Hosting the Thanksgiving feast always has been a challenge, what with the hard-drinking uncles, the post-election political minefields, the unruly children and the matriarch hovering nearby to critique everything from the carving of the turkey to the flakiness of the pie crust.
In the past, though, you usually could count on people eating.
The typical holiday gathering this year is likely to include a vegan, somebody on a paleo diet, at least one person avoiding dairy products, a few who eschew carbohydrates, a member of the fat-free crowd, someone with a nut allergy and heaven knows how many who are gluten-free and won’t stop talking about it.
While the vast majority of these friends and family members are merely trying to eat carefully or are maybe just the teensiest bit obsessed with dietary restrictions, some may have moved into dangerous, even deadly territory.
“It’s not uncommon for wonderfully intelligent, sensitive, capable, driven, perfectionist, very accomplished people — both men and women — to begin what turns into life-threatening anorexia nervosa with an instinct to eat more healthy,” said Dr. Jennifer L. Gaudiani, associate medical director at the ACUTE Center for Eating Disorders at Denver Health and an associate professor at the University of Colorado School of Medicine.
Gaudiani, a certified eating disorder specialist, said she has treated patients from 17 to 65 for the condition that has the highest death rate of any mental illness.
“A lot of the most capable, loving, wonderful people who are really accomplished and are intrigued by very healthy eating are at the most risk for getting this,” she said. “It starts out as a quest for health and preservation of longevity and turns into one of the deadliest disorders an otherwise healthy young person can get.
The illness has been dubbed orthorexia nervosa and two Colorado researchers were part of a team that recently identified criteria for the condition in an attempt to facilitate medical research on its prevalence, risk factors and effective treatments for it. Orthorexia nervosa differs from anorexia nervosa in that sufferers dangerously limit their diets in an attempt to eat what they perceive to be the healthiest diet possible. Anorexics restrict their diets in an attempt to be as thin as possible.
Thom Dunn, associate professor of psychological sciences at the University of Northern Colorado and a clinical instructor at the School of Medicine, and Dr. Ryan M. Moroze, a psychiatry fellow at the School of Medicine, became interested in orthorexia nervosa when they were consulting on a case at the ACUTE Center.
A 28-year-old man came to the center at about 50 percent of normal body weight. He was extremely malnourished, essentially starving to death.
In an attempt to eat only healthy food, over time he had reduced his diet to a mixture of amino acids and water and little else.
He attributed magical powers to certain vegetables, such as broccoli, and believed that taking half a multi-vitamin in the morning and again in the afternoon boosted his energy.
By the time he was admitted to the center, he was having trouble finding words and was “disorganized and tangential in his thought processes,” the case study reported. He was effectively treated through a multi-disciplinary approach by psychiatrists, psychologists, internal medicine doctors, nutritionists and others.
Moroze and Dunn caution against assuming that anyone who takes healthy eating seriously is in danger of orthorexia.
“There are lots of good reasons for being a vegetarian,” or for adhering to religious practices surrounding foods, or for pursuing other restrictive diets, said Dunn. “This is definitely the extreme end of the spectrum.”
But Gaudiani said the path to orthorexia is paved with small changes and good intentions, and many people who embark on seemingly innocent dietary restrictions may find themselves at risk.
Highly disciplined people often at risk
She described some scenarios that have become familiar to her.
There’s the highly accomplished, driven, intelligent man whose father has had a heart attack. The father may be obese and may have always eaten recklessly. The young man goes to an appointment with a cardiologist with his father, and listens as the doctor warns the man of the serious risks he faces if he doesn’t lose weight and change his diet and his lifestyle.
The young man decides, “I never want this to happen to me,” and embarks on a campaign to eat healthy.
“A lot of my patients are such rule-followers, they are so determined and so self-disciplined, that they take it to extremes,” she said. “Once their brain starts getting starved, they become more and more obsessed, anxious and rigid. Then we see patients entering life-threatening” eating disorders.
Another typical pathway, Gaudiani said, is the person who, as a child, was very intelligent and highly perceptive of other people’s emotions.
“They just had great radar from a very early age,” she said.
The child comes to believe that she must be good all the time, that anything less is unacceptable.
The parents may be anxious people or the child has a sibling who is a rebel. But for whatever combination of reasons, the child never develops a language for expressing emotions.
As a result, the child begins to experience physical symptoms of emotional stress, such as a stomachache. The parents take the child to a doctor, who administers a battery of tests and pronounces the child to be fine.
But the stomachaches continue.
“Now the parents turn to somebody in the naturopathic world or maybe an inexperienced dietitian,” Gaudiani said, “and in 2014, the classic recommendation for a high-functioning young woman with belly pain is to cut gluten or soy or sugar or dairy from her diet.”
The child takes the message very seriously and starts losing weight because of the dietary restrictions. Then friends and family members begin complimenting her on her weight loss, and before long the child has a full-blown eating disorder.
“In 2014, weird ideas about nutrition and the magic of weight loss, body size and shape and the glory of fitness get wonderfully accomplished, delightful people into grave medical trouble,” she said.
Dunn and Moroze acknowledge that orthorexia nervosa is not yet recognized by the Diagnostic and Statistical Manual of Mental Disorders.
“We still have a great deal of research to do on the condition,” said Moroze. The team hopes that the criteria they developed will be tested and refined, and enable researchers to determine how common the condition is.
The criteria differentiate orthorexia nervosa from anorexia nervosa by the motivations that inform the patients. Orthorexia patients usually are not obsessed with losing weight and don’t have distorted images of their own bodies, like persons with anorexia nervosa. What keeps orthorexic patients from eating is an extreme drive to limit their diets to what they perceive to be the purest, healthiest foods they can find.
Not all dietary restrictions are bad
“I want to be very respectful,” said Gaudiani. “There are people, my mom included, who do better on a gluten-free diet.”
Her mother has not been diagnosed with celiac disease, she said, but “just because we can’t quantify the impact yet doesn’t mean it’s not real.”
Dunn emphasized that the spectrum of food-related behaviors is wide and includes perfectly healthy people who use restraint in their eating habits, to people who take food restrictions to a moderately unhealthy level and may be compromising their well-being, all the way to those with a full-blown phobia or eating disorder.
“When do you stop being kooky and start being crazy?” said Dunn. “It’s when your obsession starts interfering with your day-to-day life. That’s where you cross the line.”
Moroze and Dunn said they are amazed by the level of interest in their research, which was published in the journal, Psychosomatics.
“It’s shocking to me how much interest there is in this right now,” said Moroze.
One thing on which they all agree is that moderation is the key to healthy eating.
“There’s no formula,” said Dunn.
“It’s time for us all as professionals, as moms and dads and sisters to change the way we speak about food,” Gaudiani said, especially around young children.
“We speak in dangerous words about food to little people who put teeth under their pillows and believe they will magically turn into money. We have to be little outposts of reason in our families and our communities.”
In her household, just as in the Italian family in which she was reared, Gaudiani said no food is off-limits. “We eat everything, and while we don’t eat gobs of sugar, we certainly enjoy some each day.
“We need to speak truth to the wild nonsense that is taking over the country right now,” she said.
“In America, moderation is not a sexy topic, but it is the future of real health.”