What does the ORTO-15 measure? Assessing the construct validity of a common orthorexia nervosa questionnaire in a meat avoiding sample

Orthorexic Tendency in Light of Eating Disorder Attitudes, Social Media Addiction and Regular Sporting Among Young Hungarian Women

This study examined a set of background psychological and other variables of orthorexic (ON) tendency in a sample of young women with special interest in healthy lifestyle. The sample consisted of female young adults (N = 310; aged 18-35 years; mean age = 24.3 years; SD = 4.97 years) who were recruited through social media health sites. Besides Orthorexia Nervosa Questionnaire (ORTO‑15), BMI, regular sporting activity, the following scales were used: Eating Disorder Inventory (EDI, drive for thinness, ineffectiveness and maturity fears); Bergen Social Media Addiction Scale (BSMAS); and The Proactive Coping Inventory. In this sample, 37.7% were at risk for ON. Eating disorder attitudes, regular sporting and social media addiction were the most relevant predictors of orthorexic tendency with drive for thinness being the strongest contributor (β = 0.54, p < 0.001). For young women with a special interest in healthy lifestyle, drive for thinness together with regular sporting, ON tendency may serve as a tool for achieving their goal. Social media addiction and other psychological problems (feeling of ineffectiveness or maturity fears) can also contribute to orthorexic rendency. It would be important to ask for support from qualified health professionals when changing nutritional practices.

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.

Orthorexia Nervosa and Healthy Orthorexia in a Physically Active North American Population

The Teruel Orthorexia Scale (TOS) defines two related but distinct constructs: Orthorexia Nervosa (OrNe), a pathological fixation on a healthy diet, and Healthy Orthorexia (HeOr), an interest in a healthy diet independent of psychopathology. Here, we (a) assessed both types of Orthorexia in a large North American sample using the TOS and (b) explored if engaging in regular physical activity was associated with a greater risk of Orthorexia. A cohort of physically active adults (n = 927; 41% men) completed the TOS, as well as the Rapid Assessment of Physical Activity (RAPA), to broadly assess aerobic physical activity level and participation in strength and/or flexibility training. As expected, scores for HeOr and OrNe differed between participants, with lower scores for Orthorexia Nervosa in our physically active non-clinical sample. Higher HeOr scores were associated with lower BMI, and this was true for both men and women. We also found that measures of Orthorexia were associated with self-reported physical activity: active adults reporting more aerobic physical activity had higher HeOr scores, with the most active men having the highest scores. Notably, adults who reported regular strength training had higher scores for both HeOr and OrNe, with men who strength trained showing higher OrNe scores than women. Here, those who participate in regular strength training are more likely to exhibit orthorexic behaviors, and this effect was more pronounced for men than women. Prior work has validated the TOS in young, primarily female samples of non-English speakers outside the United States: present data from an age-diverse, physically active, gender balanced sample support the use of TOS for measurement of Orthorexia Nervosa and Healthy Orthorexia in English speakers and suggest that more work is needed to assess potential gender differences in these constructs.

Reliability generalization meta-analysis of orthorexia nervosa using the ORTO-11/12/15/R scale in all populations and language versions

BACKGROUND

The ORTO scale was developed in 2004 as a self-report questionnaire to assess symptoms of orthorexia nervosa (ON). ON is an unhealthy preoccupation with eating healthy food. The scale aims to measure obsessive attitudes and behaviors related to the selection, purchase, preparation, and consumption of pure, healthy food. Since its development, the ORTO-15 has been adapted into several shorter versions. The objective was to conduct a reliability generalization meta-analysis of the ORTO scale and its variant versions in all populations and languages.

METHODS

A systematic literature search was conducted to identify studies reporting the internal consistency of ORTO. Random-effect models were used to evaluate summary statistics of reliability coefficients, weighting the coefficients by the inverse variance using the restricted maximum likelihood method. The heterogeneity among the reliability coefficients was evaluated and assessed using numerous statistical metrics. The tau (τ), tau2 (τ2), I2, H2, R2, df, and the Q-statistic are among those obtained. Meta-regression analyses were used to examine moderators such as age and sex.

RESULTS

Twenty-one studies (k = 21) involving 11,167 participants (n = 11,167) were analyzed. The overall effect estimate on internal consistency was 0.59 (95% CI 0.49-0.68), with a minimum reliability coefficient of 0.23 and a maximum reliability coefficient of 0.83. The heterogeneity statistics were found to have an I2 of 99.31%, which suggested high heterogeneity owing to a decrease in the confidence interval (95% CI) and an increase in variability. Sensitivity analysis revealed that a few studies strongly influenced the overall estimate. Egger's test suggested possible publication bias. Neither age nor sex significantly moderated reliability via meta-regression.

CONCLUSIONS

The ORTO scale has a relatively low pooled reliability coefficient. Alternative ON assessment tools with enhanced psychometric properties are needed. Clinicians should not base diagnoses or treatment decisions on ORTO alone. Comprehensive psychiatric assessment is essential for accurate ON evaluation.

On Orthorexia Nervosa: A Systematic Review of Reviews

INTRODUCTION

Orthorexia nervosa (ON), characterized by a pathological preoccupation with "extreme dietary purity," is increasingly observed as a mental health condition among young adults and the general population. However, its diagnosis is not formally recognized and has remained contentious.

OBJECTIVE

In this systematic review, we attempt to overview previous reviews on ON, focusing on the methodological and conceptual issues with ON. This would serve both as a summary and a way to highlight gaps in earlier research.

METHODS

This systematic review took reference from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, and using combinations of the search terms ("orthorexia" OR "orthorexia nervosa" OR "ON") AND ("review" OR "systematic review" OR "meta-analysis"), a literature search was performed on EMBASE, Medline and PsycINFO databases from inception up to October 31, 2023. Articles were included if (1) they were written or translated into English and (2) contained information pertaining to the diagnostic stability or validity of ON, or instruments used to measure ON symptoms and behaviors. Only review articles with a systematic literature search approach were included.

RESULTS

A total of 22 reviews were qualitatively reviewed. Several studies have reported variable prevalence of ON and highlighted the lack of thoroughly evaluated measures of ON with clear psychometric properties, with no reliable estimates. ORTO-15 and its variations such as ORTO-11, ORTO-12 are popularly used, although their use is discouraged. Existing instruments lack specificity for pathology and several disagreements on the conceptualization and hence diagnostic criteria of ON exist.

DISCUSSION

Previous reviews have consistently highlighted the highly variable (and contradictory) prevalence rates with different instruments to measure ON, lack of stable factor structure and psychometrics across ON measures, paucity of data on ON in clinical samples, and a need for a modern re-conceptualization of ON. The diagnosis of ON is challenging as it likely spans a spectrum from "normal" to "abnormal," and "functional" to "dysfunctional." "Non-pathological" orthorexia is not related to psychopathological constructs in the same way that ON is.

Orthorexia nervosa versus healthy orthorexia: Anxiety, perfectionism, and mindfulness as risk and preventative factors of distress

BACKGROUND

Orthorexia nervosa is a recently conceptualised pathological entity presenting as an obsessive focus on healthy eating with associated psychosocial impairment.

AIMS

The present study investigated the differential associations between orthorexia nervosa and healthy orthorexia with distress and impairment.

MATERIALS & METHODS

With a community sample (N = 268) multiple measures of orthorexia nervosa and health orthorexia were compared as explanatory variables in mediation structural equation modelling (SEM). Outcome variables assessed and investigated were psychological distress while demographic variables were controlled. The mediating roles of perfectionism and health anxiety on orthorexia nervosa were examined with further preventative mediation role of mindfulness on distress.

RESULTS

Distinctive to other eating disorders, gender showed no significant effects on orthorexia nervosa and healthy orthorexia. Signalling measurement issues for this disorder, the different measures of orthorexia nervosa resulted in mixed findings regarding body mass index and age. Findings supported perfectionism and health anxiety as risk factors, as well as mindfulness acceptance as a preventative factor in both orthorexia nervosa and healthy orthorexia. Orthorexia nervosa and healthy orthorexia assessed by most measures, contrary to the expectations, had significant positive associations with psychological distress indicated by stress, anxiety, and depression.

DISCUSSION & CONCLUSION

The complexity in differentiating orthorexia nervosa from healthy orthorexia calls for further investigation. This research effort should serve to substantiate the status of orthorexia nervosa as a distinct clinical disorder.

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).

Exploring the role of positive body image in healthy orthorexia and orthorexia nervosa: A gender comparison

Current scholarship on orthorexia nervosa remains undecided about the role of body image in this novel eating disorder. This study aimed to explore the role of positive body image in differentiating between healthy orthorexia and orthorexia nervosa and assess how this might differ for men and women. A total of 814 participants (67.1% women; age M = 40.30, SD = 14.50) completed the Teruel Orthorexia scale, as well as measures of embodiment, intuitive eating, body appreciation and functionality appreciation. A cluster analysis revealed four distinct profiles characterized by high healthy orthorexia and low orthorexia nervosa; low healthy orthorexia and low orthorexia nervosa; low healthy orthorexia and high orthorexia nervosa; and high healthy orthorexia and high orthorexia nervosa. A MANOVA identified significant differences for positive body image between these four clusters, as well as that there were no significant differences between men and women for healthy orthorexia and orthorexia nervosa, despite men scoring significantly higher than women on all measures of positive body image. Cluster × gender interaction effects were found for intuitive eating, functionality appreciation, body appreciation and experience of embodiment. These findings indicate that the role of positive body image in healthy orthorexia and orthorexia nervosa may differ for men and women, making these relationships worthy of further exploration.

Orthorexia Nervosa Practices in Rheumatoid Arthritis: The DORA Study

Medical nutrition therapy (MNT) is an indisputable component of the multidisciplinary therapeutic approach in rheumatoid arthritis (RA). Previous research has suggested that in chronic disease where nutrition is an important effector of prognosis, healthy dietary choices might take an unhealthy turn, with patients developing disordered eating in the form of orthorexia nervosa (ON). ON is characterized by a pathological preoccupation with "healthy", "pure" eating, associated with restrictive dietary patterns, nutrient deficiencies and worsening disease outcomes. The aim of the present cross-sectional study was to evaluate ON tendencies in a sample of adult patients with RA. A total of 133 patients with RA were recruited, and completed the ORTO-15 questionnaire for the assessment of ON tendencies. Most of the patients were overweight/obese (53.4%). The results revealed ON tendencies in the sample, with the median ORTO-15 score reaching 36 (IQR: 33-39). Greater ON tendencies were associated with the female gender, and lowered ON tendencies with increasing age and body mass index. The present findings highlight the need for health professional awareness regarding the problem of ON in patients with RA and the importance of screening patients.

A Case of Eating Disorder Diagnosed As Orthorexia Nervosa

A 13-year-old girl presented to our hospital with chief complaints of rapid weight loss, fatigue, discomfort, chills in the extremities, and alopecia. We initially suspected anorexia nervosa (AN). However, she did not express fear of gaining weight or have a distorted perception of her weight or body shape; thus, her presentation was not typical of AN. We also suspected avoidant/restrictive food intake disorder (ARFID), but she did not exhibit any food-avoidance behaviors. However, she was obsessed with nutrition control, so we diagnosed her with orthorexia nervosa (ON). She was hospitalized, given education on proper nutrition, and her eating behavior subsequently improved. After discharge, we administered the ORTO-15, which assesses the propensity for ON, and her score met the diagnostic criteria for ON. The incidence of ON has increased during the COVID-19 pandemic. In this case, her obsession was brought about by information she read in magazines and on social media that promoted an unbalanced diet centered almost exclusively on vegetables. Pediatricians should raise awareness of misinformation regarding children's health to ensure healthy growth.

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.

The prevalence of feeding and eating disorders symptomology in medical students: an updated systematic review, meta-analysis, and meta-regression

PURPOSE

Medical students have a higher risk of developing psychological issues, such as feeding and eating disorders (FEDs). In the past few years, a major increase was observed in the number of studies on the topic. The goal of this review was to estimate the prevalence risk of FEDs and its associated risk factors in medical students.

METHODS

Nine electronic databases were used to conduct an electronic search from the inception of the databases until 15th September 2021. The DerSimonian-Laird technique was used to pool the estimates using random-effects meta-analysis. The prevalence of FEDs risk in medical students was the major outcome of interest. Data were analyzed globally, by country, by research measure and by culture. Sex, age, and body mass index were examined as potential confounders using meta-regression analysis.

RESULTS

A random-effects meta-analysis evaluating the prevalence of FEDs in medical students (K = 35, N = 21,383) generated a pooled prevalence rate of 17.35% (95% CI 14.15-21.10%), heterogeneity [Q = 1528 (34), P = 0.001], τ2 = 0.51 (95% CI 0.36-1.05), τ = 0.71 (95% CI 0.59-1.02), I2 = 97.8%; H = 6.70 (95% CI 6.19-7.26). Age and sex were not significant predictors. Body mass index, culture and used research tool were significant confounders.

CONCLUSION

The prevalence of FEDs symptoms in medical students was estimated to be 17.35%. Future prospective studies are urgently needed to construct prevention and treatment programs to provide better outcomes for students at risk of or suffering from FEDs.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

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.

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.

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.

Psychometric evaluation of the French version of the Düsseldorfer Orthorexia Skala (DOS) and prevalence of orthorexia nervosa among university students

PURPOSE

This study aimed at obtaining a French version of the DOS (F-DOS) and evaluating its psychometric properties in a sample of university students, then assessing the prevalence of orthorexic eating behavior among the participants.

METHODS

The F-DOS was obtained using back translation, and then administered to 3235 university students (10.32% men, 89.67% women) with a mean age of 21.13 (SD = 2.23). The Eating Habits Questionnaire and Eating Attitudes Test were used to assess convergent and divergent validities, respectively. Confirmatory factor analysis was performed to explore the factor structure.

RESULTS

Ordinal ⍵ of F-DOS was 0.87, indicating very good internal consistency. F-DOS and EHQ total scores were strongly correlated (r_s = 0.74, p < 0.001), indicating very good construct validity. Factor analysis revealed a well-fitted one-factor model. Regarding Orthorexia Nervosa (ON) prevalence, according to DOS cut-off score, 3.28% of participants could be considered having ON, while an additional 11.31% could be at risk of developing ON.

CONCLUSIONS

The F-DOS appears to be a valid and reliable instrument to assess orthorexic eating behavior. ON prevalence in college students appeared similar to Germany and lower than in the US.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, Level V.

The Safe and Effective Use of Plant-Based Diets with Guidelines for Health Professionals

Plant-based diets, defined here as including both vegan and lacto-ovo-vegetarian diets, are growing in popularity throughout the Western world for various reasons, including concerns for human health and the health of the planet. Plant-based diets are more environmentally sustainable than meat-based diets and have a reduced environmental impact, including producing lower levels of greenhouse gas emissions. Dietary guidelines are normally formulated to enhance the health of society, reduce the risk of chronic diseases, and prevent nutritional deficiencies. We reviewed the scientific data on plant-based diets to summarize their preventative and therapeutic role in cardiovascular disease, cancer, diabetes, obesity, and osteoporosis. Consuming plant-based diets is safe and effective for all stages of the life cycle, from pregnancy and lactation, to childhood, to old age. Plant-based diets, which are high in fiber and polyphenolics, are also associated with a diverse gut microbiota, producing metabolites that have anti-inflammatory functions that may help manage disease processes. Concerns about the adequate intake of a number of nutrients, including vitamin B12, calcium, vitamin D, iron, zinc, and omega-3 fats, are discussed. The use of fortified foods and/or supplements as well as appropriate food choices are outlined for each nutrient. Finally, guidelines are suggested for health professionals working with clients consuming plant-based diets.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level V, descriptive study.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

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.

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.

Traits of Orthorexia Nervosa and the Determinants of These Behaviors in Elite Athletes

Background: The purpose of this study was to evaluate the traits of orthorexia nervosa (ON) and its relation to body composition and anthropometric indices among elite athletes. Methods: We studied 273 (125 female, 148 male) competitive athletes. ON was assessed with the self-administered ORTO-15 questionnaire. Total body composition was determined using dual-energy X-ray absorptiometry (DXA). Results: The ORTO-15 score was independent of sex, type of effort or age. The ORTO-15 score was related to: total body mass (TBM) (p = 0.037; R = 0.170), body mass index (BMI) (p = 0.022; R = 0.187), bone mineral content (BMC) (p = 0.035; R = 0.172), lean soft tissue (p = 0.026; R = 0.182) and visceral adipose tissue (VAT) (p = 0.007; R = 0.255) in the male; BMI (p = 0.045; R = 0.412) and BMC (p = 0.012; R = 0.506) in weight-dependent male athletes. There was no relationship between ORTO-15 score and body composition in the total study group and subgroup of female athletes. In female athletes, ON tendencies were related to the weekly training time (p = 0.039), but in sprint and high-intensity intermittent efforts subgroup exclusively. Conclusions: Factors related to ON tendencies concerned exclusively BMI and body composition in male, and the weekly training time in female athletes. The results from this study demonstrate that a significant percentage of athletes, irrespective of sex, age, type of sport or hours of training per week, may manifest traits of orthorexia nervosa.

The psychometric properties of Orthorexia Nervosa assessment scales: A systematic review and reliability generalization

The main objective of this systematic review was to provide a comprehensive overview of the psychometric properties of all available Orthorexia Nervosa (ON) assessment tools, in order to evaluate their scope of application for research and practice. Ten databases were searched for studies quantitatively assessing ON. The psychometric properties were evaluated according to specified quality criteria, focusing on the reliability, structural validity and construct validity of the scales. A meta-analytic approach was used to summarize eligible Cronbach's alpha coefficients between studies. Sixty-eight unique studies fulfilled the inclusion criteria for this systematic review. Ten discrete ON scales were identified. Half of the included studies exclusively utilized a version of the ORTO-15. The evaluation of all available ON measures raise issues regarding ON's dimensionality and conceptualization. Most of the identified scales require further validation. Based on the reported psychometric properties it is advised to re-evaluate existing tools and to focus on establishing consensus regarding the conceptualization of ON to establish a measure with sound psychometric properties.

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.

Disordered eating behaviours and correlates in yoga practitioners: a systematic review

PURPOSE

Yoga has been increasingly used as a complementary therapy for eating disorders. However, it is still not clear whether yoga is effective in the prevention and treatment of eating disorders, as some studies suggest that yoga practitioners show elevated levels of disordered eating behaviours. The goal of this systematic review is, thus, to analyse the occurrence of disordered eating behaviours and correlates in yoga practitioners.

METHOD

PRISMA guidelines for systematic reviews were used. Search was conducted in several databases and specific journals.

RESULTS

Twelve articles, all cross-sectional, were identified, following PRISMA guidelines. Results across studies were inconsistent. Yoga practice was usually associated with healthier eating behaviours, lower disordered eating symptoms, and higher positive body image and body satisfaction, suggesting that yoga practitioners may be at a lower risk of developing eating disorders. However, other studies suggested that a high dosage of yoga practice may be associated with a higher prevalence of disordered eating behaviours.

CONCLUSIONS

As yoga is increasingly used as therapy for eating disorders, understanding the relationship between yoga dosage and disordered eating behaviours is critical to guide treatment recommendations and establish yoga as a valuable complementary therapy.

LEVEL OF EVIDENCE

Level I, systematic review.

Orthorexia nervosa, eating patterns and personality traits: a cross-cultural comparison of Italian, Polish and Spanish university students

BACKGROUND

The amount of research about orthorexic attitudes and behaviours has increased in the last five years, but is still mainly based on descriptive and anecdotal data, yielding a variety of prevalence data and inconsistent results. The interplay between socio-cultural context and orthorexia has been poorly investigated and is still far from being understood.

METHOD

Multicentre, cross-sectional study involving Italian (N = 216), Polish (N = 206) and Spanish (N = 242) university students, assessed through a protocol including informed consent, socio-demographic and anamnestic data sheet and self-administered questionnaires (ORTO-15, Eating Attitudes Test- 26 [EAT-26], Temperament and Character Inventory [TCI]).

RESULTS

Higher prevalence of orthorexia (as described by the ORTO-15 cutoff) was found in Poland. Female gender, Body Mass Index (BMI), current Eating Disorder, dieting, EAT-26 score ≥ 20 and low/medium Persistence were associated with orthorexia in the whole sample. The cross-cultural comparison showed several differences among the three subgroups of students.

CONCLUSIONS

The associations found between orthorexic attitudes, self-reported current eating disorder, BMI and adherence to a dieting need to be supported by further research. The differences among students from the three countries seem to suggest a possible rolve for cultural elements in the construct of orthorexia.

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.

Are the Motives for Food Choices Different in Orthorexia Nervosa and Healthy Orthorexia?

Recent research points to the bidimensional nature of orthorexia, with one dimension related to interest in healthy eating (healthy orthorexia) and another dimension related to a pathological preoccupation with eating healthily (orthorexia nervosa). Research was needed to provide further support for this differentiation. We examined the food-choice motives related to both aspects of orthorexia. Participants were 460 students from a Spanish university who completed the Teruel Orthorexia Scale and the Food Choice Questionnaire. By means of structural equation modeling, we analyzed the relationship between orthorexia, food-choice motives, gender, body mass index, and age. The motives predicting food choices in orthorexia nervosa and healthy orthorexia were quite different. In the case of orthorexia nervosa, the main motive was weight control, with sensorial appeal and affect regulation also showing significant associations. For healthy orthorexia, the main motive was health content, with sensorial appeal and price also showing significant associations. This supports the hypothesis that orthorexia nervosa is associated with maladaptive eating behavior motived more by weight control than by health concerns.