A few years ago, I wrote a piece for Dolly magazine about an increasing common style of eating in which teenagers became somewhat obsessed with ‘healthy eating’. The girls typically presented with concerned parents who had noticed a change in eating habits and significant weight loss. These tall, lanky, lean girls did not satisfy the diagnostic criteria for a clinical eating disorder but refused to eat anything other than low calorie, low fat, unprocessed foods. Epitomizing all things natural’ and ‘healthy’, such a diet, solely consisting of fruits and vegetables, nuts, seeds and grains, while lacking in essential nutrients remained adequate (just) in calories so that followers become exceptionally thin, although not necessarily underweight.
Now whether it is becoming increasing common, or I just happen to see it in my clinic, again this week I have been referred two teenage girls with the same presentation - a presentation I am now treating as ‘orthorexia’. “Orthorexia’ was first described by an American doctor in the late 1990’s, who was seeing an increasing number of female patients who were exhibiting a number of eating
disorder related symptoms including eating only an extremely limited food variety, and maintaining an extremely low body weight without satisfying the criteria for a clinical eating disorder. These girls were obsessed with only consuming foods that were “pure” and “healthy”, and as a result tended to consume only extremely low calorie, unprocessed foods, which in turn kept their body weight extremely low.
Unlike sufferers of a clinical eating disorder, these girls were not malnourished, as their diets were packed full of nutritious food choices, but in many cases their mood state was low either a result of a low food intake or a result of other stressors in their lives such as school issues caused by a clinical depression.
All cases I have seen in practice have been teenagers between the ages of fourteen to sixteen, from middle class family backgrounds attending good schools. All girls have been classified as “very intelligent” but struggle socially with the pressures only teenage girls experience from peers - the lure of boys, the pressure to achieve at school and to look good. A trigger, either family distress or negative interaction at school appears to be a common link with all cases, leading to depressed mood and the desire to be in control of as many other variables in their life as they can, such as their food intake and the way they feel about their body.
From a clinician’s perspective, this is a challenging situation. The girls are underweight but not “unhealthy” and their eating patterns are disturbed, without being clinically disordered. Blood biochemistry can be checked for signs of physiological distress but in a number of cases, return within normal ranges as food or supplement intake, although minimal keeps the girls within normal biochemical ranges.
For parents the scenario is exceptionally daunting. The rigid ‘all or nothing’ thinking that accompanies clinical eating disorders can be observed with this patient group, and we can be talking just a few kg shy of becoming clinically underweight. For this reason parents can be assured that the best thing they can do is to take control of the home food environment. Be strict with meal times, ensure family meals are enjoyed together and insist that your teen consumes the protein rich foods that they require for optimal growth and development in some form, whether it is in vegetarian protein rich options or via supplementary foods. Failure to comply with these basic eating rules needs to result in clear consequences such as removal of privileges or social media in the same way you would parent a toddler or small child. Most importantly, any link to weight loss and monitoring needs to be removed from the home, which means that the scales may need to be quickly thrown away.
Secondly, but most importantly exploring the underlying emotional triggers such as stressors at home or at school that may be directly or indirectly related to the depressed mood and rigid eating patterns of these girls is an important part of the process to help empower them to be able to manage the various scenarios that arise in their day to day lives. There are a number of simple
techniques including diarising all personal interactions with both friends and family that may be causing distress or anxiety is one way to help the girls learn to identify and manage their emotions, rather than using food and exercise as an escape from them. For teens that are exceptionally bright, keeping them busy and their minds active with scheduled exercise and/or sport, controlled social media usage and regular relaxation via pilates, yoga or meditation are other possible ways to shift their focus from food to life.
While adolescents’ can be an extremely challenging group to work with, they can also be an enormously rewarding client group. I have now seen a number of what I would describe as ‘orthorexic’ teens gradually work through their eating distress and are now well on their way into their final years of school, significantly happier and healthier than when I first saw them.
Unfortunately, the powerful media images of health and beauty are unlikely to disappear entirely and hence the incidence of conditions such as orthorexia is likely to increase. The key for health professionals and families affected is to know how to identify and manage this healthy food habit before it is too late.