Orthorexia nervosa links strongly to perfectionism and OCD traits, review shows

by · News-Medical

An umbrella review reveals how commonly orthorexia nervosa symptoms are reported across studies and why inconsistent diagnostic tools continue to cloud understanding of this emerging eating-related condition.

Understanding Orthorexia Nervosa: A Systematic Review of Meta-analytical Findings. Image Credit: Lightspring / Shutterstock

Review findings revealed that while prevalence estimates vary widely, around 27.5 percent, ON is significantly linked to perfectionism, obsessive-compulsive traits, and eating disorder symptoms. The review further highlights that although a growing body of literature seeks to elucidate ON, inconsistent diagnostic tools currently limit the conclusiveness of pre-existing evidence.

Defining Orthorexia Nervosa and Its Impact

Orthorexia Nervosa (ON) is an emerging term referring to an obsession with healthy eating accompanied by restrictive behaviors. Paradoxically, this attempt to attain optimum health through attention to diet is increasingly associated with malnourishment, loss of relationships, and reduced quality of life.

ON is now recognized as distinct from healthy orthorexia, which reflects a non-pathological interest in diet. While traditional eating disorders, such as anorexia nervosa, focus on food quantity and weight control, ON is characterized by fixation on food quality and purity. Individuals may rigidly avoid foods they deem unclean, such as sugar, dairy, or non-organic produce, leading to malnutrition and social isolation.

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

Purpose and Scope of the Umbrella Review

This umbrella review, defined as a synthesis of existing meta-analyses, aimed to address this gap by clarifying the global prevalence of ON symptoms and identifying the psychological traits that drive them.

Eligible publications were identified through systematic searches of PubMed, Google Scholar, and Scopus from database inception through July 31, 2025. Screening of titles, abstracts, and full texts narrowed 62 candidate publications to five robust meta-analyses for inclusion. These analyses encompassed large datasets, including one meta-analysis drawing on data from more than 30,000 individuals across 18 countries.

Methodological Quality and Evidence Classification

The quality of included publications was evaluated using the Risk of Bias in Systematic Review (ROBIS) tool, alongside an evidence-classification framework ranging from Class I, convincing evidence, to Class IV, weak evidence.

Analyses focused on two primary questions. First, how prevalent are reported ON symptoms? Second, which psychological traits are statistically associated with ON?

Prevalence Estimates Across Populations

The review identified substantial variability across prevalence estimates, largely attributable to methodological heterogeneity, including differences in study design and diagnostic instruments. 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 earlier assumptions that eating disorders disproportionately affect women, the largest included meta-analysis found no statistically significant difference between females, 34.6 percent, and males, 32.1 percent.

Prevalence varied across subgroups. Individuals focused on sports performance or body composition showed the highest observed prevalence, 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 earlier studies.

Psychological Traits 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 analyses 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 = 0.27, driven primarily by perfectionistic strivings rather than perfectionistic concerns. Unlike anorexia nervosa, where perfectionism often centers on weight, ON-related perfectionism appears to focus on dietary correctness.

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

Clinical and Research Implications

This umbrella review indicates that ON symptoms are commonly reported, particularly in fitness-oriented populations. Findings position ON along a psychiatric spectrum, sharing features with obsessive-compulsive disorder and anorexia nervosa while remaining distinct in its 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, reaching Class II, highly suggestive. High statistical heterogeneity across studies limited the ability to draw stronger conclusions. These findings highlight the urgent need for standardized diagnostic criteria, validated screening tools, and longitudinal research designs.

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