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Table 4 Detailed classification criteria for ON delineated by some scholars (and presented in the latest research)

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

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 dependence 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 anorexia 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 composition 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 behaviors 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
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
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 frequent 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 behaviors about healthy diet
B3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior