A review shows that orthorexia nervosa is closely linked to perfectionism and obsessive-compulsive disorder

A review shows that orthorexia nervosa is closely linked to perfectionism and obsessive-compulsive disorder

A review overview shows how commonly orthorexia nervosa symptoms are reported across studies and why inconsistent diagnostic tools continue to cloud the understanding of this emerging eating-related disorder.

In a recent review published in the journalCurrent nutritional reportsResearchers synthesized data from previous meta-analyses to summarize reported prevalence estimates and identify psychological correlates of orthorexia nervosa (ON). Despite growing awareness and recognition in the scientific literature, ON remains unrecognized in major psychiatric diagnostic systems.

The results of the study found that although prevalence estimates vary widely (approximately 27.5 percent), ON is significantly related to perfectionism, compulsive compulsive behavior, and eating disorder symptoms. The review also highlights that although a growing body of literature attempts to elucidate ON, inconsistent diagnostic tools currently limit the power of existing evidence.

Definition of orthorexia nervosa and its effects

Orthorexia nervosa (ON) is an emerging term that refers to an obsession with healthy eating accompanied by restrictive behaviors. Paradoxically, this attempt to achieve optimal health through mindfulness of diet is increasingly associated with malnutrition, loss of relationships, and reduced quality of life.

ON is now recognized as distinct from healthy orthorexia, reflecting a non-pathological interest in nutrition. While traditional eating disorders such as anorexia nervosa focus on controlling the quantity and weight of food, ON is characterized by a fixation on the quality and purity of food. Individuals may strictly avoid foods they consider impure, such as sugar, dairy, or non-organic products, leading to malnutrition and social isolation.

Despite these documented harms and increasing symptom reports in recent studies, ON is not officially recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), making clinical identification and treatment difficult.

Purpose and scope of the umbrella review

This comprehensive review, defined as a synthesis of existing meta-analyses, aimed to fill this gap by clarifying the global prevalence of ON symptoms and identifying the psychological characteristics that trigger them.

Eligible publications were identified through systematic searches of PubMed, Google Scholar and Scopus from database inception to July 31, 2025. By reviewing titles, abstracts, and full texts, 62 candidate publications were narrowed down to five meaningful meta-analyses for inclusion. These analyzes included large data sets, including a meta-analysis based on data from more than 30,000 people in 18 countries.

Methodological quality and evidence classification

The quality of included publications was assessed using the ROBIS (Risk of Bias in Systematic Review) tool and an evidence classification framework ranging from Class I (strong evidence) to Class IV (weak evidence).

The analyzes focused on two main questions. First, how frequently are ON symptoms reported? Second, what psychological traits are statistically associated with ON?

Prevalence estimates across population groups

The review found significant variability between prevalence estimates, largely due to methodological heterogeneity, including differences in study design and diagnostic tools. Despite these limitations, several consistent patterns emerged.

The pooled prevalence of ON symptoms was estimated at 27.5 percent, with a 95 percent confidence interval of 23.5 to 31.6 percent. Contrary to previous assumptions that eating disorders disproportionately affect women, the largest included meta-analysis found no statistically significant difference between women (34.6 percent) and men (32.1 percent).

Prevalence varied between subgroups. People who focused on athletic performance or body composition showed the highest observed prevalence at 34.5 percent, although differences between population types were not statistically significant. A non-significant temporal trend toward higher prevalence was also observed, with studies conducted between 2020 and 2023 generally reporting higher estimates than previous studies.

Psychological characteristics associated with ON

The review confirmed significant associations between ON and several psychological traits.

Eating disorder symptom measures showed a moderate association with ON, with a pooled correlation of r = 0.36, suggesting partial overlap with traditional eating disorders.

Obsessive-compulsive symptoms were also significantly associated with ON, r = 0.25. When analyzes were restricted to studies using newer diagnostic tools developed after 2016, this association strengthened to r = 0.40, supporting the hypothesis that ON involves rigid and ritualized food-related behaviors.

Perfectionism was a significant predictor of ON, r = .27, driven primarily by perfectionistic aspirations rather than perfectionistic concerns. Unlike anorexia nervosa, where perfectionism often focuses on weight, ON-related perfectionism appears to focus on proper nutrition.

The exercise showed variable connections. General exercise was weakly correlated with ON (r = 0.12), whereas compulsive or addictive exercise had a stronger association (r = 0.29).

Clinical and research implications

This overall review shows that ON symptoms are common, particularly in fitness-oriented populations. The results fall within a psychiatric spectrum and share similarities with obsessive-compulsive disorder and anorexia nervosa, but further differ in their emphasis on food purity rather than weight loss.

Most evidence was classified as Class III suggestive, with some correlates, including obsessive-compulsive traits and perfectionism, classified as Class II and highly suggestive. High statistical heterogeneity between studies limited the ability to draw more meaningful conclusions. These results highlight the urgent need for standardized diagnostic criteria, validated screening tools, and longitudinal study designs.

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