Last spring, I was honored to be asked to write the foreward to Jordan Younger’s memoir, Breaking Vegan. The book is now available in print. I expect it to have a major impact on public awareness of the concept of orthorexia nervosa, especially in her demographic, and will be of help to many who have gone down a similar road. I highly recommend it.

Breaking Vegan is also fodder for reams of hatemail, written almost if not entirely by those who have not read the book. I understand the instinctive protectiveness of vegans for veganism, but this book does not in any sense attack, disparage or criticize veganism! It was partly to protect against this natural but seriously mistaken reaction that I wrote my introductory words.

Note to vegans: Many of you find the title disturbing. I have been asked, “Why didn’t she call it ‘Breaking Orthorexia?'” Honestly, I personally would have loved the title to include the word I invented. But that would have been a truly terrible title. And, anyway, veganism (or, at least, plant-based diet) IS part of Jordan’s story. It’s also part of the story of many other people with orthorexia, and, because of this, I believe the title is perfectly appropriate, even if potentially misunderstood.

I do understand fears that the title itself will bring down criticism on the vegan lifestyle. Unfortunately, it is impossible to perfectly serve all audiences simultaneously; every choice is a compromise, and every possible title will have its own issues. And I constantly hear Jordan publicly stating words to the effect of: “Veganism is great! It’s healthy and ethical. However, in some susceptible people, it can cause problems. I am one of those people. Here is my story.” Seriously, she’s not your enemy.

Below is the “director’s cut” of the foreward, as originally written, a bit longer than what is printed in Breaking Vegan.

Orthorexia Nervosa: The Health Food Eating Disorder

How can eating healthy food become an eating disorder?

On its face, the idea sounds ridiculous. We live in a society where high fructose corn syrup infests the supermarket shelves, antibiotics and other chemicals pile up in the food chain and obesity starts in childhood. Wouldn’t any intelligent person interested in their health want to find a better diet than the one that is on offer?

Yes of course!

Choosing healthy food does not equate to orthorexia. People can adhere to just about any theory of healthy eating without having an eating disorder (with the only caveat that such a diet must provide adequate nutrients). For example, veganism itself is not an eating disorder. Far from it. Veganism can be a wonderful, admirable healthy lifestyle, and its ethical and environmental motivations are exemplary.

Nonetheless, some people who are devoted to healthy eating develop an eating disorder in relation to that focus. Some vegans become orthorexic.

Consider the analogy of body weight. Everyone agrees that it is unhealthy to become overweight, and that it is sensible to avoid obesity. However, in connection to this goal, and in combination with other psychological factors, some people develop anorexia nervosa. A similar process can happen with healthy food. Just as some people in their quest to maintain healthy body weight go down an emotionally and physically unhealthy path, some people in their quest to eat healthy food develop orthorexia nervosa.

Orthorexia is not the same thing as devotion to healthy food. The latter is a conscious choice. Orthorexia an obsession with healthy food that involves other emotional factors and has become psychologically and perhaps even physically unhealthy. It is an eating disorder. [NOTE: For more information on the distinction, see Healthy Eating vs. Orthorexia.]

The Origin of “Orthorexia”

When I invented the term “orthorexia nervosa” 20 years ago, I didn’t realize I was naming an eating disorder. I was practicing a form of “tease therapy.”

I practiced alternative medicine at the time, and although I was a proponent of healthy diet I thought a few of my patients took it too far. I remember one in particular who began every visit by asking, “Doctor, what food should I cut out of my diet?” I came to feel that she did not need to cut anything out; rather, she needed to relax the grip of her mind and live a little.

However, because I had once been a raw food vegan myself (and, at other times, a follower of macrobiotics) I understood how difficult it would be for her to hear this. To ask her to lighten up on her diet was tantamount to asking her to embark on a life of crime. “Go and commit some larceny. It will be good for you.” She saw healthy diet as pure virtue. How can one lighten up on a virtue?

As a devious therapeutic technique, I decided to stand her virtue on its head by calling it a disease. I consulted a Greek scholar, and coined the term orthorexia nervosa. It is formed in analogy to anorexia nervosa, but using ortho, meaning “right,” to indicate an obsession with eating the right foods.

From then on, whenever this patient would ask me what food she should cut out, I would say, half tongue-in-cheek, “We need to work on your orthorexia.” This made her laugh, and ultimately it helped her loosen the lifestyle corset. She moved from extremism to moderation.

Later, I published a funny article on the subject, and then a humorous book with a bad cover color scheme. I didn’t take my own idea too seriously. I was just trying to get a few overly obsessed health foodists to take a look at themselves.

It was only after the publication of the book that I began to realize I had tapped into something bigger than tease therapy: I learned that there are people who die of orthorexia.

That was a shock. I understood that people can make themselves crazy with healthy diet , but not that the problem can lead to death. However, orthorexia truly can kill, via malnutrition. People with this kind of severe orthorexia don’t think they’re too fat; they think they’re impure. They want to cleanse, not to lose weight. The conscious motivation is quite different.

Because the concept of orthorexia was still little known, eating disorder specialists didn’t ask the right questions. They would say to such people, “You think you are too fat.” But that is not what it feels like to be orthorexic. This misunderstanding led to treatment failure, with occasionally tragic results.

Even when orthorexia is not fatal, it can commandeer a person’s life. Eating disorders have that power.

The Power of a Word

Later, serious academic study of orthorexia began to occur. Organizations like the International Federation of Eating Disorder Dietitians (IFEDD ) and the National Eating Disorders Association (NEDA) began to discuss the concept at meetings and in their published literature. Thom R. Dunn Ph.D of the University of Northern California published a formal article on a case of orthorexia, and proposed diagnostic criteria. [Note: Dr. Dunn and I will be soon be publishing revised criteria that we expect to be definitive.] The authors of the DSM, the American Psychiatric Association’s classification and diagnostic tool, were even quoted as considering it for inclusion.

Perhaps most important of all, young women like Jordan Younger can now say to themselves, “I want to eat healthy food, but I don’t want to be orthorexic.”

Naming is powerful. When it comes to food, we need all the power we can get, because food can make you crazy. It hits you in the heart and goes to self esteem. It taps into all that is lonely and empty and needy, and promises to fill that emptiness. It triggers dark places. It can tie up your mind in knots so intricate and strong that even the search for healthiness can become unhealthy.

Against this, the word orthorexia is a signifier. It indicates a limit, a point not to go beyond even in search of healthy diet. Or, if you’ve already gone beyond, it can help you find your way back.

This is what happened for Jordan. After achieving fame as proponent of veganism, she came to understand that she had orthorexia. Since then, she has been liveblogging her awakening. I do not in general recommend live blogging as a method of recovery, but it is brave. Bravery is powerful and it is healing.

Do You Have Orthorexia?

Do you wonder if you have orthorexia? Read this book. Jordan’s journey does not describe every person’s path; it is personal to her demographic, her childhood, herself. But if you have orthorexia you will recognize yourself here.

Do you turn to healthy food for happiness, for meaning?

Eating the perfect diet might make you less likely to get cancer, and it could prevent bloating and give you more energy. But it won’t make you happy. Using food as primary refuge is a form of spiritual materialism. You are filling the space that longs for love with mere stuff. To quote Jordan, “I was entering into a relationship with veganism …. veganism became my boyfriend, my best friend, and my confidant.”

Does your healthy diet make you feel important? “The strict diet helped me feel extraordinary when I was very fearful of being ordinary.”

Does healthy diet make you feel in control? Do you have to keep upping the ante to get the same kick? “[Veganism] triggered a desire within me to be more and more extreme, more and more pure, and to achieve more and more nutritional perfection to the point where no foods were safe. ”

Do you use diet to ward off anxiety, not just about health, but about everything? Has the idea of healthy food become a kind of brain parasite, taking over your life, ceasing to serve you and instead making you its slave?

If you recognize yourself in any of this, read this book. If it resonates, consider consulting an eating disorders specialist who appreciates orthorexia. It may change your life. It may even save it.

— Steven Bratman, MD, MPH