The Difference Between Selective Eating And Orthorexia Nervosa

Psychiatrist Wendy Oliver-Pyatt discusses the dangers of dietary restrictions, especially among young people.

By Mark Travers, Ph.D. | May 3, 2022

A new scientific article explores the prevalence of a new trend in unhealthy eating, called orthorexia. Orthorexia is associated with significant dietary restrictions and the omission of entire food groups.

Orthorectics tend not to consume food that has been processed with pesticides, herbicides, or artificial substances, and they are highly worried about the techniques and materials involved in food preparation.

Although scientists have yet to officially label this type of eating behavior a disorder, they are concerned that orthorexia is increasingly impinging on healthy eating habits, especially among teenagers and young adults.

For instance, they found:

The prevalence of orthorexia among youth and young adults is as high as 27%
Individuals suffering from other eating disorders such as anorexia nervosa or bulimia nervosa are more likely to exhibit orthorectic eating habits
Traits related to perfectionism, such as keeping to a dietary routine and feelings of culpability after failing to retain food restrictions, are found in individuals with orthorexia
Orthorectics have a lack of pleasure linked to food consumption and, through controlling their food intake, they feel like they are able to control their life

I recently reached out to Dr. Wendy Oliver-Pyatt to help put this new research into context.

Wendy is a psychiatrist with 20 years of experience designing eating disorder treatment programs and currently serves as the chief medical officer of Within Health, an all-virtual eating disorder treatment provider.

Here is a summary of our conversation.

As a psychiatrist and eating disorder specialist, what is your take on orthorexia?

Orthorexia Nervosa is a form of eating disorder that can easily "hide" behind the premise of "clean eating" or "healthy eating."

This pursuit of health turns eating into a somewhat mechanical experience. The social aspect of eating and enjoyment of eating is considered irrelevant to the sufferer, who will forgo social interactions and potentially meaningful and important aspects of life to pursue "healthy eating."

The hyper-focus on the ingredients in foods devoids the person from the very real human, lived, and joyful experience of eating. Often the pursuit of healthy eating causes interpersonal issues due to the rigid nature of eating patterns and can even lead to significant health issues due to the low body weight, low body fat, and other nutritional deficiencies that can take place due to "healthy eating."

The fact that our society tends to reinforce this type of eating blanketly, and also weight loss, may cause the person to experience praise and awe for what is actually a potentially deadly condition.

Certainly, there are foods and food groups that should be avoided or at least moderated. How does someone know if she/he is striking the right balance?

The focus on healthy eating in our society has led to a society plagued with eating disorders and also many who suffer from chronic dieting and what is called "weight cycling," in which the person's weight goes up and down over the years but with a generally upward trajectory.

The focus should be instead on what I call a healthy relationship with food. How do we get there? It starts with what we call "internal regulation," in which the focus becomes not on the next diet trend, weight loss gimmick, or food rules but rather on the process of becoming internally regulated.

This means being able to pay attention to cues that tie eating with the actual biological need to eat. Our bodies are not hardwired to self-destruct. We are hardwired for survival. There is a need for protein, fat, and carbohydrates in our diet. When our eating becomes internally regulated (which we call "mindful eating"), our eating patterns shift in such a way that we are neither over nor under-eating. The orchestra of neurotransmitters and hormones that connect the brain and gut, and body, can all interact and guide us toward eating according to our biological and even, yes, our psychological needs.

Eating for satiety and enjoyment, recognizing cues of both hunger and satiety, instead of the exact type of food, leads to a peaceful relationship with food and the body "landing" at the place it is biologically pre-ordained to land.

What are some of the red flags people should pay attention to when attempting to gauge whether their eating habits are becoming unhealthy or psychologically counterproductive?

This is a very important question, especially since assumptions are often made that "healthy eating" and "clean eating," and even weight loss, are so often assumed to be associated with health. When a patient is forfeiting social interactions, pleasure, and enjoyment of food and eating, there is a problem.

Eating is a part of social life, human interaction, and human-to-human connection, and this is a part of well-being. Additionally, nutritional deficiencies, low body weight, or low weight for what is normative for a person's individual body are indicators of poor health.

It is important to note that body mass index (BMI) is also NOT a measure of health and is especially misleading when considering those from different cultures and those with higher muscle mass (such as athletic individuals).

Another example of this is that low heart rate is often associated with athleticism (and people can even be praised for this) when in fact, it can also be associated with poor heart functioning related to the body being starved. Another example of lack of health is amenorrhea, osteoporosis, and infertility, which can and does come up in individuals who experience orthorexia.

It is not uncommon for infertility patients to be treated with hormones for infertility who, in fact, need to eat more and eat more diverse food choices.

What tools and/or interventions do you recommend for people who might be exhibiting orthorectic, or other problematic, eating behaviors?

The first step in the process is awareness. There is so much misinformation about what constitutes healthy behavior. Take a step back and consider your quality of life, how much time and energy food is taking in your life, and whether a preoccupation with the health of food is interfering with relationships. Have others questioned your behavior? Have you experienced bone loss, amenorrhea, hair loss, low heart rate, low energy, poor concentration, irritability, infertility, or a change in the quality of your life or relationships connected to your pursuit of clean eating? Do you feel afraid of eating foods that don't constitute "healthy eating" in your mind?

Human beings are not robots or machines, and eating mindfully is a foundation for our life. We need food to sustain life, and eating is also designed, by the force of biology, to be a pleasurable experience.

Attention to working on fear foods by gradually reintroducing previously restricted foods is in fact a path toward a healthy relationship with food.

I strongly suggest working with dietitians who are trained on the principles of intuitive eating and who understand the foundations of mindful eating as a very good starting point. Consideration should also be given to more care with a comprehensive team that can include medical doctors, psychiatrists, and therapists.

What is your best advice for individuals who want to have a healthier relationship with food but can't seem to figure it out?

One of my mantras, it is not so much about the health of food, but a healthy relationship with food.

A healthy relationship with food is the foundation for health of body and mind. Considering how you would describe your relationship with food is a good tool to self-assess. Is it peaceful, positive, enjoyable, and in harmony, or is it conflicted, painful, and scary?

When we aim our energy at building a peaceful relationship with food, where the body, mind, and spirit can be taken seriously and nourished well, versus weight loss, we are on the right track. Focus on behavior and not weight.

Behaviors in alignment with self care in every sense of the word are always good choices. A couple of books that may be helpful are: "Questions and Answers on Binge Eating Disorder, A Guide for Clinicians" (my book) and "Intuitive Eating" by Elyse Resch, RD.