Their healthy eating patterns had emerged as they approached leaving their hometowns to attend university - often a key precipitating event in eating disorders. Both had ambivalent feelings about leaving 'the nest'. They had strong needs for social approval and wanting to please others - especially authority figures (typical 'good girls'). And both presented as being emotionally composed and in control although guarded.

These characteristics pretty much match what I'd come to expect in many young women with anorexia. But there was one more major warning signal that I never picked up on...

Both came from homes, not where appearance was emphasized but where there was an enormous emphasis on health and healthy eating.

My fear is you may be reading this thinking... "Are YOU nuts - emphasis on healthy living is GOOD!" i absolutely agree so - please please remember orthorexia is something good taken to bad extremes!

I remember an article I wrote for Shape Magazine on Orthorexia had no sooner been published when I had a shouting, screaming owner of a freshly squeezed juice bar telling me how dangerous my article was. I think that just like I didn't 'hear' these two young women, she did not 'hear' me either.

How would you tell Orthorexia Nervosa from Anorexia Nervosa

Once I'd read about Orthorexia Nervosa, I could readily spot the non-typical symptoms of anorexia:

Both declared they did not fear gaining weight. One told me over and over: "I'm more conscious of how my body feels than how it looks". The other in exasperation told me: "Stop obsessing about weight, I'm not trying to lose weight.".

I was not one bit convinced that it was not their body weight or shape that determined their feelings of worth - that didn't fit my picture of anorexia which was what they'd been referred to me for.

But with the wisdom of hindsight, I could easily see that their session notes showed they took inordinate pride in their ability to avoid junk food and to be more health conscious than Ms. Average.

Yes, similar to Anorexics they obsessed about food, but here was the difference. It wasn't so much the calories food contained as it was the amounts of unhealthy ingredients like sugar, or fats or preservatives, or msg that they were pre-occupied with. They spoke about vitamins and minerals. Anorexics spoke about being fat.

Like Anorexic Nervosa sufferers their session notes record a progression of reducing what they would eat: "fats....bread...refined foods... biscuits...chocolates...junk-food". Unlike an anorexic, this was not an attempt to eat less, but rather to make what was perceived as healthier nutritional choices.

For one, her attempts to eat healthier started when she was feeling fatigued, the other when she was put on a diet to reduce her high cholestrol. Diet had become a type of food therapy.

The pivotal difference is though is that while anorexics fear fatness and diet to control their weight, orthorexia nervosa sifferers lose weight, because they progressively restrict what they can eat because their goal is to eat more and more healthily.

While anorexics won't eat grandma's favorite apple pie because it has too many calories and it'll make them fat, orthorexia nervosa victims won't eat it because it has too much fat and sugar and it's not good for their body. They are the new generation of health junkies.

Typical of both anorexics and orthorexics, their main drive centered around controlling everything they ate. Both considered the nutritional content of every mouthful ("..takes me forever to choose, really stresses me out").

Both thought more about healthy eating than they did about living, loving and laughing.

Their supposed 'healthy eating' crowded out other activities or interests and had started to isolate them socially ("can't go out for pizza anymore, it's way too fatty and I can't eat gluten").

It was interfering with their relationships ("mother gets really irritated because I can never decide what to eat").

No wonder they felt misunderstood. They weren't trying to look like some or other beauty icon. All they wanted was to be fit, healthy and eat natural and pure foods. And here I was, their therapist meant to help, insisting they were lying.

Men get Orthorexia Nervosa too

In his case eating problems were not part of his referral, but he was obviously emaciated and he spoke an inordinate amount about food.M/b>

When he was following his strictly 'raw food' diet he felt powerful, self-righteous, omnipotent and vastly superior to lesser beings who succumbed to the lure of junk food.

His 'nutritional spirituality' had taken on pseudo-spiritual connotations: he would tell me it was his mission to enlighten the world about the dangers of pesticides, food processing and so on.

I Predict increasing Orthorexia Nervosa

But when the pendulum of control swung from massive restriction, he'd secretly binge on the very junk food he so scorned. This would be followed by headaches, mucus production and extreme self-hatred and guilt. Then would come the vows to eat even more chastely and an extreme fasting as punishment and to cleanse his system.

Orthorexia Nervosa was ruining his relationships. He lost friends who were sick of having him constantly foist his beliefs on them. He said he also often felt ridiculed by them. He was lonely, depressed and in constant turmoil.

His eating habits robbed him of joy and instead of being the picture of health, he was Ethiopian-thin and a depressed, confused and indecisive wreck. He echoes for me the words of Bratman: "Many of the most unbalanced people I have ever met are those who have devoted themselves to healthy eating." As disillusionment with traditional therapies increase, and more drug manufacturers are sued, I predict the 'healing through food' movement will gain momentum. And, for many ill people, improved eating canmake dramatic improvements to their health.

And here's the problem with orthorexia. It often starts with an innocent attempt to improve health and eating more healthily is a much pundited message. And before I'm sliced, diced and popped into a blender, please don't misunderstand me - eating healthily is enormously important, I'm talking about the extremes here.

We have multiple contradictory nutritional theories spreading

• vegans, raw-foodists, live-foodists, macrobiotics and so on.

We have social forces

• the push towards healthier eating, organics, pure foods and health-stores opening on every corner.

We have more emphasis on alternative health and holism

• Using food as food therapy is often a central theme of holism which is core to alternative medicine.

And that's why I predict orthorexia nervosa will become a growing problem that has a very distinct flavor to it and differs from Anorexia.

Dr. Bratman admits, "I'm no longer the true believer in nutritional medicine I used to be. Where once I was enthusiastically evangelical, I've grown cautious.... I have come to regard it as I do drug therapy: as a useful treatment with serious potential side-effects...."

What Orthorexia is not:

• Orthorexia isn't the when you're busy implementing a healthier way of eating and the initial attention on food choices is high. The focus of this initial pre-occupation should fade. But be aware if you experience growing pre-occupation with food (and the minute details of it) and a progressive narrowing of food choices, over the long-term. These are danger signs.

• Sticking to a way of eating for religious reasons is also not othorexia unless it becomes an obsessive pre-occupation based on fear rather than love. • Striving for health through improved nutrition is good, unless it’s based on predominantly fear-based motivations (e.g. fear of cooked foods, or obsessions with aging or dying). • You should be able to make exceptions to your dietary habits without being consumed with guilt or having to take obsessional corrective actions.

• It should not rob you of the fun and joy of eating or consume your thinking.

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