Ortorexia

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Deﬁnition and diagnostic criteria for orthorexia nervosa: a narrative review of

the literature
Article in Eating and weight disorders: EWD · April 2019

DOI: 10.1007/s40519-018-0606-y
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Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
https://doi.org/10.1007/s40519-018-0606-y
REVIEW ARTICLE
Definition and diagnostic criteria for orthorexia nervosa: a narrative

review of the literature
Hellas Cena1 · Friederike Barthels2 · Massimo Cuzzolaro3 · Steven Bratman4 · Anna Brytek‑Matera5 · Thomas Dunn6 ·
Marta Varga7 · Benjamin Missbach8 · Lorenzo M. Donini9
Received: 13 September 2017 / Accepted: 24 October 2018

© Springer Nature Switzerland AG 2018
Abstract
Aim In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote
health. The pursuit of an “extreme dietary purity” due to an exaggerated focus on food may lead to a disordered eating
behavior called “orthorexia nervosa” (ON). ON raises a growing interest, but at present there is no universally shared defini-
tion of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some
flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related
psychometric instruments and provides research propositions and framework for future analysis.
Methods The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last
access on 07 August 2018), using “orthorexia”, “orthorexia nervosa” and “obsessive healthy eating” as search terms, and
filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from Eng-
lish. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic
criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed.
Results The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation.
Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid,
extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diag-
nostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive
food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used
in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with
healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c)
psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia
Self-Test developed by Bratman were the most used psychometric tools.
Conclusions The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psy-
chometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow
a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both
research and clinical activity until now.
Level of Evidence Level V, narrative review.
Keyword Orthorexia nervosa
Introduction
Hellas Cena and Friederike Barthels contributed equally. In some cases, self-imposed dietary rules intended to pro-
mote health generate detrimental consequences on health,
This article is part of topical collection on Orthorexia Nervosa as stated in 1997 by Steven Bratman [1]. The pursuit of an
“extreme dietary purity” due to an exaggerated focus on food
* Lorenzo M. Donini
Lorenzomaria.donini@uniroma1.it may lead to a disordered eating behavior called “orthorexia
nervosa”.
Extended author information available on the last page of the article
13
Vol.:(0123456789)
Orthorexia is a neologism coined from the Greek (ὀρθός, 4. To develop qualitative research through well-designed
right and ὄρεξις, appetite). The term means ‘correct appe- case studies.
tite’. Conversely, orthorexia nervosa (ON) is an expression 5. To validate a new self-administered questionnaire, start-
created to indicate a possible new eating disorder whose core ing from ORTO-15, Bratman’s Orthorexia Self-Test, and
symptom is an obsessive and unsafe focus on eating foods Dusseldorf Orthorexia Scale, and taking into account the
perceived as healthy. new definition and diagnostic criteria.
A growing number of articles in literature refer to ‘ortho- 6. To investigate ON prevalence according to the new
rexia’ as a keyword, and an increasing number of published shared diagnostic criteria in different countries and dif-
articles have been observed throughout the last years [2, 3]. ferent samples (age classes, gender, social and cultural
However, at present there is no universally shared defini- context, athletes, etc.);
tion of ON, the diagnostic criteria are under debate, and the 7. To evaluate medical and psychiatric comorbidities.
psychometric instruments used in the literature (mainly the
Orthorexia Self-Test commonly called Bratman Orthorexia The article performs a preliminary narrative review of the
Test (BOT) [4] and the ORTO-15 [5]) revealed some meth- literature to assess state of the art in ON definition, diagnos-
odological flaws [6]. tic criteria and related psychometric instruments.
Two key features should be present among the diagnostic
criteria of ON:
Methods
(a) obsessive focus on dietary practices believed to pro-
mote optimum well-being through healthy eating (with The authors collected articles through a search into Pubmed/
inflexible dietary rules, recurrent and persistent preoc- Medline, Scopus, Embase and Google Scholar (last access
cupations related to food, compulsive behaviors); on 07 August 2018), using “orthorexia”, “orthorexia ner-
(b) consequent, clinically significant, impairment (e.g. vosa” and “obsessive healthy eating” as search terms and
medical or psychological complications, great distress, filled three tables (Tables 1, 2, 3) including narrative articles
and/or impairment in important areas of functioning) (English), clinical trials (English), and articles in languages
[7]. different from English.
For each paper, we defined type of the study, character-
As the theoretical discussion continues, other issues need istics of the sample, definition of ON, diagnostic criteria,
to be analyzed, such as possible body image disturbances, psychometric tests and conclusion/result.
weight concerns, and degree of insight [2]. For each abstract, the full text was retrieved for the evalu-
Therefore, it is necessary to reach a consensus on the defi- ation. The data extrapolated from the revised studies were
nition of ON, to validate new assessment instruments, and collected in tables that summarize study design and meth-
to distinguish different severity levels [8]. For this reason, ods, describe the sample, give background information, and
the Orthorexia Nervosa Task Force (ON-TF) was established present results, allowing the reader to identify important
in 2016. ON-TF includes researchers from many countries information easily. In particular, for each study the follow-
actively dealing with ON.1 It pursues seven specific aims: ing data were extracted: author, year of publication, general
characteristics of the population enrolled, study design, pos-
1. To outline a definition and reliable diagnostic criteria for sible diagnostic criteria for ON, psychometric instruments,
ON. main results and conclusions (Tables 1, 2, 3). The first draft
2. To describe, according to the available literature ON was reviewed and enhanced by all the co-authors.
development and course, risk and prognostic factors,
diagnostic issues related to gender or cultural aspects,
diagnostic markers, comorbidity (clinical, functional and Results
psychological consequences), and differential diagnosis.
3. To verify in which DSM category ON would best fit. The literature search retrieved 141 articles, published up to
2018. Among these articles, 34 are reviews, letters, com-
mentaries, editorial and case reports; 73 are studies with
clinical and non-clinical samples; 24 are articles published
1
The ON-TF is composed of the authors of the present review arti- in a language other than English. All of them were summa-
cle and (alphabetical order): Stefan Michael Bauer (Universidad de rized, and the main characteristics and results are reported
Barcelona); Daniela Converso (University of Turin, Italy); Julia Depa
in Tables 1, 2 and 3 [3–133].
(Universität Hohenheim, Stuttgart, Germany); Barbara Loera (Uni-
versity of Turin, Italy); Cristina Segura-Garcia (University of Catan- Table 4 synopsizes the diagnostic criteria for ON pro-
zaro, Italy); Jessica Setnick, (USA); Jiyeon Shin, (Korea). posed in four papers.
13
Table 1 Studies on orthorexia nervosa: reviews, letters, commentaries, editorials, case reports
Author, year Country population Sample characteristics Definition of ON Diagnostic criteria Test for ON Other tests Results/conclusions
No., sex, age, BMI/type
of study
Barthels et al. Review (not systematic) Persistent fixation on It is obvious that ON belongs
2015 healthy nutrition to the group of eating disor-
and avoidance of ders but its independency as
food considered a mental disorder of clinical
unhealthy in fear relevance and its differenti-
of developing an ation from anorexia nervosa
illness are not yet clear
Bratman 2017 Editorial Obsession with eating It remains to be discovered
the right foods whether there proves to be
a clinical utility to defining
a distinct ED-labeled ortho-
rexia, or whether such a
distinction becomes moot in
light of subsequent evolu-
tion of existing EDs
Brytek-Matera Erratum (orthorexia Female students with ON
et al. 2016 nervosa and self- analysis showed that low
attitudinal aspects of body area satisfaction, high

body image in female fitness orientation, high
and male university overweight preoccupa-
students) tion and high appearance
orientation were independ-
ent predictors of greater
fixation on eating healthy
food. A strong preoccu-
pation with healthy and
proper food was associated
with an unhealthy body–
self relationship among
Polish female student with
orthorexia nervosa
Brytek-Matera Review (not systematic) Obsession for healthy ORTO-15 Since orthorexia involves dis-
2012 nutrition leading to turbance of eating habits, it
dietary restrictions ought to be treated as a dis-
and to a variety of order concerning abnormal
negative psycho- eating behavior inseparably
logical and social linked with obsessive–com-
outcomes pulsive symptoms
13

Table 1 (continued)
13
of study
Cartwright Review (not systematic) Preoccupation with Multiple strategies aimed at

2004 eating only “healthy stabilizing the emergency
food” patient should be instituted
before treating the ED
itself. Appropriate follow-
up with pharmacotherapy,
psychotherapy and behavio-
ral therapy is warranted
Catalina Case report A 28-year-old woman Pathological obses- The fundamental differ-
Zamora with severe mal- sion for biologically ence with anorexia is that
et al. 2005 nutrition, iron and pure and healthy in orthorexia, there is no
vitamin B12 deficit, food, which leads fear of gaining weight, but
hypoproteinemia to important dietary rather to certain foods, con-
BMI: 10.7 restrictions sidered as impure and toxic.
However, both disorder
share many characteristics
Chaki et al. Review (not systematic) Obsession with eating In adults, the DSM-IV only
2013 pure, healthy and recognizes two condi-
right kinds of foods tions, anorexia nervosa and
to improve health bulimia nervosa. Many
new syndromes have been
proposed for inclusion in
the DSM-5. Orthorexia
nervosa is the most familiar
of these unrecognized
disorders. The present idea
about orthorexia rests more
on opinion and anecdotal
evidence rather than on
experiential findings. More
research is needed
Cinquegrani Review (not systematic) Fixation on eating While ON is being targeted
et al 2018 proper food (“clean as a mental illness, this is
eating”) not simply a condition of
cognitive processes driving
behavior, but a far more
complex issue which is
inherently embodied, social
and cultural and might
be considered a lifestyle
syndrome
of study
Costa et al. Systematic review 15 articles, 2012– Among the articles similari-
2017 2016 ties with other psychiatric
disorders emerged, confu-
sion about use of assess-
ment tools existed, and
the lack of evidence-based
treatments for ON was
pronounced. More research
is needed to determine the
prevalence of pathologi-
cal eating behaviors and to
determine If ON is a unique
eating disorder or just a
subset of another disorder
Cuzzolaro Editorial: “ON by A commonly estab- Proposed by Dunn BOT, ORTO-15 The problem requires atten-
et al. 2016 proxy?” lished def of ON is and Bratman (6) tion, especially on children
still missing
Dell’Osso Review (not systematic) Fixation on healthy Moroze criteria (37) ON could share traits of both
et al. 2016 food DSM-5 (ARFID) autism spectrum disorder
and obsessive–compulsive
disorder
Dunn et al. Review of the literature 17 articles appearing Pathological obses- Proposed by the ORTO-15, BOT, ON is different from ARFID
2016 in peer-reviewed sion with healthful authors ORTO-11, ORTO- and AN. Existing research
journals, books and eating 11-Hu, ORTO- is largely based on non-
book chapters 9-GE clinical samples and small
number of case studies.
Need to develop psycho-
metric instruments for ON
diagnosis
Eriksson et al. 251 participants (166 Swedish participants BOT SPAS, SATAQ An attempt to discuss and
2008 women and 85 men); in fitness center investigate the concept of
age range 17–62 activities ON addressed by research-
years; cross-sectional ers and physicians and
study which is deemed contro-
versial
Håman et al. Integrative review 19 empirical and A fixation on eating BOT, ORTO-15, The main perspectives used
2015 theoretical articles healthy food ORTO-11 to study ON have been
published in peer- medical and psychological.
reviewed journals Need for a more empirical-
holistic research and exam-
ining the role of sports
13

13
of study
Hepworth Commentary Fixation on righteous Following a healthy diet does

2010 eating; obsession not mean someone is ortho-
with healthy eating rexic. Eating healthfully is
good unless food takes up
an inordinate amount of
time and attention, deviat-
ing from the health food
diet is met with guilt and
self-loathing, and/or food
is used to control or avoid
life issues
Hepworth Review ‘Eating disor- Obsession with Eating healthfully is
2018 ders today, not just a healthy eating good unless food
girl thing’ takes up an inor-
dinate amount of
time and attention,
deviating from the
health food diet is
met with guilt and
self-loathing, and/
or food is used to
control or avoid life
issues
Koven et al. Review (not systematic) A pathological obses- Moroze criteria (37) BOT EHQ Proper diagnostic recognition
2015 sion with proper ORTO-15 is a precursory step toward
nutrition that is ORTO-11-Hu the creation of gold stand-
characterized by ard assessment instruments
a restrictive diet, for appropriate identifica-
ritualized pattern tion of ON individuals
of eating and rigid
avoidance of foods
believed to be
unhealthy or impure
of study
Kummer et al. Letter to the editor An obsession for ON should always be consid-
2008 healthy food which ered as possible premorbid
may lead to strict symptoms of a real disorder
diets, sometimes
with a shortage of
essential nutrients
and a modification
of social relation-
ship due to this
behavior
Lisle 2016 Letter People pushing their Author is concerned that
bodies and minds orthorexic beliefs are
to the limit in their being widely accepted as
quest to avoid all the norm and leaving little
processed, fattening room for people to seek
or sugary foods as psychological support with
outward displays services which are already
of their exemplary overstretched

self-control
Mac Evilly Editorial Extreme phobia about People often exclude certain
2001 eating only ‘pure’ foods from their diet
food because of something they
read or hear, when in fact
they could be doing more
harm than good. In an
attempt to sort the good
from the bad nutrition
information, the Tufts Uni-
versity Nutrition Naviga-
tor was set up to evaluate
nutrition websites using
criteria based on accuracy,
depth and usefulness of the
information
Marazziti Review (not systematic) A strict control on Need to build a standard-
et al. 2014 diet and food that is ized, comprehensive and
generally selected multidisciplinary approach
on the basis of its to coordinate research,
deemed healthy conditioning factors, social/
features health system and political
acts leading to prevention
and treatment
13

13
of study
Mathieu 2005 “Practice applications” Obsession with a per- Dietetic professionals needs
fect diet/fixation on to be aware of the growing
righteous eating public awareness of extrem-
isms in diets
Michalska Review (5 studies on Extreme concern (DSM-5) unclear BOT Non-specific EDs (as ON)
et al. 2016 ON) about healthy diet require further studies that
would help in their detec-
tion and treatment
Missbach Editorial Eating pathologically Need for high-quality
et al. 2017 healthy scientific research on ON,
diagnostic tools and meta-
evidence via systematic
reviews
Missbach Commentary A pathologically BOT, ORTO-15 Progress has been made to
et al. 2017 5 studies (BOT) + 18 healthful eating, identify the clinical char-
studies (ORTO-15) characterized by acteristics and diagnostic
a restrictive diet criteria for ON and it would
with rigid avoid- be desirable to see this
ance of certain progress in constructing
food believed to be new assessment methods on
unhealthy or impure a population level
Moroze et al. Case report 28-Year-old man, Disordered eating Author-proposed Validated diagnostic criteria
2015 underweight, behavior generated criteria have not yet been devel-
with malnutrition, by a pathologic Based on DSM-5 ON oped. Need for additional
testosterone defi- obsession for bio- should be catego- investigation etiology, diag-
ciency, constipation, logically pure and rized as ARFID nostic criteria, prevalence,
bradycardia, poor healthy nutrition comorbidities and treatment
dentition, osteopo-
rosis, leukopenia,
thrombocytopenia,
hepatitis and meta-
bolic alkalosis
Park et al. Case report 30-Year-old man with Obsession for healthy ON and AN could have
2011 ON who developed food which may complications; before
hyponatremia, lead to strict diets, feeding we should evalu-
metabolic acidosis, sometimes with a ate the comorbidity and
subcutaneous and shortage of essential consider possible refeeding
mediastinal emphy- nutrients syndrome
sema, pneumothorax
and pancytopenia
of study
Peat 2016 Overview Pathological obses-

sion not with weight
loss but with a
“pure” or healthy
diet, which can con-
tribute to significant
dietary restriction
and food-related
obsessions
Rangel et al. Research report 4 focus groups Extreme obsession Participants linked food and
2012 52 participants Adolescent (15) with healthy food health to the point where it
Focus group discussions Young adult (10) was the central organizing
Significant other (13) determinant guiding their
Parent (14) food selection. An Ortho-
rexic Society is emerging,
whereby individuals are
socialized to take charge
or their own dietary health,

constrained by a food
system that is complex,
contradictory and opaque
Saddichha Letter to the editor Extreme preoccupa- ORTO-15 Clinicians should be aware
et al. 2012 tion with food of the possibility of the
prodrome of schizophrenia
presenting as an ED
Saljoughian General article? Obsessive behavior
2017 with healthy eating
Varga et al. Review (not systematic) 11 studies Unclear Unclear BOT, ORTO-15,
2013 ORTO-11
Volpe et al. Review (not systematic) Pathological obses- DSM-5: avoidant/ There is still an open debate
2015 sion for healthy restrictive food regarding whether ortho-
or pure food, with intake disorder rexia is a unique disorder or
rigid avoidance of (ARFID) just a subtype of anorexia
food believed to be or obsessive–compulsive
unhealthy or pol- disorder 38
luted
13
Most of these papers were research articles aimed at the
rexia Test, DII Dickman impulsivity inventory, DSM (IV or 5) diagnostic and statistical manual of mental disorders, ED eating disorders, EDE-Q Eating Disorder Examination Questionnaire,
ARFID avoidant/restrictive food intake disorder, AN anorexia nervosa, BDI Beck-depression inventory, BOT The Orthorexia Self-Test developed by Bratman commonly called Bratman Ortho-
EDI Eating Disorder Inventory, EHQ Eating Habits Questionnaire, ON orthorexia nervosa, MPS (Frost) multidimensional perfectionism, PI-R Padua Inventory-revised, RSES Rosenberg’s Self
orthorexia and the potential
indicators to aid in preven-

evaluation of the prevalence of ON or at the definition of
called “worry factor” and

Pediatricians should have
groups” are the biggest

warning signs. The so-
more knowledge about
“feelings towards food

certain characteristics (gender, age, BMI, social/educational
status, eating behavior) or psychological profile (self-esteem,
Results/conclusions
narcissism, perfectionism, previous history of eating disor-

ders, overweight and appearance preoccupation). It is hard
tive efforts
to compare most results for the lack of a shared definition of
ON, standard diagnostic criteria, and reliable psychometric
instruments.
• Definition of ON:
The terms used by the different authors concerning the

Other tests
feelings accompanying the search for food were fixation,

obsession and concern/preoccupation on food quality/
healthy eating.
These terms were moreover emphasized through dif-
ferent adjectives: obsessive, exaggerated/excessive,
unhealthy, compulsive, pathological, rigid/controlling,
Test for ON
extreme, monoideistic, maniacal, time-consuming, and

overwhelming.
The suitable food was mostly identified as healthy/proper/
correct, sometimes organic, (biologically) pure, safe, while
the harmful aspect of food was defined as unhealthy, more
Diagnostic criteria
rarely impure or related to “food production”.

The diet or eating habits are usually defined as restric-
tive, seldom also as ritualised, strictly controlled, selective
food avoidance, and distorted; the risk and consequences on
the individual nutrition status and well-being are referred to
groups, be it carbo-
hydrates, trans fats,
Strictly limiting food
as shortage of essential nutrients, malnutrition and under-

leading to danger-
ous extremes and
animal products,
weight, changes in social relationships because of the con-

Sample characteristics Definition of ON
dyes or sugars,
malnutrition
stant thought on healthy food.
• Diagnostic criteria:
Most of the papers did not define the diagnostic criteria.

integrative medicine
clinic, Amsterdam,
cases: 2 sugar-free
the Netherlands. 4
diets, 1 vegan diet
Esteem Scale, TCI-105 Temperament and Character Inventory
DSM (edition IV or 5) criteria for anorexia nervosa (AN),

and 1 100% raw
Pediatric patients
at an outpatient
or avoidant/restrictive food intake disorder (ARFID), or

body dysmorphic disorder (BDD), were adapted for ON in
13 studies.
food
Specific diagnostic criteria proposed by the authors were

used in few studies (Tables 1, 2, 3).
Four of them [7, 27, 96, 134] published their proposal,

Cohort 41 patients: 4
allowing a brief comparison of criteria suggested to diag-

Country population
Poster Presentation
nose ON (Table 4). All these studies indicated as primary

diagnostic criteria: (a) obsessional or pathological preoccu-
pation with healthy nutrition; (b) emotional consequences
of study
cases
(e.g. distress, anxieties) of non-adherence to self-imposed

nutritional rules; (c) psychosocial impairments in relevant

areas of life as well as malnutrition and weight loss.
Author, year
stiel et al.
von Rosen-
Besides rigid avoidance of food considered unhealthy,

the presence of positive effects due to compliance with
2012
13
Table 2 Studies on orthorexia nervosa with non-clinical and clinical samples
Author, year Country population Sample characteristics Definition of ON Diagnostic Test for ON Other tests Results/conclusions
No., sex, age, BMI/ criteria
type of study
Acar Tek et al. 104 participants: 92 f Healthcare professionals Unhealthy ORTO-15 Demographic characteristics, health Prevalence ON: 67.3%.: 8.6% doctors, 2.9%
2016 and 12 m obsession with information, dietary habits anthro- dietitians, 41.4% nurses, 28.6% midwives, 5.7%
healthy eating pometric measurements medical officer and 12.9% health workers. No
and avoiding significant differences between occupational
foods that are groups
considered
unhealthy
Aksoydan et al. 94: 59% f and 41% m, Opera and Ballet artists Obsession ORTO-15 Sociodemographic info and lifestyle 56.4% ON
2009 mean age 33 years in Turkey with eating habits
healthy food
and avoiding
unhealthy food
Almeida et al. 193 adult gym Adult gym members Obsessive ORTO-15 ON behavior: 51.8. ON tended to be correlated
2018 members, mean age: behavior with younger ages
30.96 ± 1.03 years motivated by The presence of ON was associated with other
great concern non-dietary behaviors allied to a healthy life-
for following a style and esthetic concerns
healthy diet
Alvarenga et al. 392: 93% f, 56.2% Dietitians in Brazil Maniacal ORTO-15 (Portu- ON not completely defined. ORTO-15 seems to
2012 < 30 years, 24.6% obsession for guese version) perform differently in diverse pop
30–39 years, 12.7% healthy food
40–49 years and
6.5% > 50 years
77% normal BMI
Andreas et al. 1122 inpatients: 70% Conducted in a large Fixation on Ortho-10 EDI-2, BSI, FMPS, SF-36, BDI, BIS Two-factor structure (ortho-10): eating disorder-
2018 f, 30% m, mean age clinic in Germany, healthy specific factor and orthorexia nervosa-specific
41 ± 14 years main diagnoses: food and a factor. The eating disorder factor showed good
affective disorders pathological convergent and discriminative validity in which
(46%), eating disor- obsession to patients with eating disorders and those without
ders (13%), anxiety eat food with could correctly be classified. The orthorexia
disorders (10%), and more natural, nervosa-specific factor revealed no informa-
personality disorders higher quality tional gain compared to the eating disorder-
(10%) ingredients specific factor in this clinical sample
Arusoğlu et al. 944 participants: 578 Volunteers from the Pathological ORTO-15 (Turk- MOCI, EAT-40 ORTO-11 demonstrated statistically satisfac-
2008 f, 416 m, mean age academic and admin- fixation about ish ORTO-11 tory properties. ON was related to pathologi-
35.57 ± 9.43 years istrative personal of the consump- version) cal eating attitude and obsessive–compulsive
Hacettepe University, tion of healthy symptoms. Women exhibited more orthorexic
Turkey food symptoms than men. A high body mass was an
important variable for ON, but only together
with gender, pathological eating attitude and
increased obsessive–compulsive symptoms
Asil et al. 2015 117: 86.3% f and Dietitians in Turkey Unhealthy ORTO-15 EAT-40, MOCI 41.9% ON (36.1 ± 2.4). Neg correlation between
13.7% m, mean obsession with ORTO-15/EAT-40 scores and BMI. Pos cor-
age 34 ± 11.2 healthy eating relation between age and BMI/EAT-40 score.
years, mean BMI Who had higher risk of ON had higher EAT-40/
22.9 ± 3.2 kg/m2 MOCI score
13

13
type of study
Bağci Bosi et al. 318: 46.9% f, mean Resident medical doc- Obsession of ORTO-15 (Turk- Sociodemographic questionnaire 45.5% ON (40 point cutoff), no gender differ-
2007 age 27.2 ± 2.9 years, tors in Turkey healthy and ish translation) ences
65.7% normal weight proper nutri-
tion
Barnes et al. 220: 174 f and 46 m, Psychology students Pathological, ORTO-15 MPS, MBSRQ-AS, RSQ, RSES ORTO mean score 22.71, no gender differences.
2017 age 17–62 years and people recruited monoideistic A history of ED, overweight preoccupation and
from Facebook fixation with appearance orientation are significant predic-
(Australia) healthy eating tors of ON
and proper
nutrition
Barnett et al. 284: 83.4% f, mean Pop recruited from arts Extreme preoc- ORTO-15 AFNE (created by the authors), AFN engagement is not associated with disor-
2016 age 38.15 ± 17.89 college and through cupation with questionnaire on demographics, dered eating but with ON tendencies. Those
y, mean BMI local AFN hubs in food produc- special diets and ED history, EDE- following special diets were more likely to
24.87 ± 4.74 kg/m2 USA tion methods Q, EDDS report ON tendencies
in regards to
health and
purity
Barthels et al. 29 with low ON Female inpatients with Fixation on Author-proposed DOS EDI-2, DKB-35, BPNS-E, MIHT, ON might serve as a coping strategy for AN
2015 behavior and 13 AN health-con- criteria based FCF patients
with pronounced ON scious eating on DOS + self-
behavior + 30 HCs behavior assessed eating
behavior
Barthels et al. 406 participants; (1) vegans (n = 114), DOS RS Individuals who restrict their eating behavior,
2018 79.3% f, 20.7% vegetarians (n = 63), either predominantly due to ethical reasons or
m, mean age individuals with rare with the intention to lose weight, display more
30.7 ± 10.92 meat consumption orthorexic eating behavior than individuals not
y, mean BMI (n = 83) and individu- limiting their food consumption
24.89 ± 5.45 kg/ m2 als with frequent meat
consumption (n = 91)
(2) Participants on a diet
with dietary change
(n = 104), without die-
tary change (n = 37)
and a control group of
individuals not on a
diet (n = 258)
Bo et al. 2014 440: 53 D, 200 S and Italian students Excessive and DSM-5 for EDs ORTO-15 Demographics, anthropometrics ON 25.9% (35.9% in D, 26.5% in S and 22.5% in
187 B (dietetics D and sport time-consum- and body and eating/exercise habits, MDDI, B). No gender differences. University choice
sciences S); controls: ing preoc- dysmorphic EAT-26 may be influenced by pre-existing disorder in
biology students B cupation with disorder “with eating behaviors
healthy eating muscle dysmor-
phia” (OCD)
Brytek-Matera 400: 341 f + 59 m, University students and Maniacal obses- ORTO-15 (Polish ETA-26, questionnaire about lifestyle Polish version of ORTO-15 is a reliable and valu-
et al. 2014 mean age 23.09 personnel in Poland sion about version) habits, body satisfaction, anthropo- able instrument to assess ON in Polish pop
years (f) and 24.02 healthy and metric data
years (m) proper food
type of study
Brytek-Matera 327 students, 283 f Students (human sci- A fixation with ORTO-15 (Polish MBSRQ A strong preoccupation with healthy and proper
et al. 2015 and 44 m, age 18–25 ences and nutrition eating healthy version) food was not associated with an unhealthy
years sciences) in Poland food and an body–self relationship among Polish female
obsession for students with ON
proper nutri-
tion
Brytek-Matera 52 f with EDs, mean Outpatient referring to Pursuit for DSM-IV for EDs ORTO-15 (Polish EAT-26, MBSRQ (Polish version) In the group with lower level of eating pathology,
et al. 2015 age 22.81 years, the Polish National healthy food version) ON behaviors were more frequent (and vice-
mean BMI 21.01 kg/ Center for EDs consumption versa). ON was negatively predicted by eating
m2 pathology, weight concern, health orientation
and appearance orientation
Brytek-Matera 120 (83 f; 37 m) mean University students Italy Obsessive ORTO-15 MOCQ-R, EAT-26, BUT Lower ORTO-15 scores were related in f to
et al. 2017 age 22.74 years concern and less pathological body image discomfort and
normal weight fixation about obsessive–compulsive, while in m to less
healthy eating pathological disordered eating patterns. The
authors conclude ON might refer to the avoid-
ant/restrictive food intake disorder (ARFID),
according to DSM-5
Brytek-Matera 86 overweight/obese Fixation on ORTO-15 TFEQ-18, BIAQ Positive correlation between emotional eating and
2017 women, mean eating healthy body image-related distress. Emotional eating
age 30.43 ± 13.53 food partially mediates the effect of body image-
y, mean BMI Overly care for related distress on orthorexic behaviors among
30.24 ± 4.47 kg/m2 one’s health overweight/obese women
oral communication Obtrusive
thoughts on
being healthy
Lack of flexibil-
ity in diet
Long-term plan-
ning for food
Bundros et al. 428: 72.5% f, 27% m College students in Unhealthy BOT EAT-26, BDDQ, OCI-R Positive association between BOT and EAT-26,
2016 and 0.4% transgen- USA obsession with BDDQ and OCI-R. ON tendencies among
der; mean age healthy eating students
22.17 ± 4.83 y; 4.7%
underweight, 27.3%
overweight and
13.5% obese
13

13
type of study
Çiçekoğlu et al 62 participants: 24 Vegan/vegetarian, non- Obsession with Dunn and Brat- ORTO-11 EAT-40, MOCI, personal character- Vegans/vegetarians attitudes towards eating did
and Tunçay males, 38 females vegan/non-vegetarian consumption man 2016 istics form not have a risk of orthorexia. They adopted
2018 − 31 vegan/ vegetarian of healthy veganism/vegetarianism for ethical reasons, not
mean age 32.7 ± 5.6 food for good health
years
− 31 non-vegan/non-
vegetarian mean age:
34.4 ± 8.1 years.
BMI of most partici-
pants: 18.5–24.9 kg/
m2
Cinosi et al. 1453 adult subjects Young Italian adults An alleged eat- ORTO-15 ON prevalence: 10.9%, with a female prevalence
2015 ing disorder statistically significant (female 72.8% vs male
in which the 27.2%)
person is ON is not currently considered as a full-fledged
excessively and discrete mental disorder
preoccupied
with healthy
food
Dell’Osso et al. 2826: 59.4% f, mean University students and Concern with ORTO-15 Sociodemographic questions 32.7% ON (35-point cutoff). Female gender,
2016 age 28.9 ± 11.39 employees in Pisa proper, safe, younger age, being student, being veg and
healthy nutri- underweight were factors predictive of ON
tion
Dell’Osso L 2130 students; 58.9% Students of the Univer- Pathological ORTO-15 Socio-demographic and eating habits On prevalence (35-point cutoff) : 34.9%, with a
et al. 2018 f, 41.1%, mean age sity of Pisa, Italy approach to form higher rate of ON in females than males (37.8%
23.82 ± 4.39 years 11.3% followed a veg- feeding related vs 30.7%), in vegan/vegetarian subjects vs sub-
mean BMI etarian or a vegan diet to healthiness jects with a standard diet (56.3% vs 32.2%) and
22.25 ± 3.55 kg/m2 concerns and among subjects with a low BMI vs those with a
purity of food normal or high BMI (42.8 vs 34.2%)
and/or feeding It is proposed to interpret ON as a phenotype of
habits AN in the broader context of Feeding and eat-
ing disorders (FEDs) spectrum
Depa et al. 2017 456 (188 NS and 268 University students Constant 21-item-DOS Sociodemographic questions 3.3% ON and 9% at risk of developing ON. No
ES): 70% f and 30% (nutrition science NS pathological gender differences. Field of study does not
m, mean age 21.7 and economics ES) in preoccupation seem associated with ON prevalence in f
years Germany with healthy
nutrition
Dittfeld et al. 229 D (f 95.2%): age Dietetics (D) and physi- Obsessive–com- BOT Author’s questionnaire (not speci- 26.6% of D and 14.9% of P: healthy fanatics
2016 21.5 ± 1.6 years, otherapy (P) students pulsive focus fied) D have twofold higher chance of becoming health
BMI 21.1 ± 2.6 kg/ on a “healthy” fanatics (OR 2.07, CI 95% 1.24–3.49)
m2 diet which
201 P (f 87.1%): age manifests as
20.9 ± 1.5 years, an extreme
BMI 21.5 ± 2.7 kg/ concern about
m2 food content
type of study
Dittfeld et al. 2611 participants: Vegetarians: lacto- Introducing BOT Research questionnaire on general 26.4% of non-vegetarians and 30.5% of vegetar-
2017 1346 vegetarians ovo-vegetarians, dietary restric- personal and anthropometric ians were defined as health food fanatics
and 1265 non-vege- lactovegetarians, tions by indi- characteristics The risk for orthorexia nervosa decreases with
tarians ovo-vegetarians and viduals who age, level of education and diet duration
vegans. feel a desire to
Non-vegetarian improve their
health status
by healthy
eating
Donini et al. 404: 58.1% f and Spontaneous enroll- Maniacal No existing EES-11, MMPI, questionnaire about ON 6.9%, (> in males)
2004 41.9% m ment of employees, obsession for validated cri- sociodemographic, anthropometric
students and their healthy and teria. Authors and eating/lifestyle information
parents, residents correct food propose a
(> 16 years) in Italy combination
of eating,
behavioral and
obsessive-pho-
bic personality
traits
Donini et al. 525 (404 for test con- See previous study Maniacal See previous ORTO-15 (con- See previous study Good predictive capability (40-point threshold)
2005 struction—see previ- obsession for study (59) structed on the but limitation in identifying obsessive disorder
ous study—and 121 healthy and basis of BOT)
for test validation) correct food validated in
Italian
Dunn et al. 275: 68% f, mean age College students in Pathological ORTO-15 Demographic info and lifestyle/eat- Mean score 37.5. 71.2% ON (40 cutoff) and
2017 21.7 y USA dieting based ing habits 22.1% ON (35 cutoff). No gender differences
on being
healthy
Duyar et al. 750 participants: 375 ORTO-15 EAT-40, anthropometric measure- 2.9% of male and 4.3% of female have an eating
2016 f, 375 m ments disorder
Eating disorders occur in individuals both under-
weight and increased risk of disease according
to the waist circumference. The risk of eating
disorders increased in female with orthorexia
Ercan et al. 663 university Two subgroups by ORTO-15 Self-reported questionnaire about Mean score for ORTO-15 was 38.2 ± 3.4. Young
2013 students: 66.1% f, age as adolescents demographic and anthropometric adult group had higher mean score from
33.9% m, mean age (29.7%) and young information ORTO-15 than adolescent group. 9.7% of the
22.8 ± 2.07 years adults (70.3%) participants scored below 33 in the ORTO-15
mean BMI f 44.8% of the students test
21.19 ± 3.19 kg/ were educated in
m2 and m health-related depart-
23.69 ± 2.91 kg/m2 ments
Eriksson et al. 251, 166 f and 85 m, Participants in fitness Obsessive rela- BOT SPAS, SATAQ + questionnaire about In females: exercise frequency, followed by SPAS
2008 age 17–76 f and activities in Sweden tionship with exercise developed according to score and the SATAQ subdomains internaliza-
17–62 m food Caspersens et al tion and awareness, could together explain the
variations in BOT results
13

13
type of study
Farooq et al. 228 athletes: 39% f, Athletes: 81% played Condition char- ORTO-15 The median score for ORTO-15 was 36, with no
2016 61% m, median age for the 1st team, 5% acterized by an difference in score between females and males.
20 years, median for the 2nd team, obsession with ORTO-15 score was not significantly different
BMI 24.3 kg/m2 and 31, 15% leisure healthy eating by competition level. Based on a score of < 35,
participants 37% were diagnosed as having ON, 31% of
females and 41% of males
Fidan et al. 462 students: 39.4% Medical and economics ORTO-11 EAT-40, MOCI Obsessive–compulsive symptoms were more
2014 f, 60.6% m, mean and administrative prevalent and severe among students of eco-
age 21.4 ± 1.9 sciences students of nomics and administrative sciences, the symp-
years, mean BMI Ataturk University in tom severity of ON and eating disorders were
22.1 ± 9.1 kg/m2 Erzurum, Turkey similar to medical students. In medical students
as the knowledge about health or diseases
increased, the tendency to ON increased
Fidan et al. 878: 40.9% f and Medical students in Pathologic ORTO-11 (no EAT-40 ORTO-11 mean score: 27. High prevalence
2010 52.8% m, mean Turkey obsession for cutoff) (43.6%) if 27 was considered the cutoff. Higher
age 21.3 ± 2.1 biologically in m. Negative correlation ON-BMI
years, mean BMI pure foods
22.4 ± 2.99
Gezmen 750 healthy male and Pathological ORTO-15 For female participants, a positive weak correla-
Karadağ et al. female participants situation about tion was observed between ORTO-15 scores
2016 aged 19–50 years, consum- and BMI (r = 0.143). There was also a positive
mean BMI m ing healthy significant correlation between ORTO-15
23.9 ± 3.47 kg/m2 foods that is scores and waist/hip ratio in female participants
and f 22.7 ± 4.46 kg/ characterized (r = 0.116)
m2 by avoid- Orthorexia risk was slightly higher in BMI lower
ance of foods female participants
believed to be
unhealthy
Gkiouras et al. 120 female dietetics Female dietetics stu- BOT 24-h dietary recall method ON: 62.9%, higher prevalence compared to stud-
2018 students, mean age dents recruited from ies using samples of both sexes (35.9% in Italy
21 ± 0.8 years the Department of and 3,3% in Germany)
Nutrition and Dietetic,
in 2130 students,
Greece
Gleaves et al. (1) 147 students, 68% Psychology and nutri- Eating health- (1) EHQ (from (1) BIDR EHQ displays good internal consistency and
2013 f, age 18–38 years tion students fully become 160 to 35 (2) EAT-26 + BULIT- test–retest reliability. More research needed on
(2) 213 students, 65% an overwhelm- items) R + CES-D + PAS + MOCI + IPIP- validity and predictive value
f, 18–48 years ing preoccupa- (2) 35-item 41
tion that is the EHQ with
central focus final 21-items
of life version
type of study
Gramaglia et al. AN Italy: 23 People with AN Exaggerated, DSM-5 for AN ORTO-15 (Italian Italian HCs 46% ON, Polish HCs 82% ON.
2017 Poland: 35 diagnosis and healthy obsessive, and Polish Differences in the mean score at the ORTO-15
HCs Italy: 39 controls in general pathologi- validated ver- were found between AN and HCs in Italy but
Poland: 39 population (in Italy cal fixation sions) not in Poland
(> 18y, not age- and Poland) healthy food,
matched) eating healthy
or health-con-
scious eating
behaviors
Grammatiko- 176 undergraduate Undergraduate students Atypical eating BOT Dietary intake, EADES, mYFAS Food addiction: 4.5% and orthorexia: 68.2%.
poulou et al. students from a Department of disorder char- Orthorexic behavior was associated with
2018 Nutrition and Dietet- acterized by increased BMI, waist circumference and energy
ics in Greece an obsession intake. Emotion-and-stress-related eating was
for “healthy” negatively associated with BMI. Age was posi-
eating tively correlated with the appraisal of outside
stressors/influences
Haman et al. 14 personal trainers Subjects currently Certain sport contexts (bodybuilding, fitness
2017 working as personal competitions and elite sports) and specific
trainers and having groups (fitness professionals) contribute to
heard about ON complicating PTs’ negotiations due to a com-

petition, performance and/or profession norm,
making it difficult to determine whether or not
to intervene
Hayes et al. 404 participants: Undergraduate students Obsession with Bratman Ortho- EDEQ, AAI, SDS, MPS, OCI-R, ON symptoms: 35.4%. Orthorexia symptoms
2017 82.7% f, 17.3% eating “pure” rexia Self-Test DASS-21, BFNE demonstrated small to medium correlations
m, mean age or “healthy” (primary test), with associated impairment variables, perfec-
20.71 ± 4.36 years foods ORTO-15 tionism, disordered eating, appearance anxiety,
and obsessive–compulsive symptoms
Herranz Valera 582, mean age Yoga practitioners in Fixation on ORTO-15 Questionnaire about sex, age, weight, 86% ON (40-point threshold), 43.4% ON (35-
et al. 2014 36.96 ± 6.69, mean Madrid righteous height, years of yoga practice, point threshold). No association with age, sex
BMI 21.4 ± 2.28, eating eating habits or BMI. Association with vegetarianism
65.5% f and 34.5% m
Hyrnik et al. 1899: 52.5% f, 15–21 High school students in Excessive ORTO-15 (Polish Demographic-clinical questionnaires Mean value 39 points, no gender differences.
2016 years Poland fixation on the version) 13.7% ON (35 point cutoff) and 61.3% ON
consumption (40-point cutoff)
of healthy food
and obsessive
urge to control
the biological
purity of con-
sumed food
13

13
type of study
Kamarli et al. 121 students: 51.2% f Social sciences students, Healthy eating ORTO-15 ON prevalence: 60.3% (64.5% in females, 55.9%
2016 and 48.8% m, mean Akdeniz University, obsession in males). According to the BMI classifications,
age 22.1 ± 1.44 years Faculty of Communi- no significant relationship was found between
and 22.1 ± 1.59 cation, Turkey orthorexic and non-orthorexic students
years, mean BMI
21.0 ± 2.40 and
23.4 ± 3.29 kg/m2
Kinzl et al. 283, mean age 36.2 Austrian female dieti- Fixation on BOT FEV 12.8% ON, 34.9% some ON behavior and 52.3%
2006 years cians healthy food no ON
Korinth et al. 219 N (123 freshmen Nutrition students (N) Obsession BOT Eating Behavior Questionnaire (Ger- (1) N tend to restrict food intake to control their
2010 and 96 7th sem), and control group stu- with eating man adaptation of TFEQ), short body weight; (2) N do not have more disturbed
89% f; 114 °C, dents (C) in Germany healthy food FFQ (21 food groups) eating pattern than other students; (3) increas-
87% f. Average age and avoiding ing nutrition knowledge is associated with
22.5 years 1st sem unhealthy food healthier eating behavior and food choice
and 25.7 years 7th
sem. Average BMI
21.6 kg/m2
Luck-Sikorski 1007 participants: A randomly selected Strict, health- DOS PHQ-9, socio-demographic variables Prevalence ON: 6.9%
et al. 2018 48.6% f, 51.4% m, sample of the German oriented eating A higher rate of orthorexic behavior was
mean age 50.6 ± 0.76 general public pattern with observed in heavier, less educated, vegetarian
years, mean BMI clinically and more depressed participants; in multi-
26.44 ± 5.30 kg/m2, significant variate analysis only associations to lower
population-based impairment in educational attainment, a vegetarian diet and
telephone survey everyday life depressive symptoms remained
Maghetti et al. 1240 subjects, cohort Members of the Italian A pathological ORTO-15 The total score is significantly lower in divorced
2015 517 subjects: Association of Dietol- fixation about people biologists, free-lancers, smokers and
53.8% f, 46.2% ogy and Clinical the consump- in professionals following a diet. The main
m mean BMI Nutrition (ADI): tion of healthy score predictors are the marital status, BMI and
23.08 ± 0.14 kg/m2 39.3% medical doc- food adherence to a diet
tors, 36.2% dieticians,
12.6% biologists
and other 12%
health profession-
als. 53.8% work in
national health system
hospitals, 46.2% are
free-lancers
Malmborg et al. 118 E + 89 B, mean Exercise science Condition char- ORTO-15 SF-36, IPAQ A higher proportion of E had ON than B, but a
2017 age 22.8 y students (E) and busi- acterized by large proportion of B also expressed ON. The
ness students (B) in an exaggerated condition appeared to be especially prevalent
Sweden fixation on in men E
healthy food
type of study
Missbach et al. 1029: 74.6% f and German employees Obsessive eating DSM-5 (ARFID) ORTO-15 (Ger- Questionnaire about lifestyle and ON 69.1%. ORTO-15 has some psychometric
2015 25.4% m, age (various professions) directed at man version) eating habits flaws. ORTO-9-GE has only moderate internal
19–70 years, mean and students in nutri- healthy food → ORTO-9-GE consistency
age 31.21 ± 10.43 tion (20.2%), health-
y, mean BMI related courses (1.2%)
23.33 ± 4.37 kg/m2 and others (15.3%)
Moller et al. 585 participants: Pathological Dunn and Brat- ORTO-15 EAT-26, MOCI-R ORTO-15 and its derivatives (11- and 9-item)
2018 82.4% f, 17.6% obsession with man 2016 were not psychometrical strong in a large
m, mean age f the consump- English-speaking cohort. ORTO 7 (7-item ver-
35.24 ± 11.52 y, tion of foods sion) derived from the original ORTO-15 using
m 32.14 ± 10.54 an individual a combination of EFA and CFA was found to
years, mean BMI deems to be have a strong, stable factor structure
24.42 ± 5.1 kg/m2 ‘healthy’
Musolino et al. 25 women, 19–52 University students, Extreme care for DSM-IV for EDs EDE It is essential to understand how the complexities
2015 years anglo-australian and selection of “health” and “care” contribute to resistance
of what is con- in coming forward and asking for professional
sidered to be help
pure, healthy
food
Nevin et al. 196 women Recruited from the The study highlights the potential negative social
2017 35.43 ± 11.18 years Amazon Mechanical consequences of clean dieting and ON, and
BMI: 26.26 ± 6.91 Turk (MTurk) website point to perceptions of control and blame as
potential mechanisms underlying the stigma of
these conditions
Oberle et al. 455 students: 387 f, Students enrolled Compulsive EHQ Self-reported height and weight Orthorexia symptomatology, while unrelated to
2018 68 m in undergraduate behavior and items, a muscularity figure rating BMI, is greater for individuals who perceive
Mean age 20.83 ± 3.43 psychology courses at an obsessive scale, a body fat figure rating scale themselves as having a relatively muscular, lean
years Texas State University fixation on body type
eating healthy
for the purpose
of achieving
optimal physi-
cal health
13

13
type of study
Oberle et al. 411 students Undergraduate students Obsessive EHQ Study 1 Individuals high in orthorexia symptomatology
2018 Study 1 from psychology fixation on CET, EAI, modified Leisure-Time are internally driven to exercise for the pur-
228 students: 204 f, courses at Texas State eating healthy Exercise Questionnaire poses of improving their physical and mental
24 m, mean age University that includes Study 2 health, leading to exercise addiction character-
20.31 ± 1.88 years compulsive BREQ, EMI-2 ized by a compulsive need to follow a rigid
Study 2 behavior and schedule of intensive exercise even in the face
183 students: 156 f, accompany- of injury, illness, or other problems
27 m, mean age ing mental
22.19 ± 4.66 years preoccupation
with restric-
tive dietary
practices for
the purpose of
achieving opti-
mum health
Oberle et al. 459, 80.8% f and Psychology students Obsessive fixa- EHQ Questionnaire about weight and EHQ appeared to be a promising alternative to
2017 19.2% m, age 16–48 in USA tion on eating height, SES, NPI, MPS ORTO-15 for ON. No gender differences in
years healthy ON. Positive relationship with BMI in m. No
correlation with self-esteem, positive correla-
tions with narcissism and perfectionism
Olejniczak et al. 981 S, 19.2% f, age Humanistic, scientific, A pathological Author-developed > 3% demonstrate tendency to ON behavior. No
2017 19–22 years (70.8%) medical and economic obsession questionnaire differences regarding gender
and 23–26 years students (S) with organic (22 items)
(20.2%) and healthy
nutrition
Parra-Fernandez 454 students: 65% Students (> 18 y) from Pathological Spanish short- EDI-2 The internal consistency of the measurement was
et al. 2018 f. 35% m, mean the University of obsession for ened-version of adequate. The proposed test demonstrated a
age 21.48 8 ± 0.31 Castilla-La Mancha, healthy food ORTO-15 (11 good predictive capacity at a threshold value
years, mean BMI f Spain via adopting a item version) of < 25 (efficiency 84%, sensitivity 75% and
22.10 ± 3.36 kg/m2, restrictive diet specificity 84%). Spanish shortened-version of
m 23.67 ± 4.06 kg/ and a focus on the ORTO-15 is a reliable tool for assessing ON
m2 food prepara-
tion
Ramacciotti 177 people > 18 years General population Disorder ORTO-15 102 (57.6%) diagnosed ON (40-point thresh-
et al. 2011 (Italy) characterized old), f:m = 2:1. Only 11.9% ON with 35-point
by distorted threshold
eating habits
and cognition
concerning
supposedly
healthy nutri-
tion
type of study
Roncero 2017 Sample 1 Excessive ORTO-15 Socio-demographics Psychometric properties of the Spanish version of
807 participants, preoccupation Sample 2 the ORTO-15 are not adequate. The instrument
74.1% f, 25.9% with healthy EAT-26, SR-YBC-EDS detects people who are on diets, but it is not
m, mean age eating, causing efficient in detecting the severity of orthorexic
23.65 ± 6.01 y significant behaviors and attitudes. New instruments are
Sample 2 nutritional needed to continue the study of orthorexia
242 participants, deficiencies, nervosa
63.2% f, 36.8%, and social
mean age and personal
24.94 ± 7.07 impairments
y, mean BMI
22.41 ± 3.30 kg/m2
Rudolph 2017 1.008 participants: Active members of DOS EAI ON prevalence: 3.4%, EA: 10.2%
559 m, 449 f 3 fitness studios in 2.3% suffer from both. There is a significant
mean age Germany positive correlation between DOS and EAI
29.4 ± 11.6 years (r = 0.421). Female participants show a higher
Cross-sectional study correlation compared to male participants
design
Sanlier et al. 900 students, 522 f and Students (social sci- Obsession for ORTO-15 EAT-40 + author’s questionnaire: The majority of individuals (59.8%) had ON
2016 378 m, age 17–23 y ences, physical and biologically demographic characteristics, nutri- tendencies, higher in f. BMI had no effect on
mathematical sciences pure, organic tional habits and behaviors ON risk
and health-related and healthy
professions) in Turkey foods
Segura-Garcia 577 athletes and 217 Athletes (professional Eating behavior ORTO-15 EAT-26, BUT, YBC-EDS High positivity to ORTO-15 (28%) and EAT-26
et al. 2012 matched controls. 64.6% f and 66.5% characterized (14%) in athletes. High rate of BUT positivity
Age 16–45 years m): judged sports, by exaggerated (21%) in controls
team sports and concerns on
fitness activities. food quality
Sedentary controls:
students
Segura-Garcia 32 ED patients (18 AN Female patients attend- Pathological DSM-IV for EDs ORTO-15* YBC-EDS, eat-26 ON symptoms are highly prevalent among EDs
et al. 2015 and 14 BN) + HCs ing an outpatient attitude with patients, and tend to increase after treatment.
clinic for ED + HCs cognitions and ON seems associated with clinical improve-
from high school worries about ment and migration to less severe forms of EDs
and college students healthy nutri-
(females). Age and tion, and an
BMI—matched accurate food
selection or
a correct diet
that becomes
the most
important part
of life
13

13
type of study
Simpson et al. 505: 69.9% f and Undergraduate psychol- Pathological DSM-5 for EDs Vignettes depicting a fictional Attitudes and beliefs associated with ON are
2017 30.1% m, mean age ogy students fixation with and Moroze’s female manifesting symptoms of similar to, if not more negative than, those
20.55 y, mean BMI consuming criteria (2004) AN, BN, BED or ON. Opinions associated with DSM-5 EDs
24.44 kg/m2 healthy food for ON Scale, perceptions of severity and
and strict desirability, and Causal Attribution
avoidance of Scales
food consid- EDE-Q-I
ered unhealthy
Slof-Op’t Landt 844 patients 10 specialist ED units MPS, DII, EDE-Q, EDI-2, BDI, Latent Profile Analysis, 4 profiles: 1. Healthy
et al. 2016 throughout the PI-R, RSES, TCI-105 Impulsivity (HI; n = 191)
Netherlands, DSM- 2. Unhealthy Impulsivity (UI; n = 238), 3.
IV diagnosis: 381 Healthy and Unhealthy Perfectionism
anorexia nervosa, 146 (HP + UP; n = 153)
bulimia nervosa, 56 4. Healthy Perfectionism (HP; n = 262). Patients
binge-eating disorder, belonging to the HP + UP and the UI classes
261 ED not otherwise reported higher levels of ED psychopathology.
specified The use of dimensional features may enable the
identification of underlying mechanisms and
provide more insight into potential mechanisms
that drive or maintain disordered eating
Stochel et al. 1899 high school High school students, Pathologic fixa- ORTO-15 LOI-CV, EAT-26 Risk of orthorexia: up to 13.7%. Orthorexia
2013 students Sosnowiec, Poland tion connected diagnosis is more likely in the overweight and
with eating obese young people. Sport activities increase
healthy and the risk to app. 90%
proper food
Stochel et al. 399 participants: High school students, ORTO-15 EAT-26 ORTO-15 is a reliable tool to identify the risk of
2015 63.4% f, 36.6% m, Sosnowiec, Poland ON in population studies in the group of urban
mean age 16.9 ± 1.0 youth aged 15–21
y, mean BMI
21.1 ± 1 f, 20.9 ± 3 m
Tremelling et al. 636: 615 f and 21 m Registered dietitian Fixation on ORTO-15 EDE-Q Prevalence: 49.5% for ON and 12.9% for EDs
2017 nutritionists (RDNs) righteous
in the USA eating
Turner et al. 680, mean age 24.7 Social media users Unhealthy ORTO-15 Higher Instagram use was associated with
2017 years, mean BMI following health food obsession with stronger orthorexic symptoms. Twitter had a
22.14 kg/m2 accounts eating healthy small positive association. No effect of age,
food BMI, no. social media and diet on ON
Vandereycken 111: psychologists Professionals involved Obsession with DSM-5 + com- ON is the best known among the ‘new syn-
et al. 2011 51%, physicians in research, preven- healthy food bined descrip- dromes’ (followed by muscle dysmorphia,
17% (mainly psy- tion or treatment and selective tions by Brat- emetophobia and night eating syndrome)
chiatrists) and others of EDs in Belgium eating pattern man, Donini
32% (anonymous survey) that lead to and Mathieu
malnutrition
and under-
weight
type of study
Varga et al. 810, 89.4% f, mean age Hungarian stu- An alleged eat- Hungarian Questions about lifestyle habits and ORTO-11-Hu has adequate psychometric charac-
2014 32.39 ± 10.37, mean dents + graduated ing disorder translation food choices teristics. Need for research from other countries
BMI 23.20 ± 4.89 professionals (dietet- in which the of ORTO-15
ics, medicine and person is (ORTO-
other health-related excessively 11-HU) + ques-
professions or other preoccupied tions developed
fields) with healthy for the purpose
food of the study
AAI Appearance Anxiety inventory, AFN (Alternative Food Network) refers to a connection between consumers, producers and sellers of organic, local–regional, “sustainably grown” and other
artisanal and niche food not produced by the conventional system (Goodman & Goodman, 2007), AFNE Alternative Food Network Engagement Scale, AN anorexia nervosa, ARFID Avoidant/
Restrictive Food Intake Disorder, BDDQ Body Dysmorphic Disorder Questionnaire, BDI Beck-depression inventory, BFNE Brief Fear of Negative Evaluation Scale, BIAQ Body Image Avoid-
ance Questionnaire, BIDR: Balanced Inventory of Desirable Responding, BIS Barratt-Impulsiveness Scale, BMI Body Mass Index, BN bulimia nervosa, BOT The Orthorexia Self-Test devel-
oped by Bratman commonly called Bratman Orthorexia Test, BPNS-E Basic Psychological Needs Scale, BREQ Behavioural Regulations in Exercise Questionnaire, BSI Brief symptom inven-
tory, BULIT-R Bulimia Test-revised, BUT Body Uneasiness Test, CET Compulsive Exercise Test, CES-D Center for Epidemiologic Studies-Depressed Mood Scale, CFA Confirmatory Factor
Analysis, DASS Depression Anxiety Stress Scale, DKB-35 Dresdner Körperbildfragebogen-35 (multidimensional assessment of body image), DOS Düsseldorfer Orthorexie Skala, DSM (IV or
5) Diagnostic and Statistical Manual of Mental Disorders, EADES Eating and Appraisal Due to Emotion and Stress, EAI Exercise Addiction Inventory, EAT-26 Eating Attitudes Test-26, EAT
Eating Attitude Test, ED eating disorders, EDDS Eating Disorders Diagnostic Scale, EDE (EDE-Q) Eating Disorder Examination (Questionnaire), EDE-Q-I Eating disorder examination ques-
tionnaire with instruction, EDI-2 Eating Disorder Inventory-2, EES Emotional Eating Scale, EFA exploratory factor analysis, EHQ Eating Habits Questionnaire, EMI-2 Exercise Motivations
Inventory-2, FCF food consumption frequency, FEV Fragebogen zum Essverhalten (the German version of the TFEQ), HC healthy controls, IPAQ International Physical Activity Questionnaire,
IPIP-41 International Personality Item Pool Five Factor Personality Inventory, LOI-CV Leyton Obsessional Inventory-Child Version, MBSRQ-AS Multidimensional Body Self Relations Ques-
tionnaire-Appearance Scale, MBSRQ Multidimensional Body Self Relations Questionnaire, MDDI Muscle Dysmorphic Disorder Inventory, MIHT Multidimensional Inventory of Hypochondri-
acal Traits, MMPI Minnesota Multiphasic Personality Inventory, MOCI Maudsley Obsessional Compulsive Inventory, MOCQ-R Maudsley Obsessive Compulsive Questionnaire-Revised form,
MPS (Frost) Multidimensional Perfectionism Scale, NPI Narcissistic Personality Inventory, OCI-R Obsessive Compulsive Inventory, Revised, ON Orthorexia Nervosa, PAS Personality Assess-
ment Screener, PHQ-9 Patient Health Questionnaire, RS Restraint Eating Scale, RSQ Relationship Scales Questionnaire, SATAQ Sociocultural Attitudes towards Appearance Questionnaire, SDS
Sheehan Disability Scale, SES Rosenberg Self-Esteem Scale, SF-36 Short Form-36 (measures health status), SPAS Social Physique Anxiety Scale, TFEQ Three Factor Eating Questionnaire,
YBC-EDS Yale Brown Cornell Eating Disorders Scale, mYFAS modified Yale Food Addition scale
13

Table 3 Studies on orthorexia in languages different from English

Author, year (lan- Country population Sample character- Definition of ON Diagnostic criteria Test for ON Other tests Results/conclusions
guage) No., sex, age, BMI/ istics
13
type of study
Adriana Garcìa et al. Review (not system- Not available Spanish translation ORTO-15 and Brat- Orthorexia Self Tets – As it is a handout only
2014 atic) of Bratman and man’s Orthorexia and ORTO-15 containing summariz-
Spanish Knight’s (2000) Self Test are pro- ing answers to seven
definition of ON posed as diagnostic questions regarding
criteria ON (e. g. referring to
symptoms, diagnostic
criteria and treat-
ment), no conclusions
are drawn
Barrada et al. 2018 Spain, n = 942 Mainly university ON is an extreme or Not mentioned Development of the ORTO-15, OCI-R, The final version of
Spanish (n = 716 females, students excessive preoc- Teruel Orthorexia EAT-26, PANAS, the TOS contains 17
n = 226 males. Age: cupation with eating Scale (TOS) MBSRQ, FMPS items on two sub-
24.01 ± 6.41 years) food believed to be scales: healthy ortho-
healthy rexia (healthy interest
in a diet, independent
of psychopathol-
ogy) and orthorexia
nervosa (pathological
preoccupation with a
healthy diet). Psycho-
metric properties are
acceptable
Barthels et al. 2015 Review (not system- Not available Fixation on health- A Preoccupation with – – ON seems to be an
German atic) conscious eating healthy eating eating disorder, but its
behavior, ongoing B Anxieties for differentiation from
mental preoccupa- and avoidance of anorexia nervosa is
tion with healthy foods perceived as not yet clear. As ther-
nutrition overvalued unhealthy apeutic approaches,
ideas concerning the C Overvalued ideas psychoeducation and
effects and potential OR ritualized preoc- nutrition counseling,
health-promoting cupation with foods confrontation with
benefits of foods and D Fixation on healthy “forbidden foods”,
rigid adherence to eating causes suffer- creation of a realistic
self-imposed nutri- ing or impairments health concept, cogni-
tion rules of clinical relevance tive restructuring and
or the presence of countering probability
deficiency syndrome estimations should be
E Weight loss/ considered
underweight should
not dominate the
syndrome
type of study
Barthels 2012 Review (not system- Not available Fixation on a healthy Not mentioned DOS – Prevalence rates
German atic) diet, rigidity regard- assessed with ORTO-
ing self-imposed 11/ORTO-15 seem
nutrition standards to be too high; about
1 to 2 per cent seem
to be a more realistic
estimation in German
speaking population.
ON is most probably
an eating disorder
Barthels 2013 Doctoral thesis. 11 Various samples: Fixation on healthy A Preoccupation with DOS Depending on the The DOS is able to
German studies concerning healthy adults, dieting rigid adher- healthy eating conducted study, assess orthorexic
ON in Germany patients with AN or ence to self-imposed B Anxieties for other questionnaires eating behavior with
(some are published OCD, vegetarians nutrition stand- and avoidance of were used, e. g. good psychometric
in peer-review and vegans ards and severe foods perceived as EDI-2, TFEQ, OCI- properties
journals) restrictions in food unhealthy R, WI, BDI-II, BSI ON is associated with
selection C Overvalued ideas or characteristics of dis-
ritualized preoccu- ordered eating behav-

pation with foods ior and, therefore,
D Fixation on healthy seems to be another
eating causes suffer- variant of disordered
ing or impairments eating behavior.
of clinical relevance Patients with AN and
or the presence of vegetarians/vegans
deficiency syndrome display higher rates
E Weight loss/ of ON. More research
underweight should is needed to better
not dominate the understand orthorexia
syndrome
Bartrina 2007 Review (not system- Not available Obsessive–com- Spanish translation – – Women, adolescents
Spanish atic) pulsive disorder of the proposal by and individuals
characterized by Donini (2004, 2005) engaging in body-
an extreme fixation building or athletics
on the selection of are supposed to be at
foods perceived as a higher risk. Treat-
healthy, resulting ment of ON should
in a strict diet and include a multidis-
social isolation ciplinary team of
physicians, dieticians
and psychotherapists,
maybe also including
SSRIs
13

13
type of study
De Souza et al. 2014 Brasil, n = 150. Age: Female students of Obsessive behavior Not specified ORTO-15 Silhouettes Scale 88.7% (n = 133) of the
Portuguese 23.21 ± 6.30 years. nutritional sciences including a fixation students were at risk
BMI: only specified on healthy food, for developing ON.
as normal weight more than 3 h a day No association was
found between ON
and grade level, nutri-
tional status nor body
image disturbance
Ewers et al. 2017 Review (not sys- Not available Excessive and time- Not mentioned – – ON might be, among
German tematic) on eating consuming preoccu- other eating disorders,
behavior in general pation with healthy a relevant disordered
in people engag- eating eating behavior in
ing in competitive individuals engaging
sports in competitive sports
Glogowski et al. 2015 Interview on ON with – Disordered eating Proposal to classify – – ON seems to be of
German Martina de Zwaan behavior with obses- ON as ARFID minor clinical rel-
(head of the Depart- sive–compulsive (avoidant/restric- evance
ment of Psycho- traits tive food intake
somatic Medicine disorder) or to use
and Psychotherapy, the criteria suggest
Hannover Medical by Moroze et al.
School. Hannover, (2015)
Germany)
Janas-Kozik et al. Review (not system- Not available Pathological fixation Criteria proposed by – – There is a need to
2012 atic) on eating proper and Steven Bratman conduct the clinical,
Polish healthy food and David Knight dietary psychological
(2000)—based on and epidemiological
the BOT as well studies to present the
as by Donini et al. scale of the problem,
(2004)—based on its prevalence and
the ORTO-15 conditionings
Among the current
problems, the prior-
ity is to develop the
standard diagnostic
and classification ON
criteria
type of study
Jerez et al. 2015 Chile, n = 205 High school students Pathological fixation Not specified ORTO-15 None ON prevalence rate in
Spanish (94 females, 111 on healthy eating the entire sample:
males). Age: range 30.7%. With 35.1%,
between 16 and 18. the prevalence rate for
BMI: not available males is higher than
the rate for females
(25.5%)
Kaluaratchige 2013 Review/comment (not Not available ON is an eating dis- Deficiency syndrome – – This is a anthropo-
French systematic), includ- order with focus on and pathologic logic and psycho-
ing two case reports healthy eating and behavior: obsessive– analytic reflection
living a “good life” compulsive behavior on ON. In both case
focusing on eating reports, patients are
healthy; avoidance described with a
of foods believed to shift from anorexic
be unhealthy to orthorexic eating
behavior, which are
both explained using
the psychoanalytic
theories of hysteria
and stages of psycho-
sexual development
Karadag et al. 2016 Turkey, n = 750 (375 Healthy adults Disordered eating Not specified ORTO-15 EAT-40, 24 h food Prevalence for ON was
Turkish females, 375 males). behavior focusing recall, HEI-2010 51.3% in the male
Age females: on a healthy diet sample and 48.7% in
25.60 ± 6.83 years. and including rigid the female sample.
Age males: nutritional standards Individuals classified
25.94 ± 6.61 years. as orthorexic seem
BMI females: to consume more fat.
22.77 ± 4.46 kg/ Nonetheless, they
m2. BMI males: are mostly normal
23.92 ± 3.47 kg/m2 weight, whereas in
the non-orthorexic
sample, overweight
is more prevalent. In
females, a correlation
between ON and BMI
was observed
Kata et al. 2008 Review (not system- Eating-related obses- ORTHO-15 Further studies needed
Hungarian atic) sion about consum- to assess features,
ing healthy food prevalence and rela-
tion with sexuality
disorders
13

13
type of study
Krzywdzińska et al. Review (not system- Not available Pathological control Not available The Bratman’s ON result from genetic,
2014 atic) over nutrition, Orthorexia Self-test personality and psy-
Polish concentration over and the ORTO-15 chological factors
quality of consumed are proposed as ON is threat to children
food diagnostic tools and adolescents
Mader 2004 Review (not system- Not available Extreme fixation on Not mentioned – – ON is not an eating
German atic) healthy food disorder but rather
the beginning of a
more severe form
of disordered eating
behavior. Sometimes,
also patients with
illness anxiety and
somatic symptom dis-
order display ON as a
strategy to cope with
somatic symptoms
and low self-esteem
Nauta et al. 2016 Case report Man 71 y, BMI Fixation on healthy Bratman S Malnutrition caused by
Dutch 13.8 kg/m2, GCS food leading to a a diet coming from an
10, pitting edema, selective and restric- obsession with health
decompensation tive diet which is an insufficient
cordis with bilateral may cause severe recognized medical
pleural emphysema, malnutrition problem. Shedding
ascites light on the epide-
miology, validity of
the definition and the
clinical presentation
of ON is needed
Nyman 2002 Review (not system- Pathological fixation Etymologically, the
Swedish atic) on eating proper term orthorexia is
food hardly perfect, but it
becomes difficult to
find a better one
type of study
Pietrowsky et al. 2016 Review (not system- Not available Extreme diet sup- Not mentioned – – ON is not only a
German atic) posed to be healthy. lifestyle. ON seems
Characteristics: to be a disorder
fixation on healthy closely related to
eating, self-imposed eating disorders and
nutritional rules, is associated with
feelings of superior- health-related and
ity, negative effects psychosocial issues in
on life quality affected people
Poyraz et al. 2015 Turkey. n = 130 Clinical Sample of Strong preoccupation Not specified ORTO-11 EAT-40, PI-WSUR ON scores did not
Turkish patients (97 females, outpatients with healthy eating differ between the
33 males) of whom groups. A significant
were n = 49 diag- correlation between
nosed with OCD, disordered eating
n = 44 with panic behavior and attitudes
disorder and n = 37 (EAT-40) and ON
with generalized was found. ORTO-11
anxiety disorder. score was associated

Age females: with checking and
33.95 ± 10.59 years. dressing/groom-
Age males: ing compulsions.
31.31 ± 9.98. Underlying cognitive
BMI females: processes of ON and
25.46 ± 5.43 kg/ ritualistic compul-
m2. BMI males: sions might be similar
25.31 ± 4.22 kg/m2
Rössner 2004 Review (not system- Orthorexia nervosa or Bratman’s Orthorexia There is no food that is
Swedish atic) compulsive correct Test really useful or dan-
eating: a person gerous. It is the eating
that avoids all food habits in the long run
which in some way that determine how
seems “useless” we will feel and how
our health values will
look
The Swedish Medical
Association’s lan-
guage committee has
considered whether
the term orthorexia is
appropriate
13

13
type of study
Rudolph et al. 2017 Germany, n = 759 Students who are Disordered eating Not mentioned DOS – ON prevalence in the
German (29% males, 71% active members of a behavior character- whole sample: 2.5%.
females). Age: fitness center ized by adherence Whereas in the female
Males: 24.7 ± 3.9 to self-imposed sample orthorexic
years; females nutrition rules and eating behavior is
23.0 ± 2.8 years. mental preoccupa- associated with inten-
BMI: Males tion with healthy sity and frequency of
23.0 ± 2.2 kg/ eating athleticism, there is
m2; females: no such relation in the
21.3 ± 2.3 kg/m2. male sample
Cross-sectional
study
San Mauro Martin Spain, n = 264 Healthy adults attend- Obsessive–com- Not specified To assess orthorexic Adherence to Medi- High rates of orthorexic
et al. 2014 (156 male, 108 ing a fitness center pulsive disorder eating behavior, terranean diet test, eating behavior in
Spanish female). Age: or a sports club characterized by an several ques- STAXI-2, EEQ, the sample. Females
35.9 ± 11.1 years. and exercising on a extreme fixation the tions presumably MBSRQ seem to be more
BMI: 23.8 ± 3.1 kg/ regular basis selection of foods constructed by the affected than males
m2 perceived as healthy authors were used.
Examples: do you
read up on health
and nutrition? Do
you feel bad when
you have eaten too
much?
Schumacher et al. Interview on ON with Not available Focus on healthy Not mentioned – – Cognitive–behavioral
2013 Friederike Barthels eating, anxiety of therapy might be
German foods perceived as indicated when a
unhealthy deficiency syndrome
occurs or when chil-
dren are affected
ARFID avoidant/restrictive food intake disorder, AN anorexia nervosa, BDI Beck-depression inventory, BOT The Orthorexia Self-Test developed by Bratman commonly called Bratman Ortho-
rexia Test, DII Dickman Impulsivity Inventory, DSM (IV or 5) Diagnostic and Statistical Manual of Mental Disorders, ED eating disorders, EDE-Q Eating Disorder Examination Questionnaire,
EDI Eating Disorder Inventory, EHQ Eating Habits Questionnaire, ON orthorexia nervosa, MPS (Frost) multidimensional perfectionism, PI-R Padua Inventory-revised, RSES Rosenberg’s Self
Esteem Scale, TCI-105 Temperament and Character Inventory
Table 4 Detailed classification criteria for ON delineated by some scholars (and presented in the latest research)
Author, year Diagnostic criteria
Setnick, 2013 Criterion A: pathological preoccupation with nutrition and diet far beyond that which is necessary for health, and
undue influence of diet on self-evaluation, evidenced by characteristics such as
1. Phobic avoidance of or response to foods perceived to be unhealthy, such as refusal to be in proximity to such food
or experiencing panic while watching others eat the food
2. Severe emotional distress or self-harm after eating a food considered unhealthy
3. Persistent failure to meet appropriate nutritional needs leading to nutritional deficit and/or psychological depend-
ence on individual nutrient supplements in place of food intake due to the belief that synthetic nutrients are superior
to those found in food or that food is contaminated (except in cases where food is known to be contaminated)
4. Following a restrictive diet prescribed for a medical condition that the individual does not have, or to prevent illness
not known to be influenced by diet
5. Insisting on the health benefits of the diet in the face of evidence to the contrary
6. Marked interference with social functioning or activities of daily living, such as isolation when eating, avoidance
of social functions where food is served, or neglect of work, school or family responsibilities due to food-related
activities
Criterion B: not the result of a lack of available food or a culturally sanctioned practice
Criterion C: the individual endorses a drive for health or life extension rather than a drive for thinness
Criterion D: the eating disturbance is not attributable to a medical condition or another mental disorder such as ano-
rexia nervosa, bulimia nervosa or obsessive–compulsive disorder
Moroze et al. 2014 Criterion A. obsessional preoccupation with eating “healthy foods,” focusing on concerns regarding the quality and
composition of meals. (Two or more of the following.)
1. Consuming a nutritionally unbalanced diet due to preoccupying beliefs about food “purity.”
2. Preoccupation and worries about eating impure or unhealthy foods, and on the impact of food quality and composi-
tion on physical and/or emotional health
3. Rigid avoidance of foods believed by the patient to be “unhealthy,” which may include foods containing any fat,
preservatives, food-additives, animal products, or other ingredients considered by the subject to be unhealthy
4. For individuals who are not food professionals, excessive amounts of time (e.g. three or more hours per day) spent
reading about, acquiring and/or preparing specific types of foods based on their perceived quality and composition
5. Guilty feelings and worries after transgressions in which “unhealthy” or “impure” foods are consumed
6. Intolerance of others food beliefs
7. Spending excessive amounts of money relative to one’s income on foods because of their perceived quality and
composition
Criterion B. The obsessional preoccupation becomes impairing by either of the following
1. Impairment of physical health due to nutritional imbalances, e.g. developing malnutrition due to unbalanced diet
2. Severe distress or impairment of, social, academic or vocational functioning due to obsessional thoughts and behav-
iors focusing on patient’s beliefs about “healthy” eating
Criterion C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as obsessive
compulsive disorder, or of schizophrenia or another psychotic disorder
Criterion D. The behavior is not better accounted for by the exclusive observation of organized orthodox religious
food observance, or when concerns with specialized food requirements are in relation to professionally diagnosed
food allergies or medical conditions requiring a specific diet
Barthels et al. 2015 Criterion A: enduring and intensive preoccupation with healthy nutrition, healthy foods and healthy eating
Criterion B: pronounced anxieties for as well as extensive avoidance of foods considered unhealthy according to
subjective beliefs
Criterion C
C1. At least two overvalued ideas concerning the effectiveness and potential health benefits of foods
AND/OR
C2. Ritualized preoccupation with buying, preparing and consuming foods, which is not due to culinary reasons but
stems from overvalued ideas. Deviation or impossibility to adhere to nutrition rules causes intensive fears, which can
be avoided by a rigid adherence to the rules
Criterion D
D1: the fixation on healthy eating causes suffering or impairments of clinical relevance in social, occupational or other
important areas of life and/or negatively affects children (e.g. feeding children in an age-inappropriate way) AND/
OR
D2. Deficiency syndrome due to disordered eating behavior. Insight into the illness is not necessary, in some cases the
lack of insight might be an indicator for the severity of the disorder
Criterion E: Intended weight loss and underweight may be present, but worries about weight and shape should not
dominate the syndrome
For diagnosing orthorexia, criteria A, B, C, and E must be clearly fulfilled. Criterion D should be fulfilled at least
partially. If criterion E is not clearly fulfilled, diagnosing atypical anorexia nervosa is recommended
13
Author, year Diagnostic criteria
Dunn and Bratman 2016 Criterion A: obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details
may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight
loss may ensue as a result of dietary choices, but this is not the primary goal. As evidenced by the following:
A1. Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices believed
by the individual to promote optimum health
A2. Violation of self-imposed dietary rules causing exaggerated fear of disease, sense of personal impurity and/or
negative physical sensations, accompanied by anxiety and shame
A3. Dietary restrictions escalate over time, up till removing entire food groups, and involve progressively more fre-
quent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads
to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy eating
Criterion B: the compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:
B1. Malnutrition, severe weight loss or other medical complications from restricted diet
B2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behav-
iors about healthy diet
B3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-
defined “healthy” eating behavior
Table 5 Differences and (a) ED ON

similarities between orthorexia
nervosa and eating disorders Differences Fears of gaining weight No fears of gaining weight
(a) or obsessive–compulsive
Focus on the quantity of food Focus on the quality of food
disorders (b)
Hidden rules related to eating Open, rationalized rules related to eating
Body image disturbances No body image disturbances
Female » male No gender differences
Common characteristics Over-concern about food and eating dominates one’s life
Adaptation of behavior and lifestyle to eating
Diet becomes intertwined with identity and self-esteem
Consequences: social isolation, somatic problems, malnutrition
Bio-psycho-socio etiology
Obsessive compulsive personality traits (rigidity, perfectionism)
Ego-syntonic OC symptoms
(b) OC ON
Differences Non-specific, different types of Healthy eating/food-related OC symp-

symptoms toms
Common characteristics Rigidity, perfectionism
Consequences: anxiety, depression, social isolation
Impairment in social function
Obsessive–compulsive features
ED eating disorder, ON orthorexia nervosa, OC obsessive compulsive disorder
self-defined healthy eating behavior was indicated as a cri- Additionally, each set specified some unique criteria or
terion for diagnosis [7]. aspects not used by the others. Barthels et al. [27] affirmed
Two proposals [27, 134] additionally mentioned the pres- that insight is not a necessary criterion. Dunn et al. [7] pro-
ence of overvalued ideas as a criterion, while Dunn et al. [7] posed that an escalation of dietary restrictions over time
described compulsive behavior as crucial. should be used as a criterion. Moroze et al. [96] proposed
All proposals also included criteria for a differential diag- spending excessive amounts of time and money as criteria.
nosis. While Dunn et al. [7] and Barthels et al. [64] only Setnick [134] added as a criterion of exclusion that eating
mentioned that the desire for weight loss must be absent, behavior should not be the result of a lack of available food
Moroze et al. [38] and Setnick [65] specified additional cri- or culturally sanctioned practice.
teria, e.g. the absence of an obsessive–compulsive disorder
and psychotic disorders.
13
• Psychometric tests: used to define the essential feature of ON better need to be

encompassed in the definition that the ON-TF will endorse.
ORTO-15 was the most used psychometric tool (49 stud- As to eating behavior, the suitable food was identified
ies) with different versions (translated and validated in vari- with different levels of quality. In most papers, it was defined
ous languages, integral or short version). The Orthorexia in a generic and sometimes opposite way: healthy/proper/
Self-Test developed by Bratman (BOT) was used in nine correct/safe or unhealthy, depending on the point of view
studies, the Dusseldorfer Orthorexie Skala (DOS) in five of the authors. In other studies, the definition considered
studies [21, 22, 51, 86, 115] and the Eating Habits Question- specific aspects (organic, (biologically) pure, or related
naire (EHQ) in five studies [65, 101–103]. Finally, Olejnic- to food production). Last, in some cases, the definition of
zak et al. [104] used a new questionnaire while Varga et al. healthy food seems not to refer to the biological quality but
[130] added to the ORTO-15 different items, developed for to pseudo-moral aspects (two studies used the term impure).
the 2014 study. The diet followed by subjects with ON was also defined
looking at different characteristics referring to dietetic
(restrictive, characterized by the avoidance of certain foods,
Discussion distorted eating habits, shortage of essential nutrients, lead-
ing to malnutrition and underweight) or behavioral aspects
The present review synopsizes the literature based on the (ritualised, strictly controlled, becoming the central focus of
definition of ON, proposed diagnostic criteria and psycho- life, with modification of social relationships).
metric instruments used to assess orthorexic attitudes and
behaviors. This work represents a necessary starting point
to allow a further progression of the studies on the possi- Diagnostic criteria
ble new syndrome and to overcome the criticisms that have
affected both research and clinical activity. An official set of diagnostic criteria does not yet exist. Four
The results show a considerable variety of answers to the authors proposed formal diagnostic criteria and, in some
three core issues. cases, used the DSM (IV or 5) classification and tried to
adapt to ON the criteria employed for AN, ARFID or BDD.
The debate is ongoing in the literature to decide whether ON
Definition should be considered as a distinct disorder, a variant of an
existing eating disorder or an obsessive compulsive disorder
ON was defined in the different papers with three/four terms: or finally (just) a disturbed eating habit [36].
obsession (the most frequent), fixation, and concern/preoc- Defining the boundaries of ON concept of ON and verify-
cupation. Obsession indicates a persistent and disturbing ing which elements (e.g. eating behavior, compulsivity, body
thought, while fixation is a stereotyped behavior related to image disturbance, body weight concerns, insight, medical
an obsessive and unhealthy preoccupation or attachment. complications, psychosocial functioning) need to be consid-
Concern refers to an uneasy state of blended interest, uncer- ered in its definition, is a ON-TF mission. The consistency
tainty, and apprehension while preoccupation may be con- of some of the proposed criteria provides a useful starting
sidered a synonym of concern with probably a higher degree point to develop diagnostic criteria further and, if necessary,
of alarm representing a state in which someone gives all modify them and add criteria only mentioned by one or two
his/her attention to something (https://www.merriam-webst authors to find a reasonable consensus.
er.com/dictio nary/ ). The three/four terms seem, therefore, to
be complementary since they look to different aspects and
moments of the same problem: the concern about healthy Psychometric instruments
diet leads to having all the attention captured by food (pre-
occupation), thus evolving to a persistent and disturbing The ORTO-15 (including its versions with a reduced number
thought (obsession) and a stereotyped behavior (fixation). of items) and the Orthorexia Self-Test were the most used
These terms were moreover emphasized through different psychometric tools. They both present significant psycho-
adjectives defining diverse aspects of the behavior from a metric flaws, and one of the aims of the ON-TF is the vali-
quantitative point of view (exaggerated/excessive, extreme, dation of a new self-administered questionnaire taking into
overwhelming, time consuming) and a qualitative perspec- account a new shared definition and new shared diagnostic
tive. This latter was further outlined considering clinical criteria for ON.
(unhealthy, pathological) and psychological (rigid, com- As Missbach et al. [8] correctly stated, an instrument
pulsive, maniacal, monoideistic) characteristics. The three aimed at assessing behavioral traits should be consistent and
aspects of the definition and the two/three groups of terms reliable across different population groups (also reflecting
13
cultural and religious backgrounds) and consider the essen- Compliance with ethical standards
tial features that describe a disorder (e.g. ON).
One of the most important challenges is to draw a bound- Conflict of interest All the authors declare that they have no conflict of
ary between adopting a healthy diet—which is recom- interest regarding this publication.
mended to everybody to prevent “hidden” malnutrition and Ethical approval This article does not contain any studies with human
reduce morbidity and premature mortality—and developing participants performed by any of the authors.
inflexible beliefs, attitudes, and behaviors related to nutrition
Informed consent For this type of study, formal consent is not required.
with unhealthy consequences.
Strengths and limitations References
The present review considers studies on ON written in Eng- 1. Bratman S (1997) Health food junkie. Yoga (September/Octo-
ber). http://www.beyondveg.com/bratman-s/hfj/hf-junkie-1a.
lish and quoted in PubMed till 07 August 2018 and pro-
shtml. Accessed August 18, 2018
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Orthorexia nervosa and eating disorder symptoms in registered
Affiliations
Hellas Cena1 · Friederike Barthels2 · Massimo Cuzzolaro3 · Steven Bratman4 · Anna Brytek‑Matera5 · Thomas Dunn6 ·

Marta Varga7 · Benjamin Missbach8 · Lorenzo M. Donini9
1 7
University of Pavia, Pavia, Italy Semmelweis University, Budapest, Hungary
2 8
Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Open Innovation in Science Research and Competence
Germany Center, Ludwig Boltzmann Gesellschaft, Vienna, Austria
3 9
Formerly Sapienza University of Rome, Rome, Italy Food Science and Human Nutrition Research Unit, Medical
4 Pathophysiology, Food Science and Endocrinology Section,
Vallejo, CA, USA
Experimental Medicine Department, Sapienza University
5
SWPS University of Social Sciences and Humanities, of Rome, Rome, Italy
Katowice, Poland
6
University of Northern Colorado, Greeley, USA
13
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Deﬁnition and diagnostic criteria for orthorexia nervosa: a narrative review of

Article in Eating and weight disorders: EWD · April 2019

Hellas Cena Friederike Barthels

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Massimo Cuzzolaro Anna Brytek-Matera

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Orthorexia Nervosa View project

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Definition and diagnostic criteria for orthorexia nervosa: a narrative

Received: 13 September 2017 / Accepted: 24 October 2018

Keyword Orthorexia nervosa

attitudinal aspects of body area satisfaction, high

Cartwright Review (not systematic) Preoccupation with Multiple strategies aimed at

Hepworth Commentary Fixation on righteous Following a healthy diet does

of their exemplary overstretched

Peat 2016 Overview Pathological obses-

or their own dietary health,

Most of these papers were research articles aimed at the

indicators to aid in preven-

called “worry factor” and

groups” are the biggest

“feelings towards food

narcissism, perfectionism, previous history of eating disor-

The terms used by the different authors concerning the

feelings accompanying the search for food were fixation,

extreme, monoideistic, maniacal, time-consuming, and

rarely impure or related to “food production”.

as shortage of essential nutrients, malnutrition and under-

weight, changes in social relationships because of the con-

stant thought on healthy food.

Most of the papers did not define the diagnostic criteria.

diets, 1 vegan diet

Esteem Scale, TCI-105 Temperament and Character Inventory

DSM (edition IV or 5) criteria for anorexia nervosa (AN),

or avoidant/restrictive food intake disorder (ARFID), or

Specific diagnostic criteria proposed by the authors were

Four of them [7, 27, 96, 134] published their proposal,

allowing a brief comparison of criteria suggested to diag-

nose ON (Table 4). All these studies indicated as primary

(e.g. distress, anxieties) of non-adherence to self-imposed

nutritional rules; (c) psychosocial impairments in relevant

Besides rigid avoidance of food considered unhealthy,

heard about ON complicating PTs’ negotiations due to a com-

Table 3 Studies on orthorexia in languages different from English

ritualized preoccu- ordered eating behav-

anxiety disorder. score was associated

Table 5 Differences and (a) ED ON

Differences Non-specific, different types of Healthy eating/food-related OC symp-

ED eating disorder, ON orthorexia nervosa, OC obsessive compulsive disorder

• Psychometric tests: used to define the essential feature of ON better need to be

Strengths and limitations References

Hellas Cena1 · Friederike Barthels2 · Massimo Cuzzolaro3 · Steven Bratman4 · Anna Brytek‑Matera5 · Thomas Dunn6 ·

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Table 3 Studies on orthorexia in languages different from English

Table 5 Differences and (a) ED ON