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

The Psychosocial Aspects of Vegetarian Diets: A Cross-Sectional Study of the Motivations, Risks, and Limitations in Daily Life

INTRODUCTION

The popularity of vegetarian and vegan diets is linked to various motivations, such as health, ethics, ecology, and social and religious influence. India has the highest proportion of vegetarians and vegans. The practise of these diets is linked to moral and health reasons and environmental concerns. Vegetarianism may also be associated with eating disorders such as orthorexia (ON).

AIM

The main aim of this study was to determine the psychosocial aspects of vegetarian diets. Understanding these aspects is crucial for identifying potential risks and developing effective interventions. This study investigated the reasons for following vegetarian diets, the duration of dietary adherence, the occurrence of feelings of restriction in selected situations, and the risk of orthorexia and other eating disorders.

METHODS

A questionnaire survey was conducted among 186 individuals (82 vegetarians and 104 traditional dieters) between October 2023 and April 2024. The survey was administered via a Computer-Assisted Web Interview (CAWI) using Google Forms, distributed through social media, forums, and private messages. The inclusion criteria for the study group included consent, an age over 18, and a vegetarian diet, excluding those with eating disorders or diseases requiring strict diet therapy. The control group criteria were similar, excluding vegetarians and those requiring special diets. Four unreliable questionnaires were excluded from the analysis. The survey consisted of four sections: metric data, the ORTO-15 questionnaire, the EAT-26 questionnaire, and the TFEQ-13 questionnaire.

RESULTS

The main motivations for following vegetarian diets were ethical and environmental (86.9%) and health (32.1%) reasons. Over half of the vegetarians had been following a plant-based diet for over five years. Vegetarians were more likely to feel restricted in restaurants and when grocery shopping. The ORTO-15 results indicate a higher risk of orthorexia among vegetarians (48.8% vs. 29.4% in the control group; p = 0.00673). The EAT-26 questionnaire showed a higher, but not statistically significant, risk of eating disorders among vegetarians (23.8% vs. 14.7%; p = 0.11391). The TFEQ-13 showed no significant differences between groups (Subscale 1: food restriction, p = 0.77279; Subscale 2: lack of control in overeating, p = 0.91935; Subscale 3: eating under the influence of emotions, p = 0.16612).

CONCLUSIONS

This study concluded that ethical and environmental considerations and a belief in health benefits mainly drive vegetarians. An analysis of BMI revealed no significant differences between groups. The ORTO-15 results suggest a higher risk of orthorexia among vegetarians. The EAT-26 indicated a higher, but not statistically significant, risk of eating disorders among vegetarians and vegans. The TFEQ-13 showed no significant differences in restrictive eating, lack of control in overeating, and emotional eating. Vegetarians were likelier to encounter dietary difficulties in restaurants and shopping but less likely to feel socially excluded.

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.

The association between food neophobia, bi-dimensional aspects of orthorexia, and anxiety among vegetarians and omnivores

Vegetarianism is a growing trend, and food neophobia and orthorexia nervosa could act as barriers to achieving a healthy vegetarian diet. The aim of this study is to compare the levels of food neophobia, anxiety, and both healthy and pathological aspects of orthorexia among vegetarians and omnivores. Additionally, the study aims to identify the relationships between food neophobia, anxiety, and orthorexia. In this cross-sectional online survey, a total of 324 vegetarian and 455 omnivores adults participated. The questionnaire consisted of four sections: sociodemographic, lifestyle, and health-related characteristics, the Food Neophobia Scale (FNS), the Teruel Orthorexia Scale (TOS), and the Generalized Anxiety Disorders-7 Scale. Vegetarians exhibited lower FNS scores (p < 0.001) and had higher healthy orthorexic scores (p < 0.001) than omnivores. There were no differences between groups for anxiety scores (p > 0.05). Regression analysis indicated that higher food neophobia (OR: 0.953, 95% CI:0.937-0.968) and TOS-OrNe scores (OR: 0.946, 95% CI: 0.901-0.993) were associated with lower odds of following a vegetarian diet. Conversely, higher TOS-HeOr scores (OR: 1.135, 95% CI:1.096-1.176) were linked to an increased likelihood of adopting a vegetarian diet. Furthermore, both FNS and GAD-7 scores showed negative correlations with TOS-HeOR (r = -0.124, p < 0.001 and r = -0.129 p < 0.001, respectively), and positive correlations with TOS-OrNe (r = 0.106, p < 0.001 and r = 0.146, p < 0.001). In conclusion, vegetarians exhibit lower levels of food neophobia and a greater interest in healthy eating than omnivores. Additionally, the distinct correlation between two dimensions of orthorexia and food neophobia and anxiety provides support for the two-dimensional nature of orthorexia.

The various facets of orthorexic eating behavior: five case reports of individuals with supposed orthorexia nervosa

BACKGROUND

Orthorexia nervosa, defined as a fixation on eating healthy according to subjective criteria, is recently being discussed as another variant of disordered eating behavior. Further characteristics are rigid adherence to nutritional rules, anxieties and avoidance behavior in the context of eating as well as a focus on health, not on body shape or weight loss, which is supposed to differentiate orthorexic from other disordered eating behavior. Although diagnostic criteria have been suggested, they have rarely been used in case reports published to date. Hence, the aim of this study was to present five individuals with supposed orthorexia nervosa, using preliminary diagnostic criteria to assess their eating behavior.

CASE PRESENTATION

The five cases (three females, two males) reveal the great variety of disordered eating behavior. Fear of unhealthy overweight (case A), supposed orthorexic eating behavior as a coping strategy for anorexia nervosa (case B), the exclusive consumption of animal products with a total exclusion of fruits and vegetables (case C), the fixation on exercise and athletic goals (case D) as well as a focus on a vegan diet and unprocessed foods (case E) are facets of orthorexia nervosa with varying degrees of impairment.

CONCLUSIONS

It is concluded that orthorexia nervosa manifests itself in very different ways and that more research is needed in order to determine whether it could be a useful additional category of disordered eating behavior.

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

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

The 26-Item Eating Attitudes Test (EAT-26): Psychometric Properties and Factor Structure in Vegetarians and Vegans

The eating disorder screener, Eating Attitudes Test (EAT), has been used widely; however, its usability in specific dietary groups such as vegetarians and vegans remain unknown. Considering the rising popularity of vegetarianism and veganism, the current study aimed to assess the psychometric properties and theoretical assumptions of the 26-item EAT in separate groups of vegetarians (n = 278), vegans (n = 580), and omnivores (n = 413). Confirmatory factor analysis of four models from previous literature revealed inadequate fit of the data, with the exception of a 16-item four-factor model in vegetarians and vegans. Further assessment of the original three-factor model and 16-item four-factor model demonstrated poor psychometric properties. The primarily inadequate test-retest reliability discovered in this study, independent of whether a shortened version was used, raises concerns around the utility and stability of the EAT-26 in vegetarians and vegans. Future research should potentially investigate novel ways of measuring eating disorder pathology in these groups.

Dietary patterns and eating behaviors on the border between healthy and pathological orthorexia

PURPOSE

The obsession with healthy eating associated with restrictive behaviors is called Orthorexia Nervosa (OrNe). Nevertheless, some studies suggest that orthorexia can also be a non-pathological interest in healthy eating which is called Healthy Orthorexia (HeOr). First, one of the main objectives of this study is to compare HeOr, OrNe and eating behaviors in different dietary patterns (vegan, vegetarian and omnivore). Second is to reveal the relationship between HeOr, OrNe and eating behaviors (cognitive restraint, uncontrolled eating, and emotional eating). Lastly, to determine the potential predictors of HeOr and OrNe.

METHODS

Participants (N = 426 with an omnivorous diet; N = 415 with a vegan diet, N = 324 with a vegetarian diet) completed a web-based descriptive survey, the Teruel Orthorexia Scale and the Three-Factor Eating Questionnaire-R 21.

RESULTS

HeOr and OrNe were more common in individuals following both vegan and vegetarian diets. Individuals following a vegan or a vegetarian diet had lower body mass index and higher body image satisfaction than individuals following an omnivorous diet. Cognitive restraint and following a vegan or a vegetarian diet were the two main predictors of both HeOr and OrNe. Cognitive restraint was positively associated with both HeOr and OrNe (more strongly correlated with OrNe), whereas uncontrolled eating and emotional eating behaviors were positively related to OrNe and negatively related to HeOr.

CONCLUSION

The present study contributes to a better understanding of the some similarities and differences between HeOr and OrNe. It also points to higher rates of orthorexia in individuals following a vegan or vegetarian diet and represents a further step towards developing prevention and intervention programs by identifying risk factors for OrNe. Level V Cross-sectional descriptive study.

A consensus document on definition and diagnostic criteria for orthorexia nervosa

PURPOSE

Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with "correct" eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included.

METHODS

47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A-Definition, Clinical Aspects, Duration; B-Consequences; C-Onset; D-Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants.

RESULTS

27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON.

CONCLUSIONS

This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel.

LEVEL OF EVIDENCE

Level V: opinions of expert committees.

Exploring the association of body mass index, mindful and emotional eating, and orthorexia

BACKGROUND

Orthorexia nervosa (ON) is defined as a fixation on healthy eating behaviours. Research exploring ON and body mass index (BMI) has been inconsistent, with some findings indicating a positive relationship between ON and BMI, while other studies have suggested no relationship. To date, potential associations with emotional and mindful eating have been explored only in a vegan population. The present research adopted an exploratory approach and examined the relationship between orthorexia and BMI, and possible associations with emotional and mindful eating. The potential predictive value of mindful and emotional eating with respect to ON was also explored, while the role of four different types of emotional eating (happiness, sadness, anger, anxiety), utilising an emotional eating scale incorporating positive and negative emotions, was further explored.

PARTICIPANTS AND PROCEDURE

Two hundred and twenty-three participants completed the online survey that was distributed via social media to a British sample.

RESULTS

The findings suggested a negative correlation between ON and BMI. Participants who presented higher levels of orthorexia were more likely to display higher levels of focused eating, a central aspect of mindful eating, as well as lower levels of emotional eating in response to happiness - two elements that further predicted ON in multiple regression models.

CONCLUSIONS

The results suggest a need to conduct further research to explore the possible role of happiness as a potential protective tool against ON, and further suggest the likely negative role of some components of mindful eating in ON. Future directions are discussed in light of the present findings.

Predictors of Orthorexia Nervosa behavior in women within the framework of the theory of planned behavior

PURPOSE

This study aims to examine the predictors of Orthorexia Nervosa behavior in women.

DESIGN AND METHODS

This cross-sectional study was conducted with 418 women of reproductive age in Turkey.

FINDINGS

More positive attitudes towards healthy eating and higher levels of control were significantly associated with more positive intentions. High Orthorexia Nervosa and low control were significantly associated with high body mass index.

PRACTICE IMPLICATIONS

Within the framework of the Theory of Planned Behavior, predictors of Orthorexia Nervosa behavior in women were determined as an attitude towards healthy eating, perceived behavioral control, intention, and body mass index.

Exploring the role of mindful eating and self-compassion on eating behaviours and orthorexia in people following a vegan diet

Orthorexia nervosa (ON) is a new concept that is more prevalent in vegan populations. ON is characterised by obsessive focus on healthy eating, following restrictive dietary practices and dietary restrictions escalating over time. The aim of this study was to explore problematic eating behaviours in a vegan population, and to explore whether mindful eating and self-compassion have an impact on ON. Two hundred and eighty-seven females and twenty-eight males who followed a vegan diet completed scales in Orthorexia, Self-Compassion, Mindful, Emotional, External and Restraint Eating. The results indicated that individuals with high levels of ON display low levels of self-compassion, and high levels of restrained eating. Moreover, the findings indicated that self-compassion, but not mindful eating, partially mediated the relationship between restrained eating and orthorexia nervosa. The present results contribute to a better understanding of orthorexic eating behaviours in a vegan population, and identifies the mediating capacity of self-compassion. Further implications and future directions are discussed.Level of evidence: Level V, cross-sectional descriptive study.

Disordered eating and the meat-avoidance spectrum: a systematic review and clinical implications

PURPOSE

Meat avoidance has long been thought to be related to eating psychopathology; however, research does not necessarily support this notion. Furthermore, commonly used eating disorder scales may be picking up on normal meat-avoiding behaviours in vegetarians and vegans. As such, we systematically reviewed the association between vegetarianism, veganism, and disordered eating, and reviewed the psychometric properties of eating disorder scales for use in these populations.

METHODS

We searched electronic databases MEDLINE, PsychINFO, and CINAHL for literature published until June 2021.

RESULTS

Forty-eight studies met eligibility criteria, with no consensus as to whether meat avoidance was associated with higher rates of disordered eating. Most studies reported a significant positive association with both vegetarianism and veganism, and orthorexia nervosa. Six studies provided evidence for the use of eating disorder measures in vegetarians and vegans, reporting poor psychometric fit among all scales.

CONCLUSION

This systematic review highlights the extent to which vegetarians and vegans have been highly understudied, with limited research suggesting higher levels of orthorexia nervosa behaviours in vegetarians and vegans. Furthermore, our results provide tentative evidence that the factorial validity of commonly used eating disorder scales, such as the EDE-Q, may be poor in vegans.

LEVEL OF EVIDENCE

Level I, systematic review.

Individual differences in selective attentional bias for healthy and unhealthy food-related stimuli and social identity as a vegan/vegetarian dissociate "healthy" and "unhealthy" orthorexia nervosa

Previous work identified the operation of an attentional bias (AB) towards healthy food related stimuli among those with increasing tendencies towards orthorexia nervosa (ON) using a modified Stroop task. The current work aimed to replicate and extend our understanding of this effect by incorporating alternative measures of AB (i.e., the dot probe task) and ON (i.e., the Teruel Orthorexia Scale [ToS]) in a sample of self-defined vegans/vegetarians. The theoretical assertion of the ToS is the conceptual broadening of orthorexia with differentiable dimensions - one characterised as a "healthy" preoccupation with healthy food/eating patterns (HeOr) and the other by a more underlying pathology (OrNe). This study also aimed to examine the pattern of responding across these two dimensions according to factors known to predict ON. Eighty-six participants (mean age = 33.0 years; 20 males, 66 females) completed measures of obsessive compulsivity, perfectionism, state/trait anxiety and ToS as well as a dot probe designed to measure AB for healthy and unhealthy-related food stimuli, threat ratings of each of words utilised and perceived identity centrality as a vegan/vegetarianism. Results showed a dissociation of predicted determinants for "healthy" ON (HeOr) and pathological ON (OrNe). HeOr was predicted by increasing identity centrality whereas OrNe was predicted by increased OCD and perfectionism, and increased interference for healthy-related food words (in particular slowed disengagement) and not unhealthy related food words. Threat-related ratings of unhealthy food words was shown to be common across both dimensions. This pattern highlights cognitive and individual differences-based correlates of pathological and non-pathological ON.

Orthorexia nervosa is a concern in gastroenterology: A scoping review

There is concern that use of restrictive therapeutic diets, such as those used in disorders of the gut-brain interaction (DGBI), may increase disordered eating. In this issue of Neurogastroenterology and Motility, Burton Murray et al. and Peters et al. both demonstrate a high prevalence of disordered eating in patients with gastrointestinal conditions, particularly those with DGBI. Given these findings, it is likely that orthorexia is common in this patient group, although this was not directly examined in these studies. Orthorexia nervosa is described as an obsessive and unsafe focus on eating foods perceived as healthy. This mini-review therefore focuses on orthorexia by conducting a scoping review, as per the PRISMA extension for scoping reviews, aimed to assess the prevalence of orthorexia, and associations between orthorexia and restrictive eating practices. While a wide range of orthorexia prevalence has been reported (0%-97%) across the 57 studies included, no studies assessed prevalence specifically in gastrointestinal conditions. Four of eight studies describing diseases associated with specific dietary patterns suggested that participants who followed a diet for "digestive issues" or "food intolerances" were at higher orthorexia risk. These results suggest that dietary modifications may be a factor contributing to orthorexia. Additionally, we provide a commentary on the clinical implications of the findings for gastrointestinal conditions including a clinical flow chart. Clinicians should consider if a restrictive diet is appropriate for individuals with DGBI and include screening for disordered eating prior to implementation of dietary modifications. Future prospective studies should evaluate orthorexia within this patient group.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

The Spanish Version of the Eating Habits Questionnaire (EHQ-ES) and Its Links to Symptoms and Concerns Characteristic of Eating Disorders among Young Adults

The aim of the study was to investigate the psychometric properties (internal consistency, factor structure, and convergent validity) of the Spanish version of the Eating Habits Questionnaire (EHQ-ES) and its links to disordered eating in young adults. Two university student samples with a total of 487 participants (N1_age = 21.75 ± 5.10; N2_age = 21.17 ± 6.81) participated in the study. They filled out the Eating Habits Questionnaire and the Eating Attitudes Test. Our findings showed that the EHQ-ES demonstrated strong internal consistency, with a Cronbach’s α = 0.903 and ω = 0.939. The EHQ-ES consists of 20 items to measure problems associated with healthy eating (α = 0.855, ω = 0.879), knowledge of healthy eating (α = 0.783, ω = 0.826) and feeling positively about healthy eating (α = 0.775, ω = 0.773). In addition, subscales of the EHQ correlated with subscales of the EAT-26, showing that Orthorexia Nervosa is associated with disordered eating in a sample of university students. The current study is the first to describe a Spanish version of the EHQ. This demonstrates that EHQ-ES is a reliable screening tool for Spanish-speaking young adults. Moreover, the EHQ-ES can be a useful instrument for assessing ON in research and clinical practice.

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.

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.

Specific dietary practices in female athletes and their association with positive screening for disordered eating

BACKGROUND

To determine if following specific diets was associated with reporting behaviors that are consistent with disordered eating compared to non-diet-adherent athletes. We hypothesized that athletes adhering to specific diets were more likely to report disordered eating than those not following a diet.

METHODS

One thousand female athletes (15-30 years) completed a comprehensive survey about athletic health and wellness. Athletes were asked to specify their diet and completed 3 eating disorder screening tools: the Brief Eating Disorder in Athletes Questionnaire, the Eating Disorder Screen for Primary Care, and self-reported current or past history of eating disorder or disordered eating. Descriptive statistics were calculated for all study measures and chi-squared tests assessed relationships between athletes' dietary practices and their responses to eating disorder screening tools. Statistical significance was defined as p < 0.05.

RESULTS

Two hundred thirty-four of 1000 female athletes reported adherence to specific diets. 69 of the 234 diet-adhering athletes (29.5%) were excluded due to medically-indicated dietary practices or vague dietary descriptions. Of the 165 diet-adherent athletes, 113 (68.5%) screened positively to ≥1 of the 3 eating disorder screening tools. Specifically, athletes practicing a low-carbohydrate diet were more likely to report disordered eating vs. athletes without dietary restrictions (80% vs. 41.8%; p < 0.0001).

CONCLUSION

Specific diet adherence in female athletes may be associated with reporting behaviors that are consistent with disordered eating. Health practitioners should consider further questioning of athletes reporting specific diet adherence in order to enhance nutritional knowledge and help treat and prevent eating disorders or disordered eating.

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.

Orthorexic tendencies moderate the relationship between semi-vegetarianism and depressive symptoms

PURPOSE

Vegetarianism and semi-vegetarianism (i.e., overly vegetarian diet with rare consumption of meat) have been repeatedly linked with depression. As the nature of this association is unclear, we explored whether orthorexic (i.e., pathologically healthful eating) tendencies and ecological/ethical motives to follow a vegetarian diet may moderate the relationship between (semi-)vegetarian diets and depressive symptoms.

METHODS

Five-hundred eleven adults (63.4% females; 71.2% omnivores, 19.2% semi-vegetarians, 9.6% vegetarians) completed the Patient Health Questionnaire (PHQ-9) questionnaire-measuring depressive symptoms-and the Düsseldorf Orthorexia Scale (DOS)-measuring orthorexic tendencies. Based on respective questions, participants were categorized as omnivores, semi-vegetarians, and vegetarians (including vegans) and were asked to indicate whether they chose their diet based on ecological/ethical motives. Moderation analyses were carried out with PROCESS.

RESULTS

Adjusted for age, sex, and body mass index, there was a statistically significant interaction effect between diet (omnivore vs. semi-vegetarianism vs. vegetarianism) and DOS scores when predicting PHQ depression scores. At low or medium DOS scores, diets did not differ in PHQ depression scores (all ps > 0.05). At high DOS scores, however, semi-vegetarians had higher PHQ depression scores than both omnivores (p = 0.002) and vegetarians (p < 0.001). The interaction between diet and ecological/ethical eating motives when predicting PHQ depression scores was not statistically significant (p = 0.41).

CONCLUSION

Semi-vegetarians with strong orthorexic tendencies show more depressive symptoms than omnivores and vegetarians. The complex nature of the relationship between vegetarianism and depression requires further investigation.

LEVEL OF EVIDENCE

III, case-control analytic studies.

Efficacy of Popular Diets Applied by Endurance Athletes on Sports Performance: Beneficial or Detrimental? A Narrative Review

Endurance athletes need a regular and well-detailed nutrition program in order to fill their energy stores before training/racing, to provide nutritional support that will allow them to endure the harsh conditions during training/race, and to provide effective recovery after training/racing. Since exercise-related gastrointestinal symptoms can significantly affect performance, they also need to develop strategies to address these issues. All these factors force endurance athletes to constantly seek a better nutritional strategy. Therefore, several new dietary approaches have gained interest among endurance athletes in recent decades. This review provides a current perspective to five popular diet approaches: (a) vegetarian diets, (b) high-fat diets, (c) intermittent fasting diets, (d) gluten-free diet, and (e) low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diets. We reviewed scientific studies published from 1983 to January 2021 investigating the impact of these popular diets on the endurance performance and health aspects of endurance athletes. We also discuss all the beneficial and harmful aspects of these diets, and offer key suggestions for endurance athletes to consider when following these diets.

Vegetarian diet and orthorexia nervosa: a review of the literature

BACKGROUND

The number of individuals following a vegetarian diet has increased in the last 50 years. Although the causal connection between orthorexic behaviors and vegetarianism remains widely assumed, evidence in support of this assumption has been largely inconsistent.

OBJECTIVE

The purpose of the study was to conduct a review of the relationship between vegetarian diet and orthorexic eating behavior and to give future directions in this area.

METHODS

A search of the literature within PubMed/Medline was conducted. The search terms were "orthorexia", "orthorexic", "orthorexia and vegetarian", "orthorexia and vegan" and "orthorexia and vegetarianism". Out of 117 journal articles, 14 met the predefined inclusion criteria and were analyzed.

RESULTS

The results demonstrated that following a vegetarian diet was found to be related to orthorexic eating behaviors (in 11 out of 14 studies).

CONCLUSION

Further longitudinal research is needed to investigate whether following a vegetarian diet serves as a risk factor in the development of orthorexia nervosa.

LEVEL OF EVIDENCE

Level V, narrative review.

Pathological Preoccupation with Healthy Eating (Orthorexia Nervosa) in a Spanish Sample with Vegetarian, Vegan, and Non-Vegetarian Dietary Patterns

Orthorexia nervosa (ON) has been defined as an obsessive and pathological attitude towards healthy nutrition. The aim of this study was to compare individuals who followed a vegan, vegetarian, and omnivore diet in terms of ON behaviors and to examine their prime motivations, attitudes, and behaviors towards food. The Spanish version of the ORTO-15 test — ORTO-11-ES — and the Food Choice Questionnaire (FCQ-SP) were used with a demographic questionnaire in an online survey disseminated among the social networks of different vegetarian associations and the general population. Of 466 individuals, 55% followed an omnivore diet, 23.5% were vegetarian and 21.7% were vegan. Results revealed relationships between type of diet and FCQ-SP dimensions for: health and natural content (H = 8.7, p < 0.05), sensory appeal (H = 11.4, p < 0.01), weight control (H = 40.4, p < 0.01), and familiarity (H = 37.3, p < 0.01). Our results confirm the findings of recent studies showing that individuals who follow a vegan or vegetarian diet are more likely to develop a pathological preoccupation with healthy eating versus omnivores. Further studies are required to determine the potential lines of action for the prevention of ON.

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

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

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.

The inter-relationship between diet, selflessness, and disordered eating in Australian women

Personality traits and diet can be used to predict if a person is predisposed to disordered eating. Results of this study demonstrate a strong significant relationship between the personality trait of selflessness, diet group, and disordered eating. Vegans were most likely to display selflessness tendencies associated with disordered eating; however when selflessness was controlled for, vegans displayed substantially less disordered eating pathology than non-vegetarians.

OBJECTIVE

To explore the relationship between diet group (non-vegetarian, semi-vegetarian, true-vegetarian, and vegan) and disordered eating while investigating to what extent personality trait of selflessness mediates the relationship between diet group and disordered eating.

METHOD

Cross-sectional data from 634 Australian nonclinical women who completed a series of online questionnaires including measures of diet group, disordered eating, and selflessness were used to examine associations between diet, personality (selflessness), and disordered eating.

RESULTS

Selflessness was found to be a significant positive predictor of disordered eating. Results confirm that selflessness played a suppressing role in the relationship between the vegan diet group and disordered eating, when compared to non-vegetarians. Surprisingly, vegans displayed significantly less disordered eating than non-vegetarians and semi-vegetarians.

DISCUSSION

Results of the current study imply that the role of selflessness on disordered eating, when broken down across diet group, may be more complex than first thought. If replicated, these results suggest that targeted treatment of selflessness in different diet groups may improve treatment outcomes for disordered eating. Further research should explore why diet groups differ in terms of selflessness and how this impacts disordered eating.

Examining vegetarianism, weight motivations, and eating disorder psychopathology among college students

OBJECTIVE

Previous research has suggested a link between vegetarianism, broadly defined, and symptoms of eating disorders (ED). However, the literature supporting this link is mixed and limited by possible measurement artifacts. Using data from a national sample of college students, the present study examines ED symptomatology among three groups: (a) vegetarians whose meat avoidance is motivated by weight concerns; (b) non-weight motivated vegetarians; and (c) nonvegetarians.

METHOD

Participants include 9,910 students from 12 colleges and universities across the United States who participated in the web-based Healthy Bodies Study. ED symptomatology was measured using the Short-Eating Disorder Examination-Questionnaire (S-EDE-Q). First, multi-group confirmatory factor analysis was conducted to test measurement invariance (MI) of the S-EDE-Q across weight-motivated vegetarians, non-weight-motivated vegetarians, and nonvegetarians. Gender- and BMI-adjusted ANCOVA was used to compare S-EDE-Q scores across groups.

RESULTS

9.3% of participants were vegetarian. Cis-women and gender minority students were more likely to be vegetarian; those who became vegetarians after entering college were more likely to report weight-related motivations. Strict MI was supported for the S-EDE-Q global and subscale scores. Weight-motivated vegetarians reported higher levels of restraint, shape/weight overvaluation, body dissatisfaction, and global ED psychopathology relative to other participants.

DISCUSSION

To our knowledge, this is the first to explicitly link weight motivations for vegetarianism to ED psychopathology in a large, representative sample of young adults. Results suggest that students presenting with ED symptoms should be assessed for their motivations for adopting a vegetarian diet, and this information should be considered in treatment decisions.

Restrained Eating and Vegan, Vegetarian and Omnivore Dietary Intakes

There are a significant number of studies on cognitive restraint among individuals with varying dietary patterns. Although most research has found that vegetarians report higher levels of cognitive restraint compared to non-vegetarians, many studies have contributed inconsistent results. The aim of the current study, therefore, was to assess any differences between groups with varying dietary patterns on cognitive restraint and other disordered eating pattern. The second objective was to examine determinants of cognitive restraint in individuals adhering to a vegan diet, a vegetarian diet and an omnivore diet. Two-hundred and fifty-four participants with varying dietary patterns completed the Three-Factor Eating Questionnaire, the Perseverative Thinking Questionnaire and the Eating Habits Questionnaire. Our results indicated that both vegetarian and vegan groups showed a significantly lower cognitive restraint, lower emotional eating and lower uncontrolled eating than those who followed an omnivorous diet. In addition, these both groups following a plant-based diet have shown more cognitions, behaviours and feelings related to an extreme focus on healthy eating (orthorexia nervosa) than group following an omnivorous diet. There were no significant differences between the groups in perseverative thinking. Core characteristics of repetitive negative thinking was a significant predictor of cognitive restraint in vegans. Feeling positively about healthy eating predicted cognitive restraint among vegetarians. Problems associated with healthy eating and feeling positively about healthy eating predicted cognitive restraint among individuals following an omnivorous diet. Knowledge of predictors of cognitive restraint may serve as a psychological intervention goal or psychoeducation goal among individuals with varying dietary patterns.

Orthorexic eating behavior in vegans is linked to health, not to animal welfare

PURPOSE

This study aimed to analyze the association between the importance of several reasons to follow a vegan diet and the degree of orthorexic eating behavior in a sample of vegan individuals (N = 65, 53.8% women, age: M = 28.22 (SD = 9.13) years, BMI: M = 22.91 (SD = 3.44) kg/m²).

RESULTS

The results reveal that orthorexic eating behavior is associated with the importance of the underlying motives health, esthetics and healing, whereas animal welfare, politics and ecology are not linked to orthorexia.

CONCLUSION

Hence, this study reveals that a vegan lifestyle is not per se associated with orthorexic eating behavior, but rather that it varies with the underlying motivation for following a vegan diet.

Orthorexia Nervosa, a challenging evaluation: analysis of a sample of customers from organic food stores

An excessive control of quality of food can turn into Orthorexia Nervosa (ON). The organic store customers (OSCs) can be apopulation at risk for ON. The aims of this study were to assess ON symptoms prevalence among them, comparing them with non-OSCs and investigate potential predictors of ON. Across-sectional survey was carried among 121 OSCs and 119 non-OSCs. The questionnaire assessed socio-demographic characteristics and investigated current dietary habits. The main outcome measures used were ORTO-15 and Eating Habits Questionnaire (EHQ). Chi-squared analyses were performed to assess differences between groups (OSCs and non-OSCs). Logistic and linear regressions were performed to evaluate potential predictors of ON symptoms and to compare questionnaires. As main results, OSCs had ahigher probability to result positive at ORTO-15 compared to non-OSCs. The prevalence among OSCs was 69.4% and 23.1% (using ORTO-15 with 40 and 35 cut-offs). Higher EHQ scores were reported among OSCs (p < 0.001). Potential predictors were mainly being an OSC or following food restrictions. Predictors varied using different cut-offsof ORTO-15 and EHQ. These results suggest the association between OSCs and ON symptoms. Some differences were found between ORTO-15 and EHQ. Further studies need to be performed to improve diagnostic tools.

Veganism, aging and longevity: new insight into old concepts

PURPOSE OF REVIEW

Plant-based diets are associated with better health and longevity. Veganism is a strict form of vegetarianism, which has gained increasing attention in recent years. This review will focus on studies addressing mortality and health-span in vegans and vegetarians and discuss possible longevity-enhancing mechanisms.

RECENT FINDINGS

Studies in vegans are still limited. Epidemiologic studies consistently show lower disease rates, such as lower incidence of cancer and cardiovascular disease, but mortality rates are comparable with rates in vegetarians and occasional meat eaters. Reasons for following strict vegan diets differ, which may affect diet quality, and thus health and life-span. New insights into some characteristics of veganism, such as protein restriction or restriction in certain amino acids (leucine or methionine) show potentially life-span-enhancing potential. Veganism improves insulin resistance and dyslipidemia and associated abnormalities. Gut microbiota as mediator of dietary impact on host metabolism is more diverse in vegans and has been suggested to be a health-promoting factor. Vegan diets do not fulfill the requirements of children, pregnant women or old individuals who should receive adequate supplements.

SUMMARY

There is substantial evidence that plant-based diets are associated with better health but not necessarily lower mortality rates. The exact mechanisms of health promotion by vegan diets are still not entirely clear but most likely multifactorial. Reasons for and quality of the vegan diet should be assessed in longevity studies.

Interaction between Vegetarian Versus Omnivorous Diet and Unhealthy Eating Patterns (Orthorexia Nervosa, Cognitive Restraint) and Body Mass Index in Adults

The objective of the present study was two-fold: Firstly, to investigate unhealthy eating patterns and body mass index among individuals following a vegetarian diet and those following an omnivorous diet. Secondly, to examine interaction between vegetarian versus omnivorous diet and unhealthy eating patterns (orthorexia nervosa, cognitive restraint) and body mass index using a structural equation modeling approach (SEM). The study included 370 participants: 188 participants following a vegetarian diet and 182 following an omnivorous diet. Unhealthy eating patterns and body mass index were measured. Our results showed that individuals following a vegetarian diet were more likely to engage in orthorexic eating behavior compared to individuals following an omnivorous diet. In addition, they had a significantly lower levels of cognitive restraint and lower body mass index than individuals following an omnivorous diet. Use of SEM method showed that: (1) following a vegetarian diet and orthorexia nervosa were directly associated, (2) following an omnivorous diet and cognitive restraint were directly related and (3) following an omnivorous diet had a greater tendency to cognitive restraint and an elevated body mass index. More research is necessary to further understand the complexity of the relationship between type of diet and unhealthy eating patterns in adults.

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.

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.

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.

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.