The orthorexia nervosa (ON) introduces a behavioral pattern that has been classified as a pathological fixation on healthy nutrition. In this case, the individual with ON, also called orthorexic, is extremely concerned about the quality and quantity of food ingested in the diet. This specification with food quality can lead to a restrictive diet, leading to nutritional deficiencies, malnourishment, medical complications, and mental disorders (Koven and Abry, 2015). The ON is a new concept of disorder, introduced in the 1990s, that is not recognized as an eating disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) nor the International Statistical Classification of Diseases and Related Health Problems (ICD-10; Moroze et al., 2015; Dunn and Bratman, 2016), Definition of ON is in its earliest (Dunn and Bratman, 2016; Cena et al., 2019); however, there are several diagnostic tools available (Niedzielski and Kaźmierczak-Wojtaś, 2021).

The diagnosis of risk of orthorexia nervosa is mostly derived from a questionnaire of eating habits, in which Donini et al. (2005) developed the ORTO-15 questionnaire with data from the Italian population. This toll for the diagnosis of orthorexia includes 15 multiple-choice items that investigate the obsessive attitude of the subjects in choosing, buying, preparing, and consuming food considered healthy. Nowadays, the questionnaire is one of the most commonly psychometric tools used in studies to identify ON (Cena et al., 2019) and has been translated and validated in several languages (Pontes et al., 2014; Varga et al., 2014; Missbach et al., 2015; Stochel et al., 2015). To interpret the results from the questionnaire, a cutoff score set of 40 (with a score below 40) was able to correctly identify subjects believed to have ON; however, the authors point out that the cutoff point values can be set depending on the purpose for which the scales used (Donini et al., 2005).

Orthorexic behavior has been positively associated with perfectionism self-presentation (Pratt et al., 2022) or exercise addiction (Rudolph, 2018). Moreover, it has been demonstrated in people obsessed with a healthy lifestyle such as yoga practitioners (Herranz Valera et al., 2014; Domingues and Carmo, 2021), fitness sports (Rudolph, 2018), and users of social media (Turner and Lefevre, 2017); nonetheless, in sports settings, this relationship is still not summarized. In the context of athletic settings, disordered eating is a general term used to describe the spectrum of abnormal or harmful eating behaviors primarily used in an attempt to lose or maintain normal body weight to optimize performance. Lower body weight has a beneficial effect on athletic performance in some sports disciplines (e.g., endurance-based or aesthetic). To achieve desired weight outcomes, athletes often go on diets resulting in low energy availability, where the body is not adequately fueled, negatively affecting physiological functions needed for optimal health (Logue et al., 2018). This behavior attributes to the concept of Relative Energy Deficiency in Sport (RED-S) that IOC introduced recently and addressed serious health issues in both male and female athletes, beyond what is known as the female athlete triad (Reardon et al., 2019).

Therefore, the purpose of the present mini-review was to summarize the prevalence of risk for orthorexia nervosa in athletes, using the ORTO-15 questionnaire. In this review, we focus on competitive sports and with the specific use of the questionnaire ORTO-15 developed for this purpose. Moreover, it was also described the risk of orthorexia considering the cutoff of 40 and 35 points, as suggested elsewhere (Donini et al., 2005; Ramacciotti et al., 2011; Dell’Osso et al., 2016).

The systematic mini-review was performed in accordance with the guidelines to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) updated in 2020 (Page et al., 2021), and the protocol was registered at PROSPERO with the number CRD42021288935.

The present review summarized the orthorexic profile in athletes and found that athletes from different disciplines presented scores ranging from 38 to 35 points of the ORTO-15 questionnaire. Therefore, the results demonstrated that the risk of orthorexia nervosa in athletes may vary depending on the cutoff point established. No difference in orthorexia scores was found between athletes and non-athletes, demonstrating that orthorexia is an issue that needs to be considered in the general population.

Regarding the cutoff point, the authors that developed the ORTO-15 questionnaire first considered predictive a score over 40 points to classify as the risk of presenting an orthorexic behavior (Donini et al., 2005). Nonetheless, previous studies have criticized the ORTO-15 and pointed out that a 35 cutoff point can maximize either sensitivity or specificity (Ramacciotti et al., 2011; Dell’Osso et al., 2016). In the present review, it is possible to notice that the risk of ON will depend on what cutoff will be chosen, highlighting the importance of establishing a better sensitivity to diagnose the prevalence of orthorexia, especially in athletes. As pointed out by Cena et al. (2019), it is still a challenge to draw a boundary between adopting a healthy diet… and developing inflexible beliefs, attitudes, and behaviors related to nutrition with unhealthy consequences.

The comparison of orthorexic profiles between sexes was explored recently, in a review article with the general population, showing similar tendencies toward healthy eating in men and women in the studies that used the ORTO-15 questionnaire (Strahler, 2019). Likewise, the studies included in this review also reported no significant differences between male and female athletes either in Olympics athletes (Surala et al., 2020) and professional (Uriegas et al., 2021) or students athletes (Clifford and Blyth, 2019). Furthermore, the athletes’ food behavior did not differ from the general population, showing an interesting and unexpected result.

In general, orthorexic behavior may manifest as dietary, behavioral, and exercise-related. Excessive training has been associated with an increased risk of low energy availability (Melin et al., 2019). Moreover, an association between unhealthy exercise behavior (e.g., exercise dependence or exercise addiction) and disordered eating has been found (Taranis et al., 2011). The distinction between athletes and non-athletes must be made in terms of highly variable exercise behavior. Athletes undertaking high training volume and low energy availability may occur without disordered eating due to unintentionally failing to consume sufficient energy (Loucks et al., 2011). In agreement with the present findings, interestingly a high prevalence of orthorexia symptoms via ORTO-15 was also found in the non-athletic healthy eating community on Instagram (Turner and Lefevre, 2017) and yoga practitioners (Herranz Valera et al., 2014; Domingues and Carmo, 2019, 2021). Altered eating behavior as a consequence of body dissatisfaction attributed to the pressure experienced by athletes through social media has also been proposed (Wasserfurth et al., 2020).

The results summarized in this review demonstrated that athletes from different sport modalities presented no risk of orthorexia nervosa considering the cutoff of 40 points but not for the cutoff of 35 points in the ORTO-15 questionnaire. The athletes’ scores ranged between 38 and 35 points; thus, attention should be given considering the diagnoses and classification about orthorexic behavior when using the ORTO-15 in athletes, to avoid false-negative results. The non-difference between athletes and non-athletes demonstrated that orthorexia nervosa is a concern of the general population. However, these assumptions should be given using ORTO-15 as a complementary tool to diagnose orthorexia nervosa or any other disordered eating may be recommended to avoid the biased result. This review adds a piece of information about the orthorexia nervosa and ORTO-15 questionnaire topic, recommending further studies to improve the quality of psychometric instruments to facilitate the use in non-clinical populations.

AP, MM, HM, MVM, and MK provided article conceptualization. AP and MM were involved in search and data analysis. AP, MM, HM, and MK drafted the manuscript. AP, MM, HM, MVM, and MK critically revised the manuscript. All authors contributed to the article and approved the submitted version.

This project was supported by the Evaluation of Graduate Education, and from Operational Programme Research, Development and Education–Project “Postdoc2MUNI” (No.CZ.02.2.69/0.0/0.0/18_053/0016952).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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