The acceptable face of eating disorders

The #CleanEating movement has reached fever pitch — but how healthy is a diet of spinach smoothies, goji berries and almond milk?

It started, ironically, with a desire to get healthy. Laura Wilson was 28, 5ft 6in and, at 15st, the heaviest she had been in her life. So she embarked on a high-protein diet. Within a year she lost 4st. She was hooked. To keep herself motivated, she began reading blogs, entering a world of “clean eating” that, back in 2009, had just begun. There are trends in the health-food world, and veganism was “in” at the time, Laura tells me. By 2011, Kris Karr’s “plant-based” Crazy Sexy Diet was a bestseller. Alicia Silverstone’s Kind Diet was out. “I became really passionate about eating healthily,” Laura says. “I was obsessed.”

She was already watching her carbohydrate intake. She avoided refined sugar and gluten where she could. Next, she began a vegetarian diet. Soon, she turned vegan: no meat, no fish, no dairy. Then raw vegan, avoiding too much fruit — “Too much sugar,” she explains. Laura insists that she wasn’t undereating; she was downing giant smoothies stuffed with spinach for breakfast, huge lettuce, chickpea, avocado and pepper salads for lunch, courgetti (courgette noodles) smothered in raw tomato sauce for dinner. “I always loved food,” she says. She stocked up on superfoods, ordering niche ingredients online: maca root powder, cacao nibs, spirulina, chia seeds … things that, at the time, were unusual to eat and difficult to find.

Laura started exercising six days a week. As the weight dropped off and she was showered with “praise and compliments”, her focus changed. “At first it was about being healthy and weight loss, but it turned into being about having the perfect diet,” she says. “Quickly, my behaviour became really unhealthy. It was all-consuming.” She says she became “controlling” about what she ate, planning meals and avoiding friends out of “a fear that if I socialised I would be peer-pressured into eating things I shouldn’t”. She avoided one friend’s birthday party because she was afraid she might end up eating cake. Soon, if Laura missed even one gym session she panicked about gaining weight.

Physically, she noticed other changes. She was constantly cold. Her periods stopped. As she rapidly lost another 2st, people began commenting not on how good she looked, but how thin she’d become.

When Laura first heard the term “orthorexia”, she thought: “Oh, that’s not me.” She justified her diet to herself, saying: “‘It’s not me that’s wrong; the rest of society has an obesity problem.’ If anyone asked, I would say I was just being really healthy. When you say that, people can’t argue back.” Now, she admits, she was unhealthily obsessed with healthy eating. She believes she was orthorexic.

The term orthorexia entered the lexicon about a year ago, cited in news stories and written about in blogs. Orthorexia nervosa, it was dutifully reported, was an obsession with healthy eating, derived from the Greek orthos (correct) and orexis (appetite). A new eating disorder had arrived.

350%: the estimated rise in the number of vegans in Britain in the past 10 years

Dr Steven Bratman, an American physician, had coined the phrase in 1997 in an article for Yoga Journal magazine, deliberately modifying the term anorexia nervosa. Half-joking about nutritional-medicine zealots in the US, he described “lacto-ovo-vegetarians” who are afraid of milk, raw foodists who worried that chopping vegetables would destroy their “etheric field”, and a “non-garlic non-onion Hindu-influenced crowd” who believed that “onion-family foods provoked sexual desire”. Bratman admitted that he, too, had once been so “seduced by righteous eating” that he wouldn’t eat vegetables more than 15 minutes after they’d been plucked from the ground.

When Bratman conceived of orthorexia nervosa, he was referring to the eating habits of a rarefied Jesus-sandal-wearing set. Almost two decades later, the health-food obsession has gone mainstream and #CleanEating is trending on Twitter.

In Britain, there are now 542,000 vegans — a 350% increase over the past 10 years, according to research from the Vegan Society; 63% of them are female, nearly half of them are aged 15-34 and 88% of them live in urban areas. According to Public Health England, young women are also particularly likely to be deficient in both iron and calcium, both of which can be in short supply on a vegan diet if poorly planned.

Meanwhile, sales of “free-from” foods are one of the fastest growing parts of the retail sector. Sales of foods marketed directly at consumers following avoidance diets are forecast to grow by 13% from an estimated £470m in 2015 to £531m in 2016. A third of Brits have bought or eaten free-from foods in the past six months. This, despite the fact that gluten-free products are, on average, 242% more expensive than their gluten-containing counterparts.

By now we’re accustomed to ricocheting between fad diets, eschewing toxins and going gluten-free as we eat organic and order soya lattes. We buy Waitrose LoveLife quinoa and stock up on the Sainsbury’s Freefrom range. In a quest to Eat Awesome (as one popular vegan recipe book urges us), we flood Instagram with images of our kale smoothies and avo toast.

Our efforts are inspired by a coterie of meat-free, gluten-free, grain-free, dairy-free or sugar-free social-media goddesses with names like those of 18th-century courtesans: Deliciously Ella, Naturally Hannah, Hemsley+Hemsley, Madeleine Shaw, the Gracious Pantry — clean-eating sirens calling from the rocks of Instagram. Deliciously Ella’s website alone commands 5m hits a month.

Something that would have been unthinkable in the 1960s — when only hippies ate muesli — has happened: healthy eating has become aspirational, a status symbol. You need time to devote days to making cashew cream, and money to spend £7.50 on an acai bowl at Tanya’s Cafe, west London’s raw-food trough where the Made in Chelsea crowd ruminate. No wonder the term “orthorexia” chimes with people.

Besma Whayeb discovered this first hand when she wrote about the subject on her wellness blog, Curiously Conscious. She was contacted by numerous girls who believed they had a problem. Besma, 23, does not identify as orthorexic, but does identify with the pressures the term describes. She first got into clean eating at university, and “bought into all the hype. Everything I consumed online was about healthy eating: what’s the newest thing? What can I try? I bought a juicer. I asked my parents for a food processor for Christmas.”

Besma became devoted to her Instagram heroes: “Deliciously Ella, Naturally Hannah, Sprouted Kitchen … It was like food porn,” she says. The constant stream of bright smoothie bowls dotted with berries, locally sourced salads arranged in fresh swirls and gluten-free desserts sprinkled with rose petals was addictive and inspired her to start her own blog. She soon felt pressure to compete — “the same pressure you feel when you look at magazines and see skinny women wearing expensive clothes. At first it’s a desire to be like them. Then you don’t feel good enough.”

On a student budget, she struggled to afford baobab powder and Himalayan pink salt. “It seems like all these bloggers have the perfect life. Their food looks amazing. But it takes so much work and planning to create. I’d think, ‘How do you have time? Where do you get these amazing little flowers that you put on your breakfast? What is this powder called?’”

Researching and preparing food, finding organic farms and undergoing three-day juice cleanses, Besma “got to a point where it was almost obsessive”. At times, when she couldn’t afford the right organically sourced products, it seemed “impossible to eat”.

Social media exacerbated the problem. The healthy-eating community may be pure, but it can be judgmental. When followers were impressed by the food Besma posted on Instagram, they showered her in “likes”. On other posts, the silence was deafening. She confesses it is hard not to read that as “a measure of how much people like you”. So, if in 2013 Besma was posting pictures of her grandma’s chocolate cake and herself at the Green Man festival eating blue candyfloss (seven likes), by 2015 she was posting images of a raw-chocolate flapjack topped with goji berries, captioned “#healthyeating”, attracting 100 likes.

Besma felt under pressure to make her food look just right. “Because I was writing about healthy eating online, I felt I should be showing how amazing my food was. If I made a salad for lunch that wasn’t perfect, I felt lacking.” She says this despite knowing that much of what you see on Instagram is staged. That bloggers arrange food for photographs, but “by the time they’ve finished, the banana bits have gone brown and the food is cold. I would make an amazing peach smoothie bowl, but it’d be 2pm, I’d leave it on the side, it would defrost and I wouldn’t do anything with it.”

Besma says she wishes Instagrammers would be more honest; that they would admit, from time to time, that they binged on toast, went for a Chinese with friends or skipped 6am yoga sessions.

She thinks the clean-eating trend is as much about weight loss as it is about health — the “clean and lean” mentality; the way juice cleansers promise to get you into “the skinny mindset”. The trend also touches on our fear of mortality. Besma notes that Deliciously Ella’s brand is built on the story of how eating only natural ingredients helped Ella Woodward bounce back from postural tachycardia syndrome, an abnormal increase in heart rate after sitting or standing up that causes dizziness.

80-90% of people with anorexia seen by the consultant Mark Berelowitz say they are “clean eating”

Besma watched one documentary in which “a guy makes everyone drink green juice and it makes you feel great. You’re no longer obese. You can’t get heart disease. There’s a feeling like it’s the immortal juice.” It was a message that spoke to Besma, whose mother had fought breast cancer. Afterwards, she “spiralled into healthy eating. I got really strict. Now, looking back, I see that pressure. I wanted to be the girl on Instagram and have those amazing meals in front of me. I also wanted to be invincible.”

Wellness gurus don’t claim to be doctors or nutritionists, but sometimes their science is questionable. For instance the Hemsley sisters, who were not available for comment, suggest on their blog that gluten “breaks down the microvilli in your small intestine, eventually letting particles of your food leach into your bloodstream, which is referred to as ‘leaky gut syndrome’” — but this is only true if you have coeliac disease, which affects about 1% of the population. Others have stated that “7 out of 10 people don’t have the enzyme to digest dairy properly” — which is true of the world as a whole; however, the NHS points out that only 1 in 50 people of northern European descent has any degree of lactose intolerance.

Some clean-eating bloggers’ claims aren’t just misleading, they are outright lies. The Australian “wellness” blogger Belle Gibson claimed on her mobile app The Whole Pantry and in a recipe book of the same name, published by Penguin Australia, that her diet cured her brain cancer — before she confessed last month that she never had cancer. Her company now faces potential fines of up to 1.1m Australian dollars (£548,000) by a consumer affairs watchdog. Penguin Australia has been fined A$30,000 for failing to check her claims.

Miguel Toribio-Mateas, a nutritional therapist and clinical neuroscientist, worries that some clean-eating gurus may “take healthy eating to an extreme when they remove whole food groups or advocate diets that are very low-protein, or with no animal protein”. Excluding foods “willy nilly … with no scientific basis” does not make “much nutritional sense”, Miguel says. “A lot of clean-eating ingredients are very low in protein, which makes it easy to follow a clean-eating diet that’s protein deficient. Protein is required for cellular structure, function and regulation of the body’s tissues and organs. A low-protein diet also makes you prone to picking up infections.”

The nutritionist Jo Travers adds that cutting out dairy means “you have to concentrate a lot harder on getting enough calcium to achieve and maintain good bone density”. She notes that vegan diets can lead to deficiencies in protein, iron, calcium, vitamin B12 and omega 3. Meanwhile, cutting carbohydrates forces your body to fuel itself on fat or protein.

A study by the British Nutrition Foundation found that 1 in 10 teenagers risks nutritional deficiencies, half of teenage girls take in insufficient iron and 1 in 5 inadequate calcium.

While not all clean eaters advocate cutting out carbohydrate and fat, Mark Berelowitz, clinical lead for child and adolescent mental-health services at the Royal Free Hospital in London, says that those diets that do are a “catastrophe” for teenagers. “The last thing they need is courgetti pasta and cauliflower rice. They will starve on that.”

He sees a link between obsessive clean eating and anorexia, which has an incidence rate of 1.5% among teenage girls in the UK. “A preoccupation with clean eating can be a symptom of significant issues with food,” says Berelowitz. “And 80-90% of the people with anorexia I see on the ward will be obsessed with clean eating. This is a problem that is increasing.”

Carrie Armstrong, 36, is an example of how extreme the obsession can become. She first turned to health food as a cure for her fatigue, which prevented her from working as an actress. Doctors said she had “post-viral fatigue syndrome”. After leaving hospital aged 26, she was in a wheelchair for the few hours a day she had the energy to get out of bed. Desperate to get better, she started Googling for cures: “The first thing that came up was diet,” she says. “‘Change your diet!’ Before-and-after miracles: ‘Doctors told me I was a hopeless case, but through diet I was healed!’ The first thing I thought was, ‘No wonder I got so sick.’ The second was, ‘How did I take so long to get sick when I’ve clearly been doing everything wrong for years?’ Then it was: ‘There is hope.’”

First she cut out meat. Then carbs. Then sugar. When one diet didn’t work, she would try the next: only eating cooked vegetarian food, then cooked vegan food. No dairy. When she didn’t see any improvement, she tried raw vegan. Soon, she was just eating salads, fruit and raw nuts. She stayed on raw food for a long time because “it seemed logical that something that severe had to work”. When it didn’t, she became a fruitarian. At one point, she fasted for 23 days, only consuming water. She had lost so much weight she was wearing children’s clothing. “This is the myth of the detox: you strip yourself down because your fat is where your toxins are stored. The aim is to get down to nothing, then the body builds itself back up. I’d think, ‘I must be there soon.’ Then I realised something was incredibly wrong.”

Carrie noticed she was constantly freezing. Her skin was sallow, her eyes sunken. The little energy she’d had was gone. She suffered stomach pains and bloating — “raw food is hard to digest”. Then her hair began falling out. In the mornings she would wake to find fresh bruises from where the mattress had touched her bone. Within a year, Carrie dropped from 11½st and “indifferent to food”, to 6st and eating just organic melon.

Isn’t melon quite high in sugar, I ask.

“Exactly!” she laughs. “Everyone has their own rules. They are just making it up.”

And yet the concept of “healthy eating” made it difficult for others to argue with her behaviour. “Unlike anorexia or bulimia, orthorexia you can wear as a badge of honour,” Carrie admits. “You can use it to say, ‘I’m right and you’re wrong.’”

Added to this is the way food has become morally charged: sugar is “evil”, while the terms “clean” eating and “cleansing” have religious connotations.

“Physically I was a wreck and emotionally I was a mess,” Carrie says. “It’s the ultimate First World problem, to say I’m afraid of celery,” she grins. Still, food addiction is relentless. Carrie would panic, three times a day: what can I eat? How little can I get away with? What diet am I on now? What do I need to avoid? She nods towards the cup of tea I’m drinking, which her boyfriend made me. “I’d be thinking, ‘What if there’s dairy in it, or caffeine?”

Unlike an alcoholic going dry, food isn’t something you can avoid. Carrie says her recovery involved learning to become indifferent to food once again — difficult, given the ubiquity of the clean-eating trend. When I ask Carrie if she is healthy now, she replies tentatively: “Healthy is such a loaded word for me. I don’t think there is healthy or unhealthy eating; it’s the thinking that’s unhealthy.”

Dr Angela Guarda, associate professor of psychiatry and behavioural sciences and director of the eating-disorders programme at Johns Hopkins School of Medicine, says many cases of what might be termed orthorexia fall under the diagnosis of Arfid (avoidant/restrictive food intake disorder). Some Arfid patients experience significant weight loss after developing idiosyncratic ideas about their food tolerances or what is healthy. Guarda says the behaviour of some Arfid sufferers is strikingly similar to that of people with anorexia. Patients share “an overvalued belief they have to stick to a very rigid diet”. Arfid patients may claim to be focused on health rather than weight loss, but then Guarda notes this is also true of anorexic people. “That is what they tell you, but when you watch both groups in an environment where they have to eat, they often act in very similar ways. Both have narrowed their food repertoire down to very limited foods. They have ritualised eating habits and preparation rituals. They prolong eating. They generally avoid calorie-dense food. The reasons they give you may be different, but the restrictive-eating behaviour is similar.”

Guarda suggests that this is because “individuals with eating disorders rationalise their behaviour in various ways. Patients with anorexia often become vegetarian and say it is because they like animals, but it also allows them to limit what they eat, and explain why they are only having salad when everyone else is having a hamburger.” The same is true of some so-called orthorexics. “They may say, ‘I only eat organic food,’ but when you look at what organic food they are eating, it is low-fat, low-calorie and only what they prepare, so the end result is the same: many of them lose weight. They will talk about being vegetarian because it is healthy, how they developed a lactose intolerance, or how they had to cut out gluten. But this is part of their rationalisation for why they have restricted their food repertoire — a rationalisation that seems more acceptable both to other people and themselves.”

Creating a new label risks mistreating them, Guarda says. She also worries that orthorexia has positive connotations. “It can be seen as a virtue rather than a problem. In some cases, it is used by people as a more acceptable explanation for what essentially looks like and is anorexic behaviour.”

I ask Guarda if she feels the trend for clean eating, played out on social media, fuels obsessive behaviour. She says: “In part, perhaps because online blogs can provide a community of others that validate and normalise extreme beliefs.”

The popular bloggers mentioned in this article do advocate balanced diets, and issue warnings about extreme eating habits — although this is not always the message some teenage girls take away.

Clean Eating Alice, aka Alice Living, is a blogger with 313,000 Instagram followers and a feed peppered with pictures of almond milk and cinnamon zoats (a hybrid of oats and zucchini, the American word for courgette). She insists that she doesn’t advocate any one diet, physique or approach. “Make decisions based on them being right for you,” she says. “Don’t fear food, don’t restrict food groups and don’t cut stuff out because your friend down at the gym told you it worked for them.”

Alice believes having an audience on social media comes with responsibility — to be factually correct, and not to offer misleading advice. “People do take everything you say as gospel and you have to be so wary of that. I always say, ‘Take what I’m doing as inspiration,’ but I’m not dictating how they should eat.”

She advocates a “No BS” approach. It may be “trendy now to be gluten-free”, but “unless there is a medically diagnosed intolerance”, she wouldn’t tell anyone to cut gluten out. She never offers medical advice and insists that eating healthily shouldn’t mean rummaging on your knees in Whole Foods for specialist ingredients. Everything in her book is stocked in her local Tesco.

“People can eat well with the most basic ingredients,” she says. “Balance” sums up her approach. Some days she eats salmon salads topped with toasted seeds. Some days she’ll make a tub of ice cream. And she posts pictures of both. Interestingly, the ice cream pictures are starting to get as many “likes” as the salads. Perhaps, after years of crazy fads, a normal, balanced diet is finally coming back into vogue. Additional reporting by Kitty Drake

Reality check: food blogger Besma Whayeb on the truth behind the pictures she posts

Himalayan pink salt

“It’s pretty, it’s pink, it’s nice, but really is it any better for you? I took this photo to brighten up my Instagram more than I did to talk about any health benefits.”

Peanut butter cacao smoothie

“My favourite smoothie, but I’d never make it like this for breakfast. It’s excruciating to make it look so good.”

Flaxseed oil

“While it may be healthy, I really hate flaxseed oil. It tastes plain awful. However, its benefits needed to be shouted about, hence the post.”

Baobab smoothie

“See all those almonds? They went straight back into the packet once I’d taken the shot. In fact, by the time I was finished the smoothie was warm … gross.”

Green powders

“Health powders are so expensive and you don’t even really know what they do. I have jars of powders in my cupboard I’ll never eat. They taste disgusting.”