De la stil de viață la diagnostic medical: reprezentări și tendințe bibliometrice ale ortorexiei în literatura științifică

Introduction

The evolution of the definition of orthorexia nervosa

Orthorexia nervosa (ON) is an obsessive concern with eating foods considered “healthy” and “pure”, leading to rigid and dysfunctional eating behaviors. The concept was first introduced in 1997 by physician Steven Bratman as a personal observation on how the desire to eat healthily can become pathological⁽¹⁾. Initially, the term had no clinical status, being more of a cultural metaphor. Later, in the 2000s, Donini’s studies (2004) initiated the formalization process, developing assessment tools such as ORTO-15⁽²⁾. At this stage, orthorexia was analyzed in parallel with obsessive-compulsive disorder (OCD) and anorexia nervosa, highlighting symptomatic overlaps and conceptual differences.

Between 2010 and 2020, the literature began to differentiate between “healthy orthorexia” (a balanced interest in healthy eating) and “orthorexia nervosa” (a pathological preoccupation)^(3,4). This dual framework has allowed for a clearer delineation of the phenomenon, supported by psychometric studies and behavioral analyses. After 2020, recent research proposes more rigorous diagnostic criteria for the integration of orthorexia nervosa into the official classifications of mental disorders⁽⁵⁾. Modern definitions include cognitive (perfectionism, rigid thinking), affective (food anxiety), social (isolation) and somatic (malnutrition) components. Thus, the defining evolution of orthorexia nervosa reflects the transition from a cultural construct to a possible clinical entity, still requiring empirical validation and diagnostic consensus. In addition to the medical conceptualization process, the negative impact on social life remains to be investigated.

The social impact of orthorexia

The impact on children occurs through parental models that are passed on; children adopt their parents’ eating and dysfunctional attitudes, including an obsession with “pure” foods and a fixation on weight⁽⁶⁾. Predispositions to eating disorders may develop; parents with rigid attitudes towards diet may cause their children to develop eating problems, including orthorexia, on an emotional and genetic basis⁽⁷⁾. Obviously, there is an impact on the individual, which is also influenced by the combination of preexisting comorbidities. Strict dietary restrictions can cause nutritional deficiencies and may be associated with mental disorders such as obsessive-compulsive disorder, depression and anxiety^(8-11). People with orthorexia have difficulty regulating their emotions, controlling their impulses and avoiding negative emotions, which are strong predictors of orthorexic behavior^(10,12). The social impact manifests itself in several ways. On the one hand, it can manifest as isolation and compromised relationships; due to food obsessions, affected individuals may avoid social activities involving food, alienating themselves from friends and family^(8,13). On the other hand, stigmatization and the manifestation of rigid norms may be experienced; rigid views on “good” and “bad” foods can create dissent and judgement in the community, with an impact on various social dynamics^(13,14). The impact on mental health cannot be ignored. Mental comorbidities interfere with how orthorexia affects each individual’s life; orthorexia nervosa is correlated with increased anxiety, depression, obsessive-compulsive disorders, and stress-related symptoms^(8,10,13).

Links to childhood trauma have been described; adverse childhood experiences may predispose individuals to developing orthorexia nervosa, mediated by alexithymia and emotional avoidance⁽¹⁵⁾. The impact also manifests itself in social and intimate relationships. Attachment issues can be observed; affected individuals exhibit anxiety and avoidance in relationships, influencing emotional connections⁽¹⁰⁾. Relationships with loved ones can become strained; the obsession with controlling food creates tension within the family and with partners, fueling emotional conflicts that can extend to the affected individual’s social group.

Children may internalize their parents’ rigid eating patterns, increasing the risk of eating disorders, and the affected person suffers from physical deficits, emotional instability and mental comorbidities. Socially, people with orthorexia may become isolated and stigmatized because of their rigid dietary beliefs. Psychologically, orthorexia nervosa is associated with depression, anxiety, OCD, childhood trauma, and difficulties in managing emotions and relationships. In relationships, orthorexia nervosa affects attachment and leads to friction, isolation, and avoidance of social situations involving food.

Cognitive mechanisms involved in orthorexia

Cognitive patterns and fundamental beliefs are altered. Maladaptive schemas can be observed in areas such as “disconnection/rejection”, “autonomy/performance” and “rigid thresholds”, which are correlated with dysfunctional eating attitudes⁽¹⁶⁾. Unaddressed emotions mediate the effect of these schemas on eating behaviors⁽¹⁵⁾. The perfectionist schema tends towards rigid standards and “all or nothing” thinking, which promotes an obsession with food control. In terms of emotional regulation and metacognition, difficulties in emotional regulation can be observed; the expression of emotions is often suppressed, evoking food fixation as an avoidance mechanism. Dysfunctional metacognitive processes include beliefs such as “I must control my thoughts”, which amplify food anxiety, and the lack of reappraisal accentuates the obsession⁽¹⁷⁾. In terms of cognitive flexibility and executive functions, mental rigidity and inflexibility (reduced set shifting) can be observed; tests (e.g., Wisconsin Card Sorting Test) show that people with orthorexia have difficulty changing mental strategies⁽¹⁸⁾. Deficits in working memory and self-control manifest themselves in an excessively self-centered perception, impaired attention and difficulty in modulating eating behavior. At the same time, there may be cognitive bias and selective attention. Similar to other eating disorders, people with orthorexia are hyperfocused on information related to foods considered dangerous, reinforcing the dysfunctional pattern⁽¹⁹⁾.

There are indications that, in Romania, orthorexia manifests itself concretely in the family, in kindergartens and in schools through a series of observable attitudes and behaviors. In the family, we may have rigid dietary rules. Parents who impose strict rules on “pure” food without flexibility can create a context in which children internalize food obsession. Food becomes the “center of family life”, influencing children’s self-esteem⁽²⁰⁾. Families may develop a moralistic attitude, evaluating themselves after consumption (“because I ate something else, I am bad”) and comparing themselves to others (“we eat healthily, they don’t”). Emotional isolation stems from the fact that food becomes a source of conflict or isolation; family meals become a source of tension, and children may become more withdrawn. In nurseries or schools, we can observe eating behaviors within the social spectrum of this disorder. Children refuse snacks or buffets offered at kindergarten, asking for “special” food, which can affect social inclusion. The behavior can evolve into a ritualized one; food preparation follows a rigid ritual, unsuited to the collective menu of the kindergarten or school, which can lead to complications or generate comments from educators. Group stigmatization can become an undesirable consequence; children may be perceived as “weird” or be prone to comments from others, which deepens social isolation. On a psychological and behavioral level, we can observe obsessive preoccupations with food (spending more than three hours a day discussing, thinking about or preparing “healthy food” is a typical sign of orthorexia nervosa), nutritional anxiety (any deviation from the imposed diet generates feelings of guilt, shame or inferiority, even unrelated to body weight) and psychological effects (fatigue, decreased concentration, irritability, symptoms that can be confused with something else but have their origins in severe dietary restrictions). A series of social and cultural benchmarks are beginning to make their presence felt in Romania, through truly ideologized dietary norms. The “healthy living” movements in Romania (dieticians, bloggers, image vectors, online communities) are sometimes taken up indiscriminately, amplifying the pressure on parents and children. Overall, there is a lack of institutional intervention; neither the medical, nor the education system yet recognizes orthorexia as a specific disorder, which delays early identification and intervention.

Objectives

The aim of this study was to analyze the evolution of scientific interest and social representations of orthorexia and orthorexia nervosa in international medical literature through a quantitative and bibliometric evaluation of publications indexed in PubMed. The specific objectives were to identify temporal trends in the publication of articles on orthorexia between 2002 and 2025, to map the dominant thematic areas through keyword analysis and to explore how medical discourse reflects and shapes the social dimensions of orthorexia – for example, its relationship to cultural norms about food, health and morality, as well as the processes of medicalization of behavior initially perceived socially as a “healthy lifestyle”.

Methodology

For data collection, a systematic search was conducted in the PubMed database using the terms orthorexia OR “orthorexia nervosa”, with no restrictions on the type of study or population investigated. The period analyzed was between January 2002 and 15 June 2025.

The search generated a total of 557 articles. The publications were unevenly distributed throughout the period analyzed. Between 2002 and 2013, the number of articles was low, ranging from one to four publications per year. Starting in 2014, there was a steady increase (seven articles), which peaked in 2021-2022, with an annual number of 102-104 publications. Subsequently, the scientific interest declined slightly: 84 articles in 2023 and 76 in 2024. By 15 June 2025, a total of 44 articles had been identified.

A set of 1238 terms was used for the keyword analysis, of which 149 had a minimum frequency of five occurrences, and 43 terms had at least 20 occurrences. This analysis provides an overview of the dominant thematic areas and the conceptual evolution of research on orthorexia. Bibliometric maps of term co-occurrence were generated using the VOSviewer program.

Results

Thematic networks and socio-medical dimensions in the discourse on orthorexia

To understand the conceptual structure of the literature on orthorexia, two co-occurrence maps were generated using VOSviewer: one based on author keywords at a co-occurrence threshold of 5 (Figure 1) and one at a threshold of 20 (Figure 2). These maps highlight the thematic nuclei, the connections between terms, and how medical and sociocultural language intersect in defining the phenomenon.

Keyword co-occurrence network

The first map (Figure 1) includes the authors’ keywords, with a minimum threshold of five occurrences. The dominant terms – “orthorexia nervosa”, “humans”, “male”, “female”, “adolescent” and “students” – occupy central positions, connected to a dense network of clinical, methodological and sociocultural terms.

The analysis identified five major thematic clusters:

The clinical/diagnostic cluster (red) brings together terms such as “orthorexia nervosa”, “eating disorders”, “obsessive-compulsive disorder”, “anorexia nervosa”, “prevalence”, “students” and “body image”. This represents the medical and psychiatric core, in which orthorexia is conceptualized in relation to eating disorders and psychological comorbidities.

The psychometric/methodological cluster (blue) includes terms such as “psychometrics”, “validation”, “factor analysis”, “ORTO-15”, “translations” and “reliability”. This reflects the rapid development of assessment tools and the concern for standardizing diagnostic criteria.

The sociocultural and nutritional cluster (green) includes “diet”, “nutrition”, “social media”, “clean eating”, “healthism” and “communication”. Peripheral but related terms indicate the medicalization of behaviors initially perceived as “healthy lifestyles”, as well as the role of digital platforms in disseminating these norms.

The dietary and lifestyle cluster (purple) focuses on terms such as “vegetarian diet”, “vegan diet”, “healthy food”, “diet” and “vegan”. It shows the conceptual proximity between orthorexia and culturally or ideologically motivated restrictive diets.

The demographic/epidemiological cluster (yellow) covers terms referring to populations and geographical contexts: “students”, “adolescents”, “Lebanon”, “Spain”, “Poland”, “Italy” and “prevalence”. This cluster reflects the dominance of cross-sectional studies among young people and in the academic environment.

From a discursive point of view, the structure of this map shows a strong clinical core, around which psychometric and sociocultural dimensions progressively gravitate. Terms related to social media, “clean” eating and alternative diets are on the periphery, but are consistently connected to the core, indicating that the medicalization of orthorexia has been built on the basis of already well-established social norms.

The second map (Figure 2) is based on keywords that have a higher co-occurrence threshold, providing an overview of the general conceptual structure of the field. Four main thematic clusters can be distinguished:

The clinical-psychological cluster (red) is centered on “feeding and eating disorders”, “orthorexia”, “exercise”, “disordered eating”, “perfectionism” and “body image”. This shows the integration of orthorexia into the broader framework of eating disorders, emphasizing links with relevant psychological traits.

The epidemiological-demographic cluster (green) includes “adolescent”, “young adult”, “students”, “cross-sectional studies”, “Poland”, “Lebanon” and “universities”. This reflects the predominantly descriptive orientation of the research, focused on prevalence in young populations.

The psychometric cluster (blue) contains “psychometrics”, “reproducibility of results”, “factor analysis” and “ORTO-15”. This confirms the importance of measurement tools and cross-cultural validation.

The social and digital cluster (purple) includes terms such as “social media” and “risk factors”, suggesting the emergence of a sociocultural dimension in defining the phenomenon.

In this map, the central terms are “feeding and eating disorders” and “humans”, indicating that orthorexia is conceptually treated as part of an existing nosologically framework. The social dimension appears less prominent but constitutes a distinct cluster, linked to the clinical core.

Integrated interpretation

The two maps provide a complementary picture of the conceptual evolution of orthorexia. The map based on keywords at a low co-occurrence threshold captures the emergence of the phenomenon in the social sphere (e.g., “clean eating”, “vegan diet”, “social media”) and its rapid approach to medical language, with an increase in the number of publications after 2014.

The map obtained at a minimum co-occurrence threshold of 20 highlights the gradual integration of orthorexia into established eating disorders, with the consolidation of methodological aspects and the delineation of an emerging sociocultural branch.

This dual perspective clearly illustrates the process of co-production between social and medical discourse. Orthorexia was initially a cultural phenomenon, articulated around ideals of health and food purity, but was later reframed in clinical and psychometric terms. Currently, medical and social language coexist and influence each other, shaping a fluid concept situated at the intersection of cultural norms and nosologically categories.

Discussion

Medicalization, language and social dimensions in the definition of orthorexia

The bibliometric analysis provides a complex picture of how the concept of orthorexia has evolved and consolidated at the intersection of medical language and social representations of food. The two thematic maps outline a dynamic process in which emerging cultural phenomena have been taken up, reinterpreted and partially reconfigured through the lens of clinical and psychometric research.

From social phenomenon to medical category

In the early stages (2002-2013), the literature on orthorexia was fragmented, with a small number of publications and a predominant focus on descriptive observations. Terms such as “vegan diet”, “healthy food” or “social media”, located on the periphery of the conceptual network, reflect the origin of the phenomenon in the social context of health culture (“healthism”), the moralization of food choices and the rapid dissemination through digital platforms.

Since 2014, the increase in the volume of publications has been accompanied by a densification of clinical and psychometric language: measurement tools (e.g., “ORTO-15”), intercultural validation studies and debates related to the nosologically status of orthorexia have emerged. This transition signals the beginning of a process of medicalization of cultural behavior: a set of socially valued eating practices is beginning to be reinterpreted in terms of disorder or psychopathological risk.

The role of medical language and the psychometric framework

A central aspect identified is the dominant position of the psychometric cluster in both maps. The development and validation of instruments (“ORTO-15”, “EHQ”, “DOS”, etc.) played an essential role in formalizing the concept and integrating it into international literature. However, this methodological focus has also generated challenges: debates about the validity of the construct, overlap with other eating disorders, and the lack of universally accepted diagnostic criteria.

Thus, medical language, through the psychometric framework, has functioned as a mechanism for terminological stabilization, but also as a filter through which the social dimensions of the phenomenon have been partially blurred or reinterpreted in a clinical grid.

The persistence of the sociocultural dimension

Although medicalization is evident, the bibliometric analysis shows that the sociocultural dimension has not disappeared, but continues to circulate in proximity to the clinical core. Terms such as “social media”, “clean eating”, “healthism”, “vegetarian diet” or “vegan” form distinct and connected clusters. This indicates that orthorexia is not only an emerging clinical entity, but also an active cultural phenomenon, rooted in social norms related to food, body and morality.

This duality, clinical and social, also explains the current conceptual tensions: the absence of a diagnostic consensus is not only a methodological problem, but also one related to the fluid boundaries between social normality and medical pathology.

Implications for research and practice

The results of this analysis suggest several important directions. Clarifying nosologically criteria is essential to avoid confusion with other eating disorders and to delineate orthorexia as a distinct entity, if warranted. Integrating sociological and cultural perspectives into clinical research can provide a more nuanced understanding, avoiding the automatic pathologization of culturally influenced eating behaviors. The analysis of medical discourse plays a crucial role: the language used in articles contributes not only to the description but also to the social construction of the phenomenon. Interdisciplinary collaboration (medicine, psychology, sociology, anthropology) could reduce conceptual fragmentation and facilitate the development of more robust explanatory models.

Limitations and future perspectives

Our analysis is based exclusively on the PubMed database, which may underestimate contributions from the social sciences or interdisciplinary journals indexed in other databases (e.g. Scopus, Web of Science, PsycINFO). Furthermore, bibliometric maps provide a structural picture, but they do not capture the qualitative nuances of the discourse. Future studies could combine quantitative analysis with content or discourse analysis to explore in depth how orthorexia is socially and medically constructed.

Orthorexia is a relevant example of how cultural phenomena can be absorbed and reinterpreted by medical discourse, generating hybrid entities that lie at the border between social norm and clinical category. The conceptual networks analyzed clearly show that this evolution is not linear, but the result of a co-evolution between social and medical language, mediated by psychometric instruments, epidemiological research and global cultural dynamics.

Conclusions

The bibliometric analysis of the literature on orthorexia, carried out over a period of more than two decades (2002-2025), highlights a clear process of emergence, consolidation and conceptual diversification. Initially defined in the sociocultural space, orthorexia was quickly taken up and reinterpreted through the lens of medical and psychological discourse, a process facilitated by the development of psychometric instruments and the expansion of epidemiological research. Thematic networks show the coexistence of three interdependent dimensions: a clinical one, centered on relationships with eating disorders; a methodological one, focused on validation and standardization; and a sociocultural one, linked to dietary norms, digital networks and health ideals.

These findings suggest that orthorexia cannot be adequately understood either exclusively as a clinical entity, or solely as a cultural phenomenon. Rather, it constitutes a hybrid construct, resulting from the interaction between social representations of health, medical classification frameworks, and research practices. In this sense, clarifying the nosological status of orthorexia requires an interdisciplinary approach that integrates medical, psychological, sociological and anthropological perspectives. In the future, significant progress could come from research that combines discourse analysis, rigorous epidemiological data and critical reflections on medicalization processes to better understand both the limits and implications of this emerging concept.

Bibliometric results and thematic network analysis show that orthorexia is not only an emerging medical construct, but also a social phenomenon with far-reaching implications, influenced by contemporary cultural norms regarding health, nutrition and physical performance. Public discourse on “healthy lifestyles”, heavily promoted through digital platforms, social networks and the mass media, plays a central role in shaping and disseminating rigid dietary ideals that can influence the attitudes and behaviors of children and adolescents.

Children and young people are a vulnerable group in this context, as they are in the process of forming their food and body identity, being highly exposed to normative social models. The analysis of thematic clusters indicates a significant concentration of research among adolescent and student populations, but also highlights the relatively low presence of studies dedicated to children in the strict sense. This absence highlights an important gap in the current literature.

From a social perspective, the food ideals promoted in educational, family and digital environments can contribute to the normalization of restrictive or obsessive behaviors, which, in certain contexts, can be internalized early and evolve into maladaptive patterns. In addition, the high prevalence of moralizing discourse about food (“clean”, “natural”, “flawless”) amplifies social pressures and the risk of stigmatization of behaviors considered “unhealthy”, which can have negative psychological effects on children and adolescents.

In conclusion, orthorexia should be understood not only as a possible emerging disorder, but also as a product of the contemporary cultural environment, with potential cumulative effects on younger generations. Future interventions should go beyond a strictly medical approach and include educational policies and public communication strategies aimed at promoting a balanced relationship with food, reducing social pressures and developing children’s critical thinking in relation to media messages about health.

Autor corespondent: Radu-Mihai Dumitrescu E-mail: dum_mihu@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.