Purpose Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with “correct” eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included. Methods 47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A–Definition, Clinical Aspects, Duration; B–Consequences; C–Onset; D–Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants. Results 27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON. Conclusions This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel. Level of evidence Level V: opinions of expert committees

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Objective Orthorexia nervosa (ON) is defined as an unhealthy obsession with healthy eating, focusing on concerns regarding food quality and composition. Currently, there is still a lack of consensus about a clear definition of the construct. Specifically, it has yet to be clarified whether ON pertains to eating disorders (EDs) or obsessive–compulsive disorder (OCD) spectrum. Hence, we conducted a systematic review and meta‐analysis addressing the magnitude of the association between these groups of symptoms. Method PubMed, Medline, SCOPUS, PsychINFO, CINAHL, and Web of Science were searched from inception up to February 2021. Data from individual studies were pooled using a random‐effects model. Pearson's r was used as the effect size metric. Subgroup analyses were conducted exploring the role of ON‐related instruments, body mass index, study quality, and cultural context. Results Thirty‐six studies met the eligibility criteria and were included in the meta‐analysis. Random‐effects model yielded a moderate association between ON and EDs symptoms with an overall effect size of r = .36 (p < .001; 95% confidence interval [CI] = 0.30–0.43). On the other hand, the results showed a small association between ON and OCD symptoms with a mean effect size of r = .21 (p < .001; 95% CI = 0.15–0.27). Discussion Meta‐analytic findings showed that ON symptoms are more associated to EDs compared to OCD. Despite the similarities, the nonhigh magnitude of the pooled correlations suggests that ON might be different from pre‐existing EDs and OCD. Hence, ON might be treated as a stand‐alone ED and included as an emerging syndrome in the DSM classification.

The clinical significance of two major aspects of perfectionism, perfectionistic strivings (PS) and perfectionistic concerns (PC), in eating disorders (EDs) symptoms was well‐established among adults. However, no systematic review has assessed evidence examining associations between both unidimensional and multidimensional perfectionism and EDs in early and middle adolescence. For this aim, three online databases (PsycINFO, Medline and PsycArticle) were searched for articles published until January 2019, and observational studies were considered. Study quality was systematically appraised, and results were summarized using a narrative synthesis approach. Fifty‐one cross‐sectional and 28 longitudinal studies were included. Most studies supported the relationship between perfectionism and EDs, with the majority adopting a unidimensional approach for assessing perfectionism. Among studies that employed multidimensional measures of perfectionism, the majority (n = 11) of evidence supported the relationship between eating symptoms and PC, while fewer (n = 5) studies provided significant unique associations with PS. These findings are consistent with the body of research suggesting the strength of the relationship between PC and EDs was greater than between PS and EDs. It was recommended that preventive interventions should be primarily focused on reducing self‐critical perfectionism, since it resulted to be the most relevant perfectionistic dimension in the development of eating symptoms in adolescents.

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