emotions behind it

The following categories overlap in various ways

PURITY: eating Clean

Key Points

Grand Idea: Back to Eden

Emotional State: Virtue/shame

Most similar to traditional eating disorders

Benign in the beginning: “Gateway drug”

Progresses, pushed onward by insatiable desire for feeling of purity

Massive literature

Basic Principles

Most commonly discussed dietary theory currently

Term expresses moralistic crux of orthorexia

UNCLEAN (IMPURE): Pesticides, antibiotics, preservatives, refined food, GMOs, sugar, meat, dairy

CLEAN (PURE): Organic, unprocessed, unrefined, semi-vegetarian, vegan, raw

Spectrum of UNCLEAN to CLEAN: Meat to dairy to vegetarian to raw vegetarian to fruit

Very popular in social and traditional media

Beautiful food photography

Healthy, environmentally friendly, and makes your skin glow

“Religious” Motivation

A sense of having gone astray and needing to return to the right path

Self-denial: avoid “impure” foods, even better fast entirely

Total commitment to a pure food diet is a vow of food

chastity, a war against lower desires of the flesh

Health Puritanism

Spirituality expressed in terms of body rather than soul

Fasting: repentance translated into physical terms

Back to Eden: Find the “original diet” (also leads to Paleo)

Combines with ethical ideas surrounding veganism

Associated Naturopathic

beliefs

Acid/alkaline foods

Food combining

Wheat is bad (became gluten is bad)

Enzymes in raw foods

Colonics (putrefaction)

Conventional nutrition wrong in SO many ways

Specific superfoods

ESCALATION

Clean eating

Vegan

Raw Vegan

Fruitarian

Breatharian

Raw Vegan

Raw carrot has more “life energy” than a cooked one.

Roughly related to Indian Prana and Chinese Qi

“Greatest enemy of man is the cooking stove”

Outdated theories about enzymes in raw foods

Fruitarian

Fruit is offered by the plant

No plants killed in the making of

applesauce

Given as free gift

Fruit is thought of as entirely clean

and pure, morally and physically

Fruit glows with energy

Breatharian

So “refined” one lives only

on air

Chinese antecedents

Purest of pure

Competitive purity

Cleansing / Fasting

Foods worse on the spectrum produce “toxins”

One can “feel the body filling up with them”

While “cleansing,” toxins are said to be released from cells (massage), pass out through the skin sauna), exhaled via breath (yogic breathing), released through colon (colon cleansing) and passed through kidneys (drinking lots of water)

Some elements of this fairly mainstream

What it feels like To Stay on

Path

Opting for the world of spirit over that of humanity

Back to Eden, back past Eden to the place before birth where there was no body at all.

Life becomes pristine

If you eat nothing but fruit, you begin to feel like the white flesh of a crisp apple: unblemished, pure smelling, like a newborn child

Self becomes pure spirit

Weightiness of earth falls away.

Filled with primal energy of life itself

What it feels like To Fall off

“I have befouled myself with

non-organic chips, I am

unclean. ”

Meditation on Purity

Confrontation

You are asking me to dirty and defile myself.

This is to take the path of evil, when I

have found to path of virtue.

I will lose all this perfection I have

attained.

My sweet smelling flesh will become

defiled, dirty, rotten.

Response

Search for absolute purity is rejection of the whole person; a war against desire, as much as crusades of any puritanical religion

James HIllman, distinguished between soul and spirit:

Spirit is the sky, the air, pure light, vast emptiness, the high you get while fasting.

Soul is deeply felt passion, character and joy.

To become pure spirit is to become an angel; to become soulful requires embracing the intestinal, sweaty, impure physical reality of human being.

It is a greater, and more difficult thing to be a whole human being than an angel.

Eat healthy food but sometimes give in to desire..

Don’t try to be perfect. Try to be whole.

Dietary Conspiracy

Theories

Key Points

Grand Idea: There is a

conspiracy to poison us

Emotional State: Fear

Overlaps with purity

Monsanto looms

Basic principles

Monsanto, McDonalds and Coca Cola consciously

poison us and conspire to keep it secret

Companies invent chemicals they know cause cancer

and birth defects and cover up via bribery or even

murder anyone who wants to blow the whistle.

Rates of cancer are “known” to have skyrocketed

The AMA and drug companies co-conspire so we will

need their products

US government dietary guidelines part of this

conspiracy (includes idea that protein guidelines are

wrong)

ESCALATION

Increasing number of

conceptual evils in foods

Increasing number of

conceptual evils in

environment

What it feels like to be on

the diet

I must use all my intelligence, and all my vigilance to navigate a treacherous world.

By educating myself, I can avoid the traps that ensnare others.

I dodge through hazards, escaping the gigantic forces that wish to injure me.

What it feels like to fall off

Terrifying: poison in the body

I can feel it moving through my veins, settling

in my fatty tissues, damaging my organs

Cancer cells are being formed, right now,

even as we speak. Brain cells are dying;

Alzheimer’s starting

Joints rotting; arthritis

Heart being poisoned

THEY are getting to me

Meditation on Food

Conspiracy

Confrontation

You are asking me to eat poison.

You are the voice of the

machine, drawing me into your

Matrix.

You work for the corporations.

I am surrounded by my enemies!

Response

Very difficult to approach due to paranoid defenses.

I hate to break it to you, but your world is surrounded by chemicals.

Yes, there are chemicals in foods, but there are chemicals in your iPhone (and rugs, cars, etc.)

I’m afraid it’s an imperfect world

You are exaggerating the effects. People actually live longer now, not shorter; there is not a higher incidence of age-related cancer, etc.

Balance: Macrobiotics

Key Points

Grand Idea: Health is Created

by Balance

Emotional State: Complex

Control

Very big in the 1990s, vanished

for a while, making a comeback

Gwynneth

Basic principles East Asian

dietary theory

Embedded in Taoist world view

Based on principles of balance

Yin/Yang

Five Elements

Historically conditioned

Prohibition on raw vegetables possibly due to use of

human nightsoil in cultivation

Population rise, especially in Japan, necessitated semi-

vegetarian diet for all but a few

Macrobiotics

Invented in late 19th century Japan

Popularized in 1960s US and Europe

Looked at by content only, is a vegan diet minus raw

foods and fruit, emphasizing Japanese staples: adzuki

beans, brown rice, miso, kombu, natto, burdock, tofu,

umeboshi plums and sea vegetables.

By theory: Foods divided into yin and yang

Ideal is to balance in food, but not with extremes

Because westerners eat a lot of meat and salty foods

(extreme yang) they crave sweets and raw foods (extreme

yin); not ideal

Yin/Yang

Yang Yin

Hard Soft

Dry Damp

Hot Cold

Contracting force Expanding force

Savory/Salt Sweet/bitter

Cooked Raw

“Extreme” Foods

Yin (somewhat yin to extremely yin)

Mild and soft cheeses Nightshade

vegetables (peppers, tomato, potato, eggplant) Fats and oils Tropical fruits

and juices Coffee, spices, chocolate,

black tea sugar, alcohol

Yang (somewhat yang to extremely yang)

Chicken Soy sauce Salty and aged

cheeses Eggs, red meat Sea salt

Middle range foods (Yin

Yang)

Temperate fruit (apple, peach, apricot)

Nuts

Leafy green vegetables (kale!)

Round vegetables (Brussels sprouts, cabbage, cauliflower, shiitake mushroom, turnips, winter squash

Beans (especially adzuki beans, black soybeans, garbanzo and lentils), tofu (sparingly)

Medium grain brown rice NEUTRAL and should be basis of diet (along with buckwheat and some other grains)

Spreading yin force of the ripening grain balances against contractive yang impulse of the husk.

Root vegetables (burdock, parsnip, radish)

Sea vegetables

Fish

Other factors

Yin cooking methods: Light sautéing, rapid stir-fry and steaming.

Yang cooking methods: baking, stewing, roasting and braising

Cooking utensils: wood, glass neutral. Plastic yin

Warmer time of year, eat more yin foods, cooler time of year

more yang foods

Long grain rice is more yin, and should be eaten during hotter

time of year, short-grain is yang and better eaten during winter

Eat by local climate

Fruits that grow in hot climates are moist, expansive and sweet,

contain coolness that balances heat

Grapefruits grown in Florida summer and consumed in North Dakota

winter exacerbate yin

Chew each mouthful 50-100 times

Claimed Whole Person

benefits

Increased energy, well being

Reduced frequency of acute illness

Reduced risk of cancer

Treatment of cancer

Improved memory and mental function

Improved mood

Enhanced ability to be emotionally generous

Increased life insight and enhanced control over personal destiny

Improved ability to perceive spiritual truth

Escalation

Macrobiotic has diets of varying levels of

strictness

Most strict level consists almost solely of

brown rice

In theory, only intended as a form of

fasting

In practice, it is utilized or approached

as part of escalation process

What it feels like to follow

diet

I have access to sophisticated ancient knowledge.

Using that knowledge, I am gradually bringing myself

into a state of equilibrium.

This takes years of effort and skillful means

Begins with gross balance, moves to more refined

Eventually gain ability to balance all subtle nuance

Goal: to become a sage, a taoist master.


the diet

Every misstep creates turbulence

Turbulence begets more turbulence

Each step into the world of illusion implicates extensive

recovery

I am spinning out of control

Meditation on Balance

Confrontation

You are asking me to veer out of control

I have finally achieved balance and you

want to throw me off

You are a product of a wildly

imbalanced society, and that is why you

don’t understand

You are all Sanpaku

You don’t understand energy

Response

Aren’t you sick of having

to work so hard to control

everything?

Food Sensitivities

Key Points

Grand idea: Everything bad that

has happened in my life is due to

eating things that I shouldn’t eat.

Emotional state: I am very

vulnerable. I must protect myself. I

can’t do things other people can

do. I have to be extremely careful.

Cottage industry

Entire industry devoted to “identifying” food sensitivities

Glossy printouts of results

Offered as explanation for all health problems

Was one of the most common routes to orthorexia in the 1990s

Very often specific vegetables and fruits are considered harmful; diets may not resemble more traditional “health” related diet

Individually idiosyncratic

Escalation

Initial elimination of foods provides temporary benefits

but later more foods need to be eliminated

Periodic elimination diets teach individual increased

capacity at food restriction

Initially can tolerate small amounts of forbidden foods,

but later cannot tolerate slightest contamination

Side effects of forbidden foods become more severe

and prolonged

Results: universe of possible foods may shrink to turkey

and white rice


diet

Clarity

Energy for first time in life

Sense of well being

(at least at first)


diet

Headaches, nausea, fuzzy thinking, fatigue

Emotional instability

Variety of other subtle symptoms

Generally unwell

Difficulty functioning

Meditation on vulnerability

Confrontation

You are asking me to give up all my gains

These foods are very dangerous for me – fear of what will happen

You don’t know my body like I do

Response

Sigh

Simple solution

Key Points

Grand idea: This is as

brilliant a discovery as

anything in the history of

science

Emotional state: Eureka!

Discovery!

There is a key to health that everyone

else has missed.

Candida

Parasites

Eat Right for your Type

Hypothyroid (The Riddle of Illness, Solved)

New theory every several years


diet

I have a key to health /

preventing illness that

practically no one else

knows!

It is arduous but I am doing

it!


diet

This is ridiculous. I know

what I should do, and I’m

not doing it. What’s wrong

with me?

Confrontation

They didn’t believe

Einstein either

Response

How well is it working for

you?

Make up your own

Path to riches

Invent your own!

Sprinkle in some facts

Add complication

The more complex and detailed the food rules the better

Make fortune

Conventional Dietary

Theory

Key Points

Grand idea: This is Science*

Emotional state: I am being a

good citizen by doing this

*A HIGHLY arguable claim. But that is an aside.

Basic Principles

Low saturated fat

Low fat in general

Low salt

Avoid “bad foods” in general: sodas, sugar, fatty food, red meat

Embrace “good foods” in general: whole grain carbs, lots of vegetables

Exercise 75 minutes high intensity, 150 minutes moderate intensity weekly

Escalation

NOTE: Simply trying to follow the recommendations completely can be fairly extreme (especially low salt and total servings of vegetables)

Young girls, especially, hear message in school, combine with ideas about weight, and begin to escalate

If reducing meat is good, eliminating it is better

If eating five servings of vegetables good, ten servings better

If 75 minutes high intensity exercise good, 150 minutes is better

Becomes orthorexia / anorexia


diet

I am a good citizen.

I am virtuous

In Norway, government ministry of health is nicknamed “Ministry of Orthorexia.”

Norwegians, as good citizens, frequently follow advice TOO STRICTLY, get orthorexia

Meditation on being a good

citizen


diet

I am being stupid and bad

Confrontation

But this is what everyone knows I should do

It has been hard for me to get to this point. Why should I stop?

Response

Moderation

Tease Therapy for dieticians

OK, I’m teasing

But look at similarities

Tendency toward dietary extremism is NOT rare

Alternative diets do NOT have a monopoly on foolishness.

Do not feel superior to people who believe in strange dietary theories!

Clinical Application Working with clients, rather than against them

Recognizing &

Understanding

Need to differentiate from unconventional food beliefs

Warning Signs:

Proselytizing

Spiritual Component

Fatigue of judgement is often the strongest pre-cursor to recovery

Self & Others

Note swing to diet

rebel mentality

Definition of self tightly wrapped into food beliefs

Know yourself

(& please remember it is not

about you)

Nutrition Approach

Rapport building

Avoid labels

Caution with complementing orthorexic messages

Educate yourself on various nutrition philosophies

Avoid judgements of philosophy

Point out inconsistencies

Move pt into less restrictive approaches that coincide

with personal values*

Align with alternative providers

Balance

Food values

Sensory Values

Taste

Aroma

Internal Cues

Hunger

Desired fullness

Environmental Factors

Budget

Location

Social Influence

Nutrition Values

Nutrition facts

Food groups

Emotional Values

Cravings / Satiety

Food memories

Ethical / Moral values

“Magical” Qualities

Expansive health

benefits

Treatment Residential Models - Behavioral Focus 1st

May need more personalized approach

Slower introduction of “common” foods

Similar to how others may perceive

desserts

Exposure work

Crash landings

Sitting in the ruins together

Working through somatic responses

Treatment Outpatient Models - Changing Mindset 1st

Collaborative pace

Note changes in social presence & peer groups

Discuss inconsistencies & move to less restrictive

food approach

This may take time to “wash out” as it mimics the

diet mentality

Consistent food exposures

Include social normalization as possible

If weight restoration needed, prioritize appropriate

nutrient intake within narrow food selection without

wavering from start.

Thank You!

Documents

the PDF of the presentation