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When Natalie Mae* was struggling to become pregnant three years ago, she was willing to do anything to up her chances, including heeding a fertility doc's suggestion to lose 15 pounds to reach her ideal BMI. "I started hitting the gym every day for two to four hours, eating healthier foods and counting calories religiously," she says. She pushed herself so hard that she passed out at work and had to be taken to the ER in an ambulance -- twice. "Because I was a little overweight, doctors never asked me about my eating or exercise habits," recalls Natalie, now 31 and a teacher in Tucson, Arizona. "Finally, I became so frustrated -- I was doing all the right things but still wasn't pregnant -- that I asked for a referral to a dietitian." Food and workout logs in hand, she went to the appointment assuming she'd be told how to eat less and exercise more. Natalie was shocked by the dietitian's response. "She said that she wasn't worried about my eating too many calories; she was concerned that I wasn't eating enough. She explained that I probably had an eating disorder and an addiction to exercise," she says.
At her lowest weight of 125 pounds, 5-foot-2-inch Natalie looked perfectly healthy, but she had made herself mentally and physically sick in order to attain that ideal number. Doctors have begun to refer to this sort of problem as orthorexia, or overly correct eating.
"Orthorexia is a new illness with many gray areas," says eating disorder specialist Ira Sacker, MD, a FITNESS advisory board member. "Orthorexics often also suffer from exercise addiction and may have symptoms that overlap with anorexia and bulimia." It's such a new phenomenon, it has yet to be included in diagnostic manuals. But one aspect of orthorexia makes it clearly different from other eating disorders: "While anorexics and bulimics typically recognize that their behaviors are harmful and feel shame about them, orthorexics believe they're doing something good for themselves," explains Jodi Krumholz, RD, the director of nutrition at the Renfrew Center of Florida, an eating-disorder treatment clinic in Coconut Creek.
Since 2008, the number of hospital stays for eating disorders other than anorexia and bulimia -- known as "eating disorders not otherwise specified," or EDNOS -- has grown by 30 percent, with the highest proportion of cases among adults ages 18 to 44, according to the federal Agency for Healthcare Research and Quality. Some experts see a link between the trend and the emergence of orthorexia. "It's a big problem for a lot of women in their twenties, thirties, and forties," says clinical psychologist Margo Maine, PhD, a FITNESS advisory board member. "They start off with the best intentions, eating healthy foods and working out, then a compulsive pattern develops and turns into a true disorder." When that happens, the organic-food aisles and fitness studios that most of us breeze in and out of become the center of an orthorexic's life. "I've seen women who belong to multiple gyms so that they can take several exercise classes a day," Krumholz says. "Others will swear off one 'unhealthy' ingredient after another until there's barely anything they feel safe eating."
The same women who seem admiringly disciplined about their raw-food diets and 5:00 a.m. runs can be dangerously out of control. "An orthorexic will often be so convinced her behavior is healthy that she doesn't realize she needs help until her fixation on food and exercise takes a terrible toll on her body or starts to destroy other aspects of her life," Krumholz says. The more restricted an orthorexic's diet, the less likely she's getting the nutrition she needs, which can trigger a host of health problems, including anemia, hormonal dysfunction, low blood pressure and heart failure. "Unfortunately, instead of feeling exhausted because of overexercise and lack of nourishment, the thrill of control often fills orthorexics with energy and excitement, driving them to push harder to the point of injury or severe illness," Dr. Sacker says. As their obsession grows, so does their eating disorder -- approximately 40 percent of people with EDNOS go on to develop anorexia or bulimia within two years. The good news: You can stop orthorexia before it reaches that point.
When a normal-weight friend skips one social event after another for Spinning class or looks visibly distraught after nibbling a brownie at an office party, you may think she's being too hard-core, but you probably don't suspect that she has an eating disorder. She might. Such behaviors are bigger red flags than a sinking BMI. In fact, a below-average body weight is no longer a criterion even for anorexia, according to diagnostic guidelines updated last year. And while someone with orthorexia may drop pounds as a side effect of restrictive eating, she's typically more focused on eating right and getting fit than becoming stick thin.
"When assessing a patient for any eating disorder, including orthorexia, we look for a fear of gaining weight, eating the wrong thing or not exercising. Is the person obsessively checking her body in the mirror? Is she dominated by thoughts of food?" says Jane Miceli, MD, the medical director of adult services for the Eating Recovery Center in Denver. Another sign that therapists watch for is a level of self-discipline that goes beyond what's rational. "Anytime someone is exceedingly strict about their eating or exercise habits to the point of neglecting close relationships or becoming agitated if they slip up in some way, it's a reason for concern," Dr. Miceli says.
What causes a health-food devotee and avid exerciser to cross the line from passionate and committed to pathologically obsessed? Heredity, for one. "Between 50 and 75 percent of the reasons some women develop eating disorders and others don't can be attributed to differences in their genes," says Kelly Klump, PhD, a professor of psychology at Michigan State University. "The specific genes involved are still being identified, but we know they are closely associated with those that control anxiety and/or depression." Women who exhibit certain personality traits are also at higher risk, research shows. Perfectionists, for example, may be vulnerable because they place a high value on self-discipline and attaining the perfect body.
When something stressful happens -- starting or losing a job, going through a breakup -- women who are genetically predisposed to these disorders may be more likely to turn to compulsive eating and exercising as a coping mechanism. "Transitional events like these can set off an eating disorder because they can leave a person feeling anxious and powerless," says Cynthia Bulik, PhD, the director of the University of North Carolina Center of Excellence for Eating Disorders and author of Midlife Eating Disorders: Your Journey to Recovery. Hypercorrect eating and exercise are ways to compensate -- and help sufferers regain a false and temporary sense of control.
Often an orthorexic will become socially isolated as she attempts to avoid all people and situations that could get in the way of her supposed health goals. Social media makes it easy to stay in denial.
By the time Wendy Greene admitted herself to an eating recovery center in 2011, she had alienated her real-world friends and was using Facebook to create an online life in which her food restrictions and over-the-top workouts were viewed as inspirational and glamorous. "You start to identify so much with the character you've created for yourself," says Wendy, 31, a former CrossFit instructor in Cheyenne, Wyoming. "The more positive the reinforcement, the more obligated you feel to maintain that front." It wasn't until she started seeing a therapist for a different problem that Wendy realized she had an eating disorder. "I had no idea it was controlling my life," she says. "I had convinced myself it was normal behavior -- obsessively counting calories, constantly monitoring my appearance, and avoiding relationships that interfered with my eating and exercise routines. Therapy helped me see how it was all connected and that, even though I wasn't underweight, I had an eating disorder that needed to be addressed."
Even if you're not posting #sweatyselfie and #cleaneats shots to Instagram every day, too much social media can be dangerous. A recent study found that female college students who spent the most time on Facebook had the highest levels of disordered eating; this was especially true of those who placed greater importance on comments and likes on their posts. Because women use the site to seek approval, it may increase pressure to conform to certain ways of eating and exercising, explains study author Pamela Keel, PhD, a professor of psychology at Florida State University.
Wendy wishes that she could use social media now without having to worry, but orthorexia makes that impossible. "I have to check myself constantly when I eat, when I work out, when I'm online," she says. "I ask myself, Why am I really doing this?"See Something, Say Something
Both Natalie and Wendy were lucky -- they happened to be seeking treatment for other reasons and their eating disorders were exposed. But if you suspect that you or someone you know is becoming orthorexic, find help.
Take an online screening test for eating disorders and search for treatment centers and specialists near you at nationaleatingdisorders.org. If you're trying to help a loved one, brace yourself. "I dismissed anyone who expressed concern for my safety as clueless; they just didn't understand the kind of sacrifice it took to be ultrafit," Wendy admits. Still, the worst thing you can do is wait. "Once a person is deeply invested in her eating disorder, whatever you say will go in one ear and out the other," Dr. Sacker says. He suggests saying something like "I know you don't think there's anything serious going on, but just get an evaluation, and do it for me. I'll go with you."
Even if a woman accepts that her habits are extreme, she may be afraid to take that first step. "There's a fear that getting an evaluation means you'll be on the psychotherapy couch for years, but that's not the case," Dr. Bulik says. You may need only a simple self-help book, a few sessions with a dietitian, or short-term treatment at a hospital.
Also, if an orthorexic looks healthy, she may feel self-conscious walking into the same recovery center where some emaciated patients are struggling to stay alive, even though everyone is suffering equally inside. "I thought I would be the fattest one there and that they would tell me that I didn't have an eating disorder after all," Natalie says. "But I talked with the other patients and realized how many of my behaviors and thought processes were actually disordered. I had no idea!" Six weeks after Natalie returned home from treatment, she found out she was pregnant. She says, "Turns out, all I needed to do was eat more and not exercise so darn much."
*Name has been changed to protect her privacy
Given that so many fitness-loving women run marathons and try paleo diets for fun, it can be tricky to determine if you're just another health nut or a dangerously fixated one. "Some things to look for are guilt for not sticking to your eating regimen, turning down opportunities to socialize because they could interfere with eating healthfully, prioritizing food and exercise over your relationships or job, and thinking about your diet and workouts at times when you should be focused on something else," says Dr. Bulik. Some prime examples:
Healthy: You sleep through your alarm and don't have time to do the tempo run on your half-marathon training schedule, so you do it when you get home from work.
Obsessive: You sleep through your alarm and don't have time to do the tempo run on your half-marathon schedule, but you do it anyway, show up late for work and miss an important meeting.
Healthy: You eat a decadent dessert at a friend's birthday dinner and think, Well, at least I worked out today!
Obsessive: You eat a decadent dessert at a friend's birthday dinner and think, That's the last time I'm eating out with friends!
Healthy: You're so into your new high-protein, low-carb diet that you think about it all the way to the grocery store.
Obsessive: You're so into your new high-protein, low-carb diet that you think about it during sex.
Healthy: You have no time to cook, so you scan a takeout menu, attempting to choose something that isn't a total fat and calorie bomb.
Obsessive: You have no time to cook, so you scan a takeout menu, attempting to calculate the exact number of calories and fat grams in each option.
Healthy: You strain a quad in Spinning class, so you take a week off before getting back in the saddle.
Obsessive: You strain a quad in Spinning class, so you ice it, heat it, wrap it, pop some ibuprofen and get back in the saddle the next day.