The stigma of clean dieting and orthorexia nervosa

Healthy orthorexia, orthorexia nervosa, and personality traits in a community sample in Turkey

OBJECTIVE

Orthorexia nervosa is an eating disorder characterized by a rigid preoccupation with a perceived healthy diet. However, little is known about healthy orthorexia compared to orthorexia nervosa. The current study examined the relationship between healthy orthorexia and orthorexia nervosa and personality traits in a Turkish sample.

METHODS

Three hundred fifty participants from a community sample aged 18-65 were included in the study. Participants completed a sociodemographic data collection form, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Teruel Orthorexia Scale (TOS), and the 10-Item Personality Inventory (TIPI).

RESULTS

The frequency of healthy orthorexia was 32.3% and orthorexia nervosa was 10.2%. There were no differences between genders regarding healthy orthorexia and orthorexia nervosa scores. Healthy orthorexia symptoms were negatively correlated with depression and anxiety (r = -0.11 and r = -0.20, respectively, P < .05), while they were positively correlated with agreeableness (r = 0.17), conscientiousness (r = 0.14), and extraversion (r = 0.15). Orthorexia nervosa symptoms were positively associated with anxiety (r = 0.12), depression (r = 0.10), and healthy orthorexia (r = 0.55). Hierarchical regression analyses demonstrated that depression was negatively associated with healthy orthorexia symptoms, explaining 4% of the variance. The agreeableness trait was positively associated with healthy orthorexia symptoms, explaining 4% of the variance. However, no specific personality trait was associated with orthorexia nervosa symptoms.

CONCLUSION

To our knowledge, the present study is the first to examine the relationships between personality traits, healthy orthorexia, and orthorexia nervosa symptoms in a Turkish sample. Sociocultural factors may be important for understanding orthorexia nervosa and healthy eating behaviors in this population.

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.

Eating Behaviors, Lifestyle, and Ischemic Stroke: A Lebanese Case-Control Study

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability on a global scale. Most clinicians tend to underestimate the importance of diet and inadequate or dysfunctional eating attitudes in patients with a complicated relationship with food. Concerned about the potential of an independent Lebanese approach, and also because prior international research has revealed a link between eating intake or choice and ischemic stroke risk, it was considered vital to broaden the scope of the literature and evaluate further the association of disordered eating attitudes and focus on the distinct relationship with food in the case of orthorexia nervosa (ON) in the Lebanese community. Consequently, the purpose of the present study is to investigate the potential association between pre-existing disordered eating attitudes, specifically ON, and ischemic stroke risk, with an emphasis on the evidence supporting a Mediterranean-style diet.

METHODS

This research is a case-control survey study involving 113 Lebanese individuals with ischemic stroke and 451 age-(within 5 years) and sex-matched controls recruited from several hospitals in Lebanon (April 2020-April 2021).

RESULTS

According to the findings of our first regression model, living 100 m from a crowded road (adjusted odds ratio [aOR]: 3.421, 95% confidence interval [CI]: 1.585-7.387), living 100 m from an electricity generator (aOR: 3.686, 95% CI: 1.681-8.085), higher waterpipe dependence (aOR: 1.204, 95% CI: 1.117-1.297), higher exposure to passive smoking (aOR: 2.651, 95% CI: 2.051-3.426), being married (aOR: 3.545, 95% CI: 1.297-9.689), having a low educational attainment (aOR: 0.239, 95% CI: 0.084-0.679), vigorous physical activity (aOR: 1.003, 95% CI: 1.001-1.006), and having more inappropriate eating (aOR: 1.040, 95% CI: 1.006-1.074) were all associated with higher odds of having ischemic stroke. Furthermore, atrial fibrillation (aOR: 2.945, 95% CI: 1.010-8.585), diabetes (aOR: 2.550, 95% CI: 1.169-5.561), heart diseases (aOR: 6.193, 95% CI: 2.196-17.463), and hypertension (aOR: 2.744, 95% CI: 1.049-7.180) were also linked to an increased risk of stroke. Moreover, having more orthorexia nervosa tendencies (aOR: 1.123, 95% CI: 1.021-1.235) was related to a higher odds of having an ischemic stroke, whereas better adherence to the MeD was significantly linked (aOR: 0.691, 95% CI: 0.583-0.819) to lower odds of ischemic stroke.

CONCLUSIONS

Ischemic stroke patients were more likely to have disordered eating attitudes and orthorexic behaviors. Furthermore, the MeD has been found to be beneficial in reducing ischemic stroke risk. Despite the study's focus, outdoor pollution, waterpipe dependence, and passive smoking were linked to ischemic stroke. In summary, this review suggests that improving one's nutritional status and making a few lifestyle changes are key stroke prevention and treatment methods.

College students' perceptions of individuals following popular diets and individuals with Orthorexia Nervosa

Dietary trends, such as "clean eating" and the ketogenic diet, are popular among young adults. However, very few studies have investigated perceptions of individuals who reportedly adhere to specific popular diets, despite research indicating that people ascribe more positive attributes to individuals described as healthy eaters. Given these diets' popularity, and the potential harm that comes from following them, it seems important to understand college students' perceptions of these eating patterns. This study investigated female undergraduates' (n = 463) perceptions of vignette characters described as adhering to specific dietary practices, including three popular diets (Clean Eating, Keto, and Intermittent Fasting), the rigid healthy eating pattern, Orthorexia nervosa (ON), and a nondieting control. Characters described as adhering to Clean Eating were viewed most positively, followed by individuals following the Ketogenic diet or nondieters. Characters following an Intermittent Fasting diet, and those with ON were viewed most negatively. Findings support the idea that perceptions of individuals are associated with their adherence to specific popular diets. Future research should investigate potential links among dieting behavior and impression management.

Traditional, Vegetarian, or Low FODMAP Diets and Their Relation to Symptoms of Eating Disorders: A Cross-Sectional Study among Young Women in Poland

Background: Eating disorders (EDs) are an ever-growing problem, seen most commonly among young women. People with EDs are particularly predisposed to restrictive eating patterns. Diet therapy for many diseases involves the elimination of certain food groups, and the use of restrictive diets in people with EDs may indirectly influence the recurrence of the disorder. The aim of this study was to assess the prevalence of the possible presence of EDs and orthorexia symptoms among young women following a traditional, alternative (vegetarian), or therapeutic (low FODMAP) diet. Methods: The analysis was based on 420 responses from female respondents aged 19 to 30 years. The research tool consisted of questionnaires to assess the possible presence of EDs (SCOFF), cognitive-behavioral aspects of eating (TFEQ-13), and the presence of orthorexia symptoms (ORTO-15). Results: Uncontrolled and emotional eating was least common in women on a vegetarian diet (5.6 ± 3.7; 3.5 ± 2.7; p < 0.05). Women on a low FODMAP diet were most prevalent with symptoms of orthorexia (n = 37, 47.4%; p < 0.05). Conclusions: It seems important to perform screening tests for eating disorders before recommending diet therapy in order to individually adjust the dietary regimen and refer patients to appropriate specialists.

A comparative study of orthorexia between premenopausal, perimenopausal, and postmenopausal women

PURPOSE

Studies suggested that menopause is a period of vulnerability for disordered eating behaviors, but whether menopause could be linked to orthorexia nervosa (ON) remains unexplored.

METHODS

A sample composed of 709 women aged between 30 and 71 years (mean age = 43.08 years, SD = 9.24) answered self-administered questionnaires assessing ON (Düsseldorfer Orthorexia Skala, DOS), body image, self-esteem, and psychopathological symptoms. The sample included a Premenopause group of 441 women reporting regular menses, a Perimenopause group of 94 women reporting the recent onset of amenorrhea or menstrual irregularities, and a Postmenopause group of 174 women reporting amenorrhea of natural onset for more than 12 months.

RESULTS

Group comparison using analysis of covariance with age as covariate showed that ON scores were statistically higher in the two groups of participants dealing with menopause (Peri- and Postmenopause) when compared with women not yet concerned by menopause (Premenopause). A Kendall's tau-b correlation performed between the menopausal status (Pre, Peri, or Postmenopause) and DOS categories (No ON; At risk of ON; Presence of ON) showed a weak but statistically significant positive correlation between the menopausal group and DOS categories (tau-b = 0.136, p < 0.001). In addition, Fisher's exact tests indicated that the percentages of participants in the "At risk of ON" and "Presence of ON" categories were statistically higher in the Postmenopause group in comparison with the Premenopause group (p < 0.001). Depressive symptoms were statistically higher in the Peri- and Post-groups, while anxiety symptoms were stronger in the Peri-group when compared with the Pre-group.

CONCLUSIONS

This study shows an increase of ON in women concerned with menopause, suggesting the existence of a relationship between menopause and ON. Further studies are necessary to identify factors involved in this association.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, level V.

Digging up the dirt on "clean" dietary labels: Public health considerations and opportunities for increased Federal oversight

BACKGROUND

"Clean" dietary labels are often viewed by consumers as referencing products that are minimally processed, without additives, preservatives, artificial colors, or ingredients, but may also be interpreted as vegan, gluten-free, dairy-free, "real," or "natural." Although the "clean" diet trend continues to grow in popularity, there is a lack of consensus regarding the definition and use of this terminology with a corresponding lack of regulation for such labels in the United States.

METHOD

This multidisciplinary scoping review examines the public health implications of the "clean" label trend and the legal and policy landscape for regulation. We report on findings from case law and legal research generated through the Westlaw database and from the U.S. Food and Drug Administration (FDA) enforcement actions and website documents to discuss options for federal- and state-level intervention to mitigate harm.

RESULTS

One feasible avenue for change is for the FDA to provide industry guidance, disseminate public statements to debunk myths, and enforce labeling statutes to police deceptive "clean" labeling claims. We also suggest consumer-protection litigation and state-level litigation via attorneys general as alternative actions to combat the abundant misinformation associated with "clean" diets and labels.

DISCUSSION

Although the FDA has taken some enforcement actions, these efforts are insufficient given the proliferation of "clean" label products in the marketplace and the potential for adverse impacts on public health including increased risk for disordered eating. The current unregulated, undefined landscape for "clean" dietary labels thus requires urgent action by federal authorities and state attorneys general.

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.

Personality profiles in young adults with orthorexic eating behaviors

PURPOSE

Orthorexia nervosa (ON), defined as an excessive preoccupation with healthy eating, has gained more interest in the literature over these past few years. However, little is known about its risk and protective factors, in particular with regards to personality.

METHODS

A total of 3235 college students (10.32% men, 89.67% women) with a mean age of 21.13 (SD = 2.23) answered self-administered questionnaires assessing ON, psychopathological symptoms, and personality disorders including schizotypal, borderline, paranoid, obsessive-compulsive, and narcissistic personality. A subsample of 106 participants (91.51% women, mean age = 20.91, SD = 2.31) was selected based on the DOS cutoff score, and was then considered as the "orthorexic subsample".

RESULTS

Hierarchical cluster analysis was performed in the orthorexic subsample and led to the identification of four groups: 1-a cluster with a low level of traits (L); 2-a cluster with moderate traits and low narcissistic traits (MD); 3-a cluster with a low level of traits and moderate narcissistic traits (MN); 4-a cluster with high paranoid and narcissistic traits (PN) and a moderate level of schizotypal and borderline traits. Levels of anxiety, obsessional-compulsive, and depressive symptoms were higher in the PN and MD clusters than in the L and MN clusters. Social phobia was higher and self-esteem lower in the MD cluster and hypochondriasis was higher in the PN and MN clusters.

CONCLUSIONS

This study suggests that ON can be associated with different personality profiles, some of them displaying significant psychopathological levels. It also emphasizes the importance of taking into account personality disorder traits of young adults with orthorexic eating behaviors.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, Level V.

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.

Orthorexia tendency and social media addiction among candidate doctors and nurses

PURPOSE

To determine orthorexia tendency and social media addiction among candidate doctors and nurses.

DESIGN AND METHODS

This was a cross-sectional study conducted in 2019 with 969 candidate doctors and nurses training in a peripheral public university. Data were collected via ORTO-15 and Social Media addiction scales and analyzed by using percentage, mean, χ ² test, and binary logistic regression.

FINDINGS

Of the study population, 78.8% were social media addicts and 62.2% had orthorexic tendencies. The ratio of orthorexic tendency was 31.0% among high/very high addicts (p < 0.05).

PRACTICE IMPLICATIONS

In preclinical years, both groups should be screened for early detection of orthorexia tendency and social media addiction. A combination of therapy and nutrition education should be used and social media literacy should be promoted to raise awareness of orthorexia.

Prevalence and Characteristics of Orthorectic Disorders in Adolescence and Young People: Polish Preliminary Studies

The aim of this work was to assess orthorectic behaviors among young people and to evaluate their attitudes towards caring for their health. The study was conducted in 2019 on a group of 538 respondents aged 16–35. After analysis, 65 questionnaires were eliminated from further research, and the assessment of orthorectic disorders was performed using a method based on the modified ORTO-15 questionnaire on a group of 473 respondents. A large percentage of them exhibited an increased risk of orthorectic behaviors (32.8), which was higher among women than men (34.7% and 28.2%, respectively). People with higher risks of orthorectic disorders significantly more often reduced their consumption of foods high in fats and sugars. Attitudes of people with orthorectic disorders towards health care proved neutral, with a tendency to be positive. Nutritional behaviors observed in the studied group show some irregularities, which indicates the need for preventive and educational measures aimed at increasing awareness of the role of proper nutrition among young people. The obtained results may be the basis for further research on ON symptoms. One of the major areas of future research would be to create a reliable diagnostic tool which would allow for distinguishing between orthorexia and overdiagnosis.

Is orthorexia nervosa a healthy way of being or a mental health disorder? Commentary on He et al. (2020)

Orthorexia nervosa is a new syndrome that has seen a marked increase in research in the past decade. Very high prevalence estimates in non-clinical populations have fuelled the debate as to whether it is a disorder in its own right, or only a problem when occurring in the context of another mental health or eating disorder. More recent assessment instruments have gone some way to address this issue. However, He et al.'s (2020, International Journal of Eating Disorder) study in older East Asian persons was not supportive of orthorexia nervosa as a disorder. Rather, people with orthorexia nervosa had better physical and mental health and lower or similar levels of eating disorder features such as body dissatisfaction when compared with people who did not have orthorexia nervosa. Albeit that selection bias in participant recruitment may in part explain their findings, the status of orthorexia nervosa is unresolved. Further studies need to employ appropriate instruments that measure psychopathology and function more broadly and investigate people with orthorexia nervosa symptoms in representative populations with longitudinal designs. The last is critical, as the most compelling evidence supporting a disorder is to find an adverse health impact over time that can be avoided by appropriate intervention.

Assessing Orthorexia Nervosa: Validation of the Polish Version of the Eating Habits Questionnaire in a General Population Sample

Extreme focus on healthy eating, called orthorexia nervosa (ON), was assessed using a 21-item Eating Habits Questionnaire (EHQ). The present study aimed to validate the Polish version of the EHQ in a general population sample. Nine hundred sixty-seven women (59%) and men participated in the present study. Data was obtained from an internet-administered survey. Exploratory factor analysis with the first split sample (n = 502) produced a three-factor solution accounting for 47% of the variance. In confirmatory factor analysis with the second split sample (n = 465), the three-factor structure showed satisfactory goodness-of-fit (comparative fit index (CFI) = 0.99, root mean square error of approximation (RMSEA) = 0.008). Reliability analysis for the Polish version of the EHQ across the whole questionnaire showed strong internal consistency (α = 0.88, intraclass correlation coefficient (ICC) = 0.86). The internal consistency, measured by Cronbach's alpha coefficients, for the EHQ subscales were 0.85 (knowledge), 0.81 (problems), and 0.81 (feelings and behaviors). Total EHQ score was positively correlated with its three subscales, cognitive restraint, uncontrolled eating, and emotional eating, and was negatively correlated with body mass index (BMI). The Polish version of the EHQ is a reliable questionnaire that can be used with confidence to better assess ON in a general population sample.

What are people's experiences of orthorexia nervosa? A qualitative study of online blogs

PURPOSE

Orthorexia nervosa (ON) is a proposed new eating disorder, used to describe a pathological obsession with healthy or 'clean' eating. Although some quantitative research has been carried out in ON, very little qualitative work has been published to date to explore individual experiences of ON. Thus, this study aimed to explore individuals' personal experiences of ON, as described in online blogs.

METHODS

Fifteen women bloggers, who self-identified as having ON, consented for their blog entries to be analysed in this study. Forty pre-existing blog entries describing the first-person experiences of ON were analysed using thematic analysis.

RESULTS

Three key themes were discussed: (1) initial motivations for a healthier lifestyle, (2) fuelling the problem-social influences, and: (3) when healthy becomes unhealthy. Bloggers described the role of social messages, comparison with others around ideas of 'healthiness', as well as confusion around diagnosis as factors influencing their disordered eating. They also described the exacerbating impact of perfectionism and perceived control, as well as a confirmatory cycle of fear and avoidance. For some bloggers, increased physical symptoms in response to feared foods provided confirmation for these fears, further exacerbating food avoidance.

CONCLUSION

Whilst the debate around the diagnosis of ON continues, these bloggers' accounts suggest that ON is experienced as a legitimate, debilitating disorder, worthy of clinical and research investigation. This study provides evidence of some of the potential triggers and maintaining factors for this disordered eating style.

LEVEL OF EVIDENCE

Level V, qualitative descriptive study.

Perceived need for treatment associated with orthorexia nervosa symptoms

Orthorexia Nervosa is characterised by a pathological fixation on food purity and nutrition, coupled with a severely restricted diet and avoidance of food believed to be unhealthy. Little is known about the risk factors associated with the condition or if the condition should be treated in a similar way to other eating disorders or whether distinct interventions are required. This study aimed to identify (1) putative variables of the need for treatment in those with orthorexia symptomology and (2) assess whether comorbid psychological symptomologies were associated with orthorexia nervosa. An online cross-sectional self-report survey was developed and the data of 130 participants analysed using regression analyses. As predicted, individuals with higher levels of orthorexic symptomology, eating disorder symptomology and those who identified their healthy eating as problematic were significantly more likely to have a perceived need for treatment, however those who self-identified as having a current or past eating disorder were not. Orthorexic symptomatology was significantly correlated with eating disorder symptomatology, obsessive-compulsive symptoms, anxiety, and depression, however in the regression analysis, eating disorder symptomatology was the only significant variable. These findings highlight the need to consider orthorexic symptoms in people with eating disorders and that this inter-relationship and the ego-syntonicity of symptoms may reduce help-seeking.

Perspective: Classifying Orthorexia Nervosa as a New Mental Illness-Much Discussion, Little Evidence

Significant prevalence rates of pathological healthful eating and its extreme form, orthorexia nervosa (ON), the pathological obsession with healthy eating, have led to increased efforts to understand this phenomenon's clinical relevance. This narrative review qualitatively summarizes existing evidence on the (psycho-)pathology and consequences of ON and offers an interpretation within the frame of existing theories and models of psychiatric disease. Adding to the controversy in the field of ON, this review offers important critiques and identifies gaps in our current understanding of ON as a (distinct) mental illness.

"It's Healthy Because It's Natural." Perceptions of "Clean" Eating among U.S. Adolescents and Emerging Adults

Definitions for the culturally trendy "clean" eating phenomenon vary: whereas some characterize it as natural and healthy, others adopt more restrictive, moralizing, and affectively-laden definitions that may reflect disordered eating. We examined levels of familiarity with "clean" eating, sources of information, and perceptions of this dietary trend among a large, diverse sample of U.S. adolescents and emerging adults recruited from the National MyVoice Text Message Cohort (n = 1266; ages 14-24 years). Participants answered five questions assessing knowledge of "clean" eating, definitions, perceived healthiness vs. harm, and willingness to adopt "clean" eating, and responses were coded by three trained researchers. Results indicate that 55% of respondents had previously heard of "clean" eating, most commonly through social media, other online sources, and peers. Definitions were heterogeneous, with 40% offering "non-processed" or "whole foods" and 13% noting "non-GMO" or "organic" components. Few respondents (0.6%) expressed outright skepticism about "clean" eating, but many (30%) identified dietary avoidance and restriction as part of the definition. Overall, 71% characterized "clean" eating as a healthy approach, whereas 6% flagged it as "unhealthy", and 18% noted elements of both healthfulness and harm. Notably, 41% reported they "probably would" try "clean" eating themselves, with greater willingness to try "clean" eating among cisgender women. Present findings highlight high levels of awareness and positive attitudes toward "clean" eating among young people in the U.S., with little recognition of the potential risks of dietary restriction. Further research should examine actual dietary behaviors to clarify potential risks of "clean" eating and related trends and thus inform strategies for eating disorder prevention.

The Social Construction of a Concept-Orthorexia Nervosa: Morality Narratives and Psycho-Politics

Our article explores orthorexia nervosa (ON)-an extreme fixation with healthy eating-from a social construction perspective. Interviews with people self-identified as "obsessed" with healthy eating or having ON ("Identifiers") and nonmedical professionals working with ON ("Professionals") were comparatively analyzed, along with orthorexia threads from an eating disorder website ("Posters"). Participants made sense of and rationalized their attitudes and feelings concerning healthy eating and aligned themselves according to their interests. Identifiers and Posters applauded "healthy eating" and regarded consumption of "impure" foods as leading to ill-health. Some framed their dietary discipline within an ethically motivated lifestyle, while others were preoccupied with appearance or weight management. Professionals expressed concern for, and disapproval of, extreme views and behaviors in clients and parental and social influences supporting them. Debates surrounding orthorexic practices are tangled; some individuals need help, yet dangers lie in over medicalizing or "troubling" what may be a preferred lifestyle.

Is #cleaneating a healthy or harmful dietary strategy? Perceptions of clean eating and associations with disordered eating among young adults

BACKGROUND

Although "clean eating" is widely propagated through social media and anecdotal reports in the popular press, there is almost no scientific research on this potentially risky dietary strategy. The current investigation explored definitions and perceptions of "clean eating" and its associations with indicators of disordered eating among diverse U.S.-based undergraduates.

METHOD

Undergraduates (N = 148, M age = 19.41 years, 70.3% women) were asked to define "clean eating" via an open-ended question and then read vignettes featuring five "clean" diets, all of which caused mild functional impairment across multiple domains. Participants rated the extent to which they believed the diet was 1) "healthy," 2) reflective of "clean eating," and 3) likely to be adopted by them. Finally, participants completed questionnaires to assess body appearance evaluation, obsessive-compulsive symptoms, eating disorder symptoms, and symptoms of orthorexia nervosa.

RESULTS

Open-ended responses indicated that participants defined "clean eating" in varied but overwhelmingly positive terms. Repeated measures ANOVAs indicated that the "meal substitution" vignette was perceived as the least healthy, least "clean," and least likely to be adopted, whereas the "new" (balanced) diet vignette was rated the highest on these domains. Correlations among diet perceptions and indicators of disordered eating were positive and significant.

CONCLUSIONS

"Clean eating" is likely a heterogeneous phenomenon that is viewed favorably by U.S.-based college students even when it is linked with functional impairment and emotional distress. Ongoing examination of "clean eating" could clarify the potential benefits and risks posed by this dietary strategy and thus inform eating disorder prevention efforts.

A pilot study comparing the prevalence of orthorexia nervosa in regular students and those in University sports teams

PURPOSE

Orthorexia nervosa (ON) is a pattern of eating characterized by a pathological fixation on restricting foods based on their perceived health. Like many eating disorders, ON is thought to be more prevalent in athletes. This was a preliminary study to explore the prevalence of ON in University students to determine whether those who compete in University sports have higher orthorexic tendencies.

METHODS

116 male and female student athletes (age 21 ± 1 years) and 99 non-athlete controls (21 ± 2) from Universities in the North East of the UK completed the ORTO-15 test (≤ 40 being the cutoff) used to screen individuals for ON.

RESULTS

ON symptoms were high in all students (76%); there was no difference in ORTO-15 scores between the athletes (36.6 ± 3.9) and non-athlete controls (37.2 ± 3.8; P = 0.279). There was a difference in scores between those who completed ≥ 10 h of exercise per week (36.65 ± 4.38) and those who do ≤ 10 h a week (37.38 ± 3.65) (P = 0.008; ES = 0.43). ORTO-15 scores were not higher in athletes competing in aesthetic and weight dependent sports (P > 0.05).

CONCLUSIONS

Being a student athlete for a University sports team did not affect ON prevalence; however, there appears to be a greater risk for students in general, and for athletes who undertake high volumes of exercise. Nonetheless, the high prevalence of ON symptoms may be attributed to flaws in the ORTO-15 questionnaire, and therefore, future studies should focus on developing a more valid method for ON diagnosis.

LEVEL OF EVIDENCE

III, case-control study.

Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature

AIM

In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote health. The pursuit of an "extreme dietary purity" due to an exaggerated focus on food may lead to a disordered eating behavior called "orthorexia nervosa" (ON). ON raises a growing interest, but at present there is no universally shared definition of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related psychometric instruments and provides research propositions and framework for future analysis.

METHODS

The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last access on 07 August 2018), using "orthorexia", "orthorexia nervosa" and "obsessive healthy eating" as search terms, and filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from English. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed.

RESULTS

The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation. Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid, extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diagnostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c) psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia Self-Test developed by Bratman were the most used psychometric tools.

CONCLUSIONS

The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psychometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both research and clinical activity until now.

LEVEL OF EVIDENCE

Level V, narrative review.

Orthorexia nervosa: A behavioral complex or a psychological condition?

BACKGROUND AND AIMS

Numerous studies have provided evidence for orthorexia nervosa (ON), an eating pattern characterized by an almost manic obsession for and fixation on healthy eating, to be of epidemiological relevance. However, there is scientific debate on whether it is merely a behavioral or lifestyle phenomenon as compared to a mental disorder. Aim of this cross-sectional study was to explore whether ON is of epidemiological and clinical relevance, and whether ON can be distinguished from other mental health disorders and healthy lifestyle features.

METHODS

An online survey including a measure of orthorexic behaviors [Duesseldorf Orthorexia Scale (DOS)], well-being and distress, eating behaviors, pathological eating, anxiety and depression, addictive behaviors, obsessive-compulsive symptoms, personality, and health behaviors was completed by 713 subjects (79.8% women, 18-75 years, median age: 25 years).

RESULTS

Twenty-seven subjects (3.8%, 21 women) showed significant orthorexic eating (DOS ≥ 30). ON cases reported lower well-being, lower satisfaction with life, and higher current stress levels than non-ON cases. The highest percentage of variation in ON was explained by pathological eating (R2 = .380), followed by eating style, Mediterranean diet, compulsive symptoms, and subjective social status. Importantly, ON provided hardly any additional predictive value for well-being when also considering pathological eating.

DISCUSSION AND CONCLUSIONS

Our data confirmed the epidemiological and clinical relevance of orthorexic behaviors, but the strong conceptual overlap with other mental health problems and pathological eating raise initial doubts as to whether ON is a distinct mental health disorder category. This co-occurrence, unique symptoms, and underlying processes need further exploration by comparing ON cases with patients with other mental disorders.

The Dirt on Clean Eating: A Cross Sectional Analysis of Dietary Intake, Restrained Eating and Opinions about Clean Eating among Women

Clean eating is understood in broad terms to be an approach to eating which promotes the exclusion of processed foods. Social media and websites which promote clean eating are becoming increasingly popular as sources of nutrition information. Currently, there is a lack of knowledge regarding women's opinions about clean eating sites and their influence on eating behaviour. The aim of the present study was to investigate differences in dietary intake, dietary restraint and opinions about clean eating between women who had, and women who had never adhered to dietary advice from clean eating sites. Using a cross-sectional survey design, women (n = 762) ranging in age from 17⁻55 completed a self-report questionnaire on eating behaviour and beliefs about clean eating. Findings showed that 25.5% of the sample adhered to dietary advice from a clean eating site sometimes, often or very often. A significantly higher proportion of women who had adhered to dietary advice from clean eating sites met dietary guidelines for the consumption of fruit, meats and alternatives compared to women who had seldom or never adhered. Adherers also had significantly higher levels of restrained eating and were more positive about clean eating in general in comparison to those who seldom or never adhered. Results provide new information about exposure to clean eating sites and how they may influence women's eating practices. These preliminary findings suggest additional studies are required to better understand the influence of clean eating sites, particularly with regard to whether the information on such sites are from reputable sources and to what degree their recommendations may be problematic for individuals with eating concerns.

Food addiction among Spanish-speaking Latino/as residing in the United States

OBJECTIVE

This study examined food addiction, assessed by the Yale Food Addiction Scale (YFAS), and associated features among a participant group of Spanish-speaking Latino/as residing in the United States.

METHOD

Participants were 140 Spanish-speaking Latino/as (n = 77 female) who participated in an anonymous web-based survey. Mean age and body mass index (BMI) were 31.87 (SD = 9.12) years and 28.34 (SD = 7.14) kg/m², respectively. Participants completed a battery of established self-report measures assessing food addiction, binge-eating and eating-disorder psychopathology (Eating Disorder Examination-Questionnaire; EDE-Q), depressive symptoms (Patient Health Questionnaire-2; PHQ-2), and mental and physical functioning (MOS Short Form Health Survey; SF-12).

RESULTS

Of the 140 participants, 25 (17.9%) exceeded the clinical threshold of food addiction; no significant differences were observed between those categorized with versus without food addiction in age, sex, or race. YFAS scores were significantly correlated with EDE-Q overvaluation, EDE-Q dissatisfaction, BMI, SF-12, and the PHQ-2 (all p-values < .01). Categorical analyses revealed similar findings with participants categorized with clinical levels of food addiction being significantly more likely to meet clinical levels of overvaluation of weight/shape, and reporting significantly greater frequency of binge-eating, depressive symptoms, and poorer overall mental health than those not meeting food addiction criteria (all p-values < .05).

CONCLUSION

Our findings for this Spanish-speaking participant group are generally consistent with those reported in a meta-analysis of English-speaking individuals in suggesting that higher YFAS scores are associated with greater disturbances in eating psychopathology. Future studies should examine whether level of acculturation might contribute to differences in food addiction symptoms and associated psychopathology among Spanish-speaking Latino/as.