Correlates of orthorexia nervosa among a representative sample of the Lebanese population

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.

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).

Prevalence of Orthorexic Tendencies and Their Correlates Among Lebanese Patients with Cancer

Individuals with cancer face daily challenges regarding diet and healthy lifestyle behaviors that may lead them to better health. This quest for improved health can be exaggerated in unhealthy ways if it is not approached with moderation as occurs with a condition called orthorexia nervosa (ON). Our aim in this study was to determine the prevalence of ON tendencies and their behavioral correlates among Lebanese adults with cancer. This was a monocentric cross-sectional study, conducted between December 2021 and February 2022, involving 366 patients. We collected data via telephone and recorded answers online on a Google form. We used the Düsseldorf Orthorexia Scale (DOS) to assess orthorexic behaviors, and we checked for behavioral correlates of orthorexia through a linear regression model using the DOS score as the dependent variable. On the DOS scale, we found that 9% of these participants showed possible ON tendencies, whereas 22.2% had definite ON tendencies. Factors associated with having more ON tendencies were (a) receipt of hormonotherapy, (b) being female and (c) having breast cancer. Having prostate cancer was significantly associated with fewer ON tendencies. Our results should help improve the management of patients with cancer through programs to increase patient awareness and education.

Exploring the relationship between dysfunctional metacognitive processes and orthorexia nervosa: the moderating role of emotion regulation strategies

BACKGROUND

Dysfunctional metacognitive processes and emotional dysregulation have been widely documented in the eating disorder literature. Despite numerous research and recent consensus suggesting the categorization of orthorexia nervosa as a form of eating disorder, no previous study has examined whether aberrant metacognitive processes also correlate with orthorexia nervosa tendencies. This paper investigates potential associations between symptoms of orthorexia nervosa and dysfunctional metacognitive processes while also exploring whether such relationships may be influenced by adaptive/maladaptive emotion regulation strategies.

METHODS

We conducted a cross-sectional study in all Lebanese governorates. In total, 423 Lebanese adults completed an online questionnaire including the Teruel Orthorexia Scale, the Emotion Regulation Questionnaire, the Difficulties in Emotion Regulation Scale - 16 Item Version, and the Metacognitions Questionnaire - Short Form.

RESULTS

Higher physical activity, expressive suppression, emotion regulation difficulties, positive metacognitive beliefs about worry, and need to control thoughts were significantly associated with higher orthorexia nervosa. Additionally, the emotion regulation strategies moderated the relationships between two dysfunctional metacognitive processes and orthorexia nervosa. Specifically, cognitive self-consciousness was negatively related to orthorexia nervosa only in individuals with low (versus higher) emotion suppression (maladaptive emotion regulation strategy). In contrast, negative beliefs about worry uncontrollability and danger positively predicted orthorexia nervosa only in individuals with lower (versus high) cognitive reappraisal (adaptive emotion regulation strategy). Lower socio-economic status and having a university level of education compared to secondary level were significantly associated with lower orthorexia nervosa.

CONCLUSION

Our study provides the first empirical evidence for the existence of significant associations between dysfunctional metacognitive processes and orthorexia nervosa. It also highlights that these pathways are considerably modulated by individuals' ability to regulate their emotions adaptively versus maladaptively. Our findings thus suggest that therapies aimed at improving thought monitoring and emotional regulation may be beneficial for individuals with symptoms of orthorexia nervosa.

Psychometric properties of Turkish Orthorexia Nervosa Inventory in a clinical adolescent sample

PURPOSE

Orthorexic tendencies are increasingly prevalent among children and adolescents. This study set out to investigate the reliability and validity of the Turkish version of the Orthorexia Nervosa Inventory (ONI) in a clinical adolescent sample.

METHODS

266 adolescents aged 12-18 years, who applied to the Department of Child and Adolescents Psychiatry were included in the study. Participants completed sociodemographic data form, ONI, Eating Attitude Test, Revised Child Anxiety and Depression Scale-Child Version and ORTO-15.

RESULTS

The Cronbach's alpha coefficient for the ONI reached 0.92, indicating very good internal consistency. Total factor scores and Cronbach alpha values for behaviors, impairments, and emotions were found to be 0.84, 0.84, and 0.83, respectively. The CFA performed supported the three-factor structure of the ONI obtained in the first sample. The minimum discrepancy per degree of freedom = 1.89 and the model generally fit well to the structure (RMSEA = 0.058, SRMR = 0.033, CFI = 0.92, TLI = 0.91).

DISCUSSION

This study has shown that the Turkish version of the ONI is a valid and reliable scale for specifying the tendency for Orthorexia Nervosa in a Turkish adolescent population. These findings contribute in several ways to our understanding of orthorexic tendencies and provide a basis for more concrete research data that can be obtained by using the ONI, which is a reliable scale in studies to be conducted among adolescents.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Psychometric properties of an Arabic translation of the Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) in a community sample of adults

BACKGROUND

No epidemiological data is yet available on Avoidant/Restrictive Food Intake Disorder (ARFID) in Arab countries, which may in part be due to the lack of measures available in Arabic language. This constitutes a major obstacle to further progress of our understanding of the nature, aetiology, course, treatment, and prevention of ARFID, especially as some evidence suggested that ARFID may vary across cultures and food environments. We aimed to contribute to the literature in the eating disorders field by examining the psychometric properties of an Arabic translation of the Nine Item ARFID Screen (NIAS).

METHOD

This was a cross-sectional, web-based study. A total of 515 Lebanese community adults (mean age of 27.55 ± 10.92 years, 69.9% females) participated. The forward-backward method was adopted to translate the NIAS from English to Arabic.

RESULTS

Confirmatory Factor Analyses provided evidence for the adequate fit indices for the three-factor model (i.e., Picky eating, Fear, and Appetite) and the 9-item version of the NIAS. An adequate reliability of the Arabic NIAS was achieved, with McDonald's ω ranging from .75 to .90 for the total score and all three subscores. Multi-group analyses demonstrated measurement invariance by sex (males vs. females) and weight groups (underweight/healthy weight [BMI ≤ 25] vs. overweight/obese [BMI > 25]) at the configural, metric, and scalar levels. Adequate patterns of correlations between the NIAS and measures of disordered eating symptoms, psychological distress and well-being were seen. In particular, fear was significantly associated with non-ARFID disordered eating symptoms. Appetite and Picky eating, but not Fear, were inversely correlated with well-being. All three NIAS subscores and the total score were positively correlated with psychological distress.

CONCLUSION

Findings provided evidence that the Arabic NIAS is a short, valid and reliable self-report measure to screen for ARFID symptoms. In light of these findings, we recommend its use for clinical and research purposes among Arabic-speaking adults.

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.

Too healthy for their own good: orthorexia nervosa and compulsive exercise in the community

BACKGROUND

The similarities and differences between orthorexia nervosa symptoms (ONs) and the symptoms and correlates of eating disorders listed in the DSM-5 need to be elucidated. ONs were examined in a volunteer community sample in conjunction with compulsive exercise, disordered eating, as well as emotional and behavioral correlates of eating disorders.

METHODS

Participants were 561 adult volunteers (93 men, 17.09%) aged 19-72 (M = 32.7 ± 11), recruited via social media networks. Participants self-reported on the following measures online: Düsseldorf Orthorexia Scale, Compulsive Exercise Test, Retrospective Child Feeding Questionnaire, Experiences in Close Relationships, Difficulties in Emotional Regulation Scale, Toronto Alexithymia Scale, and Eating Disorder Examination Questionnaire 13. Data were downloaded and analyzed in SPSS26 and Amos26.

RESULTS

A theoretical model of the connections between the study variables was tested via SEM and confirmed. The profiles of participants with high, average and low levels of ONs were compared. Participants with the highest levels also scored highest for compulsive exercise, insecure attachment, alexithymia, emotion regulation difficulties, weight and shape concerns, body dissatisfaction, restriction, bingeing, purging and parental feeding practices of concern about child's weight and restricting and monitoring the child's intake of calorie-rich foods.

DISCUSSION

High levels of ONs are related to disordered eating attitudes and behaviors, as well as to emotional and behavioral correlates of eating disorders. It is unclear to what extent these ONs are distinguishable from symptoms of other eating disorders listed in the DSM-5. Longitudinal studies may help to elucidate distinct trajectories and risk factors for ON.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Nutrition knowledge, diet quality and orthorexic behaviors in Polish students-a pre-post repeated cross-sectional study

Nutrition knowledge acquired in college students may not only help in promoting an adequate diet, but also lead to excessive preoccupation with healthy eating, which is referred to as orthorexic behaviors. This study aimed to assess the relationship between nutrition knowledge, diet quality and orthorexic behaviors among college students of food and nutrition majors. Data were collected from a sample of 131 college students through a pre-post repeated cross-sectional study conducted from 2018 to 2021. The participants were asked to complete the ORTO-6 questionnaire, the nutrition knowledge test "GAROTA", and the Beliefs and Eating Habits Questionnaire (KomPAN). The results indicated that students' preoccupation with healthy eating (orthorexic behaviors score) during the study period did not change, in contrast nutrition knowledge and diet quality increased. There was no correlation between the orthorexic behaviors score and the nutrition knowledge score, both at the beginning and end of the study. At the beginning of the study, the orthorexic behaviors score correlated positively with "Pro-Healthy Diet Index" and "Diet-Quality Index", and inversely with "Non-Healthy Diet Index". However, at the end of the study, no significant correlations were observed between these variables. It can be concluded that nutrition knowledge determined positively the quality of the diet of students in food and nutrition majors, while did not affect the occurrence of orthorexic behaviors.

Attachment styles and orthorexia nervosa among Lebanese adolescents: The indirect effect of self-esteem

BACKGROUND

Orthorexia nervosa (ON), defined as the pathological obsession for pure foods, remains a novelty in the field of eating disorders. Many studies in the literature have shown that attachment styles correlate with the development of eating disorders. Patients with eating disorders were found to be more avoidant and anxious and less secure than individuals who do not have eating disorders. However, studies on the relationship between attachment styles and ON remain limited, particularly in adolescents. This study assessed the relationship between attachment styles and ON in Lebanese adolescents (15-18 years), along with evaluating the indirect effect of self-esteem on this association.

METHODS

This study used a cross-sectional design and was carried out during May-June 2020 with 555 students (15-18 years) enrolled. The Düsseldorf Orthorexia Scale was utilized to screen for ON tendencies. A linear regression was conducted taking the DOS score as the dependent variable. The PROCESS Macro was used to test the indirect effect of self-esteem between attachment styles and ON.

RESULTS

Higher fearful and preoccupied attachment styles, female gender, and more physical activity were significantly associated with more ON tendencies, whereas higher self-esteem was significantly associated with less ON tendencies. When adjusting for all sociodemographic characteristics and other attachment styles, none of the attachment styles remained significantly correlated with ON tendencies. Self-esteem mediated the association between secure attachment style and ON and between dismissive attachment style and ON.

CONCLUSIONS

The rise in ON warrants further studies and investigations to raise awareness and plan behavioral interventions in order to treat it.

Validation of the Arabic version of the Muscle Dysmorphic Disorder Inventory (Ar-MDDI) among Lebanese male university students

BACKGROUND

To date, the vast majority of research on disordered eating symptomatology and body image disturbances from the Arab world have been performed exclusively among women; and mainly used thinness-oriented measures that are not sensitive to detect muscularity-oriented symptoms, which are more evident in males. Therefore, the objective of our study was to validate the Arabic version of the Muscle Dysmorphic Disorder Inventory (Ar-MDDI), in order to make it accessible for Arabic-speaking populations.

METHODS

Using a snowball sampling technique, men university students (n = 396) from multiple universities in Lebanon filled the survey in this cross-sectional designed study (January-May 2022). A soft copy of the questionnaire was created using google forms software, and sent to participants through the different social media platforms such as Facebook, Instagram, and WhatsApp. We used the Muscle Dysmorphic Disorder Inventory to assess Muscle Dysmorphia, along with the Big Three Perfectionism Scale to assess perfectionism and Eating Attitude Test (EAT) to evaluate the inappropriate eating attitudes. To explore the factor structure of Ar-MDDI, we computed a principal-axis Exploratory Factor Analysis (EFA) with the first split-half subsample using the FACTOR software. We used data from the second split-half to conduct a Confirmatory Factor Analysis (CFA) using the SPSS AMOS v.29 software. Pearson correlation test was used to test the convergent and divergent validity of the Ar-MDDI scale with the other scores included in the study.

RESULTS

The results of the EFA revealed three factors, which explained 57.68% of the common variance: Factor 1 = Appearance intolerance, Factor 2 = Drive for size, and Factor 3 = Functional impairment. The CFA fit indices of the three-factor model of the Ar-MDDI scale showed good results. Moreover, 254 (64.1%) of the participants had inappropriate eating attitudes (EAT scores ≥ 20). Indices suggested that configural, metric, and scalar invariance was supported according to eating attitudes. No significant difference between participants with appropriate versus inappropriate eating attitudes in terms of functional impairment, drive for size and appearance intolerance. Perfectionism scores correlated positively with the Ar-MDDI, which suggests divergent validity.

CONCLUSION

Our findings revealed that the validation of the Arabic scale yielded excellent properties, preliminarily supporting its use for the assessment of muscle dysmorphia among Arabic-speaking university men. This would hopefully allow for its timely detection and management in Arab clinical settings and encourage cross-cultural research on this topic.

The indirect role of orthorexia nervosa and eating attitudes in the association between perfectionism and muscle dysmorphic disorder in Lebanese male University students - results of a pilot study

BACKGROUND

The literature highly concentrates on disorders related to body image among women but only minimally when it comes to the male population; hence, in order to provide general practitioners, and primary care physicians in general, and psychiatrists in particular, with additional information concerning muscle dysmorphia among male university students in Lebanon, this study seemed essential, and was therefore conducted to (1) identify the prevalence of MDD, and (2) evaluate the indirect effect of eating attitudes in general and orthorexia nervosa in particular, in the association between perfectionism and muscle dysmorphic disorder (MDD) among a sample of male university students.

METHODS

In this cross-sectional study conducted between September 2021 and May 2022, 396 male university students from multiple universities in Lebanon filled the online Arabic questionnaire.

RESULTS

The results showed that 26 (6.6%) of the participants had MDD. Orthorexia nervosa and eating attitudes mediated the association between perfectionism and MDD; higher perfectionism was significantly associated with higher ON and more inappropriate eating; higher ON and more inappropriate eating were significantly associated with higher MDD, whereas perfectionism had a significant total direct effect on MDD. The high prevalence of MDD among male university students in Lebanon implies further investigation on the national level in the country.

CONCLUSION

Awareness campaigns among the university students could be adopted at the national level to increase the level of knowledge on the concepts of obsessive self-destructive perfectionism, orthorexia nervosa and muscle dysmorphia.

Translation and validation of the Chinese version of the orthorexia nervosa assessment questionnaires among college students

PURPOSE

The main objective of the study was to translate, validate, and compare the Chinese ORTO scales (ORTO-15 and ORTO-R). The secondary objective was to assess factors that may be related with risk of orthorexia nervosa (ON).

METHODS

Two cross-sectional surveys were conducted on March-to-June 2021 for ORTO-15 and April 2022 for ORTO-R. ORTO questionnaires were translated into Chinese using the forward-backward-forward method. Exploratory factor analysis (EFA), discriminant validity and confirmatory factor analysis (CFA) were used to examine the construct validity of the questionnaires. The internal consistency was assessed using the Cronbach alpha coefficient and the test-retest reliability. Multivariate linear regression analysis was used to explore potential factors related with ON scores.

RESULTS

Totally, 1289 and 1084 eligible participants were included for assessment of ORTO-15 and ORTO-R, with the mean age of 20.9 ± 2.0 years and 21.0 ± 2.3 years. The internal consistency of Chinese ORTO-15 scale and ORTO-R scale were both satisfactory (α = 0.79, ICC = 0.79; α = 0.77, ICC = 0.82). However, all ORTO-15 models showed a poor fit using CFA whereas the ORTO-R was characterized by acceptable goodness-of-fit. Multivariate linear regression indicated that physical activities and mental disorders were positively associated with ON risk assessed by both ORTO-R and ORTO-15.

CONCLUSION

The Chinese ORTO-R scale was a more reliable tool to screen for ON tendencies than the Chinese version of ORTO-15. Mental disorders and physical activities might be associated with the increased ON risk.

LEVEL OF EVIDENCE

Level V (descriptive cross-sectional study).

Association between the bi-dimensional aspect of orthorexia and healthy behaviors among lebanese adolescents

BACKGROUND

Recently, there has been a blooming focus on "eating healthy and clean", with the ideal of being healthy becoming a popular lifestyle trend. Previous research suggested the presence of two forms of orthorexia: Orthorexia Nervosa (OrNe) and Healthy Orthorexia (HeOr). Taking into consideration that orthorexia thoughts are led by the desire to reach an optimal physical health, the dedication to a healthy living may require healthy lifestyle habits: smoking cessation, moderate alcohol intake, and increased physical activity. The main study aim was to determine, among Lebanese adolescents, the association between healthy behaviors and the two likely forms of orthorexia (OrNe and HeOr), given that the adolescent phase is a risky period in the development of eating disorders.

METHODS

A cross-sectional study, conducted between January and April 2022, enrolled 444 adolescents aged between 14 and 18 years, with an equitable random sample from all the Lebanese governorates (mean age 16.23 ± 1.15 years; 60.1% females). The Teruel Orthorexia Scale (TOS) was used to assess orthorexic eating tendencies. The Lebanese Waterpipe Dependence Scale, the Fagerström Test for Nicotine Dependence and the Alcohol Use Disorder Identification Test scales, all validated in adolescents, were used to evaluate the association between orthorexia and healthy behaviors.

RESULTS

Higher TOS OrNe scores were significantly and highly correlated with the TOS HeOr scores (r = 0.68; p < 0.001). In the bivariate analysis, waterpipe smoking was weakly but significantly associated with more OrNe, whereas more physical activity was significantly and moderately associated with more HeOr. After adjusting over all sociodemographic characteristics, other behaviors and the other dimension of orthorexia, more alcohol use disorder was significantly but strongly associated with higher OrNe, whereas more physical activity remained significantly associated with higher HeOr.

CONCLUSION

In light of our results, OrNe and HeOr might be considered as different entities, mainly in their associations with alcohol consumption and physical activity. This supports the hypothesis of OrNe being a new form of eating disorder, whereas HeOr possibly showing protective characteristics. Orthorexia is still a topic of controversy, especially in the probable presence of two facets that are still difficult to differentiate.

Association between religiosity and orthorexia nervosa with the mediating role of self-esteem among a sample of the Lebanese population - short communication

BACKGROUND

Orthorexia Nervosa is not yet classified as an eating disorder albeit it can be found in different populations. This condition can be characterized by a preoccupation with the quality of food, accompanied by obsessive thoughts regarding eating behaviors, leading to malnutrition. Previous associations have been reported between high levels of eating disorders and lower levels of self-esteem; where individuals have low self-esteem due to the pressured felt to fit the norms of society in beauty standards. The aim of the present study was to evaluate the relationship between religiosity and orthorexia nervosa via either trait or state self-esteem.

METHODS

This study was conducted between September 2021 and February 2022 and included 428 participants from all Lebanese governorates. The Teruel Orthorexia Nervosa scale was used to measure orthorexia nervosa. The following scales state self-esteem and religiosity were used to measure self-esteem.

RESULTS

Sociodemographic characteristics (age, gender, marital status, household crowding index, body mass index and education) were entered in the mediation model as confounding variables. Higher religiosity was significantly associated with higher state self-esteem (Beta = 0.07), while higher state self-esteem was significantly associated with lower identification of those that exhibited ON tendencies or symptoms (Beta= -0.11).

CONCLUSION

A high state self-esteem was correlated with a lower level of orthorexia nervosa. Higher religiosity was shown to be associated with higher self-esteem, which in turn was associated with a decrease in the scores of orthorexia nervosa.

The effect of orthorexia nervosa on food label reading habits among university students

PURPOSE

This observational cross-sectional study aimed to evaluate university students' food label reading habits with and without orthorexia nervosa (ON) tendency.

METHODS

Data were collected online with a questionnaire. The questionnaire form included sociodemographic variables, the ORTO-11 scale, the reading frequency of some components on the food label, and the evaluation of some opinions about the food label. The obtained data were evaluated with SPSS 25.0 statistical package program and GraphPad Prism program.

RESULTS

A total of 674 university students (mean age: 21.03 ± 2.43 years), 537 women (79.7%) and 137 men (20.3%) were included in the study. It was determined that individuals with ON tendency read some nutrients, content information, serving size, health information, instructions for use, additives and brand more frequently compared to individuals without ON tendency (p < 0.05). At the same time, it was determined that individuals with ON tendency were more likely to agree with the idea that reading food labels is important for a healthy diet, compared to individuals with normal eating behavior (p < 0.001).

CONCLUSION

The study findings show that individuals with ON tendency have a higher habits of reading food labels compared to individuals with normal eating behavior. To reach a decision on this issue and to determine the diagnostic criteria for ON, future studies should be conducted on different groups and samples with higher participation, as well as studies using different screening tools to determine the tendency for ON.

LEVEL OF EVIDENCE

V, Cross-sectional descriptive study.

Validation of the Arabic version of the ORTO-R among a sample of Lebanese young adults

BACKGROUND

Within the literature, there is a variety of different measurement methods for orthorexic behaviours. The ORTO-15 is the one that attracted most research attention. Many scholars criticized the ORTO-15 for its unstable factor structure and over-estimation of the prevalence of orthorexia nervosa. For this purpose, Rogoza and Donini (Eat Weight Disord 26:887-895, 2020) re-assessed the original data and created a new tool, ORTO-R. The development of the ORTO-R theoretically solved many ambiguities associated with its parent measure. However, to date, no study, including the original one, tested the validity of the ORTO-R, leaving its utility somewhat speculative.

METHODS

We gathered data from 363 Lebanese individuals, who answered the ORTO-R questions and a set of measures used to determine the validity of the scale (eating attitudes, perfectionism, body dissatisfaction, self-esteem, anxiety, and depression). Within this study, we analysed the internal consistency of the scale and different aspects of its validity (factorial, convergent, and divergent).

RESULTS

Results supported all expectations; we successfully confirmed a one-factor measurement model of the ORTO-R, which appeared to be internally consistent. The ORTO-R score correlated positively to other orthorexic behaviours as well as to disordered eating attitudes, perfectionism, anxiety, and depression. It was also negatively related to self-esteem, but was unrelated to body dissatisfaction.

CONCLUSION

The ORTO-R may be deemed as a valid instrument for the assessment of orthorexic behaviours.

LEVEL OF EVIDENCE

V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Any overlap between orthorexia nervosa and obsessive-compulsive disorder in Lebanese adults? Results of a cross-sectional study and validation of the 12-item and 4-item obsessive-compulsive inventory (OCI-12 and OCI-4)

BACKGROUND

Orthorexia Nervosa (ON), a compulsive obsession with vigorous eating, has increasingly caught researchers' attention. Although Orthorexia Nervosa has not been labeled an eating disorder, research about ON highlighted a strong link with anorexia nervosa or obsessive-compulsive disorder (OCD). Therefore, this study aimed to (1) validate the Arabic version of the Obsession-Compulsion Inventory (OCI-12 and OCI-4) and (2) check if there is an overlap between ON and OCD among a sample of Lebanese adults.

METHODS

This cross-sectional study involved 487 Lebanese participants between July and August 2021. The Dusseldorf Orthorexia Scale (DOS) was used to assess ON; scores between 25 and 29 indicate probable ON, whereas scores ≥ 30 indicate ON tendencies. A confirmatory factor analysis (CFA) was carried out using SPSS AMOS v.24 on the OCI-12 and OCI-4 scales' items. The root mean square error of approximation (RMSEA) statistic, the Tucker Lewis Index (TLI) and the comparative fit index (CFI) were used to evaluate the goodness-of-fit of the model.

RESULTS

The CFA results indicated an excellent fit of the model: the Maximum Likelihood Chi-Square = 147.73 and Degrees of Freedom = 48, which gave a χ2/df = 3.08, TLI = 0.934, CFI = 0.952, and RMSEA = 0.065 [95% CI 0.054-0.078]. The fit indices of the one-factor structure of the OCI-4 were excellent as well: χ2/df = 6.15/2 = 3.08, TLI = 0.95, CFI = 0.98 and RMSEA = 0.065 [95% CI 0.007-0.127]. The Area Under the Curve was 0.600 [95% CI 0.524-0.674]. There was no cutoff value that showed good sensitivity or specificity at the same time. At the DOS cutoff of 25, sensitivity was 19.1%, whereas the specificity was 90.6%. The positive and negative predictive values (PPV and NPV) at this cutoff value were 24.4% and 88.7% respectively. At the DOS cutoff of 30, sensitivity was 8.8%, whereas the specificity was 94.3%. The PPV and NPV at this cutoff value were 10.6% and 92.5% respectively. The results showed that higher total OCD scores (Beta = 0.15) were significantly associated with more ON tendencies. Moreover, higher OCD washing scores (Beta = 0.52), physical activity index (Beta = 0.06), and Body Mass Index (Beta = 0.17) were significantly associated with more ON tendencies.

CONCLUSION

The present results suggest that ON, as measured by the DOS, shares more common features with disordered eating and cannot adequately predict the presence of OCD symptoms.

Prevalence of Orthorexia in Groups of Students with Varied Diets and Physical Activity (Silesia, Poland)

(1) Background: The literature emphasizes the role of many factors influencing the onset of eating disorders (EDs) and their mutual influence on each other. Therefore, this study aimed to evaluate and compare the prevalence of orthorexic behaviors in groups of health-related and non-health-related students in terms of their differential health behaviors—diet and physical activity levels. (2) The study included 300 individuals representing two equal groups of fields of study, which for the study were called the health-related field (HRF) and the non-health-related field (NRF). (3) Results: Based on the results of the dietary assessment, it was found that the best dietary model was characterized by the HRF group; in this group, 97.2% of students were characterized by a very good and good dietary mode. The NRF group, on the other hand, was dominated by a sufficient dietary mode for 64.4% of all cases in this group (94 people), while the dietary model marked as “good” was less popular, at 24.6% of this group (36 people). (4) Conclusions: Based on the cited self-research and information from the literature, it can be concluded that the problem of orthorexia is still a new issue at the level of social sciences, medical sciences, and health sciences. The psychometric tools used in this study allowed us to demonstrate the prevalence of the aforementioned eating disorders in the sample groups of students.

Eating disorders and their relationship with menopausal phases among a sample of middle-aged Lebanese women

OBJECTIVES

The objective of our study was to evaluate the association between the transition to menopause, body dissatisfaction, and abnormal eating habits (restrained eating, binge eating, and orthorexia nervosa) in a sample of middle-aged Lebanese women.

METHODS

A cross-sectional study conducted between July 2019 and January 2020 enrolled 1001 women aged 40 years and above from all Lebanese governorates. Data were collected by face-to-face interviews with all participants. The Body dissatisfaction subscale of the Eating Disorder Inventory‑second version was used to assess body dissatisfaction, whereas the Binge Eating Scale, Dutch Restrained Eating Scale, ORTO-15, Dusseldorf Orthorexia Scale (DOS), and Teruel Orthorexia Scale (TOS) were used to assess eating disorders (binge eating, restrained eating and orthorexia nervosa respectively. Multivariable analysis of covariance (MANCOVA) was used to compare multiple measures among the three menopausal phases, after adjustment over potential confounding variables (age, monthly income, body mass index, marital status, education level, and body dissatisfaction).

RESULTS

Postmenopause was significantly associated with more orthorexia nervosa tendencies (lower ORTO-15 scores) than premenopause (β = - 1.87; p = 0.022). Perimenopause was associated with more binge eating (β = 1.56; p = 0.031), and less orthorexia nervosa (as measured by the DOS) than premenopause, with this association tending to significance (β  = - 1.10; p = 0.051). Furthermore, higher body dissatisfaction was significantly associated with higher restrained eating (β = 0.02; p < 0.001), binge eating (β = 0.48; p < 0.001), and orthorexia nervosa as measured by ORTO-15 (β = - 0.17; p < 0.001) and TOS (β = 0.08; p = 0.002), but not DOS.

CONCLUSION

Our study showed that menopausal stages are associated with some disordered eating behaviors (binge eating and orthorexia nervosa) among middle-aged women. Those results may serve as a first step towards spreading awareness among women within this age group regarding eating attitudes. Moreover, healthcare professionals should screen for the presence of disordered eating during those women's routine visits to the clinics.

Attachment styles and their association with aggression, hostility, and anger in Lebanese adolescents: a national study

Background

The idea that attachment styles can affect the level of anger in an individual educes a reason why people develop anger issues and behavioral problems in adolescence that escalate into adulthood. Lebanon suffers from a shortage of data pertaining to insecure attachment styles and the affective and cognitive aspects of anger and behavioral anger expression among the Lebanese youth population. This study aimed to investigate the association between attachment dimensions and anger expression (trait anger, hostility, physical aggression, and verbal aggression) among a sample of Lebanese adolescent participants.

Methods

This cross-sectional study was performed between January and May 2019 among 1810 Lebanese high-school students aged 12–18 and used two validated measures, the Adolescent-Relationship Questionnaire (A-RQ) and The Buss-Perry Aggression Questionnaire (BPAQ). The A-RQ assessed attachment behaviors, while the BPAQ evaluated aggression.

Results

Higher fearful and dismissing attachment styles, and higher physical activity index were significantly associated with higher physical and verbal aggression. A higher fearful attachment style was significantly associated with more anger. A higher secure attachment style was significantly associated with less anger. Higher preoccupied and dismissing attachment styles were significantly associated with higher hostility.

Conclusion

Our findings revealed a significant relationship between both insecure attachment dimensions and the tripartite model of anger expression. This study adds to the anger literature by providing a more informed understanding of how variations in anger expression are linked to the processing of interpersonal interactions, which are the hidden facets of attachment systems.

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.

The relationship between orthorexia nervosa, anxiety, and self-esteem: a cross-sectional study in Turkish faculty members

BACKGROUND

Orthorexia nervosa (ON) may be a disorder on the spectrum of obsessive-compulsive disorders, maybe a separate eating disorder, or it may be an eating disorder on the spectrum of other eating disorders. We aimed to explore how anxiety and self-esteem affect the orthorectic tendency among higher-educated groups.

METHODS

This cross-sectional study was conducted on 248 faculty members selected by stratified sampling method from Ondokuz Mayis University in Samsun, Turkey. Data were collected by face-to-face interview method using Ortho-15, Rosenberg self-esteem, and Beck Anxiety scales.

RESULTS

The study group consisted of 144 (58.1%) males and 104 (41.9%) females, and the mean age was 42.5 ± 6.3 years. We found a tendency for orthorexia nervosa in 47 (19%) participants. The mean scores were 41.0 ± 2.6 for the Ortho-15 scale, 0.7 ± 1.2 for the Self-esteem scale, and 5.9 ± 5.8 for the Beck Anxiety Scale. Self-esteem scores were low, and anxiety scores were high in participants who tended to orthorexia (p < 0.001). Logistic regression analysis showed that the high self-esteem scores decrease the orthorectic tendency, while high anxiety scores increase the tendency.

CONCLUSIONS

We found a significant relationship between anxiety, low self-esteem and orthorexia nervosa. This result can be considered as a preliminary finding leading to further research. Further clinical and longitudinal studies are needed to determine the characteristics of individuals with orthorexia nervosa and identify the cause and effect relationship with psychiatric comorbidities.

Orthorexia Nervosa and Disordered Eating Attitudes, Self-Esteem and Physical Activity among Young Adults

A relation between Orthorexia Nervosa (ON) and increased frequency of physical activity has been put in evidence by recent studies. It is well known that intense physical exercises are typically related to eating disorders, but its relationship with ON is still a subject of debate. Other transdiagnostic features could be necessary to conceptualize and understand ON; in this way, low self-esteem is related to eating behavior but is not still extensively investigated in ON, and, to date, data are so heterogeneous that they do not allow us to understand if this is a psychological feature somehow associated with ON. The current study aimed to assess whether disordered eating attitudes, self-esteem, and physical activity are associated with ON in young adults from Poland and Italy. Moreover, we investigated the differences by comparing lower and higher ON levels related to disordered eating attitudes, self-esteem, and physical activity. Our results indicated that a great concern about dieting significantly predicted problems associated with healthy eating, knowledge about healthy eating, and feeling positive about healthy eating. In addition, young adults with a high level of ON demonstrated higher levels of disordered eating attitudes and vigorous-intensity physical activity than young adults with a low level of ON. Future studies are needed to assess the direct effect of physical activity and self-esteem on ON.

Orthorexia nervosa and substance use for the purposes of weight control, conformity, and emotional coping

PURPOSE

Orthorexia nervosa (ON), characterized by extreme behaviors driven by the goal of eating only healthy and pure foods, could plausibly be associated with avoidance of nicotine, alcohol, and illicit drugs. However, findings from the limited research on these relationships are mixed, and other eating disorders are associated with greater substance abuse.

METHOD

An online survey was completed by 471 participants (86% women, mean age = 20) recruited from undergraduate courses and through an Instagram advertisement. The questionnaires assessed ON symptomatology; frequency of smoking, alcohol consumption, and illicit drug use; abuse of these substances; and motivations for using these substances.

RESULTS

ON scores were not significantly related to the level of use or abuse of nicotine, alcohol, or most illicit drugs. Yet, ON scores were positively correlated with frequency of using illicit depressant drugs. Further, among substance users, ON scores were positively associated with smoking or vaping for the purpose of weight control, and with consuming alcohol and using illicit drugs for the purposes of conformity and coping with such negative emotions as anxiety and depression.

CONCLUSION

Although people who are high in ON symptomatology may be at least partly driven by a strong desire to be as healthy as possible, they are not less likely to use potentially harmful drugs. Instead, many of them may even turn to certain drugs for the same weight control and emotional-coping motives that guide the behaviors of individuals with other eating disorders.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Associations between orthorexia, disordered eating, and obsessive-compulsive symptoms: A systematic review and meta-analysis

OBJECTIVE

Orthorexia nervosa (ON) is defined as an unhealthy obsession with healthy eating, focusing on concerns regarding food quality and composition. Currently, there is still a lack of consensus about a clear definition of the construct. Specifically, it has yet to be clarified whether ON pertains to eating disorders (EDs) or obsessive-compulsive disorder (OCD) spectrum. Hence, we conducted a systematic review and meta-analysis addressing the magnitude of the association between these groups of symptoms.

METHOD

PubMed, Medline, SCOPUS, PsychINFO, CINAHL, and Web of Science were searched from inception up to February 2021. Data from individual studies were pooled using a random-effects model. Pearson's r was used as the effect size metric. Subgroup analyses were conducted exploring the role of ON-related instruments, body mass index, study quality, and cultural context.

RESULTS

Thirty-six studies met the eligibility criteria and were included in the meta-analysis. Random-effects model yielded a moderate association between ON and EDs symptoms with an overall effect size of r = .36 (p < .001; 95% confidence interval [CI] = 0.30-0.43). On the other hand, the results showed a small association between ON and OCD symptoms with a mean effect size of r = .21 (p < .001; 95% CI = 0.15-0.27).

DISCUSSION

Meta-analytic findings showed that ON symptoms are more associated to EDs compared to OCD. Despite the similarities, the nonhigh magnitude of the pooled correlations suggests that ON might be different from pre-existing EDs and OCD. Hence, ON might be treated as a stand-alone ED and included as an emerging syndrome in the DSM classification.

Validation of the Arabic version of the Teruel Orthorexia Scale (TOS) among Lebanese adolescents

OBJECTIVES

This study aimed at examining the reliability and validity of the Teruel Orthorexia Scale (TOS) among a sample of Lebanese adolescents (15 to 18 years old).

METHODS

This is a cross-sectional study that was conducted between May and June 2020 and had enrolled 555 Lebanese adolescents. To assess the internal structure of the TOS scale, we administered the confirmatory factor analysis based on polychoric correlation matrix using Weighted Least Squares with Means and Variance Adjusted estimation (WLSMV) method in Mplus v 7.2 as suggested in the original validation paper. To assess the degree to which the Lebanese adaptation converges with the original scale, we have conducted the Multigroup Confirmatory Factor Analysis (MGCFA; estimated as CFA) between the data reported in the current paper and from the original validation paper.

RESULTS

The mean age of the participants was 16.66 ± 1.01 years, with 76.1% females. The bi-dimensional model fitted the data well (χ²₍₁₁₈₎ = 429.09; p < 0.001; CFI = 0.954; RMSEA = 0.069[0.062, 0.076]). The latent factors were highly correlated (ρ = 0.74; p < 0.001), and the strength of the standardized factor loadings was adequate on both factors (i.e., all > 0.60). The fit indices of the scalar model were at the boundary of the threshold and thus, with some pinch of caution, it might be interpreted as invariant (i.e., having equal item intercepts across groups). We have identified latent mean differences in orthorexia nervosa (0.30; p < 0.001), where Spanish individuals scored higher, but we did not find any differences in the healthy eating (0.03; p = 0.636). Higher DOS scores were significantly correlated with higher scores on the TOS subscale OrNe (r = 0.715; p < 0.001) as well as with higher scores on the TOS subscale HeOR (r = 0.754; p < 0.001). Higher ORTO-R scores were significantly associated with less TOS OrNe (r = - 0.437; p < 0.001) and TOS HeOr (r = - 0.305; p < 0.001) scores, respectively.

CONCLUSION

The Arabic version of the TOS can be considered a reliable valuable instrument to assess the ON tendencies and behaviors in Lebanese adolescents, emphasizing the fine contrast between ON's two dimensions: healthy vs. pathological.

LEVEL V

Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

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.

Association between impulsivity and orthorexia nervosa / healthy orthorexia: any mediating effect of depression, anxiety, and stress?

BACKGROUND

There is a lack of studies investigating the possible mediating role of psychological factors, such as depression, anxiety and stress on orthorexic eating behaviors. Given that personality attributes might affect the manifestation of psychological disorders, it was hypothesized that depression, anxiety and stress mediate the relationship between impulsivity-related traits and orthorexic eating, noting that previous research had evaluated the role of depression as a mediator between impulsivity and other pathological eating behaviors. The study objectives were to explore the mediating effect of depression, anxiety, and stress, on impulsivity and orthorexia nervosa, and healthy orthorexia.

METHODS

This cross-sectional study conducted between July and December 2019 recruited 519 Lebanese adults from seven community pharmacies randomly selected from a list provided by the Lebanese Order of Pharmacists.

RESULTS

Our results showed that depression and anxiety were positively correlated with ON. We also found a notable gender difference in findings: higher anxiety and female gender were significantly associated with higher TOS healthy orthorexia, while higher stress was associated with lower TOS healthy orthorexia. Finally, higher urgency was associated with lower TOS healthy orthorexia, while higher perseverance was significantly associated with higher TOS healthy orthorexia. Depression and anxiety partially mediated the association between perseverance and ON while anxiety and stress partially mediated the association between urgency and healthy orthorexia.

CONCLUSION

Our study suggests that depression, anxiety and stress play a mediating role between impulsivity and orthorexia nervosa/healthy orthorexia. Our findings provide a ground for future investigations of impulsive behaviors, psychopathology, and orthorexia in different populations.

Orthorexia nervosa and its association with alexithymia, emotion dysregulation and disordered eating attitudes among Lebanese adults

OBJECTIVE

This study aims to explore whether orthorexia nervosa, like other eating disorders, is associated with difficulties identifying, describing, and regulating one's own emotions among a sample of Lebanese adults.

METHODS

A cross-sectional study was conducted during October 2020, during the lockdown period imposed by the government for the COVID-19 pandemic. All participants above 18 years of age were allowed to participate in this study. A total of 787 Lebanese adults out of 920 (85.54%) completed an online survey including Arabic versions of the ORTO-R measure of orthorexia, the Toronto Alexithymia Scale, the Difficulty in Emotion Regulation Scale, and the Eating Attitudes Test.

RESULTS

After making sure that all norms are verified, hierarchical linear regressions were conducted to evaluate the association between disordered eating attitudes (EAT scores) and ON (model 1), and after controlling for difficulties in emotion regulation (DERS score) (model 2). Model 1 accounted for 15.1% of the variance of ON (adj. R² = 0.151, F(1, 786) = 140.06, p < 0.001) and showed that higher levels of disordered eating (higher EAT scores) (β = 0.15) were significantly associated with more ON tendencies and behaviors. When adding the DERS total score to the model, Model 2 was a much better fit with 17.7% of the variance of ON (adj. R² = 0.177, F(2, 786) = 84.44, p < 0.001), with higher levels of emotion dysregulation (higher DERS scores) (β = 0.06) and more disordered eating attitudes (higher EAT scores) (β = 0.13) were associated with higher levels of ON (Table 5).

CONCLUSION

The present research suggests that people with high ON tendencies experience troubles recognizing, regulating, and describing their emotions, similarly to other disordered eating.

LEVEL OF EVIDENCE

5.

Validation of the Greek ORTO-15 questionnaire for the assessment of orthorexia nervosa and its relation to eating disorders symptomatology

PURPOSE

The aim of the study was the validation of the Greek version of the ORTO-15 questionnaire. An additional aim was to explore the relation between orthorexic and eating disorder behaviors in a sample of Greek students.

METHODS

ORTO-15 was translated and adapted in the Greek language. After its final version was drafted, its test-retest reliability was checked. Then, the questionnaire was administered to 120 students of psychology along with EAT-26. Additionally, demographics, BMI and information related to eating disorders were collected.

RESULTS

The Greek version of the ORTO-15 questionnaire showed acceptable internal consistency (Cronbach's a 0.7). Factor analysis produced a three-factor model similar to the original English version of the questionnaire. The correlation of ORTO-15 and EAT-26 revealed that higher measurements in the diet and bulimia EAT-26 scale were related to increased orthorexic symptomatology. Finally, there was no significant correlation between the 3 factors of the ORTO-15 (emotional, rational and behavioral) and age, education or Body Mass Index.

CONCLUSIONS

This study is the first attempt to assess orthorexia nervosa in a Greek student population. ORTO-15 was found to be a reliable tool for the measurement of orthorexia in Greece. Finally, in accordance with other studies, orthorexic symptoms were partially related to eating disorder symptomatology, thus raising the question of possible similarities and overlap between the two clinical constructs.

LEVEL OF EVIDENCE

Level V, Cross-sectional descriptive study.

Validation of the Arabic version of the Dusseldorf Orthorexia Scale (DOS) among Lebanese adolescents

BACKGROUND

Orthorexia Nervosa (ON) is defined as a pathological preoccupation characterized by obsessive beliefs and compulsive behaviors regarding 'pure' eating behaviors. Many scales have been established and display good results regarding reliability and validity measures, including but not limited to ORTO-R (revised version of ORTO-15), Eating Habits Questionnaire, Teruel Orthorexia Scale (TOS) and the Düsseldorf Orthorexia Scale (DOS). Among these, the DOS seems to be a promising measure for multiple reasons. The current paper aims to validate the DOS, a measure of ON, in a non-Western population of Lebanese adolescents.

METHODS

This was a cross-sectional designed study, conducted between May and June 2020, which enrolled 555 adolescents (15-18 years old; 75.7% females). Due the coronavirus pandemic outbreak, the data were gathered through snowball sampling using an online questionnaire. The DOS, TOS and ORTO-R scales were used in this study to screen for orthorexic tendencies and behaviors.

RESULTS

We tested four competing structural models of the DOS assessing its factorial validity. The results of the current investigation revealed that the one-factorial model is the best one to represent the structure of the questionnaire. We provided evidence for validity for the DOS through demonstrating that it correlates significantly with other measures of orthorexic behaviours (Teruel Orthorexia Scale and ORTO-R). Finally, we have gathered evidence that the orthorexic behaviours as measured by DOS are not associated with age (r = -.02; p = .589), household crowding index (r = .02; p = .578), and Body Mass Index (r = .04; p = .297). Yet, females as compared to males achieved higher scores (M = 20.07, SD = 6.38 vs M = 18.29, SD = 6.37; p = .005; d = .28).

CONCLUSION

The Arabic version of the DOS seems to be a structurally valid and internally consistent questionnaire measuring orthorexic eating behavior in a sample of Lebanese adolescents. This tool may be useful for psychologists, psychiatrists, dietitians and other clinicians in the assessment and the treatment of the multidimensional nature of ON.

Orthorexia nervosa and disordered eating attitudes among Lebanese adults: Assessing psychometric proprieties of the ORTO-R in a population-based sample

BACKGROUND

Previous research demonstrated a relationship between ON and disordered eating symptoms (eating concern, restraint, cognitive preoccupations about body shape and weight) and disordered eating attitudes (DEA). Since screening for orthorexia nervosa is now part of clinical practice, the measurement instruments to be used must be clinically significant, reliable, valid and sensitive to our target population. The main objective of the present study was to confirm the factor structure of the Arabic version of the ORTO-R using a first sample of Lebanese adults and confirm those results on another sample. The secondary objective was to assess sex differences in terms of ON and DEA, as well as to examine whether symptoms of ON were related to DEA in Lebanese adults.

METHODS

A total of 783 Lebanese adults was selected to participate in this cross-sectional study (January-May 2018) using a proportionate random sample from all Lebanese governorates.

RESULTS

The mean age of the total sample was 27.78 ± 11.60 years (Min. 18 -Max. 84) (33.5% females) and their mean BMI was 24.36 ± 5.31 kg/m2. All items of the ORTO-R were extracted during the factor analysis and yielded a two-factor solution with Eigenvalues > 1 (variance explained  =  50.07%; KMO = 0.570; Bartlett's sphericity test p<0.001; αCronbach = 0.755). This factor structure was confirmed by a confirmatory factor analysis; the Maximum Likelihood Chi-Square  =  26.894 and Degrees of Freedom  =  8, which gave a χ2/df  =  3.36. The Tucker Lewis Index (TLI) value was 0.914, whereas the standardized root mean square residual (SRMR) value was 0.032. The root mean square error of approximation (RMSEA) value was 0.077 [95% CI 0.046-0.111] (pclose = 0.07) and comparative fit index (CFI) value was 0.967 respectively, indicating a good fit of the model. There was also no measurement invariance between genders. Female gender was significantly associated with lower ORTO-R scores (more orthorexia nervosa) compared to males (B = -0.65; p = 0.026, 95% CI -1.22- -0.08; ɳ2 = 0.006). However, no significant difference was found between genders in terms of EAT-26 scores (B = 0.23; p = 0.813, 95% CI -1.66-2.12; ɳ2 = 0.0001). Higher ORTO-R scores (lower/ less pathological ON tendencies and behaviors) were significantly related to higher EAT-26 total scores (higher levels of DEA) as well as higher dieting, bulimia and oral control scores in both females (from a weak to a moderate positive correlation) and males (a weak positive correlation).

CONCLUSION

This cross-sectional population-based study confirmed the factor structure of the Arabic version of the ORTO-R, demonstrated an association between ON and DEA and revealed more ON among females compared to males.

The relation of orthorexia with lifestyle habits: Arabic versions of the Eating Habits Questionnaire and the Dusseldorf Orthorexia Scale

BACKGROUND

Some of the commonly used tools to assess orthorexia nervosa (OrNe) do not allow a meaningful interpretation of the scores or yield mixed results about the dimensions needed to represent orthorexia. Since no advancement in the theoretical knowledge can be made without a thorough examination of the measurement aspects, this study aimed to evaluate the correlation between orthorexia nervosa (OrNe) and lifestyle habits, notably alcohol drinking, cigarette and waterpipe smoking, and physical exercise, and to validate and assess the psychometric properties of the Arabic versions of the Eating Habits Questionnaire (EHQ) and Düsseldorf Orthorexia Scale (DOS).

METHODS

A total of 456 adult participants completed a self-administered questionnaire. Exploratory structural equation models were used to test the internal structure of the instruments. Shorter and more explicit versions were proposed for instruments. Pearson and partial correlations were computed between orthorexia scores and healthy behaviors scores.

RESULTS

Regarding the internal structure of both EHQ and DOS, evidence favored the bi-dimensional construct of orthorexia. Both tools presented two theoretically clearly interpretable factors (OrNe and Healthy Orthorexia-HeOr-). The two questionnaires presented a high convergent validity, as dimensions with the same interpretation were correlated around 0.80. While OrNe was positively correlated with the use of unhealthy substances (higher alcohol use disorder, cigarette, and waterpipe dependence), HeOr was negatively associated with these behaviors.

CONCLUSION

Our results emphasize the idea that further attention should be paid to the multidimensional structure of orthorexia, as OrNe and HeOr present an opposite pattern of associations with healthy behaviors. An OrNe etiopathogenesis common to eating disorders can explain these differences.

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.

Differences in the Associations between Body Dissatisfaction and Eating Outcomes by Gender? A Lebanese Population Study

BACKGROUND

The objective of this study was to evaluate the impact of the interaction between body dissatisfaction and gender on eating disorders (restrained eating, binge eating, orthorexia nervosa, and emotional eating) among a sample of Lebanese adults.

METHODS

This cross-sectional study, conducted between January and May 2018, enrolled 811 participants selected randomly from all Lebanese Mohafazat. The mean age of the participants was 27.6±11.8 years. The majority were females (66.5%), had a high level of education (73.2%), and low income (77.9%). This study used the following scales: body dissatisfaction subscale of the Eating Disorder Inventory-second version, binge eating scale, Dutch restrained eating scale, orthorexia nervosa scale (ORTHO-15 scale), emotional eating scale, perceived stress scale, Hamilton Anxiety Rating Scale, and Hamilton Depression Rating Scale.

RESULTS

Body dissatisfaction was positively correlated to restrained eating (r=0.293, P<0.001), emotional eating (r=0.073, P=0.042) and binge eating (r=0.250, P<0.001). The interaction between body dissatisfaction and gender was significantly associated with more restrained eating (Beta=0.01, P<0.001) and orthorexia nervosa (Beta=-0.09, P<0.001), but not with emotional (Beta=-0.43, P=0.103) and binge eating (Beta=-0.08, P=0.358). When stratifying the analysis by gender, the results revealed that higher body dissatisfaction was significantly associated with more restrained eating in both genders, but particularly among women. Body dissatisfaction was significantly associated with higher emotional eating in men only and with higher orthorexia nervosa tendencies and behaviors in females only.

CONCLUSION

The interaction between body dissatisfaction and gender was significantly associated with orthorexia nervosa and restrained eating but not with binge or emotional eating. Higher body dissatisfaction was significantly associated with higher restrained eating, more pronounced in women, while it was significantly associated with higher orthorexia tendencies (lower ORTO-15 scores) in women only. Body dissatisfaction was associated with emotional eating in men only.

Emotional eating among Lebanese adults: scale validation, prevalence and correlates

OBJECTIVES

The present study aimed at developing an Arabic version of the Emotional Eating Scale (EES) and examining its reliability and validity among a sample of the Lebanese population. The secondary objective was to evaluate the correlation between emotional eating and body dissatisfaction along with depression and/or self-esteem among a representative sample of the Lebanese population.

METHODS

This cross-sectional study was conducted between January and May 2018. The sample was drawn proportionately from all Lebanese Mohafazat.

RESULTS

All items could be extracted from the list, except items 17 and 19. The EES items converged over a solution of four factors that had an Eigenvalue over 1, explaining a total of 67.06% of the variance (KMO = 0.939; Bartlett's test of sphericity p < 0.001; α_Cronbach = 0.952). A higher body dissatisfaction was significantly associated with higher emotional eating (β = 0.31) and lower self-esteem (β =  - 0.054); however, no significant association was found with depression. Self-esteem and depression were not found to be significantly associated with emotional eating. When introducing depression and self-esteem as mediator factors for body dissatisfaction and emotional eating, body dissatisfaction did not remain significantly associated with emotional eating.

CONCLUSION

In this study, the Emotional Eating Scale was validated in Arabic among the Lebanese adult population, making this scale usable in further Lebanese research. Moreover, our results showed that body dissatisfaction was positively correlated with emotional eating and self-esteem, but not with depression. A positive association between body dissatisfaction and emotional eating was also demonstrated. This research offers new perspectives for the evaluation of emotional eating among the Lebanese adult population.

LEVEL OF EVIDENCE

Level V Cross-sectional descriptive study.

Emotion regulation among Lebanese adults: Validation of the Emotion Regulation Questionnaire and association with attachment styles

PURPOSE

Validate the Emotion Regulation Questionnaire (ERQ) and evaluate factors associated with emotion regulation among Lebanese adults.

METHODS

A proportionate random sample of 811 participants was chosen from all Lebanese governorates in this cross-sectional study.

FINDINGS

The principal component analysis of the ERQ items yielded two factors (α_Cronbach  = 0.764 and 0.658 for the Cognitive Reappraisal and Expressive Suppression facets, respectively). Higher secure attachment style was linked to higher cognitive reappraisal and expressive suppression. Higher anxious attachment style and anxiety were associated with lower cognitive reappraisal.

PRACTICAL IMPLICATIONS

The Arabic version of the ERQ is a suitable tool for the assessment of emotion regulation tendencies in clinical practice and research. The study came up with results similar to the ones given by many international studies.

Orthorexia Nervosa Inventory (ONI): development and validation of a new measure of orthorexic symptomatology

PURPOSE

To overcome the problems associated with existing measures of orthorexia, we assessed the reliability and validity of a new measure: the Orthorexia Nervosa Inventory (ONI).

METHOD

An online survey was completed by 847 people recruited from undergraduate nutrition and psychology courses and from advertisements in Facebook and Instagram targeting both healthy eaters (with keywords such as "clean eating" and "healthy eating") and normal eaters (with keywords such as "delicious food" and "desserts").

RESULTS

Exploratory factor analysis revealed three factors with 9 items assessing behaviors and preoccupation with healthy eating, 10 items assessing physical and psychosocial impairments, and 5 items assessing emotional distress. With this sample, all scales demonstrated good internal consistency (Cronbach's α = 0.88-0.90) and 2-week test-retest reliability (r = 0.86- 0.87). Consistent with past research, ONI scores were significantly greater among vegetarians and vegans, and among those with higher levels of disordered eating, general obsessive-compulsive tendencies, and compulsive exercise. Additionally, whereas ONI scores did not significantly differ between men and women, the scores were negatively correlated with body mass index.

CONCLUSION

The ONI is the first orthorexia measure to include items assessing physical impairments that researchers and clinicians agree comprise a key component of the disorder. Additionally, at least for the current sample, the ONI is a reliable measure with expected correlations based on the past research.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Binge eating, orthorexia nervosa, restrained eating, and quality of life: a population study in Lebanon

OBJECTIVES

To assess the implication of disordered eating behaviors (DEBs) on the quality of life (QOL) of a sample of the Lebanese population, after adjustment over sociodemographic characteristics of those participants. Secondary objective aimed to assess the role of body dissatisfaction (BD) in the association of DEBs and QOL.

METHODS

This cross-sectional study was done between January and May 2018 and enrolled 811 participants from the community. A proportionate random sample technique was used to select the sample from all Lebanese Mohafazat. The World Health Organization Quality-of-life (WHOQOL)-BREF was used to assess the QOL and it includes four domains: physical health, psychological health, social relations, and environment.

RESULTS

Body dissatisfaction was found to be a major confounding factor contributing to psychological and environmental HQOL impairments in patient with restrained eating. Nevertheless, orthorexia nervosa was associated with QOL impairments in its physical and environmental domains, regardless of body dissatisfaction that was shown to be a major contributor for QOL impairments. Similarly, ON was directly correlated with QOL of life impairment in its physical and environmental domains, independently of all other risk factors.

CONCLUSION

When adding body dissatisfaction as a confounding variable, restrained eating and orthorexia nervosa remained significantly associated with quality-of-life impairments.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

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.

The associations between orthorexia nervosa and the sociocultural attitudes: the mediating role of basic psychological needs and health anxiety

PURPOSE

Given the range of negative correlates associated with orthorexia nervosa (ON), it is important to identify factors that might contribute to the elevated ON tendencies. Based on the tripartite model of influence, we tested whether sociocultural attitudes towards appearance (i.e., thin and muscular internalization as well as family, peer and media pressure) could contribute to ON. We hypothesized that these attitudes could exert their effect through the intervening processes basic psychological need fulfillment and health anxiety.

METHODS

The hypotheses were tested on a sample of 710 young adults (M_age = 21.79, SD_age = 2.31). Participants completed validated questionnaires measuring the constructs of interest.

RESULTS

According to the structural equation modeling results, ON was predicted by thinness and muscular internalization as well as media pressure. Need fulfillment and health anxiety partially mediated these relationships. Family and peer pressure were not related to ON.

DISCUSSION

The present results suggest that internalization of appearance ideas and media pressure contribute to ON through need fulfillment and health anxiety. These findings also provide novel insight into the nature of ON.

LEVEL OF EVIDENCE

Level V (descriptive cross-sectional study.

Factors associated with violence against women in a representative sample of the Lebanese population: results of a cross-sectional study

To evaluate the prevalence of violence against women (VAW) and assess factors associated with VAW among a representative sample of the Lebanese population. This cross-sectional study was carried out between September and December 2018. Participants from all Lebanese governorates were enrolled in this study using a proportionate random sample. The percentages of women who were exposed to physical and non-physical abuse were 37.1% and 49.4% respectively. Factors associated with physical abuse were being divorced, having a partner addicted to substances and alcohol, or with a history of threats, violence, assaults, and crimes, higher stressful life experiences, and abuse reported from childhood (physical, sexual, or psychological). Non-physical abuse was associated with abuse reported from childhood (physical, sexual, or psychological), higher stressful life experiences, and the fact that the partner is addicted to substances and alcohol, or has a history of threats. Our results suggest that being divorced, illiterate, and unemployed, having an addicted partner, and having experienced child abuse are all factors that are associated with more violence against women.

Selfie addiction: The impact of personality traits? A cross-sectional study among the Lebanese population

OBJECTIVES

To examine the relationship between personality traits (Neuroticism, Openness, Consciousness, Agreeableness, and Extraversion) and selfie addiction among Lebanese adults.

DESIGN/METHODS

A cross-sectional study, carried out between August 2017 and April 2018, enrolled 1206 community-dwelling participants.

RESULTS

Female gender (ORa = 2.79) and higher neuroticism (adjusted odds ratio [ORa] = 1.01) were significantly associated with moderate vs low selfie-taking. Higher openness (ORa = 0.96) was significantly associated with low selfie-taking. Female gender (ORa = 3.42) was significantly associated with intense vs low selfie-taking, whereas higher age (ORa = 0.93) and higher conscientiousness (ORa = 0.99) were significantly associated with lower intense selfie-taking.

PRACTICE IMPLICATIONS

This relationship can serve as a basis for other studies to better understand this new phenomenon and, later, to draw attention to a "selfie" practice that can deviate from the norm.

Social media use disorder and alexithymia: Any association between the two? Results of a cross-sectional study among Lebanese adults

PURPOSE

To learn more about the association between social media use disorder and alexithymia among Lebanese people.

DESIGN/METHODS

Four hundred fifty-six residents participated in this cross-sectional study which was carried out between January and December 2018.

FINDINGS

The results showed that 107 (23.7%) participants were classified as having social media use disorder. Higher social media use disorder score (β = .52), higher perceived stress (β = .35), and higher depression (β = .12) were significantly associated with more alexithymia.

PRACTICE IMPLICATIONS

Our results have shown that social media use disorder and being depressed and stressed were associated with higher levels of alexithymia. Psychologists/health practitioners can benefit from these findings in their future prevention and intervention plans. People who negatively utilize social media platforms can then be offered with appropriate counseling and coping mechanisms.

The Prevalence of Orthorexia Nervosa in Polish and Lebanese Adults and Its Relationship with Sociodemographic Variables and BMI Ranges: A Cross-Cultural Perspective

The prevalence of orthorexia nervosa (ON) appears to be increasing, and more research into its cross-cultural aspects is required to provide culturally appropriate psychological treatment. Until now, there has been relatively little research published about ON across cultures. Therefore, the objectives of the present study were to determine: (1) the prevalence of ON in Polish and Lebanese adults and (2) the association between ON and sociodemographic variables and Body Mass Index (BMI) in two culturally different samples. One thousand two hundred and sixty-two adults participated in the present study (NPoland = 743 adults; NLebanon = 519 adults). The Düsseldorf Orthorexia Scale and the Eating Habits Questionnaire were used in the present study. Information about age, sex, anthropometry, and marital status was obtained from all participants as well. The Polish sample had an ON prevalence rate of 2.6%, while the Lebanese sample had an ON prevalence rate of 8.4%. No significant correlation was found between ON and age in both samples. A statistically significant difference was found between marital status and country on ON, with the highest mean score seen among Lebanese singles. In Lebanon, having a low of BMI ≤ 25 kg/m2 compared to a high BMI was significantly associated with lower ON tendencies, while this association was not significant among Polish participants. This study was the second to focus on the prevalence of ON in Western and non-Western countries and its association with sociodemographic characteristics and BMI ranges. Knowledge about ON and its correlates in diverse populations may inform the design of culturally tailored behavior change interventions and the development of culturally appropriate tools in various groups to improve their dietary patterns.

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.