Validity and reliability of the Turkish version of the Düsseldorf orthorexia scale (TR-DOS) and the prevalence of orthorexia nervosa among Turkish university students

Orthorexia Nervosa (ON) is characterized by an excessive preoccupation with healthy foods accompanied by the avoidance of self-declared unhealthy options, yet it remains unrecognized in major diagnostic guidelines. The Düsseldorf Orthorexia Scale (DOS), a 10-item self-report questionnaire using a four-point Likert scale, assesses the obsession with healthy eating. This study evaluates the reliability and validity of the TR-DOS in the Turkish context and estimates the prevalence of ON among university students. Several studies have shown that translating the DOS into various linguistic groups may exhibit different models of DOS scores. However, the psychometric properties and model fit of the DOS have not yet been investigated in Turkish-speaking populations; to address this gap, we assessed the psychometric properties of a Turkish translation of DOS (TR-DOS) in a sample of 425 university students in Türkiye. The TR-DOS revealed a 7.3% ON prevalence and a 9.0% risk of development. Weak positive associations were observed between TR-DOS total scores and BMI (r = 0.152, p = .002). Exploratory Factor Analysis confirmed the validity of TR-DOS (KMO = 0.867) with satisfactory reliability (Cronbach's alpha = 0.854). Confirmatory Factor Analysis indicated an acceptable fit for the TR-DOS model (χ2/df = 3.127, RMSEA = 0.071, SRMR = 0.046, IFI = 0.955, CFI = 0.955, GFI = 0.956, TLI = 0.932). Moderate positive correlations were found between TR-DOS and eating disorder measures (EAT-26: r = 0.428, p < .001; EDE-Q-13: r = 0.430, p < .001). The findings demonstrated that the TR-DOS is both culturally appropriate and psychometrically adequate for Turkish university students. It is a reliable and valid instrument for assessing obsessive healthy eating behaviors in this population.

A psychometric examination of the cognitive flexibility scale and its association with Orthorexia Nervosa

BACKGROUND

The Cognitive Flexibility Scale (CFS) is a 12-item self-report questionnaire designed to assess cognitive flexibility. Despite its widespread use, its psychometric properties have yet to be evaluated in the Italian context. Furthermore, while cognitive flexibility has emerged as a central correlate in Feeding and Eating Disorders, only a limited number of studies have investigated its association with Orthorexia Nervosa (ON), a clinical condition characterized by a pathological fixation with healthy eating. The present study aimed to fill these two knowledge gaps.

METHODS

A total of 803 participants (Mage = 33.89, SD = 9.44; 68.6% females) were enrolled in the investigation. The sample was randomly split into two subsamples: the first one for examining the psychometric properties of the CFS, and the second one for evaluating its association with ON symptoms. Participants completed self-report questionnaires assessing the constructs under investigation.

RESULTS

Confirmatory factor analysis revealed a global dimension of cognitive flexibility, alongside a method factor accounting for covariance arising by reverse-worded items. The CFS, which was factorially invariant across genders, yielded a reliable total score (ω = 0.834) and provided evidence of convergent and criterion-related validity. Importantly, structural equation modelling showed that cognitive flexibility was negatively associated with emotional distress resulting from violations of orthorexic dietary rules (β = -0.279, p < .001).

CONCLUSIONS

The CFS demonstrated to be a psychometrically robust instrument in the Italian context. Moreover, cognitive flexibility may be an important treatment target for mitigating the distress derived from ON symptoms, informing the development of future therapeutic approaches.

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

Introduction

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

Methods

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

Results and discussion

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

Conclusion

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

Comparison between Physical Activity and Stress-Related Lifestyle between Orthorexic and Non-Orthorexic University Students: A Case-Control Study

(1) Background: The literature regarding orthorexia nervosa (ON) has well documented the association with other mental disorders, such as obsessive-compulsive and eating disorders. However, the research has not taken into account stress-related behavior and the conduction of physical activity (PA), both structured and unstructured. (2) Methods: In this cross-sectional study, 165 students of the University of Parma (92 females and 74 males) aged between 18 and 49 years old (mean = 24.62 ± 4.81) were consecutively recruited. The ORTO-15 questionnaire was used to divide the total sample into a group without orthorexia (score > 40) and a group with orthorexia (score < 40). All subjects completed the P Stress Questionnaire, and specific items were extrapolated from the Eating Habits Structured Interview (EHSI) to investigate lifestyle, including structured and unstructured PA. (3) Results: Subjects with orthorexia represented 83% of the total sample and reported higher levels of stress-related risk behaviors (i.e., sense of responsibility (t = -1.99, p = 0.02), precision (t = -1.99, p = 0.03), stress disorders (t = -1.38, p = 0.05), reduced spare time (t = -1.97, p = 0.03), and hyperactivity (t = -1.68, p = 0.04)) and a higher frequency of PA (i.e., hours spent training in structured PA, daily (t = -1.68, p = 0.05), weekly (t = -1.91, p = 0.03), and monthly (t = -1.91, p = 0.03), the tendency to carry out physical exercise even if tired (t = -1.97, p = 0.02), and to adhere to unstructured PA (i.e., moving on foot or by bike rather than using transport (t = 1.27, p = 0.04)). (4) Conclusions: The results confirmed the presence of hyperactivity at a motor and behavioral level in people with orthorexia. Further studies are necessary to highlight the causality between ON, stress, and physical activity but it may be possible to hypothesize that "obsessive" physical exercise may not generate the benefits generally known by the literature.

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.

A systematic review and meta-analysis of the relationship between obsessive-compulsive symptoms and symptoms of proposed orthorexia nervosa: The contribution of assessments

OBJECTIVE

This systematic review and meta-analysis aimed to update the literature on orthorexia nervosa (ON), a proposed diagnosis of pathologically 'healthy' eating, by critically analysing the current evidence for the relationship between ON and obsessive-compulsive (OC) symptoms. Further, this paper aimed to compare the ON/OC relationship significance and strength based on when the ON measurement tool was developed.

METHOD

PsycINFO, PubMed and Web of Science databases were queried for quantitative, peer-reviewed studies recruiting adult participants, published in English up to April 2023. Studies not directly comparing ON and OC symptoms were excluded. After full-text review and quality assessment, 40 studies were included in the systematic review and 31 studies in the meta-analysis.

RESULTS

ON assessments created prior to the 2016 revised ON diagnostic criteria do not appear to fully capture OC symptoms. Studies using earlier developed ON assessments demonstrated inconsistent ON/OC relationships whereas studies implementing more recent assessments (from 2018 onwards) found consistently significant, larger relationships, highlighting a previously underrated OC component of ON.

CONCLUSIONS

Early ON studies, and studies utilising early ON assessments should be interpreted with caution, particularly in relation to OC symptom involvement in ON. Future research should validate novel ON assessments and investigate common underlying factors.

The Risk of Orthorexia and the Prevalence of Emotional Eating Behaviours among Polish Military Flying Personnel in Relation to Body Mass Index (BMI) and Sociodemographic Factors

BACKGROUND

Proper nutrition has a positive impact on health. Paradoxically, excessive preoccupation with healthy eating may lead to the emergence of abnormal eating behaviours and increase the risk of developing disorders. The aim of this study was to assess the risk of orthorexia (ON) and the prevalence of emotional eating (EE) in military flying personnel of the Polish Air Force in relation to BMI and sociodemographic factors.

METHODS

This study included 760 soldiers (including 60 females) taking part in the National Health Programme 2021-2025. The ORTO-15 questionnaire and EEQ were used to assess the risk of ON and EE.

RESULTS

The risk of ON occurred in 28.9% of military flying personnel and was significantly more frequent in soldiers with a normal weight (46.4%), under 40 years of age (42.7%), and with higher education (42.7%). The prevalence of EE was found in approximately 12.3% of the respondents and was significantly more common in soldiers with diagnosed obesity (17.5%), women (21.7%), and soldiers with higher education (13.6). Other sociodemographic variables did not differentiate the results of the ORTO-15 questionnaire and EEQ.

CONCLUSIONS

The obtained results indicate that the problem of eating disorders also occurs in military populations. The necessity of continuing research in this area is discussed.

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.

A Study of the Relationship between University Students' Food Neophobia and Their Tendencies towards Orthorexia Nervosa

Food neophobia, known as an avoidance of the consumption of unknown foods, can negatively impact nutritional quality. In orthorexia nervosa, there is an excessive mental effort to consume healthy food. Individuals exhibiting symptoms of food neophobia and orthorexia nervosa may experience food restrictions. This study aimed to assess food neophobia levels and orthorexia nervosa tendencies among university students, investigate the potential association between the two constructs, and explore the effect of the demographic characteristics of the participants on the variables. This is a descriptive cross-sectional study. The study sample consisted of 609 students enrolled at Recep Tayyip Erdoğan University. The data were collected through Google Forms using a sociodemographic information form, the Food Neophobia Scale, and the ORTO-11 scale. Ethics committee approval and institutional permission were obtained for the study. Of the students participating in the survey, 71.9% were female, 14.6% were classified as neophobic, and 47.1% had orthorexia nervosa symptoms. The mean scores from the Food Neophobia Scale (39.41 ± 9.23) and the ORTO-11 scale (27.43 ± 5.35) were in the normal range. Food neophobia was significantly higher among those who did not consume alcohol. Orthorexia nervosa symptoms were significantly more common among married people. In the correlation analysis, no significant relationship was found between age, food neophobia, and orthorexia nervosa. It can be said that food neophobia in this study is similar to in other studies conducted on university students. In addition, about half of the participants had symptoms of orthorexia nervosa. This result is higher compared to other studies conducted with university students. The findings of this study indicate that the participants care about the healthfulness of food.

Overall proportion of orthorexia nervosa symptoms: A systematic review and meta-analysis including 30 476 individuals from 18 countries

Background

To date, no previous meta-analysis has determined the overall proportion of orthorexia nervosa symptoms on a global scale. The aim of the present study was 2-fold: first, to establish the overall proportion of orthorexia nervosa symptoms on a global scale, assessed with the ORTO-15 questionnaire; and second, to determine the role of sex, type of population, mean age, body mass index, and the temporal trend in relation to orthorexia nervosa symptoms.

Methods

Four databases were searched (PubMed, Scopus, Web of Science, and Cochrane Database of Systematic Reviews) with date limits from January 2005 to June 2023. Studies assessing the proportion of orthorexia nervosa assessed using the ORTO-15 questionnaire with a cutoff of <35 or <40 points were included in this review.

Results

The overall proportion of orthorexia nervosa symptoms (using the cutoff <35 points) was 27.5% (95% confidence interval (CI) = 23.5-31.6, I2 = 97.0%). In addition, no significant differences were observed between females (34.6%, 95% CI = 29.5-39.8, I2 = 96.1%) and males (32.1%, 95% CI = 26.5-38.1, I2 = 93.1%). According to the type of population, the highest overall proportion was found in people focused on sports performance or body composition (34.5%, 95% CI = 23.1-47.0, I2 = 98.0%). Notwithstanding, caution should be exercised in interpreting this result, as reverse causality could be a potential pitfall in this relationship.

Conclusions

We found that approximately three out of 10 study participants showed orthorexia nervosa symptoms according to the ORTO-15 tool. This overall proportion was higher in those participants who were athletes or fitness practitioners. Over the years, the proportion of orthorexia nervosa symptoms seems to be increasing. These high percentages and their increase are worrisome from a public health perspective and highlight the need to develop psychometric instruments to aid in clinical diagnosis and treatment efficacy.

Registration

PROSPERO (CRD42022350873).

Profiling orthorexia nervosa in young adults: the role of obsessive behaviour, perfectionism, and self-esteem

BACKGROUND

Orthorexia nervosa (ON) is a relatively new potential eating disorder characterized by an intense fixation on one's eating habits and the imposition of rigid and inflexible rules on oneself. Psychological factors such as obsessive-compulsive tendencies, perfectionism and self-esteem may interact in complex ways and contribute to the development and maintenance of ON.

METHODS

This cross-sectional study included 977 participants from Italy, Lebanon, and Poland. Participants completed a questionnaire consisting of socio-demographic information, the Eating Habits Questionnaire, Obsessive-Compulsive Inventory, Obsessive Beliefs Questionnaire-44, Multidimensional Perfectionism Scale, and Rosenberg Self-Esteem Scale. Cluster analysis was used to identify subgroups of individuals with common psychological characteristics associated with ON.

RESULTS

Three distinct clusters were identified based on their levels of obsession-compulsive beliefs, perfectionism, and self-esteem. The first group, labeled "High Self-Mastery," consisted of 37.0% of participants and exhibited low levels of obsession-compulsion, obsessive beliefs, and perfectionism, but high self-esteem. The second group, "Moderate Self-Mastery," comprised 39.5% of participants and had moderate levels of these traits. The third group, "Low Self-Mastery," consisted of 23.6% of participants and exhibited the highest levels of obsession-compulsion, obsessive beliefs, and perfectionism, but the lowest self-esteem. Additionally, a multivariable analysis revealed that being Lebanese (Beta = 3.39) and belonging to the last cluster (Beta = 4.53) were significantly associated with higher ON tendencies.

CONCLUSION

Our findings show that individuals with low self-mastery, characterized by low self-esteem and high levels of obsessive perfectionism, are more likely to exhibit ON tendencies. This study emphasizes the need to have a comprehensive understanding of how cultural and psychological factors interact in the development of eating disorders.

Turkish Version of the New Instrument for Orthorexia Nervosa-Test of Orthorexia Nervosa (TON-17): A Validity and Reliability Study

This study aimed to adapt the Test of Orthorexia Nervosa- (TON-17) into Turkish and verify its validity and reliability. The study included 539 adults with a mean age of 30.2 ± 12.26 years. A reliability analysis was performed, along with a confirmatory factor analysis to test its construct validity. The time-invariance of the scale was examined by test-retest analysis, and its convergent validity was evaluated by a correlation analysis conducted to test the relationships between the scale and Eating Attitudes Test-26 and Obsessive Beliefs Questionnaire-9. Analyses were conducted using SPSS Version 28 and the AMOS-24 software. The Cronbach's α internal consistency coefficient of the total scale was found to be 0.82, suggesting a strong internal consistency. The Cronbach's α values of its factors were 0.68 for the "control of food quality", 0.64 for the "fixation on health and a healthy diet", and 0.73 for the "disorder symptoms". In addition, the test-retest reliability was found to be 0.87 for the total scale, suggesting excellent reliability. Most of the fit indices (CMIN/df, RMSEA, AGFI, NFI, and TLI) of the scale were acceptable, and the GFI indicated a good model fit. This study shows that the Turkish version of TON-17, which is a new tool with a three-factor structure to evaluate orthorexia, is a valid and reliable scale.

Diet Quality and Level of Nutrition Knowledge among Young People with Orthorexic Tendencies

The aim of the study was to determine the level of nutrition knowledge and diet quality, understood in terms of healthy and unhealthy eating habits, among young people with orthorexic tendencies. The participants were school students, university students, and those employed in the Lublin region (N = 473). The data were collected by means of a questionnaire. The participants were asked to provide socio-demographic data through filling in the ORTO-15 questionnaire and the Dietary Habits and Nutrition Beliefs Questionnaire (KomPAN). The participants obtained results ranging from 9.3 to 100 (M = 31.15; SD = 11.81) in the non-healthy diet index, from 0.4 to 78.6 in the pro-healthy diet index (M = 21.79; SD = 11.08), and from 0 to 23 in the domain of nutrition knowledge (M = 13; SD = 4.23). A variance analysis showed no significant differences between the pro-healthy diet index and the level of nutrition knowledge. The group with orthorexia obtained statistically higher results in the pro-healthy diet index. Those with a tendency toward orthorexia obtained statistically higher results in the non-healthy diet index. The variance analysis showed that the level of nutrition knowledge of those not focused on healthy foods was significantly lower than in the other groups. The results of the ORTO-15 questionnaire correlated negatively with the pro-healthy diet index and the level of nutrition knowledge, and positively with the non-healthy diet index. We concluded that: 1. the orthorexic group and the group with a tendency toward orthorexia could be characterized with a moderate intensity of a healthy diet and a low intensity of a non-healthy diet; and 2. the level of nutrition knowledge in the orthorexic group did not significantly differ from that of the other groups.

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 and Eating Disorders in Adolescents and Young Adults: A Systematic Review

Background: In recent years a new term in the field of eating behaviors has emerged, namely “orthorexia”. This behavior is associated with significant dietary restrictions and omission of food groups. The aim of the present study is to estimate the possible correlations between orthorexia and eating disorders in young adults and adolescents. Methods: A systematic review of related articles in PubMed, Google Scholar, and PsycInfo was conducted up to 30 June 2021. Results: A total of 37 studies (16,402 subjects) were considered eligible for this systematic review. Significant correlations were observed in most of the studies between orthorexia and eating disorders. However, the majority of studies adopted a cross-sectional design. Conclusions: An association between and eating disorders emerged. Prospective studies seem necessary to investigate associations and succession of orthorexia and eating disorders over time.

Orthorexia Nervosa and its association with obsessive-compulsive disorder symptoms: initial cross-cultural comparison between Polish and Italian university students

There is limited evidence of a link between Orthorexia Nervosa (ON) and Obsessive-Compulsive Disorder (OCD), and no definitive conclusions can be drawn. The interplay between socio-cultural context and ON has been poorly investigated as well. Therefore, the objectives of the present study were: (1) to investigate the differences in ON and OCD symptoms and (2) to assess the relationship between ON and OCD symptoms among university students. Six hundred and sixty-six university students participated in the present study: 286 from Poland and 320 from Italy. No age, gender and marital status differences were identified between two samples of university students. However, on average, Polish university students had a higher Body Mass Index than Italian ones. Our findings showed that Polish students present more problems related to obsessive symptomatology, core beliefs of OCD, perfectionism traits, and a major ON symptomatology than Italian ones. Also, Polish students with a higher level of ON exhibited higher levels of OCD symptoms and parental expectations/parental criticism. While Italian students with a higher level of ON showed higher levels of perfectionism features (organization and concern over mistakes). In general, correlations were low as confirmation of partial independence ON from OCD symptoms and core beliefs of OCD in both Polish and Italian university students. The present results highlight a need for further investigation of the correlates of ON across different cultural groups. Future research may screen individuals with ON to determine the comorbidity between ON and OCD symptomology to facilitate appropriate treatment choices. LEVEL OF EVIDENCE: Level V, Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Psychological Correlates of Excessive Healthy and Orthorexic Eating: Emotion Regulation, Attachment, and Anxious-Depressive-Stress Symptomatology

Orthorexia nervosa, the pathological obsession with eating healthy, shares risks and significant comorbidity with other mental disorders. Based on a behavioral conceptualization of the overlap, emotion regulation, attachment style, and anxious-depressive-stress symptomatology are prominent but insufficiently researched endophenotypes for orthorexia nervosa. This study aimed at identifying ways in which difficulties in emotion regulation and attachment-related anxiety and avoidance become apparent in orthorexia nervosa and healthy orthorexia. Additionally, the moderating role of anxious, depressive, and stress symptoms was explored. A convenience sample of 399 adults (266 women) completed questionnaires to measure orthorexia nervosa and healthy orthorexia, difficulties in emotion regulation, partnership-related bond, and anxious-depressive-stress symptomatology. The healthy orthorexia subscale was negatively associated with lack of emotional awareness but no other subscale of difficulties in emotion regulation or attachment-related anxiety and avoidance. Orthorexia nervosa scores were positively linked to difficulties in emotion regulation as well as attachment-related anxiety and avoidance. Multiple linear regression indicated non-acceptance of emotional responses and impulse control difficulties to be the strongest predictors for orthorexia nervosa. Both subscales also mediated the effects of attachment style on orthorexia nervosa with anxious-depressive-stress symptomatology moderating some of these effects. Individuals with higher orthorexia nervosa tendencies showed difficulties in emotion regulation, a common feature also of affective and eating disorders. Improvement in understanding the psychological features of orthorexia nervosa can enable a better differentiation from other disorders, advances in the development of treatment approaches and treatment planning, and outlines directions for future research on mechanisms.

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.

Association between impulsivity and orthorexia nervosa: any moderating role of maladaptive personality traits?

OBJECTIVES

To explore the possible moderating relation between impulsive behavior and maladaptive personality traits in regards to orthorexia nervosa (ON).

METHODS

This cross-sectional study was conducted between July and December 2019 and recruited 519 Lebanese adults from seven community pharmacies randomly selected from a list provided by the Lebanese Order of Pharmacists. The Teruel Orthorexia Scale (TOS) was employed to assess orthorexic eating tendencies, the I-8 measured impulsivity and the Personality Inventory for DSM-5 (PID) evaluated maladaptive personality traits.

RESULTS

Our results showed that, for I-8 subscales, only higher perseverance (B = 0.31) was significantly associated with higher ON. In regard to PID-5 subscales, only higher negative affect (B = - 0.34) was significantly associated with lower ON. Furthermore, significant interactions were found between personality traits and impulsivity to predict TOS-ON.

CONCLUSION

The current results show that female gender, maladaptive personality traits and impulsivity present contributing factors regarding orthorexic eating. Certain impulsivity dimensions were confirmed to interact with personality traits in the prediction of orthorexic eating thereby highlighting possible risk factors and psychopathological mechanisms.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Orthorexia nervosa: The relationship with obsessive-compulsive symptoms and eating attitudes among individuals with and without healthcare professionals

BACKGROUND: Today, individuals with eating disorders or orthorexia nervosa (ON) are increasing. OBJECTIVE: This study aimed to determine the association between ON, eating attitudes, and obsessive-compulsive symptoms among healthcare and non-healthcare professionals. METHODS: The present study was cross-sectional, and conducted by 310 healthcare, and non-healthcare professionals. Data on demographic characteristics, the Orthorexia Nervosa Evaluation Scale (ORTO-15), the Eating Attitudes Test-40 (EAT-40), and the Maudsley Obsessive-Compulsive Inventory (MOCI) were obtained by a questionnaire form. Additionally, the body weight and height of participants were taken to calculate the body mass index (BMI). Data were analyzed with SPSS statistical package 24.0. RESULTS: The ORTO-15 score of 30.3% of healthcare professionals and 27.1% of non-healthcare professionals were ≤40 (p: 0.616). The EAT-40 scores were found to be ≥30 in 7.7% of healthcare professionals and 4.5% of non-healthcare professionals (p: 0.081). According to the MOCI scores, the possibility of obsessive-compulsive symptoms was high in 29.7% of healthcare professionals (p <  0.001). There was a weak negative correlation between ORTO-15 and EAT-40 (r: –0.176, p: 0.002) and MOCI (r: –0.170, p: 0.003); and EAT-40 and MOCI (r:0.166, p: 0.03). CONCLUSION: Further studies are required to understand the relationship between ON and eating disorders that are included in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria.

Cultural shifts in the symptoms of Anorexia Nervosa: The case of Orthorexia Nervosa

Orthorexia Nervosa (ON) is a term describing a fixation on food purity, involving ritualized eating patterns and a rigid avoidance of "unhealthy foods." Those self-identified as having ON tend to focus on food composition and feel immense guilt after eating food deemed "unhealthy." Although not formally recognized as a psychiatric disorder by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ON has received increasing attention since its identification in 1997. There is ongoing work to establish diagnostic and empirical tools for measuring ON; embedded in this is the question as to whether or not ON is a new eating disorder. In this paper, we argue ON is not a new psychiatric disorder but rather a new cultural manifestation of anorexia nervosa (AN). We begin by providing an overview of historical representations and classification of eating disorders, with a specific focus on AN. This is followed by discussion of the rise in diet culture and healthism since the 19th century. We conclude by examining the diagnostic validity and utility of ON through a discussion of empirical evidence. Classifying ON under the diagnostic umbrella of AN may improve our understanding of factors underlying restrictive eating behaviors.

Making the leap from healthy to disordered eating: the role of intuitive and inflexible eating attitudes in orthorexic behaviours among women

PURPOSE

Orthorexia Nervosa (ON) has been a research focus in recent years. Despite the lack of consensus on its definition and classification as a psychiatric disorder, research has shown that ON is linked to certain behaviours (orthorexic behaviours, e.g.: obsessive thinking and compulsive behavior, guilt and self-punishment, restriction), associated with disordered eating. However, very little is known about this relationship. The aim of this study was to explore the eating-related processes inherent to the relationship between orthorexic behaviours and disordered eating, and understand if it is through the adoption of a more inflexible and less intuitive eating approach, that an interest in healthy eating develops into a pathological one, while controlling the effect of age and BMI. Additionally, this relationship was explored for two different groups: Omnivores and Non-omnivores.

METHODS

Four hundred fifty-one women (281 Omnivores and 170 Non-omnivores) from the Portuguese population participated in this study, by answering a set of self-report measures.

RESULTS

Non-omnivores presented significant higher levels of orthorexic behaviours and inflexible eating. In both groups, orthorexic behaviours and disordered eating were linked positively to inflexible eating and negatively to intuitive eating. A path model analyses showed that the preferred eating approach mediated the relationship between orthorexic behaviours and disordered eating, explaining 51% of the variance of disordered eating. A multigroup analysis confirmed the model invariance between Omnivores and Non-omnivores.

CONCLUSIONS

Our findings contribute to the better understanding of the relationship between orthorexic behaviours and disordered eating and its eating-related processes. Future research regarding the clinical intervention and prevention of ON in women should focus on encouraging a more intuitive eating approach.

LEVEL OF EVIDENCE

IV, cross-sectional study.

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.

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.

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.

The Polish version of the Düsseldorf Orthorexia Scale (PL-DOS) and its comparison with the English version of the DOS (E-DOS)

PURPOSE

Although orthorexia nervosa, the fixation on health-conscious eating behaviour, was first described in the 90 s, there is no clear understanding whether existing ON measures are appropriate for its assessment. The objectives of the present study were to: (1) examine the psychometric properties of the Polish version of the DOS (PL-DOS) and to compare the PL-DOS with the English version of the DOS (E-DOS) as well as (2) evaluate the prevalence of ON among Polish university students and compare the prevalence rates of ON among Polish and U.S. students.

METHODS

Four-hundred and twelve students (77.2% female) with a mean age of 24.62 years (SD = 6.86) participated in the present study. All participants completed the Polish version of the Düsseldorf Orthorexia Scale (PL-DOS), the Eating Habits Questionnaire (EHQ) and the Eating Disorder Inventory (EDI).

RESULTS

Reliability analysis for the PL-DOS showed strong internal consistency with a Cronbach's alpha coefficient of 0.840 and a coefficient omega of 0.840, 95% CI [0.808, 0.866]. Significant correlation coefficients were found between the PL-DOS and all subscales of the EHQ. Confirmatory factor analysis showed that the one-factor model had poor fit. Polish students had an ON prevalence rate of 6.6%, lower than that of U.S. students (8%).

CONCLUSIONS

Our findings validate the use of the PL-DOS as an appropriate ON measure for a Polish population.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Does ORTO-15 produce valid data for 'Orthorexia Nervosa'? A mixed-method examination of participants' interpretations of the fifteen test items

PURPOSE

Orthorexia Nervosa (ON) is defined as a pathological eating behaviour stemming from being "healthy" or "pure". Survey-based studies typically rely on the ORTO-15 questionnaire or its variations to detect orthorexia. However, frequent post-hoc adjustments to the ORTO-15 suggest psychometric problems. In this study, we explored people's cognitions about the ORTO-15 items to (1) identify problems specific to ORTO-15 items and (2) explore participants' understanding of ON symptoms.

METHODS

Fifty adult participants (40% male, mean age = 34.0 ± 14.4 years) completed the ORTO-15, the Eating Attitudes Test (EAT-26) and the Obsessive-Compulsive Inventory-Revised edition (OCI-R). Qualitative data were collected using the modified "think aloud" protocol, which asked participants to 'verbalise' their responses to the ORTO-15 items. These qualitative responses were first analysed conjunctively with the quantitative responses; then subjected to thematic analysis.

RESULTS

ORTO-15 identified 64% of the participants for orthorexic tendencies. In most cases (76%), participants reported no issues completing the ORTO-15. However, in some cases, qualitative responses differed from quantitative ones. When people encountered problems, it was because of poor psychometric construction: lack of clarity, ambiguous wording and multiple statements in a single item. Elaborations around the ORTO-15 items formed four major themes: "preoccupation with physical appearance", "control", "food is fuel" and "alone, not isolated".

CONCLUSION

Even though in the majority of cases there were no issues with completing ORTO-15, thematic analysis revealed several discrepancies between our participants' perceptions of the ORTO-15 items and the previously proposed diagnostic criteria for ON. The results suggest that ORTO-15 is, at best, a mediocre screening tool for ON, which is sensitive to diet but fails to have sufficient level of specificity to detect the pathological stage. More accurate instruments are needed to further research on ON.

LEVEL OF EVIDENCE

V (cross-sectional descriptive study with qualitative analysis).

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.

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

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

The Dark Side of Healthy Eating: Links between Orthorexic Eating and Mental Health

Orthorexia nervosa (OrNe) describes a behavior where eating overly healthy develops into an obsession leading to significant impairment and stress. Initial studies support a bi-dimensional structure of orthorexic eating with one dimension healthy orthorexia (HeOr, interest in healthy eating), which can be distinguished from the dimension OrNe. The present study pursued the goals to examine the negative consequences of OrNe on mental health, whether HeOr buffers these effects, and the role of gender. Data from two cross-sectional online surveys were combined (study 1 n = 385, 310 women; study 2 n = 398, 265 women; mean age: 28.9 ± 12.0 year) both generating data on psychological wellbeing, life satisfaction, stress, anxiety, and depressive symptoms in relation to OrNe and HeOr (Teruel Orthorexia Scale). By means of correlation and moderation analyses, OrNe was shown to be associated with poorer mental health, especially in the female sample. In terms of HeOr, clear gender differences appeared. There were no meaningful correlations in women. In men, however, HeOr correlated with better mental health. Further, the link between OrNe and poorer mental health was mitigated when there were high HeOr levels. Present findings support the hypotheses that OrNe is associated with pathological consequences and that HeOr may act as a buffer for these consequences. Gender differences in the clinical manifestation of orthorexic eating confirm previous knowledge and have important implications for targeted prevention and treatment strategies.

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.

Prevalence of orthorexia nervosa among nutrition students and nutritionists: Pilot study

BACKGROUND/AIMS

Orthorexia Nervosa (ON) is defined as an excessive concern in choosing and preparing of meals according to strict rules. The aims of this study were to determine the prevalence of ON among nutrition students and nutritionists and to identify the related variables affected by the ON tendency.

METHODS

This cross-sectional study was carried out in July and August of 2019 among 421 nutrition students from six universities, in addition to nutritionists in Jordan. Participants completed questionnaire related to individual characteristics and the ORTO-15 scale. Orthorexia Nervosa (ON) tendency was measured using ORTO-15 questionnaire, referring to different diagnostic thresholds (40/35). p < 0.05 was accepted as statistically significant.

RESULTS

Orthorexia had 72.0% prevalence in our sample using the 40-point threshold; the figure was reasonably lower with the 35-point threshold (31.8%). Also, ON tendency was significantly affected by BMI categories (p = 0.007) and gender (p = 0.043) at 35-point threshold. Males have more tendency (39.4%) than females (28.6%) (p = 0.029).

CONCLUSION

The results of this study highlight the magnitude of ON in Jordan. Using cut-off at 35 is preferable than cut-off at 40 to identify factors influencing ON. Moreover, ON tendency is affected by gender and BMI and not affected by educational level.

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.

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.

Food cue-elicited brain potentials change throughout menstrual cycle: Modulation by eating styles, negative affect, and premenstrual complaints

BACKGROUND

While there is evidence for increased food intake and craving during the luteal phase, underlying mechanisms are incompletely understood. The present study investigated electrophysiological responses to food pictures as a function of menstrual cycle phase. In addition, the moderating effects of progesterone, eating behaviors (restraint, emotional, orthorexic), negative affect, and premenstrual complaints were explored.

METHODS

Using a within-subject design, 35 free-cycling women watched and rated pictures of food (high and low caloric) and control items during the follicular, the ovulatory, and the luteal phase (counterbalanced), while EEG was recorded to examine the late positive potentials (LPP). Salivary gonadal hormones and affect were examined at each occasion. Eating behaviors and premenstrual complaints were assessed once.

RESULTS

For parietal regions, average LPPs were comparable between cycle phases but slightly larger LPP amplitudes were elicited by high caloric food pictures as compared to the neutral category. Descriptively, both food categories elicited larger parietal LPPs than neutral pictures during the luteal phase. Analyses of LPPs for central-parietal regions showed no effect of picture category or cycle phase, except higher amplitudes in the right area during the luteal phase. During the luteal phase, progesterone and functional interference from premenstrual symptoms (but not age, BMI, picture ratings, affect, estradiol, or eating behaviors) significantly predicted larger parietal LPPs towards high caloric (but not low caloric) pictures.

CONCLUSION

Our findings suggest a heightened food cue reactivity during the luteal phase, which may relate to higher ovarian hormone secretion and more functional impact of premenstrual symptoms. This research contributes to a better understanding of menstrual health and the identification of preventive strategies for premenopausal women.

Orthorexia Nervosa in China: An Exploration of Phenomenology and Clinical Correlates Among University Students

Orthorexia nervosa, characterized by pathological preoccupation with healthy eating and food purity, is conceptualized as being linked to cultural concepts of health pervasive in contemporary Western societies. However, little is known about the phenomenology and clinical correlates of orthorexia nervosa in non-Western cultures. The current study examined symptoms of orthorexia nervosa, obsessive-compulsive disorder, depression, anxiety, and fear of negative evaluation among 418 Chinese university students. A minority of participants endorsed frequent or impairing orthorexia nervosa symptoms, and females reported slightly higher severity of orthorexia nervosa symptoms than males. Orthorexia nervosa symptom severity was moderately associated with obsessive-compulsive and anxiety symptoms, and weakly associated with depressive symptoms and fear of negative evaluation. Although this study generates initial data about orthorexia nervosa among Chinese students, further research is greatly needed to establish the prevalence and clinical characteristics of orthorexia nervosa in Western and Non-Western cultures.

Validation of the Arabic version of the ORTO-15 questionnaire in a sample of the Lebanese population

PURPOSE

The aim of the study was to develop an Arabic version of the ORTO-15 test and to examine the scale reliability and validity among a sample of the Lebanese population.

METHODS

This was a cross-sectional study, conducted between January and May 2018, which enrolled 806 participants, divided into two equal samples, from all Lebanese governorates. The ORTO-15 scale was used to evaluate orthorexia nervosa (ON) tendencies and behaviors among participants.

RESULTS

The factor analysis conducted on sample 1 suggested a three-factor structure for the ORTO-15 explaining a total of 50.59% of the variance. All items could be extracted from the list; none of the items was removed. The internal consistency of the measurement was adequate (Cronbach's alpha = 0.82). Higher body dissatisfaction (r = - 0.082), higher restrained eating (r = - 0.13) and higher eating attitudes (EAT score) (r = - 0.13) were significantly associated with higher levels of orthorexia tendencies and behaviors (lower ORTO-15 score). We could not detect any significant association between BMI and ORTO-15 test. A confirmatory factor analysis performed on sample 2 supported the three-factor structure of the ORTO-15 test obtained in the first sample. The following results were obtained: the Maximum Likelihood Chi Square = 22.0 and Degrees of Freedom = 9, which gave a × 2/df = 2.4. For non-centrality fit indices, the Steiger-Lind RMSEA was 0.10 [0.040-0.208]. Moreover, the Joreskog GFI equaled 0.926 and AGFI equaled 0.901.

CONCLUSION

The Arabic version of the ORTO-15 test can be used to screen for ON tendencies and behaviors.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Assessing psychological and nutritional impact of suspected orthorexia nervosa: a cross-sectional pilot study

BACKGROUND

To date, research on the dietary patterns of individuals with potential orthorexic symptoms is lacking. This cross-sectional pilot study aimed to explore the feasibility of assessing dietary patterns with psychological traits and states of individuals with possible orthorexic tendencies.

METHODS

Dietary intakes of 10 individuals (two males and eight females) were assessed using 24-h recall. Mean age of participants was 28.3 years; mean body mass index was 21.2 kg m^-2 . Nutrient intakes were compared with current dietary guidelines and the Eatwell Guide (Public Health England, 2016). Participants completed the ORTO-15, the Eating Attitude Test (EAT-26), the Obsessive-Compulsive Inventory-Revised edition (OCI-R), Paulhus's Spheres of Control (SoC), the Rosenberg's Self-Esteem Scale (RSES) and the Multidimensional Body-Self Relations Questionnaire (MBSRQ).

RESULTS

High levels of disparity across participants' psychometric scores and 24-h recall results were observed. There was no single pattern of self-imposed dietary restrictions among participants. Described dietary practices failed to meet the guidelines for several nutrients.

CONCLUSIONS

The results of this pilot study suggest that an extensive investigation of the diets of individuals with possible orthorexic tendencies in a large-scale study would contribute to the understanding of this condition. In addition, the use of multiple psychometric instruments is recommended for diagnosing orthorexic 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.

Orthorexia nervosa: examining the Eating Habits Questionnaire's reliability and validity, and its links to dietary adequacy among adult women

OBJECTIVE

There has been increasing interest in identifying individuals with pathological healthy eating behaviours, or orthorexia nervosa (ON). This study aimed to investigate the validity (construct- and criterion-related) and reliability (internal consistency) of the Eating Habits Questionnaire (EHQ) as a measure of ON. A secondary aim was to examine how the EHQ would predict a distinct feature of ON, adequate dietary intake.

DESIGN

Cross-sectional online questionnaire incorporating existing measures of ON and dietary intake.

SETTING

Participants were recruited online via social media and a university's research webpage.

PARTICIPANTS

Women (n 286) ranging in age from 17 to 73 years.

RESULTS

Exploratory factor analysis established that the EHQ represented four ON dimensions (Healthy Eating Cognitions, Dietary Restriction, Diet Superiority and Social Impairment), inconsistent with the scale's original three dimensions (Problems, Knowledge and Feelings). Cronbach's α coefficients ranged from 0·72 to 0·80 for the four subscales and was 0·89 for the total EHQ scale. Criterion-related validity revealed a significant moderate to strong correlation (r = -0·54, P < 0·001) between the EHQ and ORTO-10 (a ten-item version of ORTO-15). The EHQ, particularly the EHQ-Diet superiority subscale, was found to be predictive of better, as opposed to, poorer dietary adequacy.

CONCLUSIONS

Findings suggest that improvements still need to be made to the EHQ for it to be a valid and reliable measure of ON. Ideally, new assessment tools based on established diagnostic criteria are needed to advance our understanding of ON.

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.

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.

Individuals who self-identify as having "orthorexia nervosa" score in the clinical range on the Eating Attitudes Test-26

PURPOSE

In recent years, there has been growing interest in pathologically healthful eating, often called orthorexia nervosa (ON). Much of the literature in this area has been about point prevalence of ON in particular populations, which range from less than 1% to nearly 90% depending on the study. Despite this interest, there has been no extensive examination of whether those with pathologically healthful eating are detected by screening instruments that identify disordered eating. This study examines whether individuals who self-report suffering from ON score in the clinical range on the 26-item Eating Attitudes Test (EAT-26).

METHOD

Individuals (n = 354) sampled from both clinical and non-clinical settings were administered the EAT-26 to determine whether those who self-identify as having ON scored in a range that suggests disordered eating.

RESULTS

Participants who self-report suffering from ON had a mean EAT-26 score of 30.89 (SD 12.60) scoring in a range that urges individuals to seek additional advice on whether there is an eating disorder present (scores of 20 and higher fall in a range suggesting a possible eating disorder). Furthermore, those in the ON group scored no differently than those reporting other eating disorders, but significantly higher than a non-clinical control group.

CONCLUSIONS

Our findings indicate that a screening instrument for a possible eating disorder is sensitive to pathologically healthful eating (but has no specificity).

LEVEL OF EVIDENCE

Level III, case control analytic study.

Sex differences in orthorexic eating behaviors: A systematic review and meta-analytical integration

OBJECTIVES

Other than the ongoing debate about the epidemiologic and clinical relevance of pathologically healthful eating, a phenomenon called orthorexia nervosa, there is not much consensus about sex differences in prevalence rates. The aim of this study was to provide a systematic review and meta-analytical combination of derived data to better conceptualize the presence and size of sex differences in the prevalence and levels of orthorexic eating behaviors and orthorexia nervosa.

METHODS

Sixty-seven publications were included in the synthesis providing data from k = 89 subsamples (39 255 participants, 67.7% women) for meta-analytical procedures. Separate analyses were conducted for each measurement tool. The impact of four moderators proposed to explain sex differences was examined: sample composition (general population versus special interest in health population; subgroup analysis), and in a meta-regression sample's mean age, year of publication, and sex distribution.

RESULTS

The results showed significant sex differences in only one of four instruments in use. Studies measuring orthorexic behaviors showed that women were significantly more likely to report pathologically healthful eating than men (small effect size). Studies employing tools to assess tendencies toward healthy eating indicated similar levels in women and men. Subgroup and moderator analyses showed comparable effects sizes in general population and high-risk samples, and that the sex difference was inconsistently and minimally related to the sample's mean age, year of publication, or sex distribution.

CONCLUSIONS

The findings indicate that, depending on the instrument in use, tendencies toward healthy eating are comparable between the genders, although pathologically healthful eating is slightly more pronounced in women. Future studies will have to adopt valid criteria for diagnosing Orthorexia nervosa and investigate additional factors contributing to pathologic healthful eating and orthorexia nervosa.

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.

Strict health-oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet

PURPOSE

Although research on vegetarianism is becoming more prevalent, to date, only a few research has been conducted on relationship between vegetarian diet and orthorexia nervosa (ON). The objective of the present study was to examine the orthorexic dietary patterns and eating behaviours among individuals following a vegetarian, vegan, and meat diet. We examined the moderating role of ethical and health reasons for following a meat-free diet on the relation between vegan versus vegetarian diet and eating behaviours and ON. The study aimed to determine the predictors of ON in individuals with differential food preferences.

METHODS

Seventy-nine individuals following a meat-free diet and 41 individuals following an omnivore diet completed the EHQ and the TFEQ-R18.

RESULTS

Our findings indicated that individuals following a vegan diet showed a higher level of knowledge of healthy eating than those who followed a vegetarian diet and those who followed an omnivore diet. Participants maintaining a vegan diet for health reasons were more likely to have greater knowledge about healthy eating. Cognitive restraint was a predictor of ON among a sample following a meat-free diet.

CONCLUSIONS

Our results could contribute to identify potential risk factors for strict health-oriented eating patterns and to gain a better insight into ON.

LEVEL OF EVIDENCE

Level V, descriptive study.

Psychometric properties of the Chinese version of the Düsseldorf Orthorexia Scale: prevalence and demographic correlates of orthorexia nervosa among Chinese university students

PURPOSE

As there is no measure available in Chinese for assessing orthorexia nervosa (ON), and as the Düsseldorf Orthorexia Scale (DOS) has demonstrated to be a valid measure for such a purpose, the current study aimed to obtain a Chinese version of the DOS (C-DOS), to evaluate psychometric properties of the C-DOS in a sample of Chinese university students, and to explore the prevalence of ON among the participants.

METHODS

According to standard procedures, the C-DOS was obtained and administered to 1075 mainland Chinese university students (52.7% female) recruited from two provinces in mainland China. To examine the factor structure of the C-DOS, the total sample was split into two halves, one for exploratory factor analysis, and the other for confirmatory factor analysis. The ordinal alpha and test-retest reliability were examined. Convergent and divergent validity was assessed by conducting Pearson correlation analyses between the C-DOS and other theoretically related/unrelated measures. Prevalence of ON was estimated based on the total score of the C-DOS with the cutoff value of 30.

RESULTS

A three-factor structure was revealed for the C-DOS. The C-DOS showed good internal consistency with an ordinal alpha of 0.80, and it also had good test-retest reliability of 0.77. The total scores of the C-DOS had strong and statistically significant positive correlations with eating inflexibility, while the total scores had weak correlations with other eating disturbances. Strong measurement invariance across gender groups was also supported. The prevalence of ON was 7.8% with males showing higher rates of ON than females (10.6% vs. 5.3%).

CONCLUSIONS

The Chinese version of the DOS (C-DOS) was psychometrically adequate for the sample of Chinese students. Given the high prevalence of ON found in the current study, more attention to ON, as well as further research and potential interventions, are warranted in China.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, Level V.