Orthorexia nervosa: a frequent eating disordered behavior in athletes

Orthorexic tendency and its association with weight control methods and dietary variety in Polish adults: a cross-sectional study

The methods for controlling weight play a central role in formally diagnosed eating disorders (EDs) and appear to be important in the context of other nonformally recognized disorders, such as orthorexia nervosa (ON). These methods also have an impact on eating behaviors, including dietary variety. Our study aimed to: (i) assess the intensity of ON tendency by sex and BMI groups, (ii) evaluate the associations between ON tendency, weight control methods, and dietary variety, and (iii) determine the extent to which weight control methods and dietary variety contribute to the ON tendency among both females and males. Data were gathered from a sample of 936 Polish adults (463 females and 473 males) through a cross-sectional quantitative study conducted in 2019. Participants were requested to complete the ORTO-6, the Weight Control Methods Scale, and the Food Intake Variety Questionnaire (FIVeQ). Multiple linear regression analysis was employed to evaluate associations between ON tendency, weight control methods, and dietary variety. Females exhibited a higher ON tendency than males (14.4 ± 3.4 vs. 13.5 ± 3.7, p < 0.001, d = 0.25). In the regression model, the higher ON tendency was predicted by more frequent use of weight control methods, such as restricting the amount of food consumed, using laxatives, and physical exercise among both females and males as well as following a starvation diet in females, and drinking teas to aid bowel movements among males. Moreover, the higher ON tendency was predicted by higher dietary variety, lower age in both sexes, and higher level of education among males. However, there were no differences in ON tendency across BMI groups. In conclusion, the findings showed that ON tendency was predicted by a higher frequency of weight control methods commonly used by individuals with anorexia nervosa (AN) and bulimia nervosa (BN). The resemblance to these two EDs is also suggested by the higher intensity of ON tendency among females and younger people. However, the prediction of ON tendency by dietary variety indicates that the obsessive preoccupation with healthy eating may not be advanced enough to observe a decrease in the dietary variety among these individuals.

Orthorexia and autism spectrum in University workers: relationship with gender, body mass index and dietary habits

OBJECTIVE

To date, few studies have investigated the relationship between autistic traits and emerging phenotypes of restrictive disorders, such as Orthorexia nervosa (ON). The aim of the present work was to investigate the relationship between ON symptoms and autistic traits in a population of University employees, focusing on the impact of gender, weight and type of diet.

METHODS

All academic and technical/administrative workers of University of Pisa were invited by mail to fulfil through an anonymous online form the Adult Autism Sub-threshold Spectrum (AdAS Spectrum) and the ORTO-R.

RESULTS

A total of 285 subjects filled out the questionnaires. Participants with significant autistic traits were included into the Broad autism phenotype (BAP) group, while others into the No BAP group. Subjects in the BAP group reported significantly higher ORTO-R scores than others, while no difference was reported for gender, work position, type of diet, age and BMI. Females showed significantly higher ORTO-R scores and lower BMI than males. Older subjects showed a higher BMI. No significant differences in ORTO-R scores were reported depending on type of diet and work position. A decision tree model, with ORTO-R score as dependent variable, revealed in the first step significantly higher ORTO-R scores in the BAP group than in the No BAP group, and in the second step significantly higher ORTO-R scores among females only in the No BAP group.

CONCLUSION

Our results further confirm the association between ON and autism spectrum, which seems to overcome the impact of gender in this population.

LEVEL OF EVIDENCE

Level V, descriptive study.

Orthorexia nervosa and executive dysfunction: symptomatology is related to difficulties with behavioral regulation

PURPOSE

This research explored whether orthorexia nervosa is associated with deficits in executive function.

METHODS

A non-clinical sample of participants (n = 405; 80% women, 53% white, mean age = 24, mean body mass index = 25) completed the Orthorexia Nervosa Inventory (ONI) and the Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A).

RESULTS

ONI scores were weakly to moderately correlated with all BRIEF-A scales (p < 0.001 for eight scales, p < 0.05 for one scale), exhibiting the greatest correlations with the scales assessing behavioral regulation: Emotional Control (r = 0.34), Inhibition (r = 0.30), Set Shifting (r = 0.25), and Self-Monitoring (r = 0.28). Hierarchical regression analyses revealed that eight of these nine relationships remained significant (p < 0.001 for five scales including all behavioral regulation scales, p < 0.01 for two scales, p < 0.05 for one scale) after controlling for demographic variables (e.g., gender, body mass index, age, education level) and diagnoses of an eating disorder, obsessive-compulsive disorder, attention deficit/hyperactivity disorder, autism, and learning disability.

CONCLUSION

These findings suggest that, despite unique manifestations, orthorexia and anorexia may possess an overlapping neuropsychological profile marked by deficits in executive function, which may negatively impact daily life.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

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.

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).

Sinful Foods: Measuring Implicit Associations Between Food Categories and Moral Attributes in Anorexic, Orthorexic, and Healthy Subjects

Recently, neurocognitive studies have shown that food categorization is sensitive to both the properties of the food stimuli (e.g., calorie content) and the individual characteristics of subjects (e.g., BMI, eating disorders) asked to categorize these stimuli. Furthermore, groups of patients with eating disorders (ED) were described as relying more on moral criteria to form food categories than were control subjects. The present studies built on these seminal articles and aimed to determine whether certain food properties might trigger moral categories preferentially in subjects suffering from ED and in the general population. Using a Go/No-Go Association Task, Study 1 focused on the extent to which food categories are laden with moral attributes in ED patients compared to control subjects. Study 2 was a follow-up with a different design (an Implicit Association Test), another food variable (calorie content), and two non-clinical subgroups (orthorexic and healthy control subjects). Results revealed for the first time implicit associations between food variables cueing for energy density and moral attributes in the general population, the population suffering from anorexia nervosa, and subjects suffering from disordered eating such as orthorexia nervosa. These findings suggest that moralization of food is a pervasive phenomenon that can be measured with methods reputed to be less vulnerable to self-presentation or social desirability biases.

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.

Use of online and paper-and-pencil questionnaires to assess the distribution of orthorexia nervosa, muscle dysmorphia and eating disorders among university students: can different approaches lead to different results?

PURPOSE

Administration of questionnaires to assess the diffusion of disordered eating behaviours via the web is becoming common today. The aim of this study is to assess whether two different approaches of administering a test to assess traits of eating disorders (EDs), orthorexia nervosa (ON) and muscle dysmorphia (MD) by email recruitment and online completion (web-based survey-WBS) and by in person recruitment and paper-and-pencil completion (paper-based survey-PBS), gives different results.

METHODS

During 2 consecutive academic years, a self-reported questionnaire consisting of questions about personal characteristics and three tests for the evaluation of ON (ORTO-15), MD (MDDI-ITA), and EDs (EAT-26) were administered to two groups of undergraduates, respectively, as a WBS and a PBS.

RESULTS

The WBS response rate was 6.7% (N = 137), and the PBS response rate was 86.5% (N = 372). The WBS group showed a statistically significant higher prevalence of students with eating disordered behaviours (21.2% vs 5.4%) and registered a higher mean score on the EAT-26 test (13.5 ± 11.1 vs 6.0 ± 8.0); no differences between the two groups emerged for ON and MD prevalence and test scores. Moreover, in the WBS group, the number of students with one or more tests with test scores above the cut-off values was significantly higher (46.0% vs 32.3%).

CONCLUSION

The choice of the approach to administer a questionnaire to assess the diffusion of EDs and related issues must take into account all the factors that can result in selection bias and that can affect the reliability of the results.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional survey.

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.

Orthorexia Nervosa in Adolescents and Young Adults: A Literature Review

Adolescents are a nutritionally vulnerable population; eating disorders are more common among adolescents and young adults. Orthorexia nervosa (ON) is a non-formally recognized condition characterized by an obsessive preoccupation with eating healthy and "pure" foods; the quality and not the quantity of food is pivotal in ON. ON is a complex entity which can be associated with severe diet restrictions, a negative impact on social relationships, and with physical and mental health conditions, including obsessive-compulsive disorder. In light of this, a literature review regarding the background, diagnosis, features, risk factors, interplay with the social media, and management of ON is presented in this article, with a focus on adolescents and young adults.

Validation of the Turkish version of the Orthorexia Nervosa Inventory (ONI) in an adult population: its association with psychometric properties

PURPOSE

To examine the reliability and validity of the Turkish version of the Orthorexia Nervosa Inventory (ONI) in a large adult population.

METHODS

Included in this cross-sectional study, were 710 individuals living in Turkey who were between 18 and 65 years of age. The individuals were reached via an online questionnaire that included their sociodemographic characteristics and the ONI and Eating Attitude Test-26 (EAT-26). Confirmatory factor analysis (CFA) was used to test the validity of the ONI. The ONI contains three sub-factors (behaviors, emotions, and impairments). Analyses were conducted using LISREL 8.80 for Windows and IBM SPSS Statistics for Windows 22.0.

RESULTS

The Cronbach's alpha coefficient was 0.91 for the ONI total factor scores and Cronbach alpha values for behaviors, impairments, and emotions were found to be 0.82, 0.84, and 0.81, respectively. The CFA performed supported the three-factor structure of the ONI obtained in the first sample. The minimum discrepancy per degree of freedom = 5.65 and the model generally fit well to the structure (RMSEA = 0.08, CFI = 0.94, NFI = 0.93, SRMR = 0.07, IFI = 0.94). A positive and moderate relationship (r = 0.42) was found between the ONI and EAT-26. A positive and low level (r = 0.16) correlation was found between the ONI and body mass index. There was no statistically significant difference between the ONI scores according to gender (p = 0.22).

CONCLUSION

The findings suggested that the Turkish version of the ONI is a valid and reliable scale for determining the tendency for ON in a Turkish adult population.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Contributing Factors to Low Energy Availability in Female Athletes: A Narrative Review of Energy Availability, Training Demands, Nutrition Barriers, Body Image, and Disordered Eating

Relative Energy Deficiency in sport is experiencing remarkable popularity of late, particularly among female athletes. This condition is underpinned by low energy availability, which is a byproduct of high energy expenditure, inadequate energy intake, or a combination of the two. Several contributing factors exist that may predispose an athlete to low energy availability, and therefore a holistic and comprehensive assessment may be required to identify the root causes. The focus of the current narrative review is to discuss the primary contributing factors as well as known risk factors for low energy availability among female athletes to help practitioners increase awareness on the topic and identify future areas of focus.

Adherence to Mediterranean Diet and Tendency to Orthorexia Nervosa in Professional Athletes

Among many lifestyle components that professional athletes have to follow, nutrition is gradually growing to be one of the key factors for achieving and maintaining optimal sport performance. The Mediterranean diet (MD) is recognized as one of the healthiest dietary patterns worldwide; however, data regarding adherence to the MD among professional athletes are still scarce. Moreover, with the imposed need for a healthy diet among professional athletes, orthorexia nervosa (ON) could become a rising issue. This cross-sectional study included 150 professional athletes and 150 matched recreational athletes from Croatia. Four questionnaires were used for the assessment: general information, a test for the diagnosis of ON (ORTO-15), the International Physical Activity Questionnaire (IPAQ) and the Mediterranean Diet Serving Score (MDSS). Significantly more professional athletes were adherent to the MD (p < 0.001) and had a tendency to ON (p < 0.001). Moreover, there was a significant negative correlation between the ORTO-15 score and the total MET min/week score (r = −0.524, p < 0.001) and a significant positive correlation between the MDSS score and the total MET min/week score in the professional athlete group (r = 0.478, p < 0.001). All of these results imply that professional athletes are more concentrated on their dietary patterns than recreational athletes, and that due to this dedication, they possibly have a higher adherence to the MD but also possibly a higher risk for developing ON. However, the association between ON and the MD should be further addressed in the future.

Investigating Orthorexia Nervosa With the ORTO-R in a Sample of University Students With or Without Subthreshold Autism Spectrum: Focus on Dietary Habits and Gender Differences

BACKGROUND

The aim of the present study was to investigate the presence of Orthorexia (ON) symptoms in a sample of University students with or without autistic traits (AT), specifically focusing on evaluating the role of gender and of dietary habits in the association between ON and autism spectrum.

METHODS

Subjects were requested to anonymously fill out the questionnaires through an online form.

RESULTS

Two thousand one hundred forty students participated in the study. Subjects with significant AT, measured by means of the Adult Autism Sub-threshold spectrum (AdAS Spectrum) reported significantly higher ON symptoms, as measured by ORTO-R scores, than subjects with low AT. Females and subjects following a vegetarian/vegan diet reported significantly higher ORTO-R scores than males and than subjects following an omnivorous diet, respectively. Significant positive correlations were found between ORTO-R and AdAS Spectrum scores. A decision tree model, with gender, type of diet and presence of high AT as independent variables and ORTO-R score as dependent variable, showed in the first step the presence of significantly higher ORTO-R scores among females than among males, and in the second step showed in both genders the presence of higher ORTO-R scores among subjects with high AT than in those with low AT. A significant interaction of gender and presence/absence of high AT was reported on ORTO-R score, with a higher increasing trend of ORTO-R score with the increase of AdAS Spectrum score among females than among males.

CONCLUSIONS

Our results further highlighted the association between AT and ON, in particular among females.

Examining Eating Attitudes and Behaviors in Collegiate Athletes, the Association Between Orthorexia Nervosa and Eating Disorders

Purpose: Orthorexia nervosa (Orthorexia) is an eating attitude and behavior associated with a fixation on healthy eating, while eating disorders (EDs) are clinically diagnosed psychiatric disorders associated with marked disturbances in eating that may cause impairment to psychosocial and physical health. The purpose of this study was to examine risk for Orthorexia and EDs in student-athletes across sex and sport type and determine the association between the two.

Methods: Student-athletes (n = 1,090; age: 19.6 ± 1.4 years; females = 756; males = 334) completed a survey including demographics, the ORTO-15 test (<40 and <35 threshold values), the Eating Attitudes Test-26 (EAT-26; >20 score), and additional questions about pathogenic behaviors to screen for EDs.

Results: Using a <40 threshold value for the ORTO-15, 67.9% were at risk for Orthorexia, a more restrictive threshold value of <35 determined 17.7% prevalence across student-athletes with significant differences across sex [ <40: χ(1,1,090)2 = 4.914, p = 0.027; <35: χ(1,1,090)2 = 5.923, p = 0.015). Overall, ED risk (EAT-26 and/or pathogenic behavior use) resulted in a 20.9% prevalence, with significant differences across sex (χ² = 11.360, p < 0.001) and sport-type category (χ² = 10.312, p = 0.035). Multiple logistic regressions indicated a significant association between EAT-26 subscales scores and Orthorexia, and between Orthorexia positivity, ORTO-15 scores, and risk for EDs.

Conclusions: Risk for Orthorexia and ED is present in collegiate student-athletes. While healthy and balanced eating is important, obsessive healthy eating fixations may increase the risk for EDs in athletes. More education and awareness are warranted to minimize the risk for Orthorexia and EDs in student-athletes.

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.

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.

Distinguishing orthorexic behaviors from eating disordered and obsessive-compulsive behaviors: a typological study

PURPOSE

This study represents a first attempt to explore the typology of young adults from a large non-clinical sample based on orthorexic (ON), eating disordered (ED) and obsessive-compulsive behaviors (OCD).

METHODS

921 individuals (Mage = 20.72, SD = 2.63), 84.6% women (n = 780) and 15.3% men (n = 141), completed a set of questionnaires assessing ON, ED, OCD behaviors and body image attitudes.

RESULTS

Cluster analysis based on ON, ED and OCD behaviors yielded four clearly distinct groups: a "Low" group that was below the sample mean for all behaviors, an "Orthorexic behaviors" group, an "Eating disordered behaviors" and an "Obsessive-compulsive behaviors" group with, respectively, mean scores on ON, ED and OCD behaviors that all were all above the sample means. Using ANOVA, these groups were compared regarding body image attitudes, self-reported BMI, age and educational level. Results show that all clusters differed from each other on virtually all variables. And compared with all other clusters, the "Orthorexic behaviors" cluster displayed greater scores in health and fitness-related aspects of body image. It also differed from the "Eating disordered behaviors" cluster, by its higher scores in appearance evaluation, body areas satisfaction and lower scores in self-classified weight.

CONCLUSION

This study demonstrates the existence of a distinct group of individuals with orthorexic behaviors and its positive body image attitudes and offers significant support for the possibility of ON being a distinct condition from ED and OCD.

LEVEL OF EVIDENCE

Level V, descriptive study.

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.

Pathways to orthorexia nervosa: a case series discussion

BACKGROUND

Orthorexia nervosa (ON) has gained increasing interest in the last 2 decades. Although a consensus on the diagnostic boundaries of ON has not yet been reached, there is some evidence for an overlap with eating disorders, obsessive-compulsive disorder, and psychotic disorder. Most of the knowledge about ON has emerged from studies of non-clinical and at-risk populations and is focused on differential diagnosis; therefore, further clinical studies are needed to better outline the ON phenomenon in a real-life setting.

OBJECTIVE

This case series aims at describing clinical cases that developed symptoms suggestive of ON after being diagnosed with a prior psychiatric disorder and then discussing them in light of possible clinical pathways.

METHODS

Four women consecutively admitted to an outpatient unit for the treatment of eating disorders were diagnosed with ON through a clinical interview, according to Dunn and Bratman's criteria and self-administered questionnaire assessment (ORTO-15), and were considered to be eligible for this case series study. Psychiatric anamnestic data were collected retrospectively.

RESULTS

The anamnesis revealed that all patients were previously diagnosed with a psychiatric disorder (i.e. obsessive-compulsive disorder, bulimia nervosa, illness anxiety disorder, and psychotic disorder) before developing ON.

CONCLUSION

Past literature focused on differential diagnosis between ON and other psychiatric disorders. This is the first description of clinical cases in a real-life setting that started with different psychiatric disorders and later developed symptoms suggestive of ON. These cases have generated a new research question on the possibility that different psychiatric disorders may associate with a later onset of ON.

LEVEL OF EVIDENCE

Level V, descriptive study.

Are orthorexia nervosa symptoms associated with deficits in inhibitory control?

PURPOSE

This study explored whether inhibitory control is associated with symptoms of orthorexia nervosa, a condition that involves substantial behavioral control in regard to healthy eating.

METHOD

Participants (50 women, 13 men) completed the Eating Habits Questionnaire as a measure of orthorexia symptomatology, along with computerized versions of the Go/No-Go Task, Flanker Task, and Stroop Task.

RESULTS

Orthorexia symptomatology did not correlate with either percent error or response time for any of the three tasks (all p's > 0.10).

CONCLUSION

These results suggest that orthorexia is not associated with deficits or other differences in inhibitory control.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

The experience of orthorexia from the perspective of recovered orthorexics

PURPOSE

Orthorexia is a proposed disorder that involves a pathological obsession with healthy eating. The condition has received much attention in popular media in recent years, but more empirical research is needed. Currently, orthorexia is an emerging construct with multiple proposed versions of diagnostic criteria, and there is confusion regarding the exact symptoms and pathology. This qualitative study aimed to explore the experiences of orthorexia from the perspective of recovered persons, as defined by Dunn and Bratman's 2016 criteria (Eat Behav 21:11-17, 2016).

METHODS

Eight participants from around the world were interviewed via Skype. These interviews were analysed using a descriptive and interpretive thematic analysis (Elliott and Timulak. A handbook of research methods for clinical and health psychology. Oxford University Press, London, pp 147-159, 2005). Informed consent was obtained from all participants.

RESULTS

Data analysis revealed four domains: (1) strong external influences; (2) psychological effects; (3) interpersonal functioning effects; and (4) classic eating disorder (ED) behaviours and processes. Some symptoms mirrored those seen in EDs and in obsessive compulsive disorder.

CONCLUSIONS

Orthorexia negatively impacted participants' physical, psychological, and social health. Additional research exploring valid and reliable screening instruments, body image, and psychological functioning would help to further understand this proposed disorder.

LEVEL OF EVIDENCE

Level V, qualitative interview study.

Electromyographic Assessment of Anterior Cruciate Ligament Injury Risk in Male Tennis Players: Which Role for Visual Input? A Proof-of-Concept Study

Anterior cruciate ligament (ACL) injury incidence is often underestimated in tennis players, who are considered as subjects conventionally less prone to knee injuries. However, evaluation of the preactivation of knee stabilizer muscles by surface electromyography (sEMG) showed to be a predictive value in the assessment of the risk of ACL injury. Therefore, this proof-of-concept study aimed at evaluating the role of visual input on the thigh muscle preactivation through sEMG to reduce ACL injury risk in tennis players. We recruited male, adult, semiprofessional tennis players from July to August 2020. They were asked to drop with the dominant lower limb from a step, to evaluate—based on dynamic valgus stress—the preactivation time of the rectus femoris (RF), vastus medialis, biceps femoris, and medial hamstrings (MH), through sEMG. To highlight the influence of visual inputs, the athletes performed the test blindfolded and not blindfolded on both clay and grass surfaces. We included 20 semiprofessional male players, with a mean age 20.3 ± 4.8 years; results showed significant early muscle activation when the subject lacked visual input, but also when faced with a less-safe surface such as clay over grass. Considering the posteromedial–anterolateral relationship (MH/RF ratio), tennis players showed a significant higher MH/RF ratio if blindfolded (22.0 vs. 17.0% not blindfolded; p < 0.01) and percentage of falling on clay (17.0% vs. 14.0% in grass; p < 0.01). This proof-of-principle study suggests that in case of absence of visual input or falling on a surface considered unsafe (clay), neuro-activation would tend to protect the anterior stress of the knee. Thus, the sEMG might play a crucial role in planning adequate athletic preparation for semiprofessional male athletes in terms of reduction of ACL injury risk.

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

PURPOSE

Disordered eating symptoms and a high prevalence of orthorexia nervosa can be found in yoga practitioners. Given that yoga is increasingly used as a complementary treatment for eating disorders (ED), understanding the relationship between yoga practice and the development of disordered eating is crucial to guide treatment recommendations. The goal of this work is, therefore, to study the relationships between orthorexia nervosa (ON) and potential risk factors for ON, in an international sample of experienced yoga practitioners.

METHOD

An online questionnaire that included several psychometric instruments was responded by 469 yoga practitioners. Instruments used were the Teruel orthorexia scale, Yoga immersion scale, Passion scale, Frost multidimensional perfectionism scale, Self-discipline scale of NEO-PI-R, Drive for thinness scale of EDI, and Beliefs about appearance scale. Descriptive statistics, correlational analysis and multiple regression were used to evaluate relationships between ON and the other variables.

RESULTS

The main predictors of orthorexia nervosa were the drive for thinness and a healthy orthorexia, suggesting that, like in anorexia and bulimia, orthorexic individuals are also concerned with food quantity and physical appearance, rather than just food quality.

CONCLUSIONS

The potential effects of yoga on eating behaviours and attitudes of long-term practitioners, particularly the high prevalence of orthorexia nervosa and the concern for physical appearance, should be taken into consideration when using yoga as prevention or treatment for eating disorders.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional 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.

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.

Selective attentional bias to food-related stimuli in healthy individuals with characteristics towards orthorexia nervosa

PURPOSE

It has been argued that orthorexia nervosa (ON) is a unique type of disordered eating of food considered by the individual to be healthy. Given that in other eating disorder populations attentional preference for food-related cues influences eating behaviours, is it also likely that these biases may be a characteristic of ON tendency.

METHODS

Eighty healthy individuals completed the ORTO-15 questionnaire (ON tendency), a modified Stroop task containing words related to healthy and unhealthy foods and perceived hunger levels pre- and post-testing. The ORTO-15 was used to identify participants within this sample who demonstrated more or less of the characteristics of ON.

RESULTS

Results suggest that the presence of attentional bias to healthy, but not for unhealthy food-related stimuli independently predict increased ON tendency. Increased attentional bias towards healthy food-related stimuli is associated with increased scores on the ORTO-15.

CONCLUSION

Attentional bias, as a deficit in information processing, towards healthy food-related stimuli accounts for variability in ON characteristics.

LEVEL OF EVIDENCE

Level I, experimental study.

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.

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.

Orthorexic Tendency and Eating Disorders Symptoms in Polish Students: Examining Differences in Eating Behaviors

Orthorexia nervosa (ON) may precede, ensue, or coexist with eating disorders (ED) and also affect eating behaviors. The aim of this study was to explore the dietary patterns (DPs) and other eating habits of people showing ON tendency, ED symptoms, and both ON tendency and ED symptoms, as well as those not showing either. The data for the study were collected from a sample of 1120 Polish college students through a cross-sectional survey in 2017. The questionnaire used in the survey included the ORTO-15, the Eating Disorder Screen for Primary Care (ESP), and the Food Frequency Questionnaire (FFQ-6), and the students were also asked questions about their eating habits and special diets. A factor analysis was conducted to identify the following five DPs: "high-sugar products and refined products," "meat and meat products," "alcohol," "high-fiber products and nuts," and "dairy products and whole-meal bread." Univariate logistic regression analyses were carried out to verify the associations between the variables. Students in the "ON and without ED" group were found to exhibit more healthy eating habits than the students in the "ED and without ON" group. The use of a special diet in the past and currently increased the risk of displaying ON tendency and ED symptoms. Students in the "ON and without ED" and "ON and ED" groups were characterized by less frequent consumption of high-sugar and refined products. Students who rarely consumed meat and related products were found to be less likely to display "ON and ED." In conclusion, different eating habits shown by people with ON tendency and ED symptoms confirmed the difference between ON and ED. However, the simultaneous displaying of ON and ED leads to the overlapping of specificity of eating habits, which can make the diagnosis based only on the eating habits difficult. Thus, there is still a need for further research involving the use of more sensitive tools that can better identify ON tendency and ED symptoms, as well as DPs.

Body dissatisfaction, addiction to exercise and risk behaviour for eating disorders among exercise practitioners

OBJECTIVE

This study investigated the association between body dissatisfaction (BD), addiction to exercise and risk behaviors to eating disorders (EDs) among Brazilian exercise practitioners, besides comparing the variables according to sex, age group and modality.

METHODS

Participants were 60 exercice practitioners of fitness (n = 44) and crossfit (n = 16), with mean age of 26.58 ± 7.76 years. Data collection was conducted through Eating Attitudes Test-26 (EAT-26), Diagnosis of Orthorexia Questionnaire (ORTO-15), Body Shape Questionnaire (BSQ) and Scale of Dedication to Exercise (SDE). Data analysis was conducted through Kolmogorov-Smirnov and independent t tests, Pearson correlation, and Path Analysis (p < .05).

RESULTS

Main results showed the association between BD, addiction to exercise and risk behaviour for EDs. Further, individuals dissatisfied with their bodies showed higher level of addiction to exercise and risk behavior for EDs. Furthermore, women showed higher presence of BD than men, and fitness participants reported higher presence of addiction to exercise than crossfit practitioners.

CONCLUSIONS

This study revealed that BD seems to be a determinant factor for risk behavior for ED's and addiction to exercise among fitness and crossfit particpants.

Association of Orthorexic Tendencies with Obsessive-Compulsive Symptoms, Eating Attitudes and Exercise

PURPOSE

The term orthorexia nervosa is used to describe the pathological fixation associated with consuming healthy food. It is assumed that orthorexia nervosa shares some phenomenological features with anorexia nervosa, obsessive-compulsive disorder (OCD), and other mental disorders. Individuals with orthorexic tendencies may have high physical activity as well as a healthy diet. This study aimed to investigate the relationship of orthorexia nervosa with obsessive-compulsive symptoms, eating attitudes, and several sociodemographic features.

PATIENTS AND METHODS

We included 63 patients diagnosed with OCD, 63 healthy volunteers who perform physical exercises at least three days a week, at least 30 minutes a day, and 63 healthy volunteers who do not perform physical exercises regularly. Sociodemographic data form, Yale-Brown Obsessive Compulsive Scale, ORTO-11 Scale, Eating Attitude Test, Hamilton Anxiety Scale, and Structured Clinical Interview for DSM-5 Disorders (SCID-5 CV) were administered to all participants. OCD data form was also applied to patients with OCD diagnosis.

RESULTS

We found a statistically significant relationship between current order-symmetry obsessions and orthorexic tendencies in patients with OCD (p<0.05). There was no relationship between the severity of the disorder and orthorexia nervosa in patients with OCD (p>0.05). Orthorexic tendencies were found to increase as impaired eating attitudes increased in participants who regularly performed physical exercises and patients with OCD (p<0.05). The orthorexic tendencies of participants who regularly performed physical exercises were higher than those diagnosed with OCD and healthy individuals who did not perform physical exercises.

CONCLUSION

The absence of a significant relationship between disorder severity and orthorexia nervosa in patients diagnosed with OCD and the increase in orthorexic tendencies as the deterioration in eating attitudes increases in both patients with OCD and the participants who regularly perform physical exercises suggest that orthorexia nervosa may be closer to the eating disorders group than obsessive-compulsive spectrum. Studies with large samples and different diagnoses are needed to determine the place of orthorexia nervosa in diagnosis and classification systems.

Orthorexia Nervosa: A cross-sectional study among athletes competing in endurance sports in Northern Italy

Orthorexia Nervosa (ON) is an eating disorder marked by an excessive control over the quality of the food eaten. Some groups present a higher prevalence of ON and people practicing sports seems to be a population at risk. The aim of this study is to assess the prevalence of ON in endurance athletes and to compare their prevalence with the ones recorded in the sedentary population and in athletes playing other sports. A cross-sectional survey was carried in Piedmont and Valle d’Aosta, among 549 participants in local sports events aged between 18 and 40 years old. The questionnaire assessed socio-demographic characteristics, physical activity, nutrition and diet, the ORTO-15 questionnaire and Eating Habits Questionnaire (EHQ). The sample was stratified according to the minutes of sport practiced in a week and the type of sport played. Crosstab chi-square analyses to determine group differences on categorical variables (e.g. gender), and ANOVAs or t tests to determine group differences on continuous variables were performed. When required, post hoc analyses were performed. Linear and logistic regressions were performed in order to investigate potential predictors of orthorexia. The EHQ mean scores ware significantly higher in people who practice sports >150 minutes/week. EHQ score resulted to be positively correlated with endurance sport practice >150 minutes/week, with a coefficient of 2.407 (I.C.95% [0.27;4.54], p = 0.027). Analyses carried out suggested a correlation between endurance sport practice and ON. Further studies should be performed to identify diagnostic criteria and to compare different questionnaire used to assess them.

Shedding light upon various tools to assess orthorexia nervosa: a critical literature review with a systematic search

AIM

The aim of this literature review was to identify the tools developed and used to assess orthorexia nervosa (ON).

METHODS

A systematic search was executed in PubMed, Biomed Central, and PsycINFO. The final list included 70 articles that were critically analyzed.

RESULTS

A total of six tools were reported to assess ON: the BOT, the ORTO-15, the EHQ, the DOS, the BOS, and the TOS. The tools were based upon different conceptualizations of ON and of its diagnostic criteria. Although they were different, all the conceptualizations derived from the initial definition of ON provided by Bratman in 1997. None of the methodologies adopted for tool construction considered end users or client perspectives and, when carried out, the validations of the tools were fragmented and often based on specific populations.

CONCLUSION

This study may be a starting point for the construction of a new diagnostic tool for ON. Starting from the methodological weaknesses identified by this review, it was possible to derive some suggestions for future research: (a) developing a modern re-conceptualization of ON, comprehensive of end-user perspectives; (b) adopting qualitative data collection techniques to gain insights into how to diagnose ON; and (c) actively involving diverse stakeholders for constructing a new tool.

LEVEL OF EVIDENCE

Level of Evidence: I, systematic review.

Assessing the Prevalence of Orthorexia Nervosa in a Sample of University Students Using Two Different Self-Report Measures

In recent decades, orthorexia nervosa (ON) has increased presence in society. It is related with beliefs and attitudes towards eating and is characterized by an obsessive behavior toward heathy eating. The prevalence of ON has been reported by numerous researchers, with rates varying considerably according to the tool used to evaluate the same parameter. The aim of this study was to compare the prevalence of ON in a single population using two different questionnaires. The test for the diagnosis of orthorexia (ORTO-11-ES) assessment tool for orthorexia nervosa and the Düsseldorfer Ortorexie Skala (DOS-ES), constitute brief self-report assessment tools which measure the risk of suffering ON. A sample of 492 students from the University of Castilla la Mancha (Spain) participated in this study, of whom 43.1% were male and 56.9% were female. The findings show that, according to the DOS-ES, only 10.5% of students displayed ON whereas, with the ORTO-11-ES, the prevalence of ON increased to 25.2%. The tendency towards orthorexic behavior is more closely associated with the female gender. The Body Mass Index (BMI) had no influence on the tendency for ON. This study provides valuable information on the usefulness of both questionnaires and the possible limitations associated with the use of these tools in the general population.

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.

Health beliefs, behaviors, and symptoms associated with orthorexia nervosa

PURPOSE

This research explored whether symptoms of orthorexia nervosa (ON), a condition involving obsessive thoughts and compulsive behaviors regarding healthy eating, are associated with differences pertaining to use of nutritional supplements and complementary and alternative medicine (CAM) techniques, to health locus of control, and to symptoms of poor physical health.

METHOD

An anonymous online survey assessing the variables above was completed by college students at a university in the southern United States: 47 in the ON symptoms group, 50 in the healthy-eating control group, and 83 in the normal-eating control group.

RESULTS

Compared to both control groups, the ON symptoms group reported greater supplement use and CAM participation, more reasons for these behaviors for the purpose of improving psychological health (i.e., to increase energy, enhance focus, and improve mood), and greater symptoms associated with poor physical health. None of the groups differed on internal or external health locus of control.

CONCLUSION

For those with ON, "healthy" eating behaviors are accompanied by other health behaviors that include supplement use and CAM activities. However, despite their goal of achieving perfect health, these individuals experience diminished physical health with symptoms that may be related to their severe dietary restrictions.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

How the obsession to eat healthy food meets with the willingness to do sports: the motivational background of orthorexia nervosa

PURPOSE

Given its relevance, the present study sought to reveal the motivational background of orthorexia nervosa (ON) and to examine its association to do sports.

METHODS

A total number of 739 participants completed a self-administered, online questionnaire including questions related to sports and three scales: Ortho-11-Hu, Motivation for Healthy Behaviors in Orthorexia Nervosa Questionnaire (MHBONQ) and Short Health Anxiety Inventory (SHAI). The age of the respondents ranged from 18 to 72 years (M = 29.67, SD = 10.18) and 79.16% of them were female. The majority of the subjects trained 3-4 times a week (37.2%), usually for 1-2 h per week (25.8%).

RESULTS

According to the hierarchical multiple regression analysis, social desirability, guilt over skipping training and health anxiety were the strongest predictors of ON with explaining 46% of the variance of ON.

DISCUSSION

The results of the present study suggested that obsessive features of sport activities (guilt over skipping training, counting calories during training) play an important role in ON. People with a higher level of ON tend to reach other people's respect, protect their general health and regulate negative emotional states through healthy eating.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Adaptation and validation of the Spanish version of the DOS questionnaire for the detection of orthorexic nervosa behavior

Introduction

Orthorexia nervosa, a term used to describe an obsession with healthy eating, has been shown to have major health implications for those affected. The aim of this study was to validate a Spanish version of the Düsseldorfer Ortorexie Skala (DOS), a questionnaire for the detection of orthorexic behavior.

Methods

A cross-sectional study comprising a total sample of 492 Spanish participants recruited from the University of Castilla-La Mancha, Spain, and randomly divided into two groups. The following tools were applied: the DOS and the Eating Disorder Inventory (EDI-2). The factorial structures were analyzed using exploratory and confirmatory factorial analysis.

Results

The internal consistency of the DOS-ES was α = .841. The exploratory factor analysis has revealed the existence of a single factor with factor loadings ranging from .508 to .802. A confirmatory factor analysis was applied to the second half of the random sample in order to confirm the factor solution.

Conclusion

The Spanish adaptation of the DOS-ES is proven to be a reliable and valid questionnaire for evaluating the obsessive tendency towards healthy eating among university students.

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.

An unhealthy health behavior: analysis of orthorexic tendencies among Hungarian gym attendees

AIM

In the present study, we aim to assess the prevalence and certain psychological and other correlates of orthorexic tendencies: health and exercise behaviors and demographic variables among gym attendees in Hungary.

METHODS

Altogether, responses of 207 gym attendees who filled out an online questionnaire (03/2017-10/2017) were analyzed. The mean age was 31.9 years; most were female and college educated, and about half resided in the capital city. Frequencies and means were calculated for the sample; and univariate linear regression and ANOVA were carried out. Finally, multivariate linear regression was used to assess the relationship between the dependent variable (Orto-11-Hu) and the independent variables (Eating Disorder Inventory, Maudsley Obsessional-Compulsive Inventory, health and exercise habits, and demographics).

RESULTS

The mean score for the Orto-11-Hu was 27.7. In the multivariate analysis, two eating disorder characteristics (drive for thinness and interpersonal distrust), age, exercising more than once a day, and yoga practice were significantly associated with higher orthorexic tendencies. There was a lack of correlation between any obsessive-compulsive traits.

CONCLUSIONS

Our data suggest and overlap between certain eating disorder traits, and a link between ON and frequent exercising and younger age. Further research is needed to investigate whether these correlates are found not only in a specific fitness-oriented population, but also in the general population.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Confirmatory factor analyses of the ORTO 15-, 11- and 9-item scales and recommendations for suggested cut-off scores

AIMS

To explore the validity and recommend cut-off scores in an English-speaking sample for 9, 11, and 15-item versions of the ORTO measure for orthorexia, a proposed eating disorder characterised by a pathological obsession with consuming only 'healthy' foods.

MATERIALS AND METHODS

The sample comprised of 585 participants (82.4% female) who completed an online questionnaire containing the ORTO-15, Eating Attitudes test, Obsessive Compulsive Inventory Revised. A series of Confirmatory Factor Analyses were conducted to test model fit. Binary logistic linear regression and receiver-operating-characteristics (ROC) analyses were used to obtain cut-offs.

RESULTS AND CONCLUSION

Results showed that none of the three published versions (9, 11, and 15-item) of the ORTO produced an acceptable model. Subsequent exploratory and confirmatory factor analyses yielded a seven-item version of the ORTO (ORTO-7) with a strong and stable factor structure. Analysis of cut-offs revealed that a cut-off score of equal or greater than 19 on the ORTO-7 represents probable orthorexia.

LEVEL OF EVIDENCE

Level V, descriptive study.

People behind unhealthy obsession to healthy food: the personality profile of tendency to orthorexia nervosa

PURPOSE

Our aim was to measure the personality profile of people with high orthorexic tendency using an assessment method which is acknowledged in the research of the classical eating disorders (anorexia nervosa, bulimia nervosa) and obsessive-compulsive disorder (OCD).

METHODS

In our research, 739 participants completed a self-administered, online questionnaire consisting of two measures: Temperament and Character Inventory-56 (TCI-56) and Ortho-11-Hu.

RESULTS

The orthorexia nervosa (ON) grouping variable has a significant effect on three factors of TCI: MANOVA revealed higher harm avoidance (F (2, 736) = 19.01, p < 0.001, η² = 0.05), lower self-directedness (F (2, 736) = 22.55, p < 0.001, η² = 0.06), and higher transcendence (F (2, 736) = 3.05, p = 0.048, η² = 0.01) in the higher ON group, compared to the lower ON group, regardless of the effect of the risk groups.

CONCLUSIONS

According to earlier studies, high harm avoidance and low self-directedness are relevant factors of anorexia nervosa, bulimia nervosa, and OCD, but now it also seems to be an important parameter of orthorexia. Nevertheless, higher transcendence may be a unique feature, which suggests that orthorexia seems to be an independent phenomenon.

LEVEL OF EVIDENCE

V, descriptive cross-sectional study.

Orthorexic Tendency in Polish Students: Exploring Association with Dietary Patterns, Body Satisfaction and Weight

Body dissatisfaction is central to clinically diagnosed eating disorders (ED) and seems to be important in causing other non-clinical disorders, including orthorexia nervosa (ON). It can also affect eating behaviors. The aim of this study was to assess the associations of ON tendency with dietary patterns (DPs) and body satisfaction. The data were collected in 2017 through questionnaire survey among 1120 students of health-oriented and other academic programs from seven universities in Poland. Principal components analysis (PCA) was conducted to derive DPs and body satisfaction factors. Six DPs, such as, ‘High-sugar products & snacks’, ‘Fresh products & nuts’, ‘Fatty products & dressings’, ‘Oils & potatoes’, ‘Dairy products & whole-meal bread’, ‘Meat’, and two body satisfaction factors, such as, ‘Bottom body & weight’, and ‘Upper body’ were identified. ON tendency was measured using ORTO-15 questionnaire with both cut-offs, i.e., 35 and 40. Logistic regression analysis was used to verify associations between ON tendency, body satisfaction factors, and DPs. More students of health related majors were characterized by ON tendency in comparison to students of other majors (35.9 vs. 37.2; p < 0.001). More women were dissatisfied with ‘Bottom body & weight compared to men (<0.001). The higher the body mass index (BMI), the more people were dissatisfied with ‘Bottom body & weight’ (p < 0.001). More students with ON tendency were satisfied with their ‘Upper body’ than those without ON tendency, but there were no differences in ON tendency in regard to ‘Bottom body & weight’ satisfaction. ON tendency was associated with more frequent consumption of vegetables, fruits, nuts and seeds, and less frequent consumption of products high in sugar, snacks, fatty products and dressings. Using cut-off at 35 in ORTO-15 seems to be more appropriate than cut-off at 40 to identify external variables describing ON. Future research on orthorexia nervosa should use other research tools than ORTO-15 to better identify individuals with ON and to confirm our findings.

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

PURPOSE

The combination of physical activity and healthy eating habits has potentially positive effects on health. However, both practices can also lead to pathological behaviors such as exercise addiction (EA) and orthorexia nervosa (ON), thus generating negative effects. So far, studies analyzing the connection between these two phenomena cannot be found. The current paper is aiming to close this gap.

METHODS

The sample (n = 1.008) consisted of 559 male and 449 female active members of three fitness studios, and was analyzed in a cross-sectional study design. The Exercise Addiction Inventory (EAI) was used to establish exercise addiction and the Düsseldorfer Orthorexie Skala (DOS) was used to evaluate orthorectic eating behavior.

RESULTS

Out of the whole sample, 10.2% exhibit EA, while ON is prevalent in 3.4%. Twenty-three (2.3%) individuals suffer from both. There is a significant positive correlation between DOS and EAI (p < .001, r = .421). Female participants (p < .001, r = .452) show a higher correlation compared to male participants (p < .001, r = .418).

CONCLUSION

The results suggest a positive correlation between ON and EA in the context of German fitness sports. Both seem to be serious phenomena and require further investigation.

LEVEL OF EVIDENCE

Level V (cross-sectional descriptive study).

Orthorexia nervosa in a sample of Portuguese fitness participants

PURPOSE

Orthorexia Nervosa (ON) is described as an obsessive behaviour motivated by great concern for following a healthy diet. Although it was first described in 1997, ON remains inconspicuous and poorly characterized in the literature. The aims of this study were to evaluate the prevalence of ON in a sample of ambulatory individuals and to investigate their common characteristics, attempting to better characterize this entity.

METHODS

A non-random sample of 193 adult gym members answered a questionnaire based on a Portuguese version of ORTO-15, supplemented with additional questions. Possible associations between the different variables and pathological scores on ORTO-15 were analysed using logistic regression models.

RESULTS

ON behaviour was documented in 51.8% of the sample, mean age 30.96 years (± 1.03 years), and this condition tended to be correlated with younger ages. Physical appearance and frequent exercising were also associated with ON, while no correlation between orthorexic tendencies and both gender and educational field was found. Furthermore, consumption of special food, dissatisfaction with physical appearance and frequent exercising could predict the presence of ON in the sample.

CONCLUSIONS

Despite the use of a convenience sample, results place us in a different perspective, considering the idea that orthorexic individuals are exclusively concerned about pursuing a pure diet. The presence of ON was associated with other non-dietary behaviours allied to a healthy lifestyle and aesthetic concerns.

LEVEL OF EVIDENCE

Level V: Descriptive study.