Tara Bannow / WesCom News Service

For more than a year, Aileen turned down breakfast invitations. Lunch was almost always a no. Dinner? Maybe.

“Even with close friends and family, I would just avoid all situations that had to do with food,” said the 23-year-old Oregon resident.

Part of it was to avoid the anxiety that came with eating in front of other people. But Aileen, who is being identified using only her middle name to protect her privacy, said she also felt “obsessive compulsive” about the foods she ate.

“Going out to eat with people prevented me from being in charge of what I was eating, to an extent,” she said.

Aileen’s doctor diagnosed her with anorexia nervosa, a serious eating disorder characterized by inadequate food intake and excessive weight loss, last December. The registered dietitian her doctor referred her to, Frankie Mauti with Bend’s St. Charles Health System, said she saw something else in Aileen’s habits: orthorexia nervosa. It’s an unofficial term, not a diagnosis, which refers to a fixation on limiting oneself, under rigid standards, to a small number of foods that are considered healthy.

Sondra Kronberg, a registered dietitian and spokeswoman for the National Eating Disorders Association, said she believes the shift toward orthorexia she’s seen in recent years is culturally driven. Whereas in the past, popular culture glorified thinness above all, nowadays it’s thinness plus being fit, pure and eating whole, antibiotic- and GMO-free foods.

People genetically predisposed to developing eating disorders are more likely to have obsessive compulsive, perfectionist or rigid tendencies, which means they’re more likely to take those messages to the extreme, said Kronberg, who also serves as executive director of the Eating Disorder Treatment Collaborative, which offers eating disorder treatment services in New York.

“If you take the cultural message that you need to be thin or you need to eat low-fat things, in general, that’s generally healthy for you, me and everybody, and we do that with two words that I use: balance and flexibility,” Kronberg said. “But in somebody whose brain doesn’t work that way, who can only do things all or none or rigidly or perfectly or obsessively, then that message drives them to an extreme.”

Rarely diagnosed alone

A number of mental health and nutrition experts interviewed for this article said orthorexia almost never presents by itself. Rather, it usually accompanies another eating disorder, such as anorexia or bulimia nervosa, which is characterized by cycles of binging and self-induced vomiting.

A June 2015 study in the journal Eating and Weight Disorders found 28 percent of a group of patients with anorexia or bulimia also had orthorexia. That percentage shot up to 53 percent among the same group three years later. The researchers concluded orthorexia could contribute to eating disorder relapse.

Orthorexia is also linked to obsessive-compulsive personality disorder, anxiety, depression and other mental illnesses.

Whereas anorexia and bulimia are focused on the quantity of food being consumed, orthorexia focuses on quality, said Michelle Adams, a mental health therapist with Lutheran Community Services Northwest in Bend who specializes in eating disorders.

“The problem becomes when that list of foods that are healthy or OK becomes so small,” she said. “Even if I’m eating pounds and pounds of broccoli because that’s a food that I feel is OK for me, I’m still not getting protein.”

The American Psychiatric Association does not classify orthorexia as a disorder in its official manual used by mental health professionals. The term was first coined in a 1997 essay by Dr. Steven Bratman, a San Francisco area physician, who wrote that he himself had the disorder at the time. “Ortho” is a Greek prefix meaning straight or correct.

Bratman said he noticed food started to dominate other areas of his life, and even carried “pseudo-spiritual connotations.”

“As orthorexia progresses, a day filled with sprouts, umeboshi plums and amaranth biscuits comes to feel as holy as one spent serving the poor and homeless,” Bratman wrote. “When an orthorexic slips up (which, depending on the pertinent theory, may involve anything from devouring a single raisin in violation of the law to consuming a gallon of Haagen Daz ice cream and a supreme pizza), he experiences a fall from grace and must take on numerous acts of penitence. These usually involve ever-stricter diets and fasts.”

For many people, Kronberg said, the purity they feel they gain through eating healthy and exercising almost replaces typical religious practices like going to church or temple. If those people ate a chocolate-dipped pretzel, they’d feel guilty, she said.

“The value for exercise and eating has shifted a little bit from being just about weight to being about this holy, pure lifestyle or religion,” Kronberg said.

Lots of gray area

Natalie Murphy, a registered dietitian with Central Oregon Nutrition Consultants, said there’s a gray area between a healthy form of paying attention to the ingredients in foods and to their origins and where it becomes problematic.

A person trying to be healthy during the day who slips up at dinner or doesn’t have healthy choices available (say they’re at a party or a restaurant) should be comfortable with that, she said. A person with orthorexia, by contrast, would skip the invite to have dinner with friends or family altogether to avoid having to eat something he or she doesn’t deem as healthy.

“They would just avoid the situation,” Murphy said.

In the event people with orthorexia do wind up eating something unhealthy, there’s self-inflicted punishment.

“That’s where the risk with anorexia or bulimia come in, which may start the purging behavior,” Murphy said. “Or they start the overexercising as a means of purging to rid their body of something they didn’t think was clean or pure.”

Despite the term orthorexia having been around for nearly 20 years, little scientific research has been performed on the subject. Studies that exist have flagged people with certain careers as being at higher risk, such as opera singers, ballet dancers, athletes, bodybuilders and dietitians.

‘It’s controlling you’

If people start noticing they can’t go to anyone’s house for dinner because they can’t eat a meal that’s not 100 percent organic or vegan, they might have a problem, said Carol Hopwood, a psychotherapist and licensed clinical social worker at Lasting Change Counseling in Bend.

“It’s when you get this rigidity that you can’t let go of and it gets a life of its own,” Hopwood said. “It’s like it’s controlling you instead of you controlling it.”

Another typical warning sign, dietitians agreed, is thoughts of food occupying a great deal of a person’s time.

Mauti, of St. Charles, said when patients tell her they’ve adopted vegan diets, it prompts her to ask about their rationale for doing so. If it’s just to remove foods from their diets, it might be orthorexia. The s ame goes for removing any food group from one’s diet, such as grains or dairy.

When Mauti identifies orthorexia in patients, she tries to challenge their rigid ideas about food by reintroducing certain foods into their diet that they’ve taken out. If it’s sweets, she’ll prescribe a few desserts a week.

“So they can see, ‘I can still eat dessert. I don’t gain weight. I’m not unhealthy,’” she said. “Just trying to repair the relationship with food so you’re able to come back to the place of flexibility, variety, less stress with eating.”

For many people, recovery takes an integrated team composed of a physician who can monitor physical changes, a dietitian who can help the patient with food and nutrition and a therapist who can work on control and perfectionism, Murphy said.

For Aileen, who said she has recovered from her eating disorder, having that team of three providers working together made a big difference. Her doctor told her she had bradycardia, or a slow heart rate, which is a common side effect of anorexia. She said Mauti’s insistence that she would feel more confident once she gained the weight back turned out to be true.

Ultimately, Aileen said she knew what to do and how to get there but wasn’t going to until she felt the time was right.

“Until I felt ready in my life to move forward, I wasn’t going to pull the trigger and make those things happen,” she said.

Today, she said she no longer restricts food. She’ll eat an extra piece of pizza if she wants to, and she enjoys a bowl of ice cream every night. She doesn’t run obsessively like she used to, but she goes mountain biking and does yoga daily.

“I’m a completely, completely different person than I was then,” she said.