Kristie Rutzel was in high school when she began adhering precisely to the government food pyramids. As the Virginia native learned more about healthy eating, she stopped ingesting anything processed, then restricted herself to whole foods and eventually to 100% organic. By college, the 5-ft. 4-in. communications major was on a strict raw-foods diet, eating little else besides uncooked broccoli and cauliflower and tipping the scales at just 68 lb. Rutzel, now 27, has a name for her eating disorder: orthorexia, a controversial diagnosis characterized by an obsession with avoiding foods perceived to be unhealthy.
As the list of foods to steer clear of (bye-bye, trans fats and high-fructose corn syrup) continues to grow, eating-disorder experts are increasingly confronted with patients like Rutzel who speak of nervously shunning foods with artificial flavors, colors or preservatives and rigidly following a particular diet, such as vegan or raw foods. Women may be more prone to this kind of restrictive consumption than men, keeping running tabs of verboten foods and micromanaging food prep. Many opt to go hungry rather than eat anything less than wholesome.
Yet when Rutzel first sought help for anemia and osteopenia, a precursor of osteoporosis triggered by her avoidance of calcium, her doctor in upstate New York, where she attended college, had never heard of orthorexia. "You should be trying to eat healthy," she remembers him telling her. He couldn't quite grasp that he was talking to a health nut who believed there were few truly healthy foods she felt were safe to eat. Her condition was eventually identified as anorexia, a diagnosis that organizations like the Washington-based Eating Disorders Coalition think is a mistake. The group, which represents more than 35 eating-disorder organizations in the U.S., wants orthorexia to have a separate entry in the bible of psychiatric illness, the Diagnostic and Statistical Manual of Mental Disorders (DSM).
For the past decade, psychiatrists have been working on the fifth edition of the DSM referred to as DSM-V to refine the classifications used by mental-health professionals to diagnose and research disorders. Without a listing in the DSM, it's tough to get treatment covered by insurance. And for researchers angling for grant money, a disorder's absence from the DSM makes it hard to get research funded.
On Wednesday, the first draft of DSM-V was published online, kicking off a three-year process of public comment and further revisions that will culminate in a new and improved version come 2013. Orthorexia is not listed in this new draft and, despite the ongoing efforts of various eating-disorder groups, is unlikely to make its way into the final edition.
"We're not in a position to say it doesn't exist or it's not important," says Tim Walsh, a professor of psychiatry at Columbia University who led the American Psychiatric Association's work group that reviewed eating disorders for inclusion in DSM-V. "The real issue is significant data." Getting listed as a separate entry in the DSM requires extensive scientific knowledge of a syndrome and broad clinical acceptance, neither of which orthorexia has.
Most doctors think a separate diagnosis is unwarranted. Orthorexia might be connected to an anxiety disorder or it might be a precursor to a more commonly diagnosed condition, says Cynthia Bulik, director of the eating-disorders program at the University of North Carolina at Chapel Hill. "We don't want people to be mislabeled and not get the care they need because they're actually on the slippery slope to anorexia," she says.
Kathleen MacDonald, who oversees legislative policy at the Eating Disorders Coalition, agrees with Bulik that people should get the care they need. Which is precisely why she thinks orthorexia should have its own classification. Although Bulik and others often use cognitive behavioral therapy, in which patients like Rutzel are coached to replace obsessive thoughts with healthy ones, MacDonald worries there is not enough known about which treatments work best for orthorexia. "It's hit-or-miss," she says.
After seeking help at three different facilities, Rutzel finally embraced a program of meal plans that challenged her to gradually incorporate foods she had blacklisted. Still slim in a size 2, she is engaged to a man whose oldest daughter is 9. And Rutzel says she is looking forward to sharing her experiences with food with her soon-to-be stepdaughter. "It's O.K. to eat potato chips and Pop-Tarts," says Rutzel, "but only every now and then."