Friday, June 10, 2011

Is orthorexia worth talking about?

In 1997, Dr. Steven Bratman published an article in Yoga Journal about what he felt was a side effect of nutritional medicine, 'orthorexia nervosa', an unhealthy obsession with ‘healthy’ diets, which he felt could lead to malnutrition and other problems. While not an officially recognized illness, orthorexia has been the subject of some discussion in the popular media and the medical literature.

Of all the criticisms leveled at alternative medicine, this one will perhaps prove the most difficult to shake. Statements about poor education standards and lack of evidence are rapidly disappearing as naturopathic doctors now receive physician-level education, and clinical and laboratory trials of vitamins and herbs are increasing. However, ‘orthorexia’ has proven to be a bit of a blind spot for alternative medicine, and solving the problem will probably take a bit of soul-searching.

The issue at stake is one that’s fairly common in alternative medicine. Dietary medicine, and specifically the restriction of certain foods, is a fairly common practice among naturopaths, acupuncturists, chiropractors, and other professionals, be it avoid sugary foods during a cold, cut out dairy for chronic ear infections, or cut out wheat for just about everything from eczema to IgA nephropathy. It’s commonly taught at schools, positive results are regularly seen in clinical practice, and research into the practice is beginning to appear. As effective as it is, it’s not always an easy practice – as clinicians can tell you, most patients resist dietary changes vehemently. In the vast majority of cases, the possibility of developing an eating disorder are negligible.

However, some clinicians can also tell you about at least one or two patients they have seen whose diets are too restricted. In his initial article, Dr. Bratman discusses a patient who had gone from four asthma medications to none through elimination of dietary allergens, but in the process had also gone from eating a full range of foods to a very narrow spectrum. I myself once worked with a patient who had started with mild digestive symptoms, and through a process of strict dietary elimination (he was on a list of about 10 ‘acceptable’ foods when I saw him), had achieved some improvement of his initial symptoms, but was now suffering an increasing number of vague constitutional symptoms (fatigue, memory loss, weakness, joint pain), and was on his way to developing something like pancytopenia (a lack of red blood cells and immune cells), largely due to malnutrition.

The atmosphere is murky around orthorexia, in part due to another theme common in alternative medicine: Dr Bratman claims that he also had a brush with the disease in the late 1970’s while living on a commune and experimenting with a variety of esoteric diets. The story of the practitioner who diagnoses and/or then cures him- or herself and then goes about spreading the word is a common one in alternative medicine, and while it doesn’t completely disqualify his points (new diseases do emerge from clinical observations of a few individuals), it makes one examine the situation a little harder while trying to become informed.

In an effort to classify orthorexia as a true disorder, a questionnaire to identify orthorexia has been developed, the ORTO-15, and a limited number of studies have been done to verify accuracy of the questionnaire to detect disordered eating. Broad research into the topic is lacking, but the small amount available indicates that orthorexia is fairly uncommon in the general populace, but that incidence is higher in certain groups – medical students, doctors, nutrition students, and members of professional art performance groups (ballet, opera, and orchestra). Should orthorexia become recognized as an ‘official’ disorder, more research will likely be done resulting in better description of its prevalence and manifestations. As as been pointed out, there is significant overlap of orthorexia with other disorders, such as obsessive compulsive disorder and anorexia, but even so, doctors shouldn’t ignore the role that they can play in exacerbating symptoms, or even setting up a unique manifestation of disordered eating.

My take-home message is this. People practicing dietary medicine should screen for any history of disordered eating before making recommendations, especially as regards elimination of foods or food groups. Regardless of whether orthorexia should be classified as a distinct illness, practitioner recommendations about diet may play into pre-existing eating disorders, and for all the talk of being natural and free of side effects, may cause harm to the patient. And after all, those of us who have become involved in natural medicine did so for a reason, because we believe in the principle of primum non nocere – let’s not forget that this principle is sometimes more complicated in practice than simply avoiding the harshest of pharmaceuticals.