Examining Eating Attitudes and Behaviors in Collegiate Athletes, the Association Between Orthorexia Nervosa and Eating Disorders

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.

Treble or Trouble: Mental Health Experiences of Gender-Diverse Collegiate Marching Band Artists

CONTEXT

For gender-diverse (GD) college marching band (MB) artists, the risks for anxiety and depression may be higher as they navigate the demands and stressors associated with MB, college, and their gender identity.

OBJECTIVES

To examine the risks of anxiety and depression across GD MB artists and to explore their barriers and attitudes toward seeking mental health (MH) care.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Seventy-eight GD individuals (transgender = 12, nonbinary = 66, age = 19 ± 1 years).

MAIN OUTCOME MEASURE(S)

A survey was used to assess demographics, anxiety risk using the State-Trait Anxiety Inventory, depression risk using the Center for Epidemiologic Studies Depression Scale, and barriers and attitudes using the Barriers Towards Seeking Help Checklist, the Attitudes Toward Seeking Professional Psychological Help Scale-Short Form, and the Mental Help Seeking Attitudes Scale. We calculated descriptive statistics and univariate analyses to evaluate scores, risks, and differences between MH and receiving assistance.

RESULTS

Participants had high state anxiety (mean = 52.0 ± 112.1), trait anxiety (mean = 55.2 ± 10.0), and symptoms of depression (mean = 30.4 ± 12.0) based on the State-Trait Anxiety Inventory and the Center for Epidemiologic Studies Depression Scale. Overall, 78.2% (n = 61 of 78) of GD MB artists were considered at risk for both state and trait anxiety and depression, and 18% (n = 11 of 61) did not seek help from an MH professional. These GD MB artists cited a lack of time (82.1%; n = 64 of 78) as the primary barrier to seeking professional help. The mean score on the Attitudes Toward Seeking Professional Psychological Help Scale-Short Form for all GD artists was 19.5 ± 5.0, and the total score for the Mental Help Seeking Attitudes Scale was 47.8 ± 9.2, which indicated more favorable attitudes toward seeking professional help.

CONCLUSIONS

We identified high rates of clinical symptoms for depression and anxiety among GD MB artists. The data are consistent with those from other minority populations and above the normative values for cisgender students. The lack of help-seeking behaviors in nearly 15% of at-risk participants highlights the need for specialized resources for GD patients and those participating in MB.

Australian elite sport coaches' mental health literacy of eating disorders, orthorexia, and muscle dysmorphia in athletes: A qualitative study

Athletes have an increased risk of developing eating disorders (EDs) compared to non-athletes. Coaches are in a unique position to identify symptoms and promote timely support; however, research has not yet explored coaches' mental health literacy about DSM-5 EDs and related orthorexia and muscle dysmorphia conditions in elite athletes. Eighteen Australian elite sport coaches from aesthetic, weight-class, and endurance sports participated in individual semi-structured interviews to investigate their mental health literacy of EDs and related conditions. Four themes emerged from the data. Theme 1 (knowledge of EDs and related conditions) highlighted coaches' awareness of maladaptive perfectionism as a key risk factor, limited awareness of EDs without observable weight loss, and conceptualisation of EDs as a nutritional issue. Theme 2 (facilitators to managing EDs) highlighted the helpfulness of building trust with athletes, accessing support staff, emphasising body functionality, and lived experience. Theme 3 (barriers to managing EDs) highlighted coaches' challenges with communicating about body image, responding to denial, and funding constraints. Theme 4 (future ED education and training) highlighted coaches' desire for in-person, interactive training and to support junior-level coaches. These findings may assist in developing tailored educational resources to improve coaches' ability to identify and manage eating-related concerns in athletes.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

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).

Triggers for eating disorder onset in youth with anorexia nervosa across the weight spectrum

To aid in more targeted eating disorder (ED) prevention efforts, we sought to identify sociodemographic and weight-related risk factors for identified triggers for the onset of anorexia nervosa (AN) in youth. We conducted a retrospective chart review of youth admitted for medical treatment of AN between January 2015 and February 2020. From multidisciplinary admission notes, we extracted patient-reported reasons for diet/exercise changes. We used qualitative thematic analysis to identify ED triggers, then categorized each trigger as binary variables (presence/absence) for logistic regression analysis of risks associated with each trigger. Of 150 patients, mean (SD) age was 14.1(2.3) years. A total of 129 (86%) were female and 120 (80%) were Non-Hispanic White. Triggers included environmental stressors (reported by 30%), external pressures of the thin/fit ideal (29%), internalized thin/fit ideal (29%), weight-related teasing (19%), and receiving health education (14%). Younger age was associated with higher odds of weight-related teasing (p = .04) and health education (p = .03). Males had greater odds of internalized thin/fit ideal than females (p = .04). Those with premorbid body mass indices ≥85th percentile for age and sex had greater odds of reporting positive reinforcement (p = .03) and weight-related teasing (p = .04) than those with weights <85th percentile. We use these findings to detail potential targets for advancing ED prevention efforts.

Omega-3 as an adjuvant in the treatment eating and psychological symptoms in patients with anorexia nervosa: a systematic review and meta-analyses

BACKGROUND

This study was carried out to assess the effects of omega-3 supplementation as an adjunct treatment for eating and psychological symptoms in patients with anorexia nervosa.

METHODS

We conducted a systematic review of the literature using the terms 'anorexia nervosa' AND 'Fatty Acids, Omega-3'. Five randomised controlled trials with a total of 144 participants, published between 2003 and 2022, were included.

RESULTS

The effects of supplementation of omega-3 on anxiety were standardised mean difference (SMD) 0.79, 95% confidence interval (CI) -0.08 to 1.66; p = 0.08; I² = 3%; two studies, 33 participants; moderate quality of evidence. For depression, the supplementation of omega-3 was SMD: 0.22, 95% CI: -0.50 to 0.93; p = 0.18; I² = 45%; two studies, 33 participants; moderate quality of evidence. For obsessive-compulsive disorder, the supplementation of omega-3 was SMD: -0.22, 95% CI: -0.70 to 2.25; p = 0.36; I² = 0%; three studies, 32 participants; low quality of evidence.

CONCLUSION

This research showed that regardless of dose, time or, if associated with other components, the use of omega-3 supplementations as an adjuvant treatment showed no evidence of effect in eating and psychological symptoms in patients with anorexia nervosa.

Popular Dietary Trends' Impact on Athletic Performance: A Critical Analysis Review

BACKGROUND

Nutrition fuels optimal performance for athletes. With increased research developments, numerous diets available, and publicity from professional athletes, a review of dietary patterns impact on athletic performance is warranted.

RESULTS

The Mediterranean diet is a low inflammatory diet linked to improved power and muscle endurance and body composition. Ketogenic diets are restrictive of carbohydrates and proteins. Though both show no decrements in weight loss, ketogenic diets, which is a more restrictive form of low-carbohydrate diets, can be more difficult to follow. High-protein and protein-paced versions of low-carbohydrate diets have also shown to benefit athletic performance. Plant-based diets have many variations. Vegans are at risk of micronutrient deficiencies and decreased leucine content, and therefore, decreased muscle protein synthesis. However, the literature has not shown decreases in performance compared to omnivores. Intermittent fasting has many different versions, which may not suit those with comorbidities or specific needs as well as lead to decreases in sprint speed and worsening time to exhaustion.

CONCLUSIONS

This paper critically evaluates the research on diets in relation to athletic performance and details some of the potential risks that should be monitored. No one diet is universally recommend for athletes; however, this article provides the information for athletes to analyze, in conjunction with medical professional counsel, their own diet and consider sustainable changes that can help achieve performance and body habitus goals.

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.

Overlap of orthorexia, eating attitude and psychological distress in some Italian and Spanish university students

BACKGROUND

Orthorexia nervosa (ON) is the persistent concern of maintaining the self-imposed diet to improve one's health. Many factors have been associated to ON in univ-ersity students.

AIM

To assess the prevalence of ON in Italian and Spanish university students in relation to eating attitude and psychological distress, and the possible overlaps between ON (evaluated with different scored questionnaires from the originally proposed ORTO-15), distress and risk of eating disorders.

METHODS

This study was carried out on 160 students recruited at La Sapienza University of Rome and at the Catholic University of Murcia. Questionnaires were administered to evaluate ON (ORTO-15 and sub-scores), body concerns (Multidimensional Body-Self Relations Questionnaire, MBSRQ, and Body Uneasiness test, BUT), psychological distress (Kessler Psychological Distress Scale, K10), physical activity (International Physical Activity Questionnaire, IPAQ), eating attitude (Eating Attitudes Test, EAT-26) and malnutrition (Starvation Symptom Inventory, SSI). Sex differences, within the same country, and differences between Italian and Spanish students, within the same sex, were evaluated.

RESULTS

The ORTO-15 positive subjects, assessed with the originally proposed cut-off, were above 70% in both Italian and Spanish students, with a higher prevalence in the Spanish sample (Italian females 76.3%, Italian males 70.7%; Spanish females 97.0%, Spanish males 96.3%). According to ORTO-7, about 30% of Italian and 48% of Spanish students were positive to ON with no significant sex differences. When excluding students underweight (UW), overweight (OW) or obese (OB), as well as those potentially at risk of eating disorders or presenting mild, moderate and severe distress, in the resultant normal weight (NW)-K10^neg-EAT-26^neg subgroup, we did not find many correlations observed in the whole sample, including those between ORTO scores and BUT, SSI, Total MBSRQ and some of its components. Moreover, ORTO-7 resulted in the only ON score unrelated with Body Mass Index, MBSRQ components and IPAQ-assessed intense activity, in the NW-K10^neg-EAT-26^neg subgroup. After this sort of “exclusion diagnosis”, the prevalence of ON of these students on the overall sample resulted in 16.9%, 12.2%, 15.2% and 25.9% for Italian females, Italian males, Spanish females and Spanish males, respectively.

CONCLUSION

In some university students ON could be a symptom of other conditions related to body image concerns and distress, as well as to high physical activity and appearance, fitness, health or illness orientation (from MBSRQ). However, ORTO-7 became independent from these confounding variables, after the exclusion of UW, OW, OB and students positive to EAT-26 and K10, suggesting the possibility of identifying orthorexic subjects with this specific questionnaire.

Prevalence of Risk for Orthorexia in Athletes Using the ORTO-15 Questionnaire: A Systematic Mini-Review

The article aims to summarize the literature about the profile of risk of orthorexia in athletes using the ORTO-15 questionnaire. The search was performed at PubMed, Embase, Web of Science, and Sport Discus databases, using the terms “orthorexia” AND “athletes” with the respective entry terms. A multistage process of selection followed the PRISMA 2020 recommendation. A total of 688 articles were identified, and six studies were available for the final process. The prevalence of risk for orthorexia was assessed by the articles by the ORTO-15 questionnaire and ranged between 38 and 35 points. The comparison between male and female athletes and, athletes and non-athletes was not significant in the six articles. In conclusion, the review highlights that athletes from different sports, included in the review, do not present a risk of orthorexia nervosa considering the cutoff of 40 points, but not 35 points. Also, athletes present the same orthorexic behavior compared to non-athletes, demonstrating that orthorexia is an issue that needs to be considered in the general population. Moreover, a special focus should be given on the ORTO-15 questionnaire, about the sensitivity to diagnose the prevalence of orthorexia, especially in athletes.