Diagnostic Criteria for Orthorexia

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Orthorexia nervosa (ON) is a recently defined eating disorder in which the affected person is fixated on eating healthy food. Its diagnosis has come under scrutiny; however, several insist that it does not represent a separate diagnostic entity as such.

It is not yet recognized with a valid diagnosis by inclusion in the Diagnostic and Statistical Manual of Mental Disorders–IV (DSM-IV) of the American Psychiatric Association (APA).

Bratman Questionnaire

It was Bratman and Knight (2000) who first suggested the following criteria for the new condition that they labelled ON:

  • Spending over three hours a day thinking about or planning, and preparing, clean food
  • A feeling of superiority to those who do not follow the same principles
  • Presence of a strict and rigidly followed diet, with compensatory deprivation in case of any violation
  • The centrality of clean eating in life, which results in displacing personal interests, relationships, hobbies, values, and even personal health
  • Attaching more importance to the nutritional value of food than to enjoying it
  • Achieving a feeling of self-worth by dietary compliance
  • Psychosocial isolation

Many researchers have pointed out that these criteria have not been validated by testing, but represent a spectrum of personal experience in one person’s life. It is also far from certain that their presence indicates a syndrome of behaviors.


In light of the recognized limitations of the Bratman questionnaire, another approach was taken via the creation of the ORTO-15 questionnaire. This was put forward by Donini et. al. (2004) after initial research on an array of subjects. This was focused on the choice of foods based on their ‘healthy’ and ‘unhealthy’ nature, which was queried by food category.

This comprises cereals, dairy, flesh foods, fish, vegetables, fruits, fast foods, snacks, sweets etc. The initial data was analyzed by percentile and reviewed in the light of additional assessment using the Minnesota Multiphasic Personality Inventory (MMPI) test for obsessive-compulsive traits, and the body mass index (BMI). This was connected to emotional eating scales. The resulting data was used to create the ORTO-15. A proposed score of 40 is used to screen for or diagnose orthorexia.


The ORTO-15 has been used by several researchers for this putative condition. At the same time, many workers have noted that ON shares features with obsessive-compulsive disorder (OCD) and anorexia nervosa, such as:

  • Perfectionism and need for achievement to establish self-worth
  • Trait anxiety at high levels
  • Need for control
  • Highly restricted weight loss
  • Intrusively recurrent thoughts about food and their health throughout the day
  • Hypersensitivity to contamination or lack of purity of food
  • A highly formalized setting for meal preparation and arrangement adhering to a strict ritual
  • Loss of time for most other normal activities

Divergences are also important in differentiating between the two diagnoses, as follows:

  • ON patients have poor motivation for maintaining thinness and body image
  • ON patients boast of their practices rather than concealing them
  • ON patients exhibit ego-syntonic, rather than ego-dystonic, obsessions

Orthorexia may also accompany health-related anxiety, which causes somatoform disorders, resulting in excessive preoccupation with food habits. The available tests do not adequately account for these psychometric parameters in people thought to suffer from orthorexia.

Diagnostic Instruments

Presently available diagnostic tools include:

  • The Bratman and Knight 10-point scale
  • The ORTO-15 scale with 15 items
  • The ORTO-11 scale with 4 items cut down from the ORTO-15
  • The ORTO-11 Hu scale with 4 less items (different from the four removed in the ORTO-11)
  • The Eating Habits Questionnaire (EHQ) with 21 items

The Bratman test is purely clinical, and non-validated. It contains ten items which are answered ‘Yes’ or ‘No.’ The ORTO-15 is partly validated by several researchers; however, significant areas of overlap with other pathological and non-pathological states still exist, making the diagnosis based on these scales somewhat non-specific.

It has 15 items covering beliefs about healthy food, its selection, eating habits, and the percentage of thought given to food - a total of less than 40 is taken to suggest orthorexia.
However, its validity is yet to be established given the lack of strict diagnostic criteria for the condition itself. As a result, modified versions of ORTO-15 are in use, namely the ORTO-11 and the ORTO-11 Hu, adapted for Hungarian and Turkish populations respectively.

A newer scale is the Eating Habits Questionnaire (EHQ). It has 21 items and considers behaviors, thought processes, and feelings, that could suggest an abnormal fixation with healthy eating.

These include feelings of superior knowledge in this area, the presence of associated maladaptive behaviors, and feelings of control related to food choices and diet. It requires further validation to be widely used as a tool in the diagnosis of orthorexia.


Further Reading

Last Updated: Feb 27, 2019

Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.


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