The clinical basis of orthorexia nervosa: emerging perspectives

The Impact of Social Media and Socio-Cultural Attitudes toward Body Image on the Risk of Orthorexia among Female Football Players of Different Nationalities

BACKGROUND/OBJECTIVES

Orthorexia Nervosa (ON) is an emerging behavioral pattern characterized by an obsessive focus on healthy eating. Despite its prevalence, ON lacks formal diagnostic criteria in major classification systems like the DSM-5 and the ICD-10. This study aims to investigate the impact of socio-cultural attitudes towards body image and the role of social media on the risk of ON among female football players from Poland, Turkey, and India. This study hypothesizes that socio-cultural pressures and media usage significantly influence the risk of developing ON, particularly in cultures more exposed to Western beauty ideals.

METHODS

The study was conducted from May to August 2024, employing the Computer-Assisted Web Interview method. A total of 142 female football players aged 16-36 from Poland, Turkey, and India participated. Data were collected using a structured questionnaire that included demographic information and health metrics, the Socio-Cultural Attitudes Towards Appearance Questionnaire, and the Duesseldorf Orthorexia Scale. Statistical analyses included an ANOVA, the Kruskal-Wallis test, the chi-square test, and Pearson's correlation coefficient.

RESULTS

The study found that nearly half of the participants were at risk of or presented with ON, with the highest prevalence being among Indian athletes. Statistically significant relationships were observed between the risk of ON and factors such as age, dietary exclusions, social media usage, and sources of nutritional information. However, no significant correlation was found between socio-cultural attitudes and the risk of ON, suggesting that other factors may play a more critical role.

CONCLUSIONS

While socio-cultural pressures and media use are contributing factors to the risk of ON, psychological factors and individual behaviors appear to be equally, if not more, significant. This study highlights the importance of targeted educational programs and psychological support for young athletes, with a focus on promoting healthy dietary practices and positive body image perceptions across varying cultural contexts. Additionally, the results suggest the need for further research into the specific psychological and behavioral mechanisms underlying ON.

Psychiatric Explanations of Poor Oral Intake: A Clinically Focused Review

BACKGROUND

Poor oral intake (POI) among medical-surgical inpatients can cause malnutrition and delay recovery due to medical consequences and the need for more invasive nutritional support. Many psychiatric conditions can cause POI; however, the role that psychiatric conditions play in POI has received limited attention to date.

OBJECTIVE

This review aggregates available information on POI due to psychiatric conditions and provides a framework for the clinical approach to these conditions in hospitalized adult patients.

METHODS

We searched PubMed and EMBASE for reviews of POI due to psychiatric causes, but no relevant publications were identified. Diagnostic criteria for relevant conditions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision and Rome IV were reviewed, as were C-L psychiatry textbooks and relevant society websites. This review was further supplemented by a case conference at the authors' institution.

RESULTS

We have divided results into five sections for clinical utility: (1) the need to rule out medical causes of POI; (2) unpleasant somatic experiences, including psychotropic causes; (3) mood, psychotic, catatonic, and neurocognitive disorders that can present with POI; (4) eating and feeding disorders; and (5) personal and interpersonal explanations of POI. Within each section, we review how to identify and manage each condition, specifically considering the effects of treatment on oral intake.

CONCLUSIONS

The clinical management of POI varies based on cause. For instance, psychostimulants can cause POI due to inappetence; however, they can treat POI due to abulia by improving motivation. The fact that such a broad range of psychiatric conditions can cause POI calls for a systematic clinical approach that considers the categories of potential causes. We also identified a need for prospective studies focused on the management of POI due to psychiatric conditions, as the literature on this topic is limited to case reports, case series, and retrospective cohort studies.

#ForYou? the impact of pro-ana TikTok content on body image dissatisfaction and internalisation of societal beauty standards

Videos glamourising disordered eating practices and body image concerns readily circulate on TikTok. Minimal empirical research has investigated the impact of TikTok content on body image and eating behaviour. The present study aimed to fill this gap in current research by examining the influence of pro-anorexia TikTok content on young women's body image and degree of internalisation of beauty standards, whilst also exploring the impact of daily time spent on TikTok and the development of disordered eating behaviours. An experimental and cross-sectional design was used to explore body image and internalisation of beauty standards in relation to pro-anorexia TikTok content. Time spent on TikTok was examined in relation to the risk of developing orthorexia nervosa. A sample of 273 female-identifying persons aged 18-28 years were exposed to either pro-anorexia or neutral TikTok content. Pre- and post-test measures of body image and internalisation of beauty standards were obtained. Participants were divided into four groups based on average daily time spent on TikTok. Women exposed to pro-anorexia content displayed the greatest decrease in body image satisfaction and an increase in internalisation of societal beauty standards. Women exposed to neutral content also reported a decrease in body image satisfaction. Participants categorised as high and extreme daily TikTok users reported greater average disordered eating behaviour on the EAT-26 than participants with low and moderate use, however this finding was not statistically significant in relation to orthorexic behaviours. This research has implications for the mental health of young female TikTok users, with exposure to pro-anorexia content having immediate consequences for internalisation and body image dissatisfaction, potentially increasing one's risk of developing disordered eating beliefs and behaviours.

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.

Higher orthorexia tendency among female fashion models: an empirical international study

PURPOSE

Female fashion models are more at risk for developing eating disorders than non-models due to the intense occupational pressure they face. The present study focuses on assessing whether female models are more prone to report orthorexia nervosa signs and symptoms than non-models.

METHODS

Female fashion models (n = 179, mean age: 25.9 SD = 4.40 years) and an age adjusted control group (n = 261, mean age: 25.0 SD = 4.97 years) were selected by snowball sampling. Participants filled out an online survey containing anthropometric questions and the 18-item Eating Habits Questionnaire.

RESULTS

According to BMI, fashion models were underweight (mean BMI = 18.1 SD = 1.68) while control participants' BMI was in the normal range (mean = 22.1 SD = 4.23, p < 0.001). On all three of Eating Habits Questionnaire subscales fashion models showed significantly higher average value (Knowledge subscale: M = 2.42 among models versus M = 2.08 in the control group, p < 0.01, Cohen's d = 0.52; Problems subscale: M = 1.93 among models versus M = 2.61 in the control group, p < 0.01, Cohen's d = 0.49; Feelings subscale: M = 3.20 among models versus M = 2.96 in the control group, p < 0.01, Cohen's d = 0.38). Orthorexic tendencies were reported by 35.1% of the models versus 20.2% of controls.

CONCLUSION

Fashion models are at risk for the development of eating disorders. Even though not yet included in the DSM-5, the assessment of orthorexia nervosa among fashion models seems to be important. It is suggested to take appropriate measures to prevent the spread of disordered eating habits among models as they can lead to the development of anorexia nervosa or bulimia nervosa.

LEVEL OF EVIDENCE

Level III, well-designed cohort study.

Exploration of the Mediating Role of Self-Compassion and Mindfulness on Orthorexia Nervosa and Perfectionism

Orthorexia Nervosa (ON) is characterized by an excessive preoccupation with healthy eating, accompanied by increasingly restrictive dietary practices over time. In light of the increased attention to ON, it is noteworthy that the existing body of research, specifically with regard to mindfulness and self-compassion remains constrained in scope and depth. A total of 151 participants over the age of 18 completed scales measuring Orthorexia, Self-Compassion, Mindfulness, and Perfectionism. The findings revealed that individuals exhibiting high levels of ON tended to have low levels of self-compassion and mindfulness, along with high levels of perfectionism. Furthermore, the results indicated that self-compassion and mindfulness acted as mediators in the relationship between perfectionism and orthorexia nervosa. These findings deepen our comprehension of orthorexia and underscore the role of self-compassion and mindfulness, or their absence, as mediating factors in this context. The implications of these results and potential future directions are discussed.

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

Introduction

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

Methods

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

Results and discussion

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

Conclusion

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

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

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

Unveiling Anxiety Factors in Orthorexia Nervosa: A Qualitative Exploration of Fears and Coping Strategies

Orthorexia nervosa represents a controversial phenomenon in the realm of eating practices, characterized by an obsessive fixation on consuming only foods deemed 'healthy', and a preoccupation with food purity. While the existing literature has identified the presence of stressful behaviors among individuals with orthorexia, the precise factors and circumstances eliciting these stress-inducing emotions remain the subject of ongoing inquiry. This study aims to explore the triggers and situations that precipitate stressful beliefs and emotions among individuals who self-identify as preoccupied with healthy eating, as well as the coping mechanisms developed to manage these feelings. Through conducting one-to-one interviews with thirteen individuals, thematic analysis was employed to elucidate the nuances of their experiences. Participants articulated concerns regarding the contamination of foods available in supermarkets and restaurants, thereby prompting the meticulous selection of food sources and aversion to dining out. The prospect of trying new foods and engaging in social gatherings involving food emerged as anxiety-inducing scenarios, prompting individuals to adhere to monotonous dietary patterns and impose self-isolation. Additionally, medical appointments were perceived as stressful, driven by health concerns underpinning the adoption of stringent dietary practices. These findings underscore the spectrum of fears and coping mechanisms exhibited by individuals with orthorexia nervosa, which hold profound implications for their overall well-being.

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

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

Motivations matter: moral and health-related motives indirectly relate to differential psychological health indicators among vegetarians

Due to rising popularity of vegetarianism in recent years, research interest has surged in examining the relationship between vegetarianism and psychological health. However, given inconsistent findings in prior research, the answer to whether practicing vegetarianism is associated with better or worse psychological health is still elusive. The present investigation aimed to demonstrate that vegetarians are not homogeneous in terms of psychological experiences, such that it is crucial to consider the motives behind vegetarians' dietary choice when examining their psychological health. In a survey study with 266 vegetarians and 104 omnivores, it was shown that health vegetarians displayed higher levels of disordered eating as compared to moral vegetarians and omnivores. Mediation analyses further revealed that, among vegetarians, health motivation was positively correlated with disordered eating tendencies, indirectly linking it with poorer psychological health; moral motivation was positively correlated with prosocial behavior, which in turn predicted better psychological health. These findings have implications for understanding the psychological health of vegetarians with different dietary motives and for developing interventions to promote their psychological health.

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.

Increased eating disorder frequency and body image disturbance among fashion models due to intense environmental pressure: a content analysis

Introduction

Female fashion models are under intense occupational pressure. The present study focuses on assessing the lived experience of fashion models with regards to their dieting and exercising habits, body image perception, eating disorder-like symptoms, and experience of abuse via self-narrated reports.

Methods

Series of open questions were distributed among international fashion models (N=84, mean age=23.2 years; mean BMI=16.9) selected by convenience and snowball sampling. Models from 17 countries participated. The questions targeted models' eating, exercising, dieting habits, body image perception, and eating disorder symptoms. The average word count of the transcripts was 2473.9 (SD = 2791.6). Thematic content analysis was performed on the transcripts. A total of 31 codes were created to address disordered eating and body image concerns.

Results

Negative body-related claims appeared in 89.3%, and positive claims in 64.3% of the models' transcripts. Negative remarks about eating were made by 45.2% of the participants, and 23.8% positively. Control over their food intake was exercised by 78.6% of the participants and 40.5% used extreme calorie restriction. Models who talked more positively about their bodies expressed significantly more frequently extreme calorie restriction. Extreme sports habits occurred in 23.8% of the transcripts, obsessive sports habits were claimed by 11.9% of participants. Self-induced vomiting was prominent in 14.3% of the answers. Criticism from other industry members was experienced by 83.3% of the participants while 44.0% received body appreciation. Body image disorder-like symptoms were expressed by 63.1% of models. Such models mentioned significantly more often content about eating disorders and talked significantly more negatively about eating. Psychological problems were mentioned by 48.8%, whereas 16.7% took part in psychotherapy. Those who partake in therapy mentioned significantly more eating disorder content in their narratives. Abuse was mentioned by 25.0% of the models.

Conclusion

Fashion models are experiencing increased environmental pressure to conform to the extreme slimness ideal. There is a heightened prevalence of disordered eating and other weight-controlling behaviours among fashion models to succeed in their careers. Qualitative research is crucial in understanding the more subtle dynamics in conforming to and maintaining the thin beauty ideal.

Assessment of eating disorders and depression in postpartum women

OBJECTIVE

To determine the prevalence of eating disorders and orthorexia in postpartum women and examine the relationship with postpartum depression.

STUDY DESIGN

Included in this study were 227 postpartum women. The Eating Attitude Test-26 (EAT-26) was used to determine the risk of eating disorders in the women, followed by the Orthorexia 11 Scale (ORTO-11) to identify orthorexia, and the Edinburgh Postpartum Depression Scale (EPDS) to identify postpartum depression.

RESULTS

63 of the women (27.8%) exhibited an orthorexic tendency, which was also related to eating disorders and postpartum depression. Each one-point increase in the EAT-26 score led to a decrease of 0.32 points in the ORTO-11 score. Similarly, each one-point increase in the EPDS score caused a reduction of 0.18 points in the ORTO-11 score. The ORTO-11 score increased by 0.26 points per each live birth.

CONCLUSION

An obsessive focus on healthful nutrition may result in the impairment of health and numerous adverse psychological and physiological outcomes in the future. Healthy eating habits should be maintained to improve the quality of life without causing an obsession with healthy eating.

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.

Body appreciation predicts lower levels of orthorexia nervosa symptoms: Prospective findings

Recent evidence shows that negative body image may be a potential risk factor for symptoms of orthorexia nervosa (ON). However, whether positive body image plays a protective role against symptoms of ON remains unclear. Although prior research has established associations between body appreciation (a core component of positive body image) and ON symptoms, this research is limited to cross-sectional designs, precluding inferences of temporal precedence. Thus, the present study overcomes this limitation by testing whether body appreciation prospectively predicts ON symptoms. Data were analysed from 1253 adult women (M age = 34 years (SD = 9.4), 81.3% Caucasian) who completed the Orthorexia Nervosa Inventory (ONI) and Body Appreciation Scale 2-Short Form (BAS2-SF) at baseline (T1) and at three-month follow-up (T2). Multiple linear regressions were used to test whether body appreciation scores at T1 predicted ONI subscale scores (behaviours, emotions, and impairments) at T2. Results revealed that higher body appreciation scores at T1 significantly predicted decreased scores on each ONI subscale at T2, though effect sizes were small. Findings provide preliminary evidence that body appreciation may protect against ON symptoms. If replicated, efforts to address ON symptoms may be enhanced by promoting body appreciation.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Measuring Pathological and Nonpathological Orthorexic Behavior: Validation of the Teruel Orthorexia Scale (TOS) among Polish Adults

Measuring orthorexia nervosa is challenging due to the use of various existing tools and problems with sample representativeness. Another challenge for the Polish population is the adaptation of existing research tools and the evaluation of their relevance and research reliability. Our research aimed to adapt the TOS to the Polish language and measure pathological and nonpathological orthorexic behavior among the Polish population. The adaptation of the PL-TOS has high psychometric value and allows us to assess healthy and nervous orthorexia levels. This scale can be used not only for further research but also for diagnostic purposes in the daily work of clinicians and psychologists. Our results obtained in the present study indicate a correlation between TOS and both the use of supplements and diet. Higher TOS, ORTO_R and KZZJ_Diet Restrictions scores were obtained for individuals using dietary supplements than for those not using dietary supplements. In the future, it is worth conducting research aimed at various risk groups of individuals with orthorexia to confirm the psychometric properties of this adaptation of the TOS.

Orthorexia nervosa in dietitians and dietetics students-prevalence, risk factors, and interventions: a scoping review using a systematic approach

CONTEXT

Orthorexia nervosa (ON) is characterized by compulsive behaviors and increased concerns about healthful eating. Dietitians appear to be especially vulnerable to ON, and it is still debatable whether the disordered eating behaviors motivate individuals to enroll in nutrition programs, or whether these behaviors result from an exaggerated preoccupation with healthy eating triggered during their nutrition studies.

OBJECTIVE

The aim was to provide an overview of the present state of knowledge about the prevalence, risk factors, and interventions addressing ON among dietitians and dietetics students. More specifically, it was examined whether dietitians and dietetics students differ from students attending different education programs or other health professionals with regard to the severity and risk factors of ON, and whether the extent of ON changes during the progression in the nutrition education years of study.

DATA SOURCES

MEDLINE (Ovid), PubMed, EMBASE (Ovid), PsycInfo (EBSCO), CINAHL (EBSCO), Cochrane, ProQuest Central, CABI, ProQuest Dissertations, Google Scholar, ScienceDirect, and SpringerLink were searched on May 8, 2021, and updated on November 12, 2022.

DATA EXTRACTION

Records were screened for eligibility; study characteristics, methodology, and findings of included articles were extracted; and the methodological quality assessed using the AXIS tool. Each step was preceded by a calibration exercise and conducted independently and in duplicate by pairs of 2 reviewers. Any disagreements were resolved through discussions.

DATA ANALYSIS

A narrative synthesis was performed, whereby the characteristics, methodologies, and results of included studies were compared.

CONCLUSIONS

Results were inconclusive; yet, a general status of the relatively "high" prevalence of ON among dietitians and dietetics students was established, stressing the need for systematic research to understand and mitigate orthorexic tendencies in this group. It is still too early to answer questions pertaining to prevalence, risk factors, interventions, and differences between dietetics students and other majors when it comes to severity and progress of ON throughout the continuing years of study, or between dietitians and other professional groups.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework Identifier: DOI 10.17605/OSF.IO/BY5KF.

Mediating effect of psychological distress and mindful eating behaviors between orthorexia nervosa and academic self-efficacy among Lebanese university female students

OBJECTIVES

This study examined the mediating effect of psychological distress and mindful eating behaviors between orthorexia nervosa and academic self-efficacy among Lebanese university female students.

METHODS

A total of 769 female participants enrolled in this cross-sectional study (mean age 21.58 ± 3.20 years). A self-administered questionnaire was distributed among university female students. The questionnaire consisted of Mindful Eating Behaviors Scale, ORTO-R, Depression Anxiety Stress Scale, and Arabic version of Academic Self-Efficacy Scale.

RESULTS

The results showed that psychological distress fully mediated the association between orthorexia nervosa and academic self-efficacy; higher orthorexia nervosa was significantly associated with less psychological distress (β= -0.31, p =.05), with more psychological distress significantly associated with lower academic self-efficacy (β= -0.32, p =.09). Focused eating fully mediated the association between orthorexia nervosa and academic self-efficacy; higher orthorexia nervosa was significantly associated with less focused eating (β=-0.09, p =.04), with more focused eating significantly associated with better academic self-efficacy (β = 1.40, p =.10). Orthorexia nervosa was not directly associated with academic self-efficacy in both models.

CONCLUSION

This study shed light on important connections between orthorexia nervosa, psychological distress, mindful eating behaviors, and academic self-efficacy within the Lebanese context. The findings will have practical implications for both educational institutions and healthcare providers striving to support young female adults' overall well-being and academic success.

Dieting, obsessive-compulsive thoughts, and orthorexia nervosa: Assessing the mediating role of worries about food through a structural equation model approach

BACKGROUND

Orthorexia Nervosa (ON) is a condition characterized by an obsessive focus on healthy eating, inflexible dietary rules, and persistent preoccupations with food. Despite it has been recently the subject of increasingly relevant studies, little is known about the mechanisms that might foster ON symptoms.

OBJECTIVE

This study used a structural equation modeling approach to test the mediating effect of thoughts, worries, and preoccupations about food on the relationship that eating disorders (EDs) attitudes (e.g., dieting) and obsessive-compulsive thoughts and symptoms have with ON in a large community sample. It was hypothesized that the effect of dieting and obsessive-compulsive thoughts and symptoms on ON would be partially mediated by the presence of thoughts, worries, and preoccupations about food.

METHODS

Data from a cross-sectional sample of 1328 participants (females = 976) recruited from the general population were asked to fill in an online survey comprising the Eating Attitude Test-26 (EAT-26), the Obsessive-compulsive subscale of the Symptom Checklist-90 Revised (SCL-90R-OC) and the Orthorexia Scale-15 (ORTO-15).

RESULTS

Structural equation models indicated that both obsessive-compulsive thoughts and symptoms and dieting had a direct effect on ON and that food preoccupation partially mediated these relationships.

CONCLUSION

These findings provide novel insight into the nature of ON that could aid its conceptualization and treatment.

Perfectionism as a moderator of the relationship between orthorexia nervosa and obsessive-compulsive symptoms

PURPOSE

Orthorexia nervosa (ON), a proposed disorder describing an obsessive focus on "healthy" eating, is characterised as having overlapping symptoms with obsessive-compulsive disorder. However, ON/obsessive-compulsive (OC) symptom relationships are inconsistently reported. The current study aimed to investigate if the contribution of OC symptoms and beliefs explain variability in ON symptoms and determine if perfectionism, a transdiagnostic factor, moderates the ON/OC symptom relationship.

METHODS

The study comprised 190 participants (Mage = 28.63, SDage = 9.88; 80% female) recruited via an undergraduate research programme, social media, advocacy organisations, and a participant registry. Participants completed an online questionnaire assessing ON, OC, and perfectionism symptoms.

RESULTS

A linear regression analysis found OC symptoms and beliefs explained 22.9% variability in ON symptoms (p < 0.001, f2 = 0.38) and perfectionism moderated the ON/OC symptom relationship, where higher levels of perfectionism with higher levels of OC symptoms was associated with higher levels of ON symptoms, explaining 2.2% variability (p = .01, f2 = 0.03).

CONCLUSION

OC symptoms appear more common in ON than previous studies indicate. However, the interaction between perfectionism and OC symptoms may drive obsessions in ON. Findings help refine our current understanding of ON phenomenology with implications for ON treatment development. Future research should further explore perfectionism in ON phenomenology.

LEVEL OF EVIDENCE

Level V (Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees).

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.

Mental Health and Disordered Eating in Athletes

Disordered eating (DE) and eating disorders (EDs) are more prevalent in athletes than non-athletes, and can cause devastating health and performance consequences. Although they can affect any athlete, DE/EDs are more common among women and athletes in lean sports, where there is a perceived competitive advantage to being lean. The sports medicine provider plays a crucial role in screening, diagnosis, and treatment of DE/ED. Treatment should involve a multidisciplinary team with a physician, dietitian, and mental health provider. Preventative efforts should seek to educate athletes and their coaches/support staff and should foster a healthy environment, which deemphasizes weight or body image.

Mediator Roles of Perfectionism and Self-Critical Rumination in the Relationship Between Perceived Maternal Rejection and Orthorexia: A Model Testing in a Female Sample

Orthorexia nervosa (ON) refers to a pathological obsession with healthy eating characterized by a restrictive diet, ritualized eating patterns, and strict avoidance of foods believed to be unhealthy or unclean. On the other hand, healthy orthorexia (HO) is defined as an interest in healthy eating and a tendency to eat healthy foods. This study aimed to investigate the relationships between the ON, HO, maternal rejection, perfectionism, self-critical rumination, and body attitude in the women sample. 445 female students from diverse universities in Turkey was attended to our study. Participants completed questionnaires regarding ON and HO, body attitude, maternal rejection, perfectionism, and self-critical rumination. The results showed that negative body attitudes could not predict both HO (B=-.008, SE=.039, p=.791) and ON (B=.008, SE=.032, p=.835). However, perfectionism and self-critical rumination had mediator roles in the relationship between ON and HO with maternal rejection, despite this relationship was positive for ON (B = .014, Boot SE = .007, 95% Boot CI [.003, .029]), but negative for HO (B = -.023, Boot SE = .010, 95% Boot CI [-.042, -.008]). Not a negative body attitude, but maternal rejection, perfectionism, and self-critical rumination played roles in developing orthorexic tendencies.

Assessing the presence and motivations of orthorexia nervosa among athletes and adults with eating disorders: a cross-sectional study

PURPOSE

Orthorexia nervosa involves restricting diet based on quality rather than quantity. Although orthorexia is well reported in many at-risk populations, limited data addresses its presence in individuals with eating disorder history (EDs) or athletes. We aimed to identify the presence and potential drivers of orthorexia in adults with EDs and endurance athletes, compared to control subjects.

METHODS

Participants ≥ 18y included: people with a diagnosed eating disorder (ED as per DSM-5); endurance athletes (training/competing ≥ 5 h/week); or control subjects. Participants (n = 197) completed an online survey assessing orthorexia (eating habits questionnaire, EHQ), eating motivations (TEMS-B) and compulsive exercise (CET).

RESULTS

ED had the highest orthorexia symptom severity (92.0 ± 3.02, n = 32), followed by athletes (76.2 ± 2.74, n = 54) and controls (71.0 ± 1.80, n = 111) (F (2) = 18.2, p < 0.001). A strong positive correlation existed between weight control motives and higher orthorexia symptom severity (r = 0.54, 95% CI [1.35, 2.36], p < 0.001), while a weak negative association existed between Hunger and Pleasure motives and higher orthorexia symptom severity (r = 0.23, 95% CI [- 2.24, - 0.34], p = 0.008; r = 0.26, 95% CI [- 2.11, - 0.47], p = 0.002, respectively). A moderate positive relationship was found between CET and orthorexia symptom severity (95% CI [1.52, 3.12], p < 0.001).

CONCLUSION

Adults with ED history and endurance athletes have greater orthorexia symptom severity compared to control. Clinicians working with at-risk populations should screen patients and be aware of red-flags of orthorexic traits, desire to control weight, and compulsive exercise behavior.

LEVEL OF EVIDENCE

III: Evidence obtained from cohort studies.

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).

Exploration of orthorexia nervosa and diagnostic overlap with eating disorders, anorexia nervosa and obsessive-compulsive disorder

OBJECTIVE

Orthorexia nervosa (ON) is characterized as obsessional healthy eating that results in malnutrition and/or psychosocial impairment. Yet, ON shares theoretical overlap with eating disorders (EDs), especially anorexia nervosa (AN), as well as obsessive-compulsive disorder (OCD). This study aimed to further understand ON and its overlap with related disorders by assessing the ability of ON for detecting the presence/absence of threshold ED, AN, and OCD symptoms.

METHOD

An observational survey was completed by 197 participants recruited through eating disorder, dieting, and mental health support groups. Receiver operating characteristic (ROC) curve analyses determined the predictive ability of ON symptoms (assessed by Eating Habits Questionnaire [EHQ] orthorexia nervosa [OrNe] and healthy orthorexia [HeOr] subscales, and the Orthorexia Nervosa Inventory [ONI]) for detecting disordered eating symptoms (determined by Eating Disorder Examination Questionnaire [EDE-Q] global cut-scores), probable AN (determined by EDE-Q cut-scores and body mass index [BMI] <18.5), and OCD symptoms and obsessional thinking (assessed by the Revised Obsessive-Compulsive Inventory [OCI-R]).

RESULTS

Results showed both the ONI and EHQ OrNe measures are able to adequately predict ED symptoms and AN; however, both were poor to moderate at detecting OCD symptoms and obsessional thinking. Healthy orthorexia was poor to moderate at detecting outcomes.

DISCUSSION

These results suggest that ON, as it is currently operationalized, may be more closely related to EDs than OCD, and that ON may represent a subtype of AN. Results also support healthy orthorexia as a distinct construct to ON. While results are limited by the lack of definitive ON diagnostic criteria, findings suggest that treatments developed for EDs might be most suited to ON.

PUBLIC SIGNIFICANCE

ON has been proposed as a psychiatric disorder, and it shares theoretical overlap with several existing disorders. This study adopts a novel approach to assessing and exploring the overlap of ON with EDs, AN and OCD. Results suggest that ON shares more overlap with EDs and might best be understood as a subtype of EDs or AN.

Personality traits and risk of eating disorders among Polish women: the moderating role of self-esteem

Objectives

Personality traits should be taken into account when diagnosing individuals with disordered eating behaviors in the hope of better understanding their etiology and symptom progression and when planning treatment. The objective of this study was to attempt to determine the moderating role of self-esteem in the relationships between personality traits included in the Big Five model among Polish women and estimated risk of eating disorders.

Methods

The study was conducted among 556 Polish women from Zachodniopomorskie Voivodeship. The average age of the women under study was 34 years. A diagnostic survey was used as the research method, and the empirical data were collected using the following research tools: The NEO Five-Factor Inventory (NEO-FFI), Rosenberg Self-Esteem Scale (SES), ORTO - 15 Questionnaire, The Three-Factor Eating Questionnaire (TFEQ-13), and the authors' original questionnaire. A multivariate linear regression analysis was conducted to examine the influence of selected independent variables. The assumptions for the linear regression model were satisfied, as indicated by the Ramsey Regression Equation Specification Error Test, White's test, and the Jarque-Bera test.

Results

Only the personality trait of neuroticism exhibits a statistically significant effect on the "Cognitive Restraint of Eating," "Uncontrolled Eating," and "Emotional Eating" scores (p < 0.001). The moderation effect was demonstrated between self-esteem and the personality trait of conscientiousness on the "Cognitive Restraint of Eating" scale score. There is a moderation effect between self-esteem and the personality trait of extraversion on the "Uncontrolled Eating" subscale score. There is a moderation effect between self-esteem and the personality trait of conscientiousness on the "Uncontrolled Eating" scale score.

Conclusion

Self-esteem was not a predictor of the occurrence of risk of eating disorders while playing a moderating role in the relationship between certain personality traits and estimated risk of eating disorders. A higher level of neuroticism was identified as an important predictor of higher results for orthorexia, Cognitive Restraint of Eating, Uncontrolled Eating, and Emotional Eating. It was also demonstrated that the orthorexia risk index decreased with increased extraversion and openness to experience. The results of this study suggest that eating behaviors and psychological factors should be included in psychological interventions in the treatment of eating disorders. The clinical goal can be considered to be an improvement in non-normative eating behaviors, such as a reduction in overeating episodes or eating less frequently in the absence of a hunger feeling. In order to assist these individuals in their attempts to achieve healthy behaviors, variables related to mental functioning can be then identified as important goals to support individuals in their efforts to change health behaviors by achieving better mental well-being.

The validation of the Barcelona Orthorexia Scale-Spanish version: evidence from the general population

PURPOSE

To validate the Spanish version of Barcelona Orthorexia Scale (BOS) in general population, analyzing its items and both its internal structure and psychometric properties (internal consistency and temporal stability). In addition, the relationship between ON and external measures of attitudes towards food was assessed.

METHOD

The general population sample consisted of 446 women and 104 men, aged between 18.31 and 69.44 years (M = 36.03; SD = 12.46). Of these, 39 participants answered again the questionnaires after one month from the first application. The assessment instruments were a sociodemographic questionnaire, the BOS, the Eating Attitudes Test-26 (EAT-26) and the Dutch Eating Behavior Questionnaire (DEBQ).

RESULTS

The final version of the BOS is composed of 35 items. Exploratory factor analysis extracted an internal structure of 5 factors (Behavioral, Concern for healthy food, Attitudes and beliefs about food, Vital achievement and Emotional discomfort). The BOS-35 and the factors presented good internal consistency (α = .80-.90), and an adequate temporal stability (r = .62-.88). The highest association was observed between the Emotional Distress (BOS) and the Diet subscale (EAT-26; r = .51).

CONCLUSIONS

This first validation of the BOS has shown adequate psychometric properties, being a valid and reliable instrument to assess ON in the general population. Level of evidence Level II: Evidence obtained from well-designed controlled trials without randomization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The mediating role of sleep quality in the relationship between orthorexia nervosa and fear of COVID-19

The COVID-19 (SARS-CoV-2) pandemic has jeopardized humanity worldwide and has considerably altered the healthy lifestyle behaviors of societies. This study examined the possible mediating role of sleep quality in the relationship between orthorexia nervosa and fear of COVID-19 among Turkish adults. This study used an observational and descriptive design. It was carried out online with 1,130 participants across Turkey between April and August 2021. The data were collected using a questionnaire, the Fear of COVID-19 Scale (FC-19S), the Pittsburgh Sleep Quality Index (PSQI), and Orthorexia Nervosa-R (ON-R). The participants had an ON-R mean score of 3.08 ± 0.90 and a mean PSQI score of 8.03 ± 2.80. Likewise, their mean FC-19S score was 18.24 ± 6.55. There was a significant positive correlation between the FC-19S and the PSQI (r = 0.208; p = 0.000) as well as a significant negative correlation between the ON-R and the PSQI (r = - 0.145; p = 0.000). In addition, the results of the process model analysis supported our hypotheses that the PSQI was a predictor of ON-R and that its direct and indirect effects were moderated by FC19S and the PSQI. A one-unit increase in FC-19S scores causes an average 1% increase on the ON-R scale, while it generates an 8% increase on the PSQI. It was determined that the PSQI total score caused an average of 6% increase in the ON-R scale score. The findings of this study showed that sleep quality has a mediating role in the relationship between orthorexia nervosa and fear of COVID-19 experienced by Turkish adults during the pandemic. For this reason, governments need to take the necessary precautions concerning this subject when creating action plans for possible global crisis situations that may adversely affect public health in the future.

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.

Eating Disorders and Diabetes: Facing the Dual Challenge

Eating disorders and diabetes mellitus are distinct yet closely linked health conditions, presenting distinct challenges in terms of care and management. Eating disorders encompass a spectrum of mental health disorders characterized by abnormal eating behaviors and disruptions in weight regulation. Research indicates that individuals with diabetes might be at an elevated risk of developing eating disorders. The necessity to adhere to specific dietary guidelines, monitor blood sugar levels vigilantly, and manage drug administration can collectively contribute to the emergence of detrimental attitudes toward food and body image. On the other hand, incorrect eating behaviors such as binge eating and purging can disrupt blood sugar control, significantly impacting the development and management of diabetes. This intricate relationship emphasizes the crucial necessity for a comprehensive understanding and specialized care to effectively address the dual challenges faced by individuals dealing with both diabetes and eating disorders. This paper represents the inaugural comprehensive review delving into the intricate connection between eating disorders and diabetes, thereby illuminating previously under-researched areas. The insights gleaned from this review may contribute to developing integrated interventions that aim to improve the overall well-being and quality of life for individuals grappling with the complexities of eating disorders and diabetes.

Orthorexia and Orthorexia Nervosa: A Comprehensive Examination of Prevalence, Risk Factors, Diagnosis, and Treatment

Orthorexia nervosa is an emerging and controversial eating disorder characterized by an obsessive preoccupation with healthy eating and an extreme fixation on food purity. Despite growing public interest in orthorexia, its classification as a distinct eating disorder remains a subject of ongoing debate in the mental health community. This paper comprehensively reviews the current literature on orthorexia nervosa, exploring the prevalence rates, risk factors, diagnosis, and treatment options. The paper offers an overview of orthorexia and its historical context and explores the challenges and considerations in diagnosing orthorexia and orthorexia nervosa. Specifically, the distinction between "orthorexia" and "orthorexia nervosa" is a debated issue in eating disorder research due to a lack of clear diagnostic criteria, making it challenging to accurately differentiate between an obsession with healthy eating and a more severe form with potential distress and impairment. Given the absence of formal diagnostic criteria, developing valid and reliable assessment tools is crucial to accurately identify and treat individuals experiencing these disorders. The paper's final section covers the existing treatment approaches for orthorexia nervosa. Overall, the paper highlights the complex and multifaceted nature of orthorexia nervosa. This review contributes to the ongoing discourse surrounding orthorexia and provides valuable insights for clinicians, researchers, and stakeholders in the mental health and eating disorders fields.

Perfectionism or Perfectionisms in Orthorexia Nervosa

Purpose: Perfectionism is considered a transdiagnostic construct that characterises eating disorders (EDs) and obsessive-compulsive disorder (OCD) and that could also depict orthorexia nervosa (ON). The principal aim of this study was to investigate what dimensions of perfectionism mostly represent ON. Moreover, it was evaluated if dieting impacted the presence of orthorexic features and perfectionistic behaviour. Methods: The sample consisted of two groups-the "Diet" (n = 93), and the "No Diet" (n = 94) groups-composed of people with high and low orthorexic tendencies, respectively. Participants filled out self-report questionnaires to investigate orthorexic tendencies and different facets of perfectionism. Results: Analyses highlighted that people with high orthorexic tendencies showed higher perfectionistic features and that ON had a significant relationship with different facets of perfectionism. No interactions with diet were found. Therefore, no other differences were highlighted when the group type (Diet/No Diet) was considered. Conclusions: Regardless of diet, different facets of perfectionism characterise ON: perfectionism as a personality trait and perfectionism related to EDs and to obsessive-compulsive features. Our results evidenced that perfectionism could also be considered a useful construct in the conceptualization of orthorexia nervosa.

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.

The Relationship between Orthorexia Nervosa and Obsessive Compulsive Disorder

Orthorexia nervosa (ON) is characterized by an intense avoidance of foods considered unhealthy, obsession with healthy eating behaviors, and pathological fixation on healthy foods. Although there are still debates in the literature about the psychological factors and symptoms of ON, it should be noted that many of the symptoms share common features with obsessive compulsive disorder (OCD). The aim of the present study was to investigate the relationship between ON and OCD with its subtypes. In this framework, the cross-sectional study was conducted with an opportunistic sample of 587 participants (86% women and 14% men), with an average age of 29.32 (s.d. = 11.29; age range = 15-74). Our work showed that almost all OCD subtypes were largely correlated with ON. The lowest correlation was for "Checking" and the highest for "Obsession". Overall, the OCD subtypes (i.e., Indecisiveness, Just Right, Obsession, and Hoarding) were more strongly associated with ON measures, while subtypes Checking and Contamination, although positively associated, had lower correlation coefficients.

Is Orthorexia Nervosa a Non-specific Eating Disorder or a Disease in the Spectrum of Obsessive-Compulsive Disorder?

BACKGROUND

In recent years, there has been a dramatic increase in awareness in society that healthy nutrition has positive effects on health. However, obsession with these behaviors towards healthy foods causes negative effects on health and quality of life.

AIM

The aim of this study was to elucidate the relationship between the incidence of orthorexia nervosa (ON) in medical school students and the level of conscious awareness, obsessive-compulsive disorder, eating attitudes and behaviors, health anxiety, and body image to clarify the unclear issues in the literature, such as whether orthorexia nervosa is among the psychological disorders, "where" it will take place, and which diagnoses it can be associated with.

METHODS

Students between the 1^st and 6^th grades of medical school were invited to participate in this research. The Sociodemographic Data Form, Maudsley Obsessive-Compulsive Question Index (MOCI), Eating Attitude Test Short Form (EAT SF-26), Health Anxiety Inventory-Weekly Short Form (HAI-SF), ORTO-11 scale, Body Perception Scale, and Conscious Awareness Scale have been applied to the students.

RESULTS

In univariate analysis, the eating disorder scale, body image scale, and awareness scale total scores all had an impact on orthorexia. Each increase in the eating disorder scale score increased the diagnosis of orthorexia 1.07 times, while each increase in the body image scale score increased the diagnosis of orthorexia 1.09 times. Additionally, each increase in the conscious awareness scale score decreased the diagnosis of orthorexia by 0.92 times. When all variables were re-evaluated in the multivariate analysis, it was seen that the total scores of the body image scale and conscious awareness scale affected the diagnosis of orthorexia. There was a weak inverse relationship between the orthorexia scale score and only the health anxiety inventory total score (p<0.05).

CONCLUSION

Regarding the outcomes of this research, one can say that orthorexia affected the eating disorder scale, body image scale, and awareness scale total scores. While the increase in the eating disorder and body image scale scores increased orthorexia, the increase in the conscious awareness scale score had a decreasing effect.

A longitudinal study of perfectionism and orthorexia in exercisers

Research suggests that trait perfectionism and perfectionistic self-presentation are related to orthorexia - a pathological obsession with correct nutrition. However, no studies have examined these relationships over time or compared the influence of the two aspects of perfectionism on orthorexia. In the present study we sought to address these two issues. Gym members who engaged in high degrees of exercise were recruited via social media platforms. They completed an online questionnaire that included the Multidimensional Perfectionism Scale-Short Form, Perfectionistic Self-Presentation Scale, and the Eating Habits Questionnaire on two occasions: 177 participants (Mean age = 31.6 years) initially completed the questionnaire and 82 completed the questionnaire six weeks later. A series of multiple regression analyses revealed that (i) trait perfectionism predicted an increase in orthorexia symptomatology over time with socially prescribed perfectionism and other-oriented perfectionism unique predictors of orthorexia, (ii) perfectionistic self-presentation predicted orthorexia over time with nondisplay of imperfection a unique predictor of orthorexia, and (iii) when considered alongside each other, only trait dimensions of perfectionism were unique predictors of orthorexia. The present study provides further evidence that perfectionism is related to orthorexia. In addition, the study also provides preliminary evidence that more engrained trait aspects of perfectionism are more predictive of orthorexia over time than the self-presentational aspects of perfectionism.

U.S. health professionals' perspectives on orthorexia nervosa: clinical utility, measurement and diagnosis, and perceived influence of sociocultural factors

PURPOSE

This study examined U.S. health professionals' perspectives on the clinical utility, measurement, and etiology of orthorexia nervosa (ON).

METHODS

Participants (n = 100) were U.S. health professionals with experience working clinically with eating disorders, including trainees, Ph.D. psychologists, social workers/mental health counselors, and medical health professionals. After reviewing the proposed ON criteria, participants responded to questions regarding the clinical utility, diagnosis, and measurement of ON, and sociocultural influence on the emergence of ON. Views of ON as a useful diagnostic category were examined as a function of participants' current involvement in clinical versus research activities.

RESULTS

Participants mostly (71.9%) agreed that ON should be a distinct clinical diagnosis. Participants who endorsed ON as a valid diagnosis spent more time on clinical work and less time engaged in research compared to participants who disagreed (both ps < 0.05). Approximately 27% of participants believed additional components should be added to the proposed ON diagnostic criteria. Participants indicated that sociocultural factors have considerable influence on the development of ON, namely the diet and weight loss industry, and the perceptions that biological/organic/vegan and low fat/low carb/gluten free food are the healthiest.

CONCLUSION

Professionals who spent more time working clinically with eating disorders were more likely to endorse ON as a unique disorder, and professionals who spent more time on research were more likely to disagree. To the extent that professionals who spend more time on research may shape the narrative around ON more visibly, this study underscores the importance of listening to practitioners' experiences in applied settings.

LEVEL OF EVIDENCE

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

Exploring the impact of the COVID-19 pandemic on perceptual disturbances and dysfunctional eating attitudes and behaviors: A review of the literature

From the outbreak of the novel coronavirus 2019 (COVID-19) a new physical and social distancing environment has changed our lives and, more particularly, the way of perceiving oneself, as well as eating attitudes and behaviors. An increasing number of studies have highlighted a risky scenario in terms of negative perceptions of one’s body as well as disordered eating and eating disorder patterns in both clinical and general population. With regard to this postulate, this literature review posits two main concepts—perceptual disturbances and dysfunctional eating attitudes and behaviors—in the general and (sub-)clinical populations, to provide an understanding of these phenomena during the COVID-19 pandemic. The main objective of this article is to provide a comprehensive and critical review of published scientific literature about perceptual disturbances (i.e., negative body image, body image disturbances, low body esteem) and dysfunctional eating attitudes and behaviors, including disordered eating (e.g., restrictive eating, binge-eating episodes, overeating, emotional eating) and eating disorders features in community (i.e., general population) and clinical and sub-clinical samples worldwide during the COVID-19 pandemic. The PubMed, ScienceDirect, Ebsco, and Google Scholar databases were searched. The initial search produced 42 references. Scientific publications from March 2020 to April 2022 were included, and among the works compiled, only published research articles have been retained. Purely theoretical papers were also excluded. The final selection consisted of 21 studies, covering both community, clinical (i.e., eating disorder population), and sub-clinical samples. The details of the results are discussed taking into consideration the potential impact of changes in the way we perceive ourselves and interact with others (e.g., the popularity of videoconferencing and the over-use of social network sites due to social isolation) as well as changes in eating attitudes and behaviors, physical activity and exercise (e.g., as an emotional response to the insecurity generated by the pandemic context), in community and (sub-)clinical samples. The discussion sheds light on two outcomes: (1) a summary of findings with methodological considerations; (2) an intervention continuum to deal with the consequences of the COVID-19 pandemic; (3) and a final conclusion.

"Your struggles are valid, you are worthy of help and you deserve to recover": narratives of recovery from orthorexia nervosa

PURPOSE

Limited research has examined recovery processes and conceptualisations of recovery within orthorexia nervosa (ON). This study harnessed Instagram data to examine how people who self-identify with ON use the hashtag #OrthorexiaRecovery and how recovery is represented within this online space.

METHODS

500 textual posts containing #OrthorexiaRecovery were extracted from Instagram. Co-occurring hashtags were analysed descriptively to determine whether this online space is specific to ON, and textual data were analysed using reflexive thematic analysis.

RESULTS

The hashtag analysis indicated that #OrthorexiaRecovery is being used within a wider context of eating disorder recovery and awareness, but also provides deep insights into experiences of recovery from ON. The thematic analysis generated five themes: the invisibility of orthorexia; a turbulent and continuous process; finding food freedom; from compulsive exercise to intuitive movement; a community of support. Our findings suggest that people with self-reported ON experience recovery as a continuous process and the current invisibility of ON within diagnostic criteria and wider society impedes recovery. While working towards recovery, users aimed to be free from diet culture, become more attuned to their bodies, and develop more adaptive relationships with food and fitness. Users noted a general lack of support for people with ON and so used this online space to create a supportive community, though some content was potentially triggering.

CONCLUSION

Our findings highlight the importance of increased recognition of ON and the potential value of targeting societal norms and harnessing social identity resources within therapeutic interventions for ON.

Exploring the moderating role of mindfulness, mindful eating, and self-compassion on the relationship between eating-disordered quality of life and orthorexia nervosa

Orthorexia nervosa (ON) is characterised by an obsessive focus on healthy eating, following restrictive dietary practices and dietary restrictions escalating over time. The aim of this study was to explore mindfulness, mindful eating, self-compassion and quality of life in a female population. Two hundred eighty-eight participants completed Orthorexia, Self-Compassion, Mindful eating, Mindfulness and Eating Disorder Quality of Life scales. The results indicated that there was a negative relationship between ON and mindfulness, self-compassion and mindful eating. Furthermore, the present study found a positive relationship between lower quality of life and ON, while findings indicated that self-compassion and the awareness facet of mindfulness moderated the relationship between ON and QOL. The present results contribute to a better understanding of orthorexic eating behaviours in a female population, and identify the moderating capacity of self-compassion and mindfulness. Further implications and future directions are discussed.Level of evidence Level V, cross-sectional descriptive study.

The prevalence of orthorexia in exercising populations: a systematic review and meta-analysis

AIM

Orthorexia Nervosa (ON) describes a pathological obsession with proper and high-quality nutrition that is necessary to research further in order to elucidate its prevalence and correlates which may bear implications for prevention and treatment. The aim of this study was to review studies that report the prevalence of ON in people who exercise, calculate an overall prevalence through a random-effects meta-analysis approach and investigate the association of ON prevalence using a random-effects meta-regression. In addition, a sub-group-analysis based on ON-instruments and a sensitivity analysis excluding students samples, were conducted.

METHOD

Systematic searches were conducted in the following online databases: PubMed, Embase, Web of Science, PsychInfo, CINAHL, Google Scholar and OpenNet. The following search terms were used: Orthore* AND (prevalenc* OR incidenc* OR frequen* OR cut-off OR epidem*). A total of 613 unique hits were reviewed by two blinded authors, and 24 studies were coded and assessed for risk of bias (Holy et.al). The meta-regression included three independent variables (sex, type of sport, and sample size).

RESULTS

The overall prevalence of ON in the exercising population was 55.3% (95% CI 43.2-66.8). Cochran's Q was 11,436.38 (df = 23, p < 0.0000), and the I² was 98.4%, indicating high heterogeneity across studies. The sensitivity showed an overall prevalence of 51.3% (95% CI 51.3-70.0). There was a significant difference in prevalence estimates based on the instruments used (Q_bet = 33.6, df = 2, p < 0.01).

DISCUSSION

The overall prevalence of ON in exercising populations was very high. The between-study disparity was large and was partly explained by the ON-instrument administered. One fourth of the studies had a moderate risk of bias. The majority of the studies did not specify relevant demographic information about the sample, and information about the type of sport was frequently missing.

Examining orthorexia nervosa: Using latent profile analysis to explore potential diagnostic classification and subtypes in a non-clinical sample

Orthorexia nervosa (ON) is a proposed psychological disorder characterized by a pathological preoccupation with healthy eating. The purpose of the current study was to clarify the relationships between ON and related forms of psychopathology. In addition, we sought to explore whether there may be subtypes of ON and if ON is associated with BMI, gender, or social media use. The sample included 333 undergraduate students (72% female, M_age = 20.91) who completed measures of ON, eating disorder (ED) symptoms, obsessive compulsive disorder (OCD), obsessive compulsive personality disorder (OCPD), and health anxiety. Latent profile analysis detected three distinct groups with high ON scores. The ON/ED combined group (n = 16) was characterized by high levels of psychopathology, particularly in the areas of ON and eating disorder symptoms. In comparison, the ON/ED combined, without weight/shape concerns group (n = 35) had fewer body-related concerns. The ON only group (n = 23) reported minimal ED pathology. Regression analyses revealed those in the ON only group were more likely to be male, while the ON/ED group was associated with higher BMI. Being in the ON/ED combined, without weight/shape concerns was associated with viewing and sharing healthy eating content on social media. Our findings suggest that ON has the most overlap with ED pathology as compared to OCD, OCPD, and health anxiety, and that there may be three subtypes of ON. The first two share significant overlap with ED symptomatology while the third appears relatively distinct, characterized by less disordered eating and fewer positive emotions related to healthy eating. Future research should examine these subtypes more closely to determine whether they are clinically meaningful, potentially requiring different interventions.

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.