Orthorexia nervosa in yoga practitioners: relationship with personality, attitudes about appearance, and yoga engagement

Body- and Fitness-Related Shame Helps Explain the Association Between Internalized Weight Bias and Orthorexia Symptoms Among North American Female Yoga Professionals

BACKGROUND

Recently, emerging population-based evidence has revealed that yoga practitioners are particularly vulnerable to engaging in disordered eating behaviors, inclusive of orthorexia symptoms (OS). Although orthorexia tends to be characterized by a hypervigilance over consuming so-called healthy or clean foods based on quality attributes, its associations with variables related to broader diet culture (eg, internalized weight bias [IWB] and body- and fitness-related shame, guilt, and hubristic pride) remain underexamined. In addition, previous research has yet to explore the psychological correlates of OS specifically among yoga professionals, who are uniquely positioned to influence their students' and clients' orientations toward eating and embodied well-being.

OBJECTIVE

This secondary analysis from the Yoga Teacher and Therapist Lifestyle and Well-Being Study (2019-2020) aimed to investigate the relationships among diet culture-related experiences, specifically IWB and body- and fitness-related self-conscious emotions, role modeling positive body image, and OS among female yoga professionals, as well as to evaluate the indirect effects of IWB via role modeling positive body image and other diet culture-related experiences on OS.

DESIGN

A secondary, cross-sectional correlational analysis was performed to address the research questions.

PARTICIPANTS

The study included 406 female yoga professionals living in the United States and Canada (37% racial/ethnic minority and 13% sexual minority).

MAIN OUTCOME MEASURES

These included IWB, body- and fitness-related self-conscious emotions, role modeling positive body image, and OS.

STATISTICAL ANALYSES PERFORMED

These included Pearson correlations and regression models.

RESULTS

Nearly 40% of participants consumed an exclusively vegetarian or vegan diet; 25% identified as engaging in "clean eating." Positive associations were observed between IWB and OS, shame, and guilt. Inverse associations were observed between IWB and role modeling positive body image and authentic pride. OS were positively linked to all body and fitness-related self-conscious emotion variables and to role modeling positive body image. The indirect effect of IWB on OS via shame was significant (β = .16, 95% CI .07 to .26). The indirect effect via role modeling positive body image was nonsignificant (β = -.01, 95% CI -.02 to .00).

CONCLUSIONS

Findings contribute to the growing scholarship recognizing orthorexia's links with harmful diet culture among yoga professionals, potentially reflecting regulating internal body- and fitness-related shame stemming from IWB and perceptions of modeling positive body image for students and clients who may be at risk. Results call for increased collaborative outreach efforts to identify appropriate interventions to effectively target these public health concerns within the broader yoga community.

Multidimensional perfectionism and orthorexia: a systematic review and meta-analysis

PURPOSE

We provide the first systematic review and meta-analysis of research examining multidimensional perfectionism-perfectionistic strivings and perfectionistic concerns-and orthorexia.

METHODS

The systematic review and meta-analysis was pre-registered and conducted using a search of PsycINFO, MEDLINE, Education Abstracts, and Oxford Academic, and ScienceDirect up to April 2023. PRISMA guidelines were also followed. Meta-analysis using random-effects models was used to derive independent and unique effects of perfectionism, as well as total unique effects (TUE), and relative weights. Moderation of effects were examined for age, gender, domain, perfectionism and orthorexia instruments, and methodological quality.

RESULTS

Eighteen studies, including 19 samples (n = 7064), met the eligibility criteria with 12 of these studies (with 13 samples; n = 4984) providing sufficient information for meta-analysis. Meta-analysis revealed that perfectionistic strivings (r+  = 0.27, 95% CI [0.21, 0.32]) and perfectionistic concerns (r+  = 0.25, 95% CI [0.18, 0.31]) had positive relationships with orthorexia. After controlling for the relationship between perfectionism dimensions, only perfectionistic strivings predicted orthorexia which also contributed marginally more to an overall positive total unique effect of perfectionism (TUE = 0.35; 95% CI [0.28, 0.42]). There was tentative evidence that orthorexia instrument moderated the perfectionistic concerns-orthorexia relationship.

DISCUSSION

Research has generally found that both dimensions of perfectionism are positively related to orthorexia. More high-quality research is needed to examine explanatory mechanisms while also gathering further evidence on differences in findings due to how orthorexia is measured, as well as other possible moderating factors.

LEVEL OF EVIDENCE

Level 1, systematic review and meta-analysis.

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.

Effectiveness of Yoga as a Complementary Therapy for Anorexia Nervosa: A Systematic Review

Anorexia nervosa (AN) is a severe psychiatric condition associated with high disability and mortality. The purpose of the present manuscript is to critically summarize evidence about the effectiveness of yoga for this condition. A bibliographic search was conducted in the main database sources (PubMed, Embase, and Scopus). Articles in English about the effectiveness of yoga in AN were included. Two hundred thirty-three articles were initially identified and 5 articles were included in the present review. With the exception of one study, all had several methodological limitations such as the presence of confounding factors (e.g., psychiatric comorbidity) or a too limited sample of patients. However, globally yoga seems to ameliorate AN symptoms, especially those regarding emotional dysregulation. Yoga is a candidate complementary treatment for the management of AN, but more randomized controlled studies with larger samples and limited bias are necessary to draw robust conclusions. It would be also interesting to verify in comparative trials the effectiveness of yoga with respect to other treatments such as psychotherapy or the administration of pharmacological compounds. Finally, the practice should be modified adapting to the specific needs of this type of patient.

Intra- and Interpersonal Dimensions of Orthorexia: Preliminary Development and Validation of an Intra- and Interpersonal Effects Scale for Orthorexia

Orthorexia nervosa (ON) is a disorder characterized by dietary restrictions and an obsessive focus on "healthy" eating. The present study analyzes two aspects of ON. One related to the inner experiences of the individual (intrapersonal). The other concerns the impact of ON on interpersonal relationships (interpersonal). The developed scale was named the Intra- and Interpersonal Effects Scale of Orthorexia (IIESO). The analysis showed an average correlation between the INTER and INTRA factors (r = 0.46). Both the INTER and INTRA scales correlated strongly with both subscales of the TOS but weakly with the ORTO-R score. Females obtained higher scores on the INTER scale (p < 0.01), while no differences were shown for the INTRA subscale or the overall scale score (p < 0.01). Subjects using supplements had higher mean scores on the INTER and INTRA subscales and for the total score. Among the analyzed results, the greatest strength effect was shown for the total score on the IIESO scale (INTER+INTRA) and the TOS scale. The questionnaires used to date have not distinguished between behaviors from interpersonal and intrapersonal perspectives. Research on these dimensions could expand our knowledge of the disorder and refine diagnostic criteria.

A longitudinal study of perfectionism and orthorexia in exercisers

Research suggests that trait perfectionism and perfectionistic self-presentation are related to orthorexia - a pathological obsession with correct nutrition. However, no studies have examined these relationships over time or compared the influence of the two aspects of perfectionism on orthorexia. In the present study we sought to address these two issues. Gym members who engaged in high degrees of exercise were recruited via social media platforms. They completed an online questionnaire that included the Multidimensional Perfectionism Scale-Short Form, Perfectionistic Self-Presentation Scale, and the Eating Habits Questionnaire on two occasions: 177 participants (Mean age = 31.6 years) initially completed the questionnaire and 82 completed the questionnaire six weeks later. A series of multiple regression analyses revealed that (i) trait perfectionism predicted an increase in orthorexia symptomatology over time with socially prescribed perfectionism and other-oriented perfectionism unique predictors of orthorexia, (ii) perfectionistic self-presentation predicted orthorexia over time with nondisplay of imperfection a unique predictor of orthorexia, and (iii) when considered alongside each other, only trait dimensions of perfectionism were unique predictors of orthorexia. The present study provides further evidence that perfectionism is related to orthorexia. In addition, the study also provides preliminary evidence that more engrained trait aspects of perfectionism are more predictive of orthorexia over time than the self-presentational aspects of perfectionism.

Effect of Yoga involvement on mental health in times of crisis: A cross-sectional study

Background

Yoga involvement can be understood as a degree of immersion in the philosophical/spiritual teachings of Yoga. Previous research has shown a positive association between Yoga involvement and mental health. This study further investigates the effect of Yoga involvement on several parameters of psychological well-being and distress amidst a global crisis precipitated by the COVID-19 pandemic.

Methods

A total sample of 246 participants (216 females; 118 Yoga versus 128 age-matched Pilates practitioners) were included in the study. Via an online-survey the following questionnaires were completed: the WHO-Five Well-Being Index, the Multidimensional Inventory for Religious/Spiritual Well-Being short version, the Leipzig Short Scale of Sense of Coherence, the Brief Symptom Inventory and the Yoga Immersion Scale which was adapted for the control group to Pilates Immersion Scale.

Results

When controlling for occupation and psychiatric disorder, involvement in general was higher for Yoga practitioners than for Pilates controls. Furthermore, Yoga practice was associated with increased religious/spiritual well-being and decreased sense of coherence, but neither with psychological well-being nor with psychological distress. Involvement, in general, positively predicted psychological well-being, religious/spiritual well-being and sense of coherence, but there was no connection with psychological distress. Lastly, involvement mediated the positive relationship between Yoga practice and religious/spiritual well-being and suppressed the negative effect of Yoga practice on sense of coherence.

Conclusion

Our findings suggest that involvement in a certain relaxation practice has a positive impact and might be a key component in understanding Yoga's influence on mental health. Further randomized controlled research, including clinical groups, is necessary to explain how involvement changes and how it effects well-being more specifically.

What do Italian healthcare professionals think about orthorexia nervosa? Results from a multicenter survey

PURPOSE

Orthorexia nervosa (ON) is an obsession for healthy and proper nutrition. Diagnostic criteria for ON are lacking and the psychopathology of ON is still a matter of debate in the clinical and scientific community. Our aim was to better understand the Italian clinical and scientific community's opinion about ON.

METHODS

Anonymous online survey for Italian healthcare professionals, implemented with the REDCap platform and spread through a multicenter collaboration. Information was gathered about socio-demographic, educational and occupational features, as well as about experience in the diagnosis and treatment of EDs. The main part of the survey focused on ON and its features, classification and sociocultural correlates.

RESULTS

The survey was completed by 343 participants. Most responders (68.2%) considered ON as a variant of Eating Disorders (EDs), and 58.6% a possible prodromal phase or evolution of Anorexia Nervosa (AN). Most participants (68.5%) thought the next DSM should include a specific diagnostic category for ON, preferably in the EDs macro-category (82.1%). Moreover, 77.3% of responders thought that ON deserves more attention on behalf of researchers and clinicians, and that its treatment should be similar to that for EDs (60.9%). Participants thinking that ON should have its own diagnostic category in the next DSM edition had greater odds of being younger (p = 0.004) and of considering ON a prodromic phase of another ED, such as AN (p = 0.039).

DISCUSSION

Our survey suggests that the scientific community still seems split between those who consider ON as a separate disorder and those who do not. More research is still needed to better understand the construct of ON and its relationship with EDs; disadvantages and advantages of giving ON its own diagnosis should be balanced.

LEVEL OF EVIDENCE

V (descriptive cohort study).

Orthorexia nervosa and eating disorder behaviors: A systematic review of the literature

BACKGROUND

Orthorexia nervosa (ON) involves obsessive thoughts about healthy eating and distress related to this obsession. There is still dispute over whether ON should be considered on the obsessive-compulsive spectrum, the eating disorder (ED) spectrum, or as its own disorder. Based on current research, orthorexic behaviors seem to be closely related to eating disorder behaviors. However, given the range of instruments used to measure ED and ON, and the lack of consistency in the specific ED domains explored, a review of the current literature is warranted.

OBJECTIVE

The objective of this study was to review the literature relating ON and ED symptoms in an effort to understand the nature of their relationship, and to identify ED symptom domains most closely related to ON.

METHODS

A search was conducted on PubMed, Science Direct, and Web of Science using the term "orthorexia" and at least one of the following: "anorexia nervosa," "bulimia nervosa," "eating disorder," "arfid," "restrictive," "body image," "weight concern," "shape concern." After exclusion criteria were applied, 42 articles were included in the review.

RESULTS

The results indicated that ON is consistently related to both trait and disordered restrictive eating symptoms of anorexia nervosa, and weight control motivations for food choice. However, ON was less consistently related to binge-spectrum eating disorder symptoms, emotional eating, uncontrolled eating, or body dissatisfaction/shape and weight concerns.

CONCLUSION

The finding that ON symptoms are related to restraint and weight loss efforts, but not to body dissatisfaction or dysregulated eating suggests that ON may represent a distinct ED.

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 vs. healthy orthorexia: relationships with disordered eating, eating behavior, and healthy lifestyle choices

BACKGROUND

Orthorexia nervosa (OrNe) is a pattern of disordered eating behavior characterized by excessive preoccupation with overvalued ideas about healthy eating. Healthy orthorexia (HeOr) refers to a non-pathological interest in healthy eating and nutrition. Despite converging evidence that OrNe is correlated with measures of psychopathology and personality traits, there is relatively little empirical data relating OrNe and HeOr to eating and health-promoting behavior.

METHODS

Aim 1: exploratory structural equation modeling was used to evaluate the factor structure of an English-language version of the Teruel Orthorexia Scale, the only measure of OrNe that also assesses HeOr in two samples (Yoga practitioners, N = 469, and Mechanical Turk workers, N = 453). Aim 2: conducted in the Mechanical Turk sample, partial correlation and linear regression analyses were used to evaluate the relationships of OrNe and HeOr with other symptoms of, and clinical impairment from, disordered eating, food choices, diet quality, body mass index (BMI), nutrition knowledge, alcohol/tobacco/vaping use, and sedentary behavior.

RESULTS

The two-factor structure of the TOS was replicated. HeOr and OrNe had opposing relationships with measures of disordered eating behavior and distress, food choices, diet quality, and nutrition knowledge. HeOr was negatively related to BMI, whereas OrNe was positively related to substance use and sedentary behavior.

CONCLUSIONS

OrNe and HeOr are distinct latent constructs, with the latter reflecting non-pathological behavior. Only OrNe is related to elevated disordered eating and clinical impairment. Despite involving obsessions and compulsions related to healthy eating, OrNe was associated with relatively unhealthy eating and other lifestyle behaviors.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Internalized weight stigma and intuitive eating among stressed adults during a mindful yoga intervention: associations with changes in mindfulness and self-compassion

Purpose

Internalized weight stigma (IWS) is common in the United States of America across body weight categories, and is implicated in the development of distress and unhealthy eating behaviors (e.g. overeating, disordered eating) that can foster poor cardiometabolic health. While emerging intervention research shows early promise in reducing IWS, long-term efficacy is unclear and novel strategies remain needed. This analysis examined whether participation in a mindful yoga intervention was associated with reduced IWS and increased intuitive eating, an adaptive eating behavior, and whether these changes correlated with each other or with changes in mindfulness and self-compassion.

Methods

Participants were stressed adults with low fruit and vegetable intake (N = 78, 64.1% White, M. Body Mass Index  25.59 ± 4.45) enrolled in a parent clinical trial of a 12-week mindful yoga intervention. Validated self-report measures of IWS, intuitive eating, mindfulness, and self-compassion were administered at pre-treatment, mid-treatment (8 weeks), post-treatment (12 weeks), and 4-month follow-up (24 weeks).

Results

Linear mixed modeling revealed significant improvements in IWS and intuitive eating across the four timepoints (p < .001). Reduced IWS correlated with increased intuitive eating pre- to post-treatment (p = .01). Improved self-compassion and mindfulness correlated with intuitive eating (both p = . 04), but not IWS (p = .74 and p = .56, respectively).

Conclusion

This study offers preliminary support for the hypothesis that mindful yoga may promote intuitive eating and reduce IWS among stressed adults with poor diet, and suggests that changes in these factors may co-occur over time. Further investigation with controlled designs is necessary to better understand the temporality and causality of these relationships.Trial registration: ClinicalTrials.gov identifier: NCT02098018.

Personality Profile in Orthorexia Nervosa and Healthy Orthorexia

Little is known about orthorexia in both its pathological (orthorexia nervosa, OrNe) and adaptive (healthy orthorexia, HeOr) forms. To date, few studies have been carried out to analyze the personality profile associated with orthorexia, and the results have been contradictory. The aim of the present study was to explore the characteristic pathological personality traits associated with OrNe and HeOr. A total of 297 participants (M_age = 30.8 years; 94.6% women) from the general population completed the Teruel Orthorexia Scale (TOS) and Personality Inventory for DSM-5-Short Form (PID-5-SF) questionnaires. Results showed significant low-medium correlations between OrNe and the four personality factors (Negative Affectivity, Detachment, Disinhibition, and Psychoticism) (rs range [0.08, 0.36]). In the regression analysis, the predictors of OrNe were Neuroticism and, to a lesser extent, Psychoticism. For HeOr, the associations were lower (rs range [−0.13, 0.05]) and negative, except Psychoticism. Only the relationship with Disinhibition was statistically significant, although after controlling for OrNe, Negative Affectivity and Antagonism also became significant. In the regression analysis, the predictors of HeOr were Disinhibition (negative direction) and Psychoticism (positive direction). The findings show that OrNe is associated with a pathological personality pattern characterized by difficulty in regulating emotions and negative affect (Negative Affectivity), as well as eccentricity, feeling special, and holding beliefs outside the norm (Psychoticism). However, HeOr seems to be related to the tendency toward high responsibility, self-control, the ability to maintain the focus of attention (low Disinhibition), and Psychoticism. Future studies should confirm whether this combination is a key component underlying the development and maintenance of orthorexia.

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.