published: 28 January 2021
Frontiers in Psychiatry | www.frontiersin.org 1January 2021 | Volume 12 | Article 640401
University of Hohenheim, Germany
University of Padua, Italy
This article was submitted to
a section of the journal
Frontiers in Psychiatry
Received: 11 December 2020
Accepted: 07 January 2021
Published: 28 January 2021
Meule A and Voderholzer U (2021)
Orthorexia Nervosa—It Is Time to
Think About Abandoning the Concept
of a Distinct Diagnosis.
Front. Psychiatry 12:640401.
Orthorexia Nervosa—It Is Time to
Think About Abandoning the
Concept of a Distinct Diagnosis
Adrian Meule 1,2
*and Ulrich Voderholzer 1,2,3
1Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich,
Germany, 2Schoen Clinic Roseneck, Prien am Chiemsee, Germany, 3Department of Psychiatry and Psychotherapy,
University Hospital of Freiburg, Freiburg, Germany
Keywords: orthorexia nervosa, anorexia nervosa, bulimia nervosa, eating disorders, obsessive-
The term orthorexia nervosa (ON) refers to an obsessive focus on healthy eating (1). Proposed
diagnostic criteria include a dietary theory or set of beliefs about healthy foods, exaggerated
emotional distress in relationship to food choices that are perceived as unhealthy, and clinical
impairment because of compulsive dietary behaviors and mental preoccupation (2). Although
research on ON has been conducted for 20 years, its measurement and clinical value are still hotly
debated. For example, it is not clear whether ON is actually a diagnostic entity that is distinct from
established eating disorders and other mental disorders such as obsessive-compulsive disorder.
MEASUREMENT OF ON
The large majority of studies on ON have been based on a questionnaire measure called the
ORTO−15 (3) or several short versions of it [e.g., (4–6)]. However, studies have shown consistently
that this instrument has poor psychometric properties, the most prominent of which is its low
internal reliability [e.g., (7–9)]. Thus, ﬁndings based on the ORTO−15 are inconsistent and
hardly interpretable. Several other instruments have been developed [cf. (9)]. However, using
these measures has not been recommended [e.g., Bratman’s Orthorexia Test (1); cf. (8,9)] or they
have only been used in a handful of studies yet [e.g., the Eating Habits Questionnaire (10) or the
Orthorexia Nervosa Inventory (11); cf. (9,12)]. A relatively new measure with sound psychometric
properties and which is increasingly used internationally (13–16) is the Düsseldorf Orthorexia Scale
[DOS; (17)]. Therefore, we focus on studies that used the DOS in this opinion piece.
OVERLAPS AND DIFFERENCES BETWEEN ON AND EATING
A key feature of ON is that food choices are based on qualitative, health-related aspects of foods.
That is, unlike in persons with anorexia nervosa, food choices are not based on quantitative, energy
density-related aspects of foods that are motivated by a drive for thinness and body dissatisfaction.
Speciﬁcally, Cena et al. (12) argue that—while established eating disorders and ON share common
characteristics such as a concern over food and eating—ON is marked by open, rationalized
rules related to eating and a focus on the quality of foods instead of fears of gaining weight
and body image disturbances. Unlike eating disorders, which are more prevalent in females than
males, conceptualizations of ON do also assume that there is no sex diﬀerence in orthorexic
symptomatology (12). However, most studies that used the DOS could not demonstrate that
Meule and Voderholzer Orthorexia Nervosa 8
orthorexic symptoms are independent from features of
disordered eating behavior. For example, positive correlations
between DOS scores and eating disorder symptoms such as
drive for thinness and body dissatisfaction have been found
in both non-clinical and clinical samples [e.g., (18–20)] and
orthorexic symptomatology tends to be higher in females than
males [e.g., (21)].
In line with these reports, we found that prevalence rates
of ON (based on DOS scores of ≥30) were high in inpatients
with anorexia nervosa (48%) and bulimia nervosa (33%) in a
recent study that tested a large sample of inpatients with mental
disorders (22). Furthermore, DOS scores signiﬁcantly decreased
from admission to discharge, although orthorexic eating was not
targeted in the eating disorder-speciﬁc treatment. Finally, higher
DOS scores strongly related to higher drive for thinness and
higher body dissatisfaction in these groups (r≥0.5). Thus, our
ﬁndings speak against the notion that ON represents a distinct
diagnostic entity and suggest that it may rather be an aspect of
restrictive eating disorder symptomatology.
OVERLAPS AND DIFFERENCES BETWEEN
ON AND OBSESSIVE-COMPULSIVE
Cena et al. (12) not only discuss similarities and diﬀerences
between ON and eating disorders but also between ON
and obsessive-compulsive disorder. Speciﬁcally, they highlight
rigidity, perfectionism, and other obsessive-compulsive features
as common characteristics while the only diﬀerence being that
obsessive-compulsive symptoms relate to food and eating in ON.
Similarly, other authors have described the rigid beliefs about
healthy eating as a form of obsessive thoughts and the avoidance
of subjectively perceived unhealthy foods as a form of compulsive
behavior [e.g., (23)] and higher DOS scores indeed relate to
higher obsessive-compulsive symptoms [e.g., (24)].
In our study in inpatients with mental disorders (22),
however, we did not ﬁnd a substantial overlap between
ON and mental disorders other than eating disorders. That
is, the prevalence of ON (based on DOS scores of ≥30)
was similar to prevalence rates reported in the general
population [0–3%; e.g., (17,20,21)] in groups of patients
with a depressive episode, recurrent depressive disorder,
phobic disorders, obsessive-compulsive disorder, trauma-related
disorders, and somatoform disorders. Unlike the changes
observed in patients with eating disorders, DOS scores did not
change from admission to discharge in these groups. Thus, this
study showed a clear distinction from other mental disorders
such as obsessive-compulsive disorder, which is in line with other
We conclude that—although orthorexic symptoms seem to be
distinct from mental disorders such as obsessive-compulsive
disorder—this distinction does not hold for established eating
disorder diagnoses. Although features of eating disorders such
as drive for thinness, body dissatisfaction, and sex diﬀerences
are not part of ON conceptually, the independence of orthorexic
symptomatology from these features could not be demonstrated
empirically. To put our results into perspective, however, we
also need to mention that DOS scores were unrelated to
features of disordered eating in two studies from China (15,26),
indicating that there might be cultural diﬀerences in orthorexic
symptomatology or in its measurement. Cultural diﬀerences—
between China and Western countries in particular—have been
previously noted in self-report measures of eating behavior
and their correlates with the reasons for these diﬀerences
remaining elusive (27,28). Thus, we cannot exclude that the
current evaluation about the ON construct is limited to Western
(particularly European) countries, in which the majority of
studies were conducted.
As a ﬁnal remark, we argue that future research on ON
requires more sophisticated approaches than cross-sectional
questionnaire studies. For example, large interview-based studies
seem to be necessary to gain deeper insights into the ON
construct. Such studies may include applying structured clinical
interviews such as the SCID−5–RV (29) and additionally the
DOS or, preferably, a newly developed ON-speciﬁc interview.
Only when individuals show an orthorexic eating behavior (e.g.,
as indicated by DOS scores ≥30) that is accompanied by a clinical
impairment or subjective distress and at the same time do not
receive an established eating disorder diagnosis (which not only
includes anorexia nervosa and bulimia nervosa but also any of
the other eating disorder diagnoses listed in the DSM−5 or
ICD−11), then a distinct diagnosis of ON may be justiﬁed. As
results from empirical studies indicate, however, we would expect
that such cases are rarely found (or may not be found at all) in the
UV conceived the topic and proposition of this manuscript. AM
wrote the ﬁrst draft. Both authors contributed to revision of
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Conﬂict of Interest: The authors declare that the research was conducted in the
absence of any commercial or ﬁnancial relationships that could be construed as a
potential conﬂict of interest.
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