On asking Janet Hackney when she last went out to a restaurant, I am met with a long silence. "It must be about five years ago," she says finally, "on my mum's 70th birthday. A group of us went to a restaurant where the owners know me and they assured me that they would be able to provide food that I could eat, cooked exactly as I wanted. You can't get that very often, though, can you? So I usually don't go out. It's sad, really, how it ruins your social life."
For Hackney, an obsession with eating only specific foods, cooked in certain ways, stretches back more than three decades. At 5ft tall and weighing just five stone, she was diagnosed with anorexia long ago, and concedes that she eats an anorexic diet (with the osteoporosis and chest pains to prove it), but insists that her disorder was never about the desire to be thin. Instead, she says, her food obsessions have been dictated by the pursuit of health, an ache to fill her body only with foods that are good and nutritious and "pure". The roots of it, she says, are therefore much more accurately defined by another label entirely: orthorexia nervosa.
Taken from the Greek "ortho" (meaning "correct" or "true"), this term was first coined by a Californian doctor, Steven Bratman, in 1997, to describe a "fixation on righteous eating". It refers to people who, while generally not as extreme in their limitations as Hackney, are obsessed with healthy eating, concerned with quality rather than quantity, refining and restricting their diets according to their own personal understanding of which foods are truly pure. Any foods containing pesticides, herbicides or artificial additives, such as MSG, are often ditched, although regimens can vary wildly from person to person, with many orthorexics being, for instance, raw foodists, vegans, fruitarians or, in one notable case that Bratman came across, committed to eating only yellow foods.
For Hackney, this compulsion began at the age of 10 when she eliminated all the obvious processed gremlins from her diet - chips, crisps, chocolate. Soon afterwards, she gave up eating fats. This was followed by the exclusion of carbohydrates and a whittling away of proteins that has left her eating primarily chicken and turkey, low-fat yoghurt and low-fat cheese. In an effort to gain weight, she has begun to eat the occasional sliver of butter again, but can't keep the tub in her own fridge. "Just the thought of having a tub of Lurpak in there makes me feel awful and dirty. I really don't like to touch it, so my mum keeps a tub at her house and brings it over. I put some in a beaker, so that no one could know what it is unless they tasted it."
While orthorexia rarely causes major health problems, it regularly leads to social exclusion and alienation - which, as Bratman has noted, are serious side effects. One of his patients, he observes, doesn't have a life: "All she has is a menu." Most orthorexics, would, like Hackney, find it difficult, if not impossible, to visit an average restaurant. They spend hours each day thinking and talking about food, making meal plans, scanning the latest food research on the internet, visiting organic farms for "perfect" produce and slowly preparing, serving and chewing their food. One orthorexic I came across in California hadn't eaten out in years and consumed nothing but grains: primarily popcorn. Another was so obsessed with organic food that she spent hours in the healthfood shop, arguing with the assistants over which foods were packaged using organic paper and adhesive and were therefore "uncontaminated".
And it seems that we are living in a uniquely orthorexic moment. There are regular food scares in the press (the colourant Sudan 1, avian flu, salmonella contamination at a Cadburys plant) and constantly conflicting messages, particularly on the internet, about the health benefits of specific foods. Anxiety and confusion regarding how best to nourish ourselves are huge, and growing. Restrictive diets crowd the bookshop shelves (including hundreds of fasting and detoxing programmes) and the market in so-called "free-from" foods (products that don't contain gluten, say, or wheat) has boomed by 300% in the last five years. In 2005, sales of organic food also leapt up by 30%. In this environment, where mass consumer choice meets information overload, anyone who really commits themselves to healthy eating can find that one dietary refinement leads very quickly to another, the apparent depth of their knowledge jeopardising the breadth of their diet.
And, in this atmosphere, too, a marked quirkiness around food has become a source of fascination, even admiration. Where "that quirkiness used to reduce your status," says Deanne Jade, a psychologist, and founder of the National Centre for Eating Disorders, "the attachment to strange eating systems and theories is now supported by a thriving industry and actually gives people a sense of status. So, for instance, when you go to a dinner party now, it's quite usual for people to say, 'Oh, I don't eat protein and carbs together, or I don't eat anything with the letter R in it, or on Tuesdays I can only eat red things.' And people are tolerant of that. The quirkiness has got a seal of approval."
David McCandless, a writer and journalist, first heard about orthorexia when one of his friends, a health writer, accused him of having it. "She was appalled by the contents of my fridge," he says. "At the time I was quite into Japanese food so I just had lots of organic hemp seeds in there and miso, and fresh seaweed. There was no chocolate, no Kettle chips, none of the usual stuff."
McCandless doesn't think that he is orthorexic but admits, "I don't know anyone more pathological about food than me. I constantly revise and revisit my diet. I've cut out caffeine. I've cut out dairy. I've been a vegetarian for 15 years and I'll probably never eat meat again. I don't eat soya - certainly not industrialised soya. I've just started on non-fat yogurt again. I have all these little rules. Five portions of fruit and veg a day is fine for Joe Public - I aim to eat 10 minimum. I've recently got back into fish again too, which I had cut out. Then I read an article about fish stocks being polluted and I had a little tremor of anxiety and almost went running straight back to my hemp seeds." He laughs. "Maybe I'm exaggerating slightly."
As McCandless sees it, the apparent rise in orthorexic behaviour is at least partly because "There is no single authority any more that can tell us what's safe or not. There is no consensus on what's good for you.'
Recently in this paper, for example, it was reported that the safety of phyto-oestrogens (plant hormones) found in soya - often touted as one of the healthiest foods - was under investigation. For many people, especially vegans and vegetarians, this was frightening news. Having thought that they were following the healthiest diet possible, embracing soya as a mainstay of that diet, they were faced with the possibility that they had been eating a potentially "toxic" substance and perhaps having to cut yet another food from their already restrictive diet.
Among the qualities Bratman has defined as specific to orthorexics are an eagerness to evangelise about their regime and a conviction that their dietary path makes them a more spiritual person. McCandless does recognise these characteristics. 'It's almost spontaneous,' he says. "As soon as you start eating healthily there's a smug, self-righteous, judgmental, puritan, religious feeling that descends. I'm really proud, for instance, when my lacto-ovo vegetarian kosher airline meal is delivered to me first on the plane."
He says eating like this is "almost like a form of devotion. We don't have a devotional culture any more, really, but now people can devote themselves to their body and it really does become a temple."
As for people who just eat what they like, McCandless says, "They will die." I try to point out that everyone will die, but he jumps back in. "It will kill you. You will be dead. Who wants to die at 55? I don't want to die at 55. I want to live to 178!'
For all McCandless's fervour, his rejection of the orthorexia label seems fair - he eats out regularly with friends, for instance, and can recognise when his eating becomes "pathological". For many of those who start on this path though, the adherence to a strict diet masks more pressing psychological concerns. Mary Wood, a psychotherapist and chief executive of the charity Foundations UK, which provides information for young people in schools and community centres on how to negotiate the "toxic environment" surrounding food, says that for some people orthorexia is the only way they know of asserting themselves, of creating an identity and establishing themselves as someone special. Diet becomes their primary or sole distinguishing factor.
"I think one has to look behind the orthorexic behaviour," she says, "and ask why they need to assert themselves in this way." She also recognises that orthorexia provides a welcome excuse for some sufferers to avoid relationships: "Instead your relationship ends up being exclusively with raw or organic food. Having a relationship with anyone else would intrude on that and it gives you a perfect excuse not to examine the real reasons why you can't be intimate with other people."
There is still confusion over whether orthorexia should be recognised as a separate and specific eating disorder. In 1997, when Bratman coined the term, many experts contended that it couldn't be a new disorder because a) in its less intense forms "orthorexic" behaviour isn't a problem - in fact, many experts felt it was very encouraging to see people taking care to eat more healthily. And b) in its more extreme forms it was simply a variant of other established eating disorders, such as anorexia.
Speaking to British experts almost 10 years later, though, there seems more acceptance that it does exist as a separate condition, although no one has done the exacting research that would see orthorexia recognised by the medical establishment. In 2004, researchers at the University of Rome carried out the first study to try to determine the prevalence of it. Out of 400 subjects, 28, or 6.9%, were found to be orthorexic, with the prevalence, interestingly, higher in men than in women).
Steve Bloomfield, spokesman for the UK Eating Disorders Association, sees orthorexia as an obsessive-compulsive disorder. "It is not yet recognised by the medical profession as a disorder in its own right," he says, "but that doesn't mean it doesn't exist.
"That is a fairly fine distinction, but just because bulimia nervosa only had the diagnostic criteria specified and accepted 26 years ago, for instance, that doesn't mean to say it didn't exist 27 years ago - it plainly has existed for hundreds of years."
One of the complications of orthorexia, he says is that, "Every time you refine your diet in an orthorexic manner, you head towards a situation where all you are eating is, say, lettuce. Then you find, obviously, that you are eating an anorexic diet."
This concern about orthorexic behaviour as a gateway to other eating disorders is echoed by others. "Orthorexia can overlap into anorexia quite rapidly and vice versa - an anorexic might try and escape the disorder by adopting an orthorexic approach to eating, which extends that sense of being in control," says Jade. "The personality traits that you see in anorexics and orthorexics are often very similar: people who are scared of taking risks, have perfectionist attitudes, a desire for simplicity and a tendency to live their lives more to avoid harm than anything else."
Jade has also seen many orthorexics who binge-eat between dietary systems, or have a tendency to develop bulimia. Any orthorexic diet, "is very difficult to maintain," Jade notes, and, by cutting out foods and even whole food groups, people with the disorder can end up so nutritionally depleted that bingeing is inevitable. When this happens, orthorexics tend to return wholesale to their former regimen, or, in penitence, develop an even more restrictive one.
The orthorexic diet is unbalanced. Jade says: "They have cravings and then they binge. There are orthorexic bulimics, orthorexic binge-eaters and many orthorexic fat people, too, who eat compulsively. I had one person who came to me who was bingeing horrifically on biscuits and cakes and it was obvious to me that she wasn't eating enough protein to sustain her. I tried to address that and she gave every excuse under the sun for why she couldn't include protein in her diet - because I'm vegan, because dairy gives me mucus, because my naturopath told me eggs are very bad for me ..."
Given all the problems that orthorexia can lead to, is there any way to treat it? The problem seems to be that, even among those orthorexics who recognise that they have the disorder, few see it as a genuine issue. In fact, many consider it a badge of honour. On the internet you find people like Renee, a health food and exercise enthusiast, who posts pictures of her meals on her personal website. She writes: "Do I have orthorexia? Yeah, probably. Do I care. Nooooo ... I decided that whole 'recovery' thing is for suckers and weaklings ... Several months ago I backed off the bodybuilding nutrition and decided I was going to relearn to eat like a normal person. You know what? Normal people are fat and depressed!"
Given that orthorexics are convinced that they are eating healthily and get a great deal of attention as a result of their dietary quirks - "If you just eat watermelon and bananas," sighs Wood, "everyone will find you fascinating" - it seems unlikely that many will seek help. "Rather than doing that," says Wood, "They are more likely to say, 'My God, you're the one who should be asking for help, given what you are doing to your insides, eating - I don't know - cooked food!"
Jade agrees. "I think it would be about as alluring for an orthorexic to get help as it is for an anorexic to get help with her weight loss ... Anorexics have only one system, which is to reject food, and to eat very little.
"Insofar as orthorexics have a number of systems to choose from, and can move from one to another, then it's almost unknown for an orthorexic to say they want to change. It's about the hardest thing in the world to dent someone's system and convince them to eat food that they actually think is going to harm them. I mean, would you?'
Given that this disorder is so difficult to treat, it is fortunate that it rarely causes really severe health problems like Janet Hackney's. But it still seems worth addressing. After all, orthorexia may win you attention and allow you to feel superior when you see someone slobbing down the street eating a McDonald's Happy Meal, but, at the very least it can also leave you feeling extremely lonely on a Saturday night.
