The connection between exercise addiction and orthorexia nervosa in German fitness sports

Excessive health behaviors in sports: links of orthorexia nervosa and exercise addiction with well-being, exercise activity in sports categories, and gender effects

Background and aims

Orthorexia nervosa (OrNe), the obsessive fixation on healthy eating, and exercise addiction (ExAdd) have been discussed as correlated excessive health behaviors with potential mental health implications. The role of gender-and sports-specific differences remains unclear. This study aimed to investigate the links of ExAdd, OrNe, and the non-pathological interest in healthy eating (healthy orthorexia; HeOr) with well-being and exercise activity in various sports, considering gender effects.

Methods

Data from two cross-sectional online surveys were combined (N = 1,064, 73.5% women, age = 28.23 ± 11.09), measuring ExAdd (Exercise Addiction Inventory Revised), OrNe and HeOr (Teruel Orthorexia Scale), well-being (WHO-5 Well-Being Index), exercise activity and sports (Physical Activity, Exercise, and Sport Questionnaire).

Results

Well-being correlated with OrNe among women (r = -0.291) and not meaningfully with ExAdd and HeOr among men. Gender differences were not significant, except for the higher correlation of ExAdd with exercise activity in resistance and fitness sports among men. Regression analyses revealed that exercise activity, especially in health, resistance and fitness sports, was linked to HeOr, but not to OrNe. ExAdd was associated with exercise activity in endurance, resistance and fitness, ball and team, antigravitation, technical, aesthetic sports, and martial arts.

Discussion

Men's well-being may slightly benefit from ExAdd and an interest in healthy eating, while obsessive healthy eating may reduce women's well-being. Although exercise activity is associated with ExAdd in a wide variety of sports, it does not explain the link between ExAdd and OrNe. Preventive measures should consider gender-specific risks in excessive health behaviors.

Orthorexia as an Eating Disorder Spectrum-A Review of the Literature

BACKGROUND

The purpose of this study is to compare and analyze research studies focused on orthorexia nervosa (ON) as a spectrum of eating disorders, and to summarize potential risk factors in different age and social groups. ON is characterized by an obsession with healthy eating, which leads to a restrictive diet and health problems.

METHODS

Due to a lack of comprehensive analyses, this review re-examined studies from 2006 to 2023, initially retrieving 53,134 articles. Upon refining the criteria and risk factors for eating disorders, 34 notable records were identified. These studies employed diagnostic tools such as ORTO and BOT, focusing on risk factors for ON.

RESULTS

Results indicate that individuals suffering from eating disorders, losing weight, exercising heavily, developing relationship problems, and suffering from body dysmorphic disorder are at high risk of developing ON. A significant correlation was found between ON, BMI, and gender, but not between ON and OCD. Interestingly, ON symptoms appear to overlap with those of other eating disorders, such as anorexia and bulimia, especially in terms of obsessive control over dieting and fear of gaining weight, indicating a close relationship between the two.

CONCLUSIONS

Interestingly, orthorexia nervosa may serve as a coping mechanism for anorexia, providing a sense of control. However, further research on its long-term effects is required.

Orthorexic Tendency in Light of Eating Disorder Attitudes, Social Media Addiction and Regular Sporting Among Young Hungarian Women

This study examined a set of background psychological and other variables of orthorexic (ON) tendency in a sample of young women with special interest in healthy lifestyle. The sample consisted of female young adults (N = 310; aged 18-35 years; mean age = 24.3 years; SD = 4.97 years) who were recruited through social media health sites. Besides Orthorexia Nervosa Questionnaire (ORTO‑15), BMI, regular sporting activity, the following scales were used: Eating Disorder Inventory (EDI, drive for thinness, ineffectiveness and maturity fears); Bergen Social Media Addiction Scale (BSMAS); and The Proactive Coping Inventory. In this sample, 37.7% were at risk for ON. Eating disorder attitudes, regular sporting and social media addiction were the most relevant predictors of orthorexic tendency with drive for thinness being the strongest contributor (β = 0.54, p < 0.001). For young women with a special interest in healthy lifestyle, drive for thinness together with regular sporting, ON tendency may serve as a tool for achieving their goal. Social media addiction and other psychological problems (feeling of ineffectiveness or maturity fears) can also contribute to orthorexic rendency. It would be important to ask for support from qualified health professionals when changing nutritional practices.

Major Dietary Patterns, Exercise Addiction, and Eating Disorders Among a Sample of Physically Active Young Adults

Background

Regular exercise has been widely acknowledged for its numerous health benefits, including improvements in physical fitness, body function, and mental well-being. However, excessive exercise and unhealthy dietary patterns can lead to adverse effects on individuals' physical and psychological well-being. This study aimed to examine the association of dietary patterns, exercise addiction, and eating disorders among physically active young adults.

Method

In this cross-sectional study, a total of 200 physically active young adults aged 18-35 years were included. The participants' dietary intake was assessed using a validated semi-quantitative food frequency questionnaire (FFQ) consisting of 80 food items. To determine dietary patterns, factor analysis was employed. Exercise addiction was evaluated using The Exercise Addiction Inventory (EAI) and Exercise Dependence Questionnaire (EDQ), and eating disorders were assessed using The Eating Disorder Examination-Questionnaire Short (EDE-QS).

Result

Three main dietary patterns were identified: western, healthy, and traditional dietary patterns. The western dietary pattern was associated with increased waist-to-hip ratio (P = .01) that remained significant after adjustment for confounders (eg, age, gender, BMI, and physical activity P = .03), while the adherence to traditional dietary pattern was linked to higher waist circumference and body shape index (P < .05). Participants that followed the healthy dietary pattern showed a higher score of EAI and body shape concern (P = .04). Furthermore, in structural equation modelling (SEM), eating disorder was identified as a significant positive predictor of exercise addiction (r = .17, P < .05).

Conclusion

According to our finding, those with the higher adherence to healthy dietary pattern had higher scores of exercise addiction and body shape concern. Also, eating disorder was a potential predictor of exercise addiction among young physically active individuals. Further research and targeted interventions are needed to better understand these complex relationships and develop effective strategies to promote healthy behaviors and mitigate the risk of adverse outcomes.

Orthorectic behavior among students and motivation for physical activity, dietary habits, and restrictive eating

Introduction

Orthorexia lacks official recognition as an eating disorder; however, orthorexic behaviors, associated with a stringent selection of food, may serve as a predisposing factor to the development of eating disorders. It is characterized by an obsessive preoccupation with healthy eating and strict dietary standards, often prevalent in high-risk groups such as athletes and individuals concerned with their physical appearance. The objective of this study was to evaluate the incidence of orthorexia among students exhibiting varying lifestyles (including dietary habits and levels of physical activity, along with their respective motivational factors). The research involved 600 participants equally distributed between health-related (HRF) and non-health-related (NRF) academic categories, with the majority of participants in the HRF category being women.

Methods

Assessments included BMI calculations, dietary evaluation based on Polish standards, categorization of physical activity levels, the EMI-2 questionnaire on motivation to exercise, the DOS test for orthorexia propensity, and the TFEQ-13 questionnaire for eating behavior.

Results and discussion

Results showed that primary motivators for physical activity included disease prevention, health maintenance, strength/endurance, and physical appearance. Orthorexia tendencies were prevalent, particularly in the HRF group, linked to lower BMI, better diet quality, higher physical activity levels, and a higher prevalence of restrictive eating. In conclusion, students in health-related fields, driven by a strong health consciousness, are at risk of orthorexia. This emphasizes the need for balanced health education and support.

Conclusion

Orthorexic tendencies are associated with distorted perceptions of food portions and calories, underscoring the importance of awareness and intervention.

Association of Social Media Use Disorder and Orthorexia Nervosa Among Lebanese University Students: The Indirect Effect of Loneliness and Factor Structure of the Social Media Use Disorder Short Form and the Jong-Gierveld Loneliness Scales

The current study aims to examine the relationship between Social Media Use Disorder (SMUD) and Orthorexia Nervosa (ON), and evaluate the indirect effect of loneliness in this association. This cross-sectional study was carried out between July and September 2021. A total of 363 university students were recruited through convenience sampling through several universities in Lebanon's governorates. Data about information about the social media applications mostly used (Instagram, Facebook, Twitter, etc.), the number of times of entry to social media applications, the time spent on these applications, ON, loneliness and SMUD, were also collected. The Mplus v.7.2 software was used to estimate categorical confirmatory factor analyses (CFA) of the SMD and loneliness scales. The one-factorial model of the SMD scale fitted well according to χ2/df (69.71/27 = 2.58), TLI (.967), CFI (.956), and RMSEA values (.066; CI [.047-.085]; pclose = .079). The one-factorial model of the loneliness scale fitted well according to χ2/df (10.30/5 = 2.06) TLI (=0.97), CFI (=0.98), and RMSEA values (=0.054; CI [0.000-0.101]; pclose = 0.379). When entering the social media applications and time spent on these applications as independent variables in a first regression model, using Instagram (Beta = 2.73), using Tumblr (Beta = 3.22), spending 30-60 minutes per day on social media apps compared to less than 30 minutes (Beta = 2.33), higher physical activity index (Beta = 0.04) and loneliness (Beta = 0.67) were significantly associated with more ON. When entering the SMUD score as an independent variable in a second regression model, the results showed that higher SMUD (Beta = 0.50) was significantly associated with more ON. Also, loneliness played a partial indirect role in the association between SMUD and ON (by 16%). The current results can help mental health professionals better detect these potential psychological disorders and might help improve future treatment of issues related to ON and SMUD.

Assessing the presence and motivations of orthorexia nervosa among athletes and adults with eating disorders: a cross-sectional study

PURPOSE

Orthorexia nervosa involves restricting diet based on quality rather than quantity. Although orthorexia is well reported in many at-risk populations, limited data addresses its presence in individuals with eating disorder history (EDs) or athletes. We aimed to identify the presence and potential drivers of orthorexia in adults with EDs and endurance athletes, compared to control subjects.

METHODS

Participants ≥ 18y included: people with a diagnosed eating disorder (ED as per DSM-5); endurance athletes (training/competing ≥ 5 h/week); or control subjects. Participants (n = 197) completed an online survey assessing orthorexia (eating habits questionnaire, EHQ), eating motivations (TEMS-B) and compulsive exercise (CET).

RESULTS

ED had the highest orthorexia symptom severity (92.0 ± 3.02, n = 32), followed by athletes (76.2 ± 2.74, n = 54) and controls (71.0 ± 1.80, n = 111) (F (2) = 18.2, p < 0.001). A strong positive correlation existed between weight control motives and higher orthorexia symptom severity (r = 0.54, 95% CI [1.35, 2.36], p < 0.001), while a weak negative association existed between Hunger and Pleasure motives and higher orthorexia symptom severity (r = 0.23, 95% CI [- 2.24, - 0.34], p = 0.008; r = 0.26, 95% CI [- 2.11, - 0.47], p = 0.002, respectively). A moderate positive relationship was found between CET and orthorexia symptom severity (95% CI [1.52, 3.12], p < 0.001).

CONCLUSION

Adults with ED history and endurance athletes have greater orthorexia symptom severity compared to control. Clinicians working with at-risk populations should screen patients and be aware of red-flags of orthorexic traits, desire to control weight, and compulsive exercise behavior.

LEVEL OF EVIDENCE

III: Evidence obtained from cohort studies.

Parental relationships, emotion regulation and orthorexia: A study on adolescent athletes

Background: This study seeks to further our understanding of the factors associated with adolescent athletes and disordered eating, by expanding current research into a less-explored eating disorder known as orthorexia. Aim: The aim of the study is to explore the impact of parents' relationships and emotional regulation on the orthorexia nervosa (ON) tendencies of adolescent athletes. Methods: The participants were 303 adolescents, ranging from 15 to 17 years old, of which 139 participated in competitive sport, and 164 did not. Three self-report questionnaires were administered to assess orthorexia (ORTO-15), relationship with parents (Inventory of Parent and Peer Attachment) and emotion regulation (Emotion Regulation Questionnaire). Results: The results highlight that those who practice sports report higher levels of orthorexia, inadequate relationships with parents, as well as greater emotional regulation difficulties. Furthermore, inadequate parents' relationship predicts orthorexia while expressive emotional regulation mediates this relationship. Conclusion: These findings highlight how ON tendencies in athletes are linked to poor management of emotions combined with inadequate relationships with parents in terms of communication and affection. Implications for practice and support for athletes are discussed.

Attachment styles and orthorexia nervosa among Lebanese adolescents: The indirect effect of self-esteem

BACKGROUND

Orthorexia nervosa (ON), defined as the pathological obsession for pure foods, remains a novelty in the field of eating disorders. Many studies in the literature have shown that attachment styles correlate with the development of eating disorders. Patients with eating disorders were found to be more avoidant and anxious and less secure than individuals who do not have eating disorders. However, studies on the relationship between attachment styles and ON remain limited, particularly in adolescents. This study assessed the relationship between attachment styles and ON in Lebanese adolescents (15-18 years), along with evaluating the indirect effect of self-esteem on this association.

METHODS

This study used a cross-sectional design and was carried out during May-June 2020 with 555 students (15-18 years) enrolled. The Düsseldorf Orthorexia Scale was utilized to screen for ON tendencies. A linear regression was conducted taking the DOS score as the dependent variable. The PROCESS Macro was used to test the indirect effect of self-esteem between attachment styles and ON.

RESULTS

Higher fearful and preoccupied attachment styles, female gender, and more physical activity were significantly associated with more ON tendencies, whereas higher self-esteem was significantly associated with less ON tendencies. When adjusting for all sociodemographic characteristics and other attachment styles, none of the attachment styles remained significantly correlated with ON tendencies. Self-esteem mediated the association between secure attachment style and ON and between dismissive attachment style and ON.

CONCLUSIONS

The rise in ON warrants further studies and investigations to raise awareness and plan behavioral interventions in order to treat it.

The Relationship between Orthorexia Nervosa and Obsessive Compulsive Disorder

Orthorexia nervosa (ON) is characterized by an intense avoidance of foods considered unhealthy, obsession with healthy eating behaviors, and pathological fixation on healthy foods. Although there are still debates in the literature about the psychological factors and symptoms of ON, it should be noted that many of the symptoms share common features with obsessive compulsive disorder (OCD). The aim of the present study was to investigate the relationship between ON and OCD with its subtypes. In this framework, the cross-sectional study was conducted with an opportunistic sample of 587 participants (86% women and 14% men), with an average age of 29.32 (s.d. = 11.29; age range = 15-74). Our work showed that almost all OCD subtypes were largely correlated with ON. The lowest correlation was for "Checking" and the highest for "Obsession". Overall, the OCD subtypes (i.e., Indecisiveness, Just Right, Obsession, and Hoarding) were more strongly associated with ON measures, while subtypes Checking and Contamination, although positively associated, had lower correlation coefficients.

U.S. health professionals' perspectives on orthorexia nervosa: clinical utility, measurement and diagnosis, and perceived influence of sociocultural factors

PURPOSE

This study examined U.S. health professionals' perspectives on the clinical utility, measurement, and etiology of orthorexia nervosa (ON).

METHODS

Participants (n = 100) were U.S. health professionals with experience working clinically with eating disorders, including trainees, Ph.D. psychologists, social workers/mental health counselors, and medical health professionals. After reviewing the proposed ON criteria, participants responded to questions regarding the clinical utility, diagnosis, and measurement of ON, and sociocultural influence on the emergence of ON. Views of ON as a useful diagnostic category were examined as a function of participants' current involvement in clinical versus research activities.

RESULTS

Participants mostly (71.9%) agreed that ON should be a distinct clinical diagnosis. Participants who endorsed ON as a valid diagnosis spent more time on clinical work and less time engaged in research compared to participants who disagreed (both ps < 0.05). Approximately 27% of participants believed additional components should be added to the proposed ON diagnostic criteria. Participants indicated that sociocultural factors have considerable influence on the development of ON, namely the diet and weight loss industry, and the perceptions that biological/organic/vegan and low fat/low carb/gluten free food are the healthiest.

CONCLUSION

Professionals who spent more time working clinically with eating disorders were more likely to endorse ON as a unique disorder, and professionals who spent more time on research were more likely to disagree. To the extent that professionals who spend more time on research may shape the narrative around ON more visibly, this study underscores the importance of listening to practitioners' experiences in applied settings.

LEVEL OF EVIDENCE

Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Associations between level of interest in nutrition, knowledge of nutrition, and prevalence of orthorexia traits among undergraduate students

Background: Orthorexia Nervosa (ON) is an unhealthy obsession wit "proper", "clean", or "healthful" eating that can potentially lead to serious physical, psychological, and social impairments. Aim: We aimed to examine associations between level of interest in nutrition, knowledge of nutrition, and prevalence of orthorexia traits in a population of college students enrolled in a general education nutrition course. Methods: Of the 579 students enrolled in the class during Spring semester of 2018, 221 (38%) completed an online survey. The survey was completed during weeks 8-9 of the 15-week semester. Results: The average nutrition knowledge score was 8.7 out of 12 (standard deviation (SD) 1.4, range 0-12). The average of the summed 29 orthorexia traits was 63.4 (SD 12.4; range = 41-102); lower scores indicated less agreeance with practicing ON behaviors. The degree of interest in the subject of nutrition was positively associated with prevalence of orthorexia traits (r = 0.43, p < 0.0001), but not nutrition knowledge (p > 0.05). Nutrition knowledge was inversely associated with prevalence of orthorexia traits (r = -0.19, p = 0.005). No associations were found between age, sex, year in school, or BMI and orthorexia traits. Conclusions: Interest in nutrition is associated with increased prevalence of orthorexia traits, however, higher levels of nutrition knowledge are associated with decreased prevalence of orthorexia traits. Additional studies should further examine these associations in prospective studies of nutrition/dietetics students as they progress in their programs and gain additional knowledge of nutrition.

The prevalence of orthorexia in exercising populations: a systematic review and meta-analysis

AIM

Orthorexia Nervosa (ON) describes a pathological obsession with proper and high-quality nutrition that is necessary to research further in order to elucidate its prevalence and correlates which may bear implications for prevention and treatment. The aim of this study was to review studies that report the prevalence of ON in people who exercise, calculate an overall prevalence through a random-effects meta-analysis approach and investigate the association of ON prevalence using a random-effects meta-regression. In addition, a sub-group-analysis based on ON-instruments and a sensitivity analysis excluding students samples, were conducted.

METHOD

Systematic searches were conducted in the following online databases: PubMed, Embase, Web of Science, PsychInfo, CINAHL, Google Scholar and OpenNet. The following search terms were used: Orthore* AND (prevalenc* OR incidenc* OR frequen* OR cut-off OR epidem*). A total of 613 unique hits were reviewed by two blinded authors, and 24 studies were coded and assessed for risk of bias (Holy et.al). The meta-regression included three independent variables (sex, type of sport, and sample size).

RESULTS

The overall prevalence of ON in the exercising population was 55.3% (95% CI 43.2-66.8). Cochran's Q was 11,436.38 (df = 23, p < 0.0000), and the I² was 98.4%, indicating high heterogeneity across studies. The sensitivity showed an overall prevalence of 51.3% (95% CI 51.3-70.0). There was a significant difference in prevalence estimates based on the instruments used (Q_bet = 33.6, df = 2, p < 0.01).

DISCUSSION

The overall prevalence of ON in exercising populations was very high. The between-study disparity was large and was partly explained by the ON-instrument administered. One fourth of the studies had a moderate risk of bias. The majority of the studies did not specify relevant demographic information about the sample, and information about the type of sport was frequently missing.

Compulsive Exercise, Exercise Identity, and Coping Styles

Abstract. Compulsive exercise occurs among the general exercise population and is associated with adverse mental and physical health outcomes. The current study explored compulsive exercise behavior regarding coping styles and its relationship to identity to improve our understanding of compulsive exercise among the general exercise population. A community sample of 1,209 adults (aged 18 – 89) with varied exercise levels completed an online survey. We examined the relationships between engagement and disengagement coping styles (as assessed by the Coping Strategy Inventory) and exercise identity (Exercise Identity Scale) with compulsive exercise (Compulsive Exercise Test) using correlation, regression, and moderation analyses. Emotion-focused engagement (β = .075, p < .01) and emotion-focused disengagement (β = .212, p < .001) coping styles significantly predicted compulsive exercise, as did exercise identity (β = .514, p < .001). Coping styles did not moderate the relationship between exercise identity and compulsive exercise behaviors. The results indicate that both adaptive and maladaptive emotion-based coping styles are associated with greater compulsive exercise behavior.

Association between the bi-dimensional aspect of orthorexia and healthy behaviors among lebanese adolescents

BACKGROUND

Recently, there has been a blooming focus on "eating healthy and clean", with the ideal of being healthy becoming a popular lifestyle trend. Previous research suggested the presence of two forms of orthorexia: Orthorexia Nervosa (OrNe) and Healthy Orthorexia (HeOr). Taking into consideration that orthorexia thoughts are led by the desire to reach an optimal physical health, the dedication to a healthy living may require healthy lifestyle habits: smoking cessation, moderate alcohol intake, and increased physical activity. The main study aim was to determine, among Lebanese adolescents, the association between healthy behaviors and the two likely forms of orthorexia (OrNe and HeOr), given that the adolescent phase is a risky period in the development of eating disorders.

METHODS

A cross-sectional study, conducted between January and April 2022, enrolled 444 adolescents aged between 14 and 18 years, with an equitable random sample from all the Lebanese governorates (mean age 16.23 ± 1.15 years; 60.1% females). The Teruel Orthorexia Scale (TOS) was used to assess orthorexic eating tendencies. The Lebanese Waterpipe Dependence Scale, the Fagerström Test for Nicotine Dependence and the Alcohol Use Disorder Identification Test scales, all validated in adolescents, were used to evaluate the association between orthorexia and healthy behaviors.

RESULTS

Higher TOS OrNe scores were significantly and highly correlated with the TOS HeOr scores (r = 0.68; p < 0.001). In the bivariate analysis, waterpipe smoking was weakly but significantly associated with more OrNe, whereas more physical activity was significantly and moderately associated with more HeOr. After adjusting over all sociodemographic characteristics, other behaviors and the other dimension of orthorexia, more alcohol use disorder was significantly but strongly associated with higher OrNe, whereas more physical activity remained significantly associated with higher HeOr.

CONCLUSION

In light of our results, OrNe and HeOr might be considered as different entities, mainly in their associations with alcohol consumption and physical activity. This supports the hypothesis of OrNe being a new form of eating disorder, whereas HeOr possibly showing protective characteristics. Orthorexia is still a topic of controversy, especially in the probable presence of two facets that are still difficult to differentiate.

"In-between orthorexia" profile: the co-occurrence of pathological and healthy orthorexia among male and female non-clinical adolescents

BACKGROUND

The profile of adolescents with orthorexic eating behaviors remains to be explored. This study is the first to explore the typology of Lebanese adolescents from a large non-clinical sample based on orthorexia nervosa (ON) and healthy orthorexia (HO).

METHOD

A total of 555 adolescents (aged between 15 and 18 years) completed a set of questionnaires assessing orthorexic behaviors, self-esteem, stress, depressive and anxiety symptoms. Cluster analysis based on ON and HO scores was used to identify the typology of the sample. More precisely, this analysis was used to reveal and distinguish between naturally occurring subgroups of individuals with different orthorexic eating profiles, within the studied sample. Further, a series of one-way ANOVA was used to compare observed clusters based on their scores on used questionnaires. This analysis was used to capture the behavioral and psychological differences between previously yielded subgroups of individuals.

RESULTS

Cluster analysis based on ON and HO scores yielded 3 distinct groups: "Low orthorexia", "Moderate in-between orthorexia" and "High in-between orthorexia". While the first group represented individuals with no particular (healthy or pathological) interest in healthy eating, the two latter groups represented those with respectively moderate and high degrees of an interest in healthy eating that has both pathological and healthy aspects. Significant differences between clusters regarding their levels of stress, depression, anxiety and self-esteem was observed, yet they were found to be negligible due to poor effect sizes.

CONCLUSION

Findings from this study suggest that ON and HO can indeed co-occur among adolescents, that this co-occurrence can be experienced at different severity levels. Low effect sizes for ANOVA comparisons may suggest the possibility of the co-occurrence of ON and HO reducing the negative effects of ON behavior to some degree. The potential role of confusion around what constitutes "healthy eating" in the emergence of these "in-between orthorexia" profiles is put forward.

Health perceptions and orthorexia nervosa tendencies among academics

PURPOSE

The aim of this study was to determine the perception of academicians' health status, identify academicians' orthorexia nervosa (ON) tendencies, and identify the factors associated with academicians' ON tendencies.

DESIGN AND METHODS

Personal information form (14 questions), Perception of Health status Scale, and ON (ORTO-11) Scale were used in data collection.

FINDINGS

The mean age of the participants was 42.23 ± 8.18. Of the academicians, 77.6% were female and 38.8% were in health-related departments. The health perception mean score was 1.82 ± 0.64. The average score of the ORTO-11 Scale was 22.86 ± 4.00, and 84.5% were found to be at risk of ON. There was a correlation between perception of health status and ORTO-11 (r = -0.286; p < 0.05).

PRACTICE IMPLICATIONS

Most of the academicians had a high tendency to ON. However, it is necessary to increase their awareness by providing training. Further studies should be carried out for certain diagnosis of ON.

Exercise dependence and orthorexia nervosa in Crossfit: exploring the role of perfectionism

Physical exercise and healthy diet have a positive effect on health. However, the pathological dimension of both behaviors, namely exercise dependence and orthorexia nervosa, can lead to negative results. So far, literature on these behaviors in the context of high-intensity sports is limited. The present study aims for investigating exercise dependence and orthorexia nervosa in a sample of Crossfit athletes, as well as examining the mediating role of perfectionism in their manifestation.The sample consisted of 110 people who attended Crossfit programs and 131 active gym members. The Exercise Dependence Scale was used to assess exercise dependence, the ORTO-15 to assess orthorexic behavior and the Almost Perfect Scale to evaluate perfectionism.19.8% of crossfitters and 3.8% of gym members were at risk for exercise dependence. 11.7% of participants in the Crossfit group and 10% of participants in the control group had orthorexic symptoms. An association was found between the scores on the two behaviors. In addition, the dimension of perfectionism high standards predicted obligatory exercise and orthorexia nervosa, while the dimension of discrepancy predicted only exercise dependence.The study suggests that exercise dependence is more evident in Crossfit compared to gym athletes and may be accompanied by orthorexic symptoms. Orthorexia nervosa is a noticeable phenomenon in the population of active exercisers. Perfectionism is a risk factor for obligatory exercise and orthorexia. A more demanding selection of target populations is encouraged in order to better understand exercise dependence, orthorexia nervosa and their personality background.

Orthorexia nervosa and dieting in a non-clinical sample: a prospective study

PURPOSE

Orthorexia Nervosa (ON) is characterised by excessive attention to a dietary regimen perceived as healthy. A critical factor in the distinction between ON and other eating disorders (EDs) is the dichotomy of quality-versus-quantity of food intake. We investigated whether specific types of diet or dieting frequency are associated with orthorexic features, explored the overlap between ON and EDs symptoms, and examined which constructs are predictive of ON after 6 months.

METHODS

A total of 1075 students (75.1% female, mean age 20.9) completed a set of questionnaires assessing Orthorexia, Eating Disorders, Obsessions and Compulsions, Anxiety and Depression; 358 individuals (79.9 female, mean age 20.9) agreed to participate in the study and completed the same questionnaires after 6 months. Different regression models were defined to investigate our hypothesis.

RESULTS

Findings suggest that ON is associated with the number and type of diets followed over a lifetime. Moreover, participants with EDs, body dissatisfaction, or a dysfunctional idea of thinness are more likely to report a greater degree of ON features. After 6 months, the best predictors of ON characteristics are the same ON characteristics assessed at the first administration, with a significant role in the ideal of thinness.

CONCLUSIONS

ON is more frequent in individuals with a previous diagnosis of EDs and in individuals who followed a restrictive diet or a vegan/vegetarian one; the number of lifetime diets, beliefs, and behaviors related to the ideals of thinness or body dissatisfaction is common features of ON. Moreover, considering that having ON features in the past is the best ON predictor in the present, we can presume that ON is a construct stable over time.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Orthorexia nervosa and its association with narcissism in fitness center users

PURPOSE

Orthorexia nervosa (ON) is an eating behavior where patients obsessively try to reach health through "purity" of food. Narcissism is a personality trait characterized with the self-belief of grandiosity, importance and need of appreciation. Both of these conditions are connected through self-image in way of reaching perfection through health and body image, whereas one of the ways for reaching it is exercising. This cross-sectional study aimed to investigate ON and its possible association with narcissism in fitness center users.

METHODS

The study included 1017 fitness center users and three questionnaires were used for the assessment: general information, ORTO-R and Narcissistic personality inventory-13 (NPI-13).

RESULTS

There was a significant negative correlation (r = - 0.467, p < 0.001) between the ORTO-R score and the NPI-13 score. Comparison of the ORTO-R score between different durations of using a fitness center showed statistically significant differences (H = 134.72, p < 0.001). The subjects who are using the fitness center for less than 1 year have the highest ORTO-R score, while those who are using it 1-3 years have the lowest ORTO-R score. Moreover, multiple linear regression showed that ORTO-R score retained significant association with NPI-13 (β ± SE, - 0.416 ± 0.026, p < 0.001) and the duration of using a fitness center (0.576 ± 0.068, p < 0.001) after model adjustment for age and BMI.

CONCLUSION

These results are implying that fitness center users could possibly be vulnerable of developing ON and that there is a strong association between ON and narcissism in this population. However, future larger-scale longitudinal studies are needed to address these findings.

LEVEL OF EVIDENCE

Level V, cross-sectional survey-based study.

Understanding exercise addiction, psychiatric characteristics and use of anabolic androgenic steroids among recreational athletes – An online survey study

Background

The purpose of this paper was to explore maladaptive behaviors among physically active individuals, including exercise dependence and use of anabolic steroids. Both exercise addiction (EA) and use of anabolic androgenic steroids (AAS) correlate to high amounts of exercise and EA have been linked to eating disorders and other mental health problems.

Methods

An internet survey was spread through fitness-related social media. Inclusion criteria were age ≥ 15 years and exercise frequency ≥ thrice weekly. Exercise addiction inventory identified those at-risk of EA (rEA). Characteristics of rEA were compared to those not at risk. In a separate analysis, AAS users were compared to AAS-naïve individuals.

Results

In total, 3,029 participants completed the questionnaire. Of these, 11% screened positive for being rEA, and 23% for ED. Factors associated with EA included daily exercise, social phobia, eating disorders and OCD. Risk consumption of alcohol was a negative predictor. Thirty seven participants had taken AAS the last year. These were mainly men, bodybuilders/powerlifters and more often used amphetamines and opioids.

Discussion

This exploratory study supports EA being strongly associated with eating disorders. Identified associations between EA and compulsive or anxiety disorders warrant further research to clarify if these associations arise prior to, together with, or secondary to EA.

Any overlap between orthorexia nervosa and obsessive-compulsive disorder in Lebanese adults? Results of a cross-sectional study and validation of the 12-item and 4-item obsessive-compulsive inventory (OCI-12 and OCI-4)

BACKGROUND

Orthorexia Nervosa (ON), a compulsive obsession with vigorous eating, has increasingly caught researchers' attention. Although Orthorexia Nervosa has not been labeled an eating disorder, research about ON highlighted a strong link with anorexia nervosa or obsessive-compulsive disorder (OCD). Therefore, this study aimed to (1) validate the Arabic version of the Obsession-Compulsion Inventory (OCI-12 and OCI-4) and (2) check if there is an overlap between ON and OCD among a sample of Lebanese adults.

METHODS

This cross-sectional study involved 487 Lebanese participants between July and August 2021. The Dusseldorf Orthorexia Scale (DOS) was used to assess ON; scores between 25 and 29 indicate probable ON, whereas scores ≥ 30 indicate ON tendencies. A confirmatory factor analysis (CFA) was carried out using SPSS AMOS v.24 on the OCI-12 and OCI-4 scales' items. The root mean square error of approximation (RMSEA) statistic, the Tucker Lewis Index (TLI) and the comparative fit index (CFI) were used to evaluate the goodness-of-fit of the model.

RESULTS

The CFA results indicated an excellent fit of the model: the Maximum Likelihood Chi-Square = 147.73 and Degrees of Freedom = 48, which gave a χ2/df = 3.08, TLI = 0.934, CFI = 0.952, and RMSEA = 0.065 [95% CI 0.054-0.078]. The fit indices of the one-factor structure of the OCI-4 were excellent as well: χ2/df = 6.15/2 = 3.08, TLI = 0.95, CFI = 0.98 and RMSEA = 0.065 [95% CI 0.007-0.127]. The Area Under the Curve was 0.600 [95% CI 0.524-0.674]. There was no cutoff value that showed good sensitivity or specificity at the same time. At the DOS cutoff of 25, sensitivity was 19.1%, whereas the specificity was 90.6%. The positive and negative predictive values (PPV and NPV) at this cutoff value were 24.4% and 88.7% respectively. At the DOS cutoff of 30, sensitivity was 8.8%, whereas the specificity was 94.3%. The PPV and NPV at this cutoff value were 10.6% and 92.5% respectively. The results showed that higher total OCD scores (Beta = 0.15) were significantly associated with more ON tendencies. Moreover, higher OCD washing scores (Beta = 0.52), physical activity index (Beta = 0.06), and Body Mass Index (Beta = 0.17) were significantly associated with more ON tendencies.

CONCLUSION

The present results suggest that ON, as measured by the DOS, shares more common features with disordered eating and cannot adequately predict the presence of OCD symptoms.

Prevalence of Risk for Orthorexia in Athletes Using the ORTO-15 Questionnaire: A Systematic Mini-Review

The article aims to summarize the literature about the profile of risk of orthorexia in athletes using the ORTO-15 questionnaire. The search was performed at PubMed, Embase, Web of Science, and Sport Discus databases, using the terms “orthorexia” AND “athletes” with the respective entry terms. A multistage process of selection followed the PRISMA 2020 recommendation. A total of 688 articles were identified, and six studies were available for the final process. The prevalence of risk for orthorexia was assessed by the articles by the ORTO-15 questionnaire and ranged between 38 and 35 points. The comparison between male and female athletes and, athletes and non-athletes was not significant in the six articles. In conclusion, the review highlights that athletes from different sports, included in the review, do not present a risk of orthorexia nervosa considering the cutoff of 40 points, but not 35 points. Also, athletes present the same orthorexic behavior compared to non-athletes, demonstrating that orthorexia is an issue that needs to be considered in the general population. Moreover, a special focus should be given on the ORTO-15 questionnaire, about the sensitivity to diagnose the prevalence of orthorexia, especially in athletes.

Orthorexia Nervosa and Disordered Eating Attitudes, Self-Esteem and Physical Activity among Young Adults

A relation between Orthorexia Nervosa (ON) and increased frequency of physical activity has been put in evidence by recent studies. It is well known that intense physical exercises are typically related to eating disorders, but its relationship with ON is still a subject of debate. Other transdiagnostic features could be necessary to conceptualize and understand ON; in this way, low self-esteem is related to eating behavior but is not still extensively investigated in ON, and, to date, data are so heterogeneous that they do not allow us to understand if this is a psychological feature somehow associated with ON. The current study aimed to assess whether disordered eating attitudes, self-esteem, and physical activity are associated with ON in young adults from Poland and Italy. Moreover, we investigated the differences by comparing lower and higher ON levels related to disordered eating attitudes, self-esteem, and physical activity. Our results indicated that a great concern about dieting significantly predicted problems associated with healthy eating, knowledge about healthy eating, and feeling positive about healthy eating. In addition, young adults with a high level of ON demonstrated higher levels of disordered eating attitudes and vigorous-intensity physical activity than young adults with a low level of ON. Future studies are needed to assess the direct effect of physical activity and self-esteem on ON.

Lifestyle-Related Risk Factors of Orthorexia Can Differ among the Students of Distinct University Courses

Orthorexia nervosa (ON) is defined as the excessive attention on healthy eating, and studies especially focused on food quality ON prevalence in university students can be extremely variable. The objective of this study is to investigate whether there was a difference in ON risk between health-scientific, economic-humanistic, sport sciences and dietetics and nutrition students, and to evaluate if lifestyle-related ON risk factors (dieting, physical activity, drugs and supplements use) could have an impact in different ways in determining ON risk among students attending these four programs. Participants were recruited at the University of Pavia and received a two-section questionnaire including demographic and lifestyle information and the ORTO-15 questionnaire. A total of 671 students (54% F e 46% M) completed the questionnaire (median age 21.00 (IQR 20.00−23.00), median BMI 21.77 kg/m2 (IQR 20.06−23.66 kg/m2)). The 31.2% had ORTO-15 test scores < 35, and were considered at risk of having ON. No differences were found in ON risk among the students attending the four university courses. Dieting was confirmed as the major ON risk factor for health-scientific, economic-humanistic and sport sciences students. The type of sport practiced was an important determinant of ON risk only for the economic-humanistic course, while supplements use was statistically different between sport sciences students with or without ON. Our findings may suggest that lifestyle-related risk factors of orthorexia can differ among the students of distinct university courses, but these results need to be supported by further longitudinal and prospective studies.

Dietary Behavior and Risk of Orthorexia in Women with Celiac Disease

Evidence points to a link between celiac disease and eating disorders. Although with the current limited knowledge, orthorexia cannot be formally recognized as an eating disorder, some features are similar. This study is the first to examine individuals with celiac disease in terms of the prevalence of risk of orthorexia. Participants were 123 females diagnosed with celiac disease. The standardized ORTO-15 questionnaire was used to assess the risk of orthorexia. In this study, eating habits and physical activity were assessed. The effect of celiac disease on diet was self-assessed on a 5-point scale. Taking a score of 40 on the ORTO-15 test as the cut-off point, a risk of orthorexia was found in 71% of individuals with celiac disease, but only in 32% when the cut-off point was set at 35. There was a positive correlation between age and ORTO-15 test scores (rho = 0.30). In the group with orthorexia risk, meals were more often self-prepared (94%) compared to those without risk of orthorexia (78%) (p = 0.006). Individuals at risk for orthorexia were less likely to pay attention to the caloric content of food (46%) relative to those without risk of orthorexia (69%) (p = 0.001). For 64% of those at risk for orthorexia vs. 8% without risk had the thought of food that worried them (p = 0.001). Given the survey instrument for assessing the prevalence of orthorexia and the overlap between eating behaviors in celiac disease and orthorexia, the prevalence of orthorexia in celiac disease cannot be clearly established. Therefore, future research should focus on using other research tools to confirm the presence of orthorexia in celiac disease.

Orthorexia nervosa and its association with alexithymia, emotion dysregulation and disordered eating attitudes among Lebanese adults

OBJECTIVE

This study aims to explore whether orthorexia nervosa, like other eating disorders, is associated with difficulties identifying, describing, and regulating one's own emotions among a sample of Lebanese adults.

METHODS

A cross-sectional study was conducted during October 2020, during the lockdown period imposed by the government for the COVID-19 pandemic. All participants above 18 years of age were allowed to participate in this study. A total of 787 Lebanese adults out of 920 (85.54%) completed an online survey including Arabic versions of the ORTO-R measure of orthorexia, the Toronto Alexithymia Scale, the Difficulty in Emotion Regulation Scale, and the Eating Attitudes Test.

RESULTS

After making sure that all norms are verified, hierarchical linear regressions were conducted to evaluate the association between disordered eating attitudes (EAT scores) and ON (model 1), and after controlling for difficulties in emotion regulation (DERS score) (model 2). Model 1 accounted for 15.1% of the variance of ON (adj. R2 = 0.151, F(1, 786) = 140.06, p < 0.001) and showed that higher levels of disordered eating (higher EAT scores) (β = 0.15) were significantly associated with more ON tendencies and behaviors. When adding the DERS total score to the model, Model 2 was a much better fit with 17.7% of the variance of ON (adj. R2 = 0.177, F(2, 786) = 84.44, p < 0.001), with higher levels of emotion dysregulation (higher DERS scores) (β = 0.06) and more disordered eating attitudes (higher EAT scores) (β = 0.13) were associated with higher levels of ON (Table 5).

CONCLUSION

The present research suggests that people with high ON tendencies experience troubles recognizing, regulating, and describing their emotions, similarly to other disordered eating.

LEVEL OF EVIDENCE

5.

Low self-esteem predicts orthorexia nervosa, mediated by spiritual attitudes among frequent exercisers

OBJECTIVE

The aim of this study was to measure how orthorexic tendencies relate to age, self-esteem, and spirituality. We conducted the study on a sample of Hungarian adults performing regular fitness activity.

METHOD

175 participants completed a four-part online survey: demographics and training habits, the Rosenberg Self-Esteem Scale, the Eating Habits Questionnaire-Revised (EHQ-R), and one of the Spiritual Awareness questionnaire's subscale. We performed univariate linear regression to assess the predictor role of age on orthorexic tendencies. Mediation analysis was conducted to determine the effect of self-esteem on orthorexic tendencies and the mediator role of spiritual attitudes.

RESULTS

Age negatively correlated with EHQ-R, and there were no gender differences. Lower self-esteem was a predictor for orthorexic tendencies with the total effect of ß = -0.3046 (p < 0.0001). In part, this is a direct relationship, but it is mediated by spiritual awareness as well.

DISCUSSION

Among frequent exercisers, strict dieting is likely to originate from a lack of self-esteem due to perfectionist standards, social comparison, and the aspiration of being in control. In case self-esteem is achieved through spiritual approaches, individuals may experience positive changes in their attitudes toward eating and their bodies as well. In the future, it is important to confirm whether the EHQ-R indicates diagnostic boundaries.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Psychometric evaluation of the French version of the Düsseldorfer Orthorexia Skala (DOS) and prevalence of orthorexia nervosa among university students

PURPOSE

This study aimed at obtaining a French version of the DOS (F-DOS) and evaluating its psychometric properties in a sample of university students, then assessing the prevalence of orthorexic eating behavior among the participants.

METHODS

The F-DOS was obtained using back translation, and then administered to 3235 university students (10.32% men, 89.67% women) with a mean age of 21.13 (SD = 2.23). The Eating Habits Questionnaire and Eating Attitudes Test were used to assess convergent and divergent validities, respectively. Confirmatory factor analysis was performed to explore the factor structure.

RESULTS

Ordinal ⍵ of F-DOS was 0.87, indicating very good internal consistency. F-DOS and EHQ total scores were strongly correlated (r_s = 0.74, p < 0.001), indicating very good construct validity. Factor analysis revealed a well-fitted one-factor model. Regarding Orthorexia Nervosa (ON) prevalence, according to DOS cut-off score, 3.28% of participants could be considered having ON, while an additional 11.31% could be at risk of developing ON.

CONCLUSIONS

The F-DOS appears to be a valid and reliable instrument to assess orthorexic eating behavior. ON prevalence in college students appeared similar to Germany and lower than in the US.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, Level V.

The Mediating Role of Orthorexia in the Relationship between Physical Activity and Fear of COVID-19 among University Students in Poland

Previous research showed that the COVID-19 pandemic has a significant impact on the wellbeing and lifestyle of populations worldwide, including eating and physical activity (PA) patterns. The present study aims to examine the mediating effect of orthorexia on the relationship between PA and fear of COVID-19. A sample of 473 university students from Poland of a mean age of 22 years (M = 22.04, SD = 2.90, 47% of women) participated in the cross-sectional online survey study. Continuous variables were measured using the Fear of COVID-19 Scale (FCV-19S) and the Test of Orthorexia Nervosa (TON-17), while categorical variables divided participants into the physically active and inactive group regarding WHO criteria (150 min per week). Weak gender differences were found. Active people showed lower fear of COVID-19 and higher orthorexia scores than those inactive. Orthorexia was found as a suppressor variable, which increases the negative predictive value of PA on fear of COVID-19. The model of cooperative suppression explained 7% of FCV-19S. The mechanism of mediation showed that health-related behavior could help reduce fear of COVID-19, but caution is necessary for people with addictive behavior tendencies. Universities should support university students by offering programs focused on increasing healthy lifestyles and improving wellbeing.

Alike and different: Associations between orthorexic eating behaviors and exercise addiction

OBJECTIVE

Symptoms of exercise addiction, a state of compulsively engaging in intense exercise, and orthorexic eating attitudes, the obsession with eating only healthy foods, often occur together. It is assumed that some more general psychological traits underlie this association. Main aim of this report was to examine similarities and differences between orthorexic eating and addictive exercising.

METHOD

Six hundred and eight individuals completed an online survey (mean age: 27.5, SD = 11.0 years; 76.5% women) measuring exercise addiction (Exercise Addiction inventory, EAI), orthorexic eating (Düsseldorfer Orthorexie Skala, DOS), personality domains (Big-Five Inventory-10), anxiety and depression (Hospital Anxiety and Depression Scale).

RESULTS

Correlations between the DOS and EAI were .43 in women and .62 in men. Structural equation models identified gender-specific as well as behavior-specific psychological correlates. Among women, anxiety correlated with both EAI and DOS. In addition, the DOS correlated with depression and neuroticism while the EAI correlated with conscientiousness. In men, both scales were associated with conscientiousness and the EAI also correlated with extraversion. Clusterability analysis provided no evidence for clusters based on DOS and EAI.

DISCUSSION

Present results showed a substantial correlation between addictive exercising and orthorexic eating, however, coefficients were smaller than expected and appeared higher in men. Both behaviors shared few psychological traits (anxiety in women, conscientiousness in men) thereby questioning the assumption of a similar origin. Additionally, gender-specific psychological correlates point to the need for different disease management approaches in women and men.

Orthorexia Nervosa: differences between clinical and non-clinical samples

BACKGROUND

Orthorexia Nervosa (ON) is a construct characterized by behaviors, emotions, and beliefs on eating healthy food and excessive attention to diet; moreover, dieting has been considered a risk factor in ON symptoms development. The principal aim of this study was to investigate the differences in clinical and non-clinical groups most at risk of ON. Aspects that could be associated with ON (Eating Disorders [EDs], obsessive-compulsive symptomatology, perfectionistic traits, anxiety, depression, Body Mass Index [BMI]) were investigated in all groups.

METHODS

The sample consisted of 329 adults belonging to four different groups. Three were on a diet: Anorexia/Bulimia Nervosa group (N = 90), Obesity/Binge Eating Disorder group (N = 54), Diet group (N = 91). The Control group consisted of people who were not following a diet (N = 94). Participants completed several self-administered questionnaires (EHQ-21, EDI-3, OCI-R, MPS, BAI, BDI-II) to assess ON-related features in different groups.

RESULTS

Analyses highlighted higher orthorexic tendencies in Anorexia/Bulimia Nervosa, Obesity/BED, and Diet groups than in the Control group. Moreover, results have shown that in the AN/BN group, eating disorders symptomatology and a lower BMI were related to ON and that in Obesity/Binge Eating Disorder and Diet groups, perfectionism traits are associated with ON.

CONCLUSION

Individuals who pursue a diet share some similarities with those who have an eating disorder regarding emotions, behaviors, and problems associated with orthorexic tendencies. Moreover, perfectionistic traits seem to predispose to higher ON tendencies. In general, these results confirm the ON as an aspect of the main eating disorders category.

A Portuguese Adaptation of the Teruel Orthorexia Scale and a Test of Its Utility with Brazilian Young Adults

The aims for this study were to perform a Portuguese language cross-cultural adaptation of the Teruel Orthorexia Scale (TOS) and to evaluate the scale's psychometric properties, including verifying the frequency of behaviors characteristic of orthorexia nervosa and healthy orthorexia, among a group of Brazilian gym users. First, we adapted the Spanish version of the TOS to the Brazilian Portuguese language following international protocols to guarantee idiomatic, semantic, conceptual, and cultural equivalence. Then participants completed both the new Portuguese version of the TOS and a socioeconomic questionnaire. Among our sample of 226 young Brazilian adults (63.7% men; M _age = 28.8, SD = 5.1 years), we assessed the bi-factorial model of the TOS through factorial, convergent, and discriminant validity, reliability, and factorial invariance. We calculated the mean scores of the TOS factors and the frequency of behaviors of both orthorexia nervosa and healthy orthorexia. The new Portuguese version was well understood by participants, and the TOS bi-factorial model presented adequate psychometric properties and showed invariance in independent subsamples and in men and women. The mean scores were different between sexes only for orthorexia nervosa, with women obtaining higher values. The frequency of orthorexia nervosa behaviors was 5.3% and of healthy orthorexia was 41.2%. Based on these findings, the Brazilian Portuguese version of the TOS can be a useful tool for investigating orthorexia-like behaviors in future research.

The relationship between orthorexia nervosa symptomatology and body image attitudes and distortion

Orthorexia Nervosa (ON), a condition characterized by a fixation on healthy eating, still does not conform to any consensus concerning diagnostic criteria, notably in regard to a possible body image component. This study investigated the relationship between ON symptomatology, measured with the Eating Habit Questionnaire, and body image attitudes and body image distortion in a non-clinical sample. Explicit body image attitudes and distortion were measured using the Multidimensional Body-Self Relations Questionnaire. Implicit body image attitudes and distortion were assessed using the reverse correlation technique. Correlational analyses showed that ON is associated with both explicit and implicit attitudes and distortion toward body image. More precisely, multivariate analyses combining various body image components showed that ON is mostly associated with explicit overweight preoccupation, explicit investment in physical health and leading a healthy lifestyle, and implicit muscularity distortion. These findings suggest that ON symptomatology is positively associated with body image attitudes and distortion in a non-clinical sample. However, further studies should be conducted to better understand how ON symptomatology relates to body image, especially among clinical samples.

Prevalence of Orthorexia Nervosa and Its Diagnostic Tools-A Literature Review

The aim of this article is to present the up-to-date diagnostic tools of orthorexia and markers of its prevalence on the basis of the available literature. The authors searched PubMedCentral (PMC) and Google Scholar with the search entry of “orthorexia”, “orthorexia nervosa”, and “orthorexicbehaviours”. We describe the tools of evaluation of orthorexicbehaviour (i.e., orthorexia self-test—BOT, the ORTO-15 questionnaire, Eating Habits Questionnaire—EHQ, Düsseldorf Orthorexia Scale—DOS, Teruel Orthorexia Scale—TOS, Barcelona Orthorexia Scale—BOS, and Orthorexia Nervosa Inventory—ONI), and offer a review of the studies on orthorexia nervosa. We conclude that there are no reliable data regarding the prevalence of orthorexia nervosa. The available studies point to significant differences in the prevalence depending on the value of cut-off points and tools used. The prevalence varies across countries and across populations, ranging from 6.9% in the Italian population to 88.7% in the group of Brazilian students of dieting. Thus, it indicates that some groups seem to be susceptible to the risk of ON more than others. It is a challenge to determine the prevalence of orthorexia, and any obtained results should be treated with caution. Consequently, we claim that the use of the ORTO-15 questionnaire to diagnose orthorexia is questionable due to a high percentage of falsely positive results.

Assessment of orthorexia nervosa via ORTO-R scores of Turkish recreational and competitive athletes and sedentary individuals: a cross-sectional questionnaire study

PURPOSE

This study aims to evaluate and compare the scores of a self-reported measurement of orthorexia nervosa among Turkish people who engage in different levels of physical activity (sedentary individuals, recreational athletes and competitive athletes).

METHODS

Data for this study were collected through a self-administered online questionnaire between March and April 2020 in Turkey. The questionnaire consisted of two parts: personal information (sociodemographic and anthropometric information, training and dieting regime) and the ORTO-11 Scale. Only the items in the revised scale (ORTO-R) were used for analysis. Measurement invariance was tested and latent means were compared across different activity groups, sexes and levels of education.

RESULTS

Analysis was done with a total of 877 participants (514 sedentary, 271 recreationally active, and 91 competitive athletes). Mean age of participants was 29.12 ± 11.15. Sedentary people were less likely to follow a particular diet. Configural, metric and partial scalar invariance were proven across three groups of physical activity and the difference between latent means was found nonsignificant (competitive vs sedentary: CR = - 0.53, p = 0.592; competitive vs recreational: CR = 0.25, p = 0.724; sedentary vs. recreational: CR = - 1.35, p = 0.183). Configural, metric and full scalar invariance were proven across sexes and different levels of education, and difference between latent means was found nonsignificant (CR = - 1,11, p = 0.272; CR = - 0.53, p = 0.587, respectively).

CONCLUSION

In conclusion, people who compete at sports events, exercise regularly at a recreational level, or lead a sedentary life have similar scores in ORTO-R. Also, females did not score higher than males.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Orthorexia Nervosa Inventory (ONI): development and validation of a new measure of orthorexic symptomatology

PURPOSE

To overcome the problems associated with existing measures of orthorexia, we assessed the reliability and validity of a new measure: the Orthorexia Nervosa Inventory (ONI).

METHOD

An online survey was completed by 847 people recruited from undergraduate nutrition and psychology courses and from advertisements in Facebook and Instagram targeting both healthy eaters (with keywords such as "clean eating" and "healthy eating") and normal eaters (with keywords such as "delicious food" and "desserts").

RESULTS

Exploratory factor analysis revealed three factors with 9 items assessing behaviors and preoccupation with healthy eating, 10 items assessing physical and psychosocial impairments, and 5 items assessing emotional distress. With this sample, all scales demonstrated good internal consistency (Cronbach's α = 0.88-0.90) and 2-week test-retest reliability (r = 0.86- 0.87). Consistent with past research, ONI scores were significantly greater among vegetarians and vegans, and among those with higher levels of disordered eating, general obsessive-compulsive tendencies, and compulsive exercise. Additionally, whereas ONI scores did not significantly differ between men and women, the scores were negatively correlated with body mass index.

CONCLUSION

The ONI is the first orthorexia measure to include items assessing physical impairments that researchers and clinicians agree comprise a key component of the disorder. Additionally, at least for the current sample, the ONI is a reliable measure with expected correlations based on the past research.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Obsessive healthy eating and orthorexic eating tendencies in sport and exercise contexts: A systematic review and meta-analysis

BACKGROUND

Orthorexia Nervosa (ON) and exercise addiction (ExAdd) are two phenomena believed to overlap. We conducted a meta-analysis exploring the link between ON and (addictive) exercise behaviors.

METHODS

A systematic review of major databases and gray literature was carried out for studies reporting on ON and (addictive) exercise behaviors. Random effects meta-analyses were undertaken calculating correlations between ON and (addictive) exercise behaviors. A sub-group analysis investigated gender differences.

RESULTS

Twenty-five studies with 10,134 participants (mean age = 25.21; 56.4% female) were included. Analyses showed a small overall correlation between ON and exercise (21 studies, r = 0.12, 95% CI |0.06-0.18|) and a medium overall correlation between ON and ExAdd (7 studies, r = 0.29, 95% CI |0.13-0.45|). Gender differences were negligible.

CONCLUSIONS

Orthorexic eating correlated slightly and moderately with exercise and ExAdd, respectively, expressing some unique and shared variance of these behaviors. While this does not suggest ON and addictive exercising to be independent, it does not indicate substantial comorbidity. Future research should focus on clinical relevance, underlying mechanisms, vulnerability, and risk factors.

The associations between orthorexia nervosa and the sociocultural attitudes: the mediating role of basic psychological needs and health anxiety

PURPOSE

Given the range of negative correlates associated with orthorexia nervosa (ON), it is important to identify factors that might contribute to the elevated ON tendencies. Based on the tripartite model of influence, we tested whether sociocultural attitudes towards appearance (i.e., thin and muscular internalization as well as family, peer and media pressure) could contribute to ON. We hypothesized that these attitudes could exert their effect through the intervening processes basic psychological need fulfillment and health anxiety.

METHODS

The hypotheses were tested on a sample of 710 young adults (M_age = 21.79, SD_age = 2.31). Participants completed validated questionnaires measuring the constructs of interest.

RESULTS

According to the structural equation modeling results, ON was predicted by thinness and muscular internalization as well as media pressure. Need fulfillment and health anxiety partially mediated these relationships. Family and peer pressure were not related to ON.

DISCUSSION

The present results suggest that internalization of appearance ideas and media pressure contribute to ON through need fulfillment and health anxiety. These findings also provide novel insight into the nature of ON.

LEVEL OF EVIDENCE

Level V (descriptive cross-sectional study.

Exercise Addiction and Satisfaction of Fitness Center Users as Precursors to the Intention of Continuing to Engage in Physical Activity

Exercise addiction occurs when a person engages in excessive physical activity until they lose control. Among individuals attending fitness centers, the risk of developing exercise addiction has been estimated to be close to 10%. The objective of this study was to determine whether exercise addiction may be an antecedent of satisfaction with the service received and/or of the intention of continuing to partake in leisure-time physical activity at fitness centers in a direct or indirect manner. A total of 361 individuals (29.05 ± 11.40 years old) who were physically active at Spanish fitness centers were asked to respond to a questionnaire on exercise addiction, satisfaction with the sports service, and their intention to continue to engage in physical activity. A multi-group analysis was conducted to check for differences in relationships by sex. The results show the relationships between addiction, satisfaction, and intention to continue physical activity. The standardized values display differences between men and women, with women exhibiting the highest values for the relationships between addiction and the rest of the constructs. Satisfaction with the sports service is a mediator in the relationship between exercise addiction and intention to engage in leisure-time physical activity.

Evaluation of Orthorexia Nervosa and Symptomatology Associated with Eating Disorders among European University Students: A Multicentre Cross-Sectional Study

The objectives of the present study were to (1) evaluate prevalence of orthorexia nervosa (ON) in university students in Spain and Poland, (2) assess differences in ON and eating disorder (ED) pathology in both samples and (3) examine the relationship between ON and ED symptoms among Spanish and Polish university students. Eight hundred and sixty university students participated in the present study (M_age = 21.17 ± 3.38; M_BMI = 22.57 ± 3.76). The Spanish and Polish samples comprised 485 and 375 students, respectively. The Düsseldorf Orthorexia Scale and the Eating Disorder Inventory were used in the present study. ON prevalence rates of 2.3% and 2.9%, respectively, are found in the Spanish and Polish samples. Compared to Polish students, Spanish university students reported increased drive for thinness and lower body dissatisfaction, lower level of ineffectiveness and lower level of interpersonal distrust. ON was positively related to drive for thinness, bulimia, body dissatisfaction, perfectionism interoceptive awareness (in both Spanish and Polish students) and ineffectiveness (in Spanish students). Our findings suggest that ON significantly overlaps with ED symptoms, which is in line with recent studies. Longitudinal studies are needed to assess how ON develops in a sample of young adults and whether it develops in isolation of or in parallel with ED pathology.

The relationship between food addiction and patterns of disordered eating with exercise dependence: in amateur endurance athletes

PURPOSE

Examine the prevalence and potential relationships among food addiction (FA)-as measured by Yale Food Addiction Scale 2.0 (YFAS 2.0), eating disorders (ED)-as measured by Eating Disorder Diagnostic Scale (EDDS)-and exercise dependence (EXD)-as measured by Questionnaire to Diagnose Exercise Dependence in Endurance Sports (FESA), for the first time worldwide, in amateur endurance athletes.

METHODS

A total of 1022 German-speaking endurance athletes (44% male, Ø 36 years, Ø BMI 23 kg/m²) replied to an online questionnaire consisting of demographics, related parameters, and the German versions of YFAS 2.0, EDDS, and FESA.

RESULTS

Prevalence of FA, ED, and EXD was 6.2, 6.5, and 30.5%. The probability for FA increases with BMI, thoughts about food and EXD score, and decreases with age and when an ED is present. People with FA and people with ED vs. people with both, FA&ED, differed significantly in this cohort. Strong significant relationships were found between FA and EXD (X² (1) = 15.117, p < 0.001, n = 1022).

CONCLUSIONS

A considerable number of amateur endurance athletes may suffer from FA. The association between FA and EXD is stronger than between ED and EXD, indicating FA as a potentially more relevant subject-than ED-for prevention or therapy in people with EXD. Further studies are needed to investigate parameters and relationships between the possibly involved types of ED, FA, and EXD.

LEVEL OF EVIDENCE

Level III, well-designed cohort analytic study.

Orthorexic eating in women who are physically active in sport: A test of an objectification theory model

The present study tested an objectification model of orthorexic eating (i.e., pattern of disordered eating characterized by a preoccupation with food quality and purity, ritualistic styles of eating, avoidance of foods considered unhealthy, and compulsive evaluation of the source and nutritional content of foods) in women who are physically active in sport. A community sample of women physically active in sport (N = 228) completed an online survey with measures of orthorexic eating, phenomenological and appearance-based self-objectification, phenomenological body shame, sport-based perfectionism, and athletic identity. Parallel mediation analysis (PROCESS; Model 4) demonstrated a significant indirect effect (ab) of phenomenological self-objectification on orthorexic eating through phenomenological body shame (b = -0.10, 95 % percentile bootstrap confidence interval (PB CI): -0.15, -0.06), adjusting for three covariate measures. The direct effect (c') of phenomenological self-objectification on orthorexic eating was not significant (b = 0.02, 95 % PB CI: -0.07, 0.10). The findings support an objectification theory model of orthorexic eating in community women who participate in sport.

Identifying the Profile of Orthorexic Behavior and "Normal" Eating Behavior with Cluster Analysis: A Cross-Sectional Study among Polish Adults

Although the amount of research about orthorexia nervosa (ON) has grown in the last two decades, to date, research on ON remains inconsistent. More is known about some behavioral characteristics of ON and its prevalence but nothing is known about the profile analysis behind this pathological eating behavior maintenance. Therefore, the objective of the present study was to determine the profiles of the participants in terms of eating behaviors, eating disorder psychopathology, obsessive-compulsive disorder symptoms and physical activity as well as check their association with ON. The sample was composed of 229 Polish female and male adults. Our findings showed three clusters and four-related factors (obsessive-compulsive disorder features; inappropriate eating and body-related behaviors; psychological and affective traits of eating disorders; perfectionism and behaviors associated with weight maintenance or weight loss). In our sample, a higher percentage of adults belonging to cluster 1 had no ON, whereas a higher percentage of adults belonging to cluster 3 had ON. Our results emphasize the possibility to target pathological eating behaviors and obsessive-compulsive disorder (OCD) symptoms in ON in psychological intervention.

Traits of orthorexia nervosa and muscle dysmorphia in Italian university students: a multicentre study

PURPOSE

This study aimed to evaluate the prevalence of traits of orthorexia nervosa (ON) and muscle dysmorphia (MD) in a group of undergraduates, investigate the associations between the risk of these conditions and the type of university course attended, the individual characteristics (gender, BMI, amount of physical activity, supplements and medicines use, dieting) and the risk of eating disorders (EDs).

METHODS

A self-reported questionnaire consisting of a socio-demographic section and three tests validated for the evaluation of a risk of ON (ORTO-15), MD (MDDI-ITA) and EDs (EAT-26) was completed by 918 students from three Italian universities.

RESULTS

29.0% of participants demonstrated traits of ON and 5.0% of MD, without differences in prevalence in the three areas of study investigated (health-scientific, economic-humanistic, sport sciences); students of sport sciences exhibited a significantly higher score for MDDI-ITA (F = 6.493, p = 0.002). Participants with ON and MD traits were more on a diet (OR = 0.47, p ≤ 0.001 and OR = 0.428, p = 0.020, respectively) and showed a higher prevalence of EDs risk (OR = 3.55, p < 0.001 and OR = 10.23, p ≤ 0.001, respectively). The simultaneous presence of ON, MD, and EDs traits was seen in 5.4% of the students and the three test scores were correlated.

CONCLUSIONS

The prevalence of ON and MD traits was found similar to that reported in the literature on undergraduates. Some associations observed improvement in the knowledge about these conditions, especially the association of participants with ON and MD traits with dieting and EDs traits and the correlation of the three test scores suggests a connection among these potential conditions.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional survey.

Traits of Orthorexia Nervosa and the Determinants of These Behaviors in Elite Athletes

Background: The purpose of this study was to evaluate the traits of orthorexia nervosa (ON) and its relation to body composition and anthropometric indices among elite athletes. Methods: We studied 273 (125 female, 148 male) competitive athletes. ON was assessed with the self-administered ORTO-15 questionnaire. Total body composition was determined using dual-energy X-ray absorptiometry (DXA). Results: The ORTO-15 score was independent of sex, type of effort or age. The ORTO-15 score was related to: total body mass (TBM) (p = 0.037; R = 0.170), body mass index (BMI) (p = 0.022; R = 0.187), bone mineral content (BMC) (p = 0.035; R = 0.172), lean soft tissue (p = 0.026; R = 0.182) and visceral adipose tissue (VAT) (p = 0.007; R = 0.255) in the male; BMI (p = 0.045; R = 0.412) and BMC (p = 0.012; R = 0.506) in weight-dependent male athletes. There was no relationship between ORTO-15 score and body composition in the total study group and subgroup of female athletes. In female athletes, ON tendencies were related to the weekly training time (p = 0.039), but in sprint and high-intensity intermittent efforts subgroup exclusively. Conclusions: Factors related to ON tendencies concerned exclusively BMI and body composition in male, and the weekly training time in female athletes. The results from this study demonstrate that a significant percentage of athletes, irrespective of sex, age, type of sport or hours of training per week, may manifest traits of orthorexia nervosa.

Body image and body change behaviors associated with orthorexia symptoms in males

In recent years, Orthorexia Nervosa has received increasing attention as a form of restrictive disordered eating driven by concerns related to "healthy eating" as opposed to weight and shape concerns. To date, however, data on the correlates of orthorexia in men are lacking, particularly pertaining to the relationship between orthorexia and muscularity-related dimensions. A sample of 103 (M_age = 19.84) male college students completed an online questionnaire reporting on orthorexia symptoms, eating pathology, drive for muscularity, exercise dependence, and internalization of the thin and athletic ideals. Correlational analyses and linear regression models were used to explore relationships between orthorexia and variables of interest. Findings revealed positive relationships between high levels of orthorexia symptoms and eating pathology, exercise dependence, thin and athletic internalization, and behavioral dimensions of drive for muscularity. The results of this study extend our understanding of the correlates of orthorexia symptoms among young men and highlight their association with other dimensions of eating pathology as well as dysfunctional exercise. In addition, concerns related to healthiness may overlap with muscularity-related concerns, perhaps due to the conflation between health and muscular appearance in social constructions of male body ideals.