Chelsea Roff: Orthorexia and Eating Disorders in Men
I was honored to be a guest this week on the Conspirituality Podcast for a conversation about orthorexia and gendered stereotypes of eating disorders. The episode features a candid conversation between hosts Derek Beres and Matthew Remski about orthorexia, as well as an interview with esteemed professor and researcher Dr. Jason Nagata about the treatment of eating disorders in boys and men. I wanted to share a few thoughts about this important conversation.
Orthorexia is a term that has become ubiquitous in popular culture, and for good reason. Defined as "a pathlogical obsession with healthy eating," it’s an intuitive concept that points to a phenomenon that's unquestionably on the rise. It was great to hear Matthew Remski clarify at the beginning of the episode that orthorexia is not a recognised mental health diagnosis by either the American Psychiatric Association, nor the World Health Organization (the two organisations that publish the seminal texts mental health professionals around the world use to diagnose mental illness). This is not to say that "orthorexia" is not a real phenomenon, nor to imply that it doesn't cause significant distress and underlie many unhealthy (even dangerous!) behaviours. But “orthorexia” is not recognized by mental health professionals in the same way as mental disorders like schizophrenia and obsessive compulsive disorder.
“Defined as ‘a pathological obsession with healthy eating,’ orthorexia is an intuitive concept that points to a phenomenon on the rise.”
There are a few reasons this term warrants caution. First, as Remski spoke to in the podcast, many researchers have identified significant overlap between "orthorexic" symptoms and those of recognised disorders, namely Anorexia Nervosa and Obsessive-Compulsive Disorder. "Orthorexia" might be better understood as an increasingly common presentation of an existing mental illness, or even two comorbid disorders, not a whole new mental disorder. As Gary Greenberg discusses at length in The Book of Woe, a critical analysis of how mental disorders are invented and uninvented, new psychiatric diagnoses are often added to the Diagnostic and Statistical Manual (DSM) without sufficient evidence and misused by pharmaceutical companies seeking a novel diagnosis to pair with an emerging medication.
Reflecting on Derek Beres' compelling personal experiences with orthorexia, as well as my own work with male clients with eating disorders, it strikes me that "orthorexia" may be a more common (and perhaps more socially condoned) way in which men express what are commonly termed “restrictive eating disorders,” namely Anorexia Nervosa and Avoidant and Restrictive Food Intake Disorder. In the latest iteration of the DSM, the diagnostic criteria for these disorders was changed to place a greater emphasis on restriction of energy intake relative to bodily needs, and a lesser emphasis on body size and weight. These criteria have helped clinicians identify people with eating disorders who may be at or above a “healthy” weight. But as Dr. Nagata notes in the episode, they still fail to represent the diverse expression of eating disorders across different genders, ages, ethnicities, and socioeconomic groups. No eating disorder looks the same, and in countries like the United Kingdom — where healthcare capacity is limited clients can be denied treatment for “not being sick enough” — narrow diagnostic criteria can become a barrier to access support.
“Orthorexia may be a more common (and perhaps more socially acceptable) way men express restrictive eating disorders.”
creating new psychiatric diagnoses is a slippery slope.
Secondly, data and research on orthorexia is significantly lacking compared to recognised eating disorders, such as Bulimia Nervosa and Binge Eating Disorder. While researchers have developed questionnaires to assess orthorexia, numerous studies have failed to demonstrate psychometric validity and reliability1. More importantly, researchers in the field still disagree about how to define the concept of orthorexia2. The question of, "at what point does healthy eating and/or physical activity become unhealthy?" has not yet been answered. It's a question that Remski and Beres reflect on during the podcast and a question we often hear from clients as they start to integrate physical exercise into their recovery.
Perhaps the most compelling reason I am cautious to use this term too liberally is that we run the risk of pathologizing and medicalizing a phenomenon that might be better understood through a non-medical, or at the very least biopsychosocial, framework. The problem with tacking a mental health diagnosis onto a person's experience, and the behaviours that emerge from that experience, is that it locates the problem within the individual, and often glosses over the sociocultural forces causing a person to behave in that way to begin with. This is a problem with nearly all mental health diagnoses — especially those with less evidence to suggest neurochemical and/or genetic factors are at play. I covered the problems with diagnosis in mental health treatment more in-depth in my TedX talk, the Diagnosis Effect.
“The problem with tacking a mental health diagnosis onto a person is that it locates the problem within the individual, and often glosses over the sociocultural forces causing a person to behave in that way to begin with. ”
This risk should invite us to be exceptionally cautious about new mental health diagnoses, which can be used (especially in prisons, mental hospitals, and care homes) to justify the overprescription of pharmaceutical drugs, some of which have even been used as involuntary "chemical restraints." The New York Times and The Guardian have reported on this issue in US, UK, and Australian care homes. I myself was on the receiving end of 'chemical restraints' while undergoing inpatient treatment for an eating disorder as a teenager.
Last but not least, I want to commend Derek, Matthew, and Julian for bringing the topic of "men and eating disorders" to their platform and to Derek especially for sharing his experience with these challenges in a public forum. The myth that "eating disorders are a women's issue" is pervasive and problematic, discourages people from seeking help, and stigmatises mental health challenges not only in men, but in people who identify across the gender identity spectrum. The truth is that eating disorders exist on a spectrum, affect far more people than are counted in research studies, and until we have a social milieu that not only allows, but encourages all people to seek support for mental illness, they will continue to run rampant in the shadows.
1 Roncero M, Barrada JR, Perpiñá C. Measuring Orthorexia Nervosa: Psychometric Limitations of the ORTO-15. Span J Psychol. 2017 Sep 20;20:E41. doi: 10.1017/sjp.2017.36. PMID: 28929989.
2 Cena, H., Barthels, F., Cuzzolaro, M. et al. Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature. Eat Weight Disord 24, 209–246 (2019). https://doi.org/10.1007/s40519-018-0606-y
About The Author
Chelsea Roff is the Founder and Director of Eat Breathe Thrive, a nonprofit organization that helps people overcome eating disorders. A certified yoga therapist, research collaborator, and educator, she has spent the better part of a decade developing and delivering mind-body programs to people with eating disorders. Prior to her work in the charitable sector, Chelsea worked as a researcher in psychoneuroimmunology under the supervision of Dr. Andrew Baum. She is currently working with Dr. Catherine Cook-Cottone on four studies to evaluate the efficacy of Eat Breathe Thrive as a preventative and complementary treatment intervention for eating disorders.