Orthorexia nervosa: When watching what you eat becomes destructive

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Michael Inglis is a sports psychologist who’s worked with professional and amateur athletes across a range of sports, including cycling. In this article he tackles the troubling issue of eating disorders among cyclists. More specifically, he looks at an eating disorder that seems to be on the rise and that is only now getting the attention it deserves: orthorexia nervosa.

It’s common for athletes to walk into a session with a sports psychologist wanting to balance out how much and what they eat while they’re training. While specific assistance on this is referred on to a sports dietitian, much of the complication in athletes’ approach to food is psychological.

For cyclists, the subject normally comes up because they’re motivated to lose weight, believing this will lead to a direct improvement of performance. However, many cyclists are competing at an endurance level so they also need to get in enough fuel to train and race to their best of their ability.

A psychological tightrope has been created — the athlete needs to eat enough calories so that they can perform, but slightly less than they burn. This way they can lose weight and be able to climb hills more efficiently thanks to higher power-to-weight ratios. But it’s not hard to see how this can lead to disordered eating.

Cycling, along with many sports, has athletes who present with clinical eating disorders such as anorexia and bulimia. Anorexia is characterised by a refusal to maintain a minimal weight and bulimia involves repeat binge-eating episodes followed by compensatory behaviours such as vomiting, the use of laxatives, fasting and excessive exercise. These are common psychological conditions present in the community generally, but I have also noticed a growing trend towards bulimic-type behaviours (high training and low food intake) among cyclists.

The other growing trend among cyclists is orthorexia nervosa.

Orthorexia nervosa (or ON for short) is a newly recognised pattern of disordered eating behaviours that involves a preoccupation with only consuming foods that are pure and nutritional. Preoccupation can lead to lower concentration, higher anxiety and less social connection to those affected. Unlike other disordered eating patterns, ON relates to the quality of food consumed, rather than the quantity.

While ON is not yet formally recognised as a mental health condition under diagnostic systems (such as the Diagnostic and Statistical Manual – DSM-5) it can lead to significant distress and negatively impact a person’s quality of life. The purity and nutritional value of food is highly debatable and can lead to high levels of distress when faced with avoided foods: malnutrition and in extreme cases, starvation. Furthermore, there is the psychological strain it puts on individuals with ON who become obsessive about what they do or do not eat.

Warning signs include compulsive checking of ingredient lists and nutritional labels, cutting out an increasing number of food groups, and spending hours per day thinking about what food might be served at upcoming events. Body image concerns may or may not be present.

Constantly obsessing over what you eat has the potential to be damaging.

Therapeutically, I notice that athletes have become more punitive than ever about what they consume in search of the purist intake to fuel their bodies. This comes from performance anxiety as they strive for outcomes they believe they can’t get with their current diet. Often they want to be lighter, again for performance outcomes (as opposed to being ‘skinnier’).

Cyclists with ON put themselves in a situation where they need fuel to race for hours and climb mountains, but also want to be light as possible and fuelled with the “right” foods to maximise endurance, climbing and a sprint to the line. It has been observed that most cyclists self-report to be on the ‘lighter’ side rather than ensuring they have ingested enough calories to perform to the line. They’ll then make adjustments from there in regard to slowly adding more food to their pre-performance regime.

However, this comes at a cost. Malnourished athletes don’t tend to recover as well from training/racing and more often become ill and fatigued as a consequence.

Researchers T.M. Dunn and S. Bratman have proposed diagnostic criteria for ON that highlight obsessive and compulsive behaviour, mental preoccupation, as well as clinical impairment in regard to the individual’s relationship with dietary theory. They further highlight the notion of emotional distress that includes shame, guilt and anxiety often seen in other psychological presentations, including eating disorders.

This suggests that ON presents a similar amount of distress and disturbance of functionality to what we would often see with other psychological conditions listed in the DSM-5.

Little research has been conducted specifically about ON and athletes, however there has been other research that can be linked to athletes, such as that on personality traits. A study by C. Oberle, R.O. Samaghabadi, and E.M Hughes found that traits such as perfectionism and narcissism are related to ON. It is common for athletes to have perfectionistic traits as they are in constant pursuit of improvement and maximising performance. As a result, it is likely they are at greater risk of ON.

People who identify themselves as having a lean, more musculature physical shape are at higher risk of ON. Again, this represents a large part of the athlete community. Another study identified that involvement in elite sports puts individuals at greater risk of ON due to the extreme physical demands required. In addition, another study found that excessive exercise was highly correlated with ON.

Overall, the above findings suggest athletes such as cyclists are at more risk of ON due to the environment they compete in and the personality traits they are more likely to exhibit.

As it is a recently identified condition, there are currently no clinical treatments developed specifically for ON. However, eating disorder experts consider orthorexia to include features of anorexia nervosa and obsessive-compulsive disorder, and it is often treated in a manner similar to these conditions. Specifically, treatment usually involves psychological therapy to increase the variety of foods eaten and exposure to anxiety-provoking or feared foods. It may also require a weight-restoration program typically seen with anorexia.

In my opinion the cycling community faces a challenge with all eating disorder conditions, with ON being a more subtle version that we may not recognise early. With such a focus on peak performance, and a desire to get an edge on competitors, cyclists are at risk of putting their health in danger as they overreach for success.

I personally have had athletes present to me with diet-related conditions that have led to chronic fatigue, burnout, malnutrition, anxiety and depression. Generally speaking, it would be good to see more education provided to athletes, team directors and staff — including coaches — to help create great awareness about eating disorders in sport, and help to provide early intervention for those in need.

Some key early warning signs that you might be developing ON includes any disturbance of usual functioning. This includes interrupting sleep as you continue to obsess about food choices, unable to complete sessions or to the same quality you usually would due to poor concentration, not enough energy or poor time management due to food choices. Furthermore, look for signs of mood disturbance such as agitation and anxiety, particularly when making food choices. If you are concerned about yourself at any stage, please consult a psychologist and/or dietician.

About the author

Michael Inglis is an endorsed and accredited sport, performance and exercise psychologist and has been working in the mental health field since 1999. Michael leads the sport and performance team at The Mind Room, a mental health and wellbeing centre he co-founded in Collingwood, Melbourne.

Michael works with athletes, coaches and teams to build and enhance performance, wellbeing and leadership skills. Some of the teams Michael has worked with include the Holden Cycling Womens’ team, the North Melbourne Football Club and the Melbourne Rebels rugby union team. He is a keen cyclist and father to three active boys.

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