Prevalence of Orthorexia Nervosa and Its Diagnostic Tools-A Literature Review

Online content on eating disorders: a natural language processing study

BACKGROUND

Online content can inform the personal risk of developing an eating disorder, and it can influence the time and motivation to seek treatment. Patients routinely seek information online, and access to information is crucial for both prevention and treatment. The primary aim of the current study was to quantify the readability scores of online content on eating disorders using natural language processing algorithms, across two languages: English and Italian.

METHODS

Unique terms related to single diagnoses were searched using Google®. The content available on Wikipedia was also assessed. Readability was defined according to the Flesch Readability Ease (FRE) and the Rate Readability Index (RIX). The scientific support of retrieved content and the authoritativeness of sources were measured through standardized variables.

RESULTS

In Italian, online content was more likely published by private psychotherapy institutes or by websites that promote diet-advice or weight-loss. In both languages, the most readable content was on Anorexia Nervosa (RIX 4.18, FRE-en 59.6, FRE-it 41.69), Bulimia Nervosa (RIX 3.99, FRE-en 66.27, FRE-it 39.66) or Binge Eating (RIX 4.01, FRE-en 68.10, FRE-it 38.62). English sources consistently had more references than Italian pages (range 35-182, vs 1-163, respectively). and had a higher percentage of citations available in the target language. The content of these references was mainly reflective of peer-reviewed or clinical manuals.

CONCLUSION

Attention should be given to developing online content for Muscle Dysmorphia and Orthorexia Nervosa, as well as improving the overall readability of online content on eating disorders, especially for languages other than English.

Psychometric Properties of Various Factorial Models of the ORTO-15 Tested With Brazilian Respondents

The ORTO-15 is a commonly used screening instrument for symptoms of Orthorexia Nervosa (ON), an obsessive overconcern with healthy eating. However, its limitations have been evidenced in several published factorial models. We analyzed the psychometric properties of seven different ORTO-15 factorial models using data from Brazilian adult participants (n = 1455; 71.4% women; M age = 29.5, SD = 8.9 years) from the country's five macro-regions who answered online questions for sample characterization and completed the Portuguese version of the ORTO-15 containing 15 items. We tested the fit of each model separately, analyzing data for men and women with separate confirmatory factor analysis, and using the Weighted Least Squares Mean and Variance Adjusted estimation method and goodness-of-fit indices. We also calculated the average variance extracted and the alpha ordinal and omega coefficients to analyze the convergent validity and reliability of the factors. None of the models tested presented adequate properties of validity and reliability. Although we found some acceptable reliability coefficients, they do not guarantee the validity of the data. Future investigators should be cautious when choosing the ORTO-15 for ON screening.

"Food faddists and pseudoscientists!": Reflections on the history of resistance to ultra-processed foods

The term 'ultra-processed food' emerged in the 1980s, mostly used in reference to highly-processed convenience foods and snacks, often energy-dense, poor in nutrients, and inclusive of various synthetic additives such as emulsifiers, colors, artificial sweeteners, and/or flavor enhancers. Concern over such foods was part of the growing holistic and environmental health movements of the 1970-80s; yet, those who raised alarm about the encroachment of ultra-processed foods were often labeled, especially by industry and their powerful allies, as 'food faddists' and 'pseudoscientists'. Today, the topic of ultra-processed foods is generating massive personal, public, and planetary health interest. However, other than discussing the history of the NOVA food classification system, a useful tool that has allowed researchers to more accurately separate foods based on processing, most lay media and academic articles are ahistorical. That is, there is a tendency to present the term ultra-processed food(s) as a relatively new entrance into the lexicon, and by default, the idea that health-related pushback on ultra-processed foods is a relatively new phenomenon. This omission overlooks decades of determined advocacy and clinical work, much of it by pioneers within the holistic medicine (now integrative, functional, and lifestyle medicine) movement. Here in this reflection paper, the authors will use historical research and reporting to fill in the historical gap and articulate the saliency of why it matters.

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.

Factors associated with food label use: focus on healthy aspects of orthorexia and orthorexia nervosa

PURPOSE

This study aimed to investigate the potential relationships between the use of different section of food label, and healthy and pathological aspects of orthorexia among adults.

METHODS

This cross-sectional study was conducted using an online survey (n = 1326). Inclusion criteria were being 19-64 years and graduated from at least primary school. Pregnant and lactating women were excluded. Data were collected using questionnaire including socio-demographic variables, lifestyle factors, body weight and height, frequency of reading different sections of food label ("always", "when buying a food for the first time", "when comparing similar packaged foods", "rarely", "never"), food label literacy, and Teruel Orthorexia Scale. Participants were categorized as nutrition facts panel-users, ingredients list-users or claim-users if they read at least one item from the relevant parts.

RESULTS

The proportions of nutrition facts, ingredients list, and claims sections users were 72.3%, 76.3%, and 79.9%, respectively. Both healthy and pathological aspects of orthorexia were associated with reading food labels. The healthy orthorexia had the strongest association with using the ingredients list (OR 1.76, 95% CI 1.41-2.20), whereas the orthorexia nervosa showed the highest association with using nutrition facts panel (OR 1.48, 95% CI 1.20-1.81). While women, physically active participants and those with higher food label literacy were more likely to use all sections of food labels; older age, having children, and chronic disease increased the likelihood of using claims and ingredients list (p < 0.05). Besides, following a diet was associated with higher use of nutrition facts and ingredients list (p < 0.05).

CONCLUSIONS

The study demonstrates that food label users have higher orthorexia tendencies compared to non-users. Of the food label sections, healthy orthorexia showed the strongest association with use of the list of ingredients, while pathological orthorexia showed the strongest association with use of the nutrition facts panel.

LEVEL OF EVIDENCE

Level V, cross-sectional study.

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.

Intra- and Interpersonal Dimensions of Orthorexia: Preliminary Development and Validation of an Intra- and Interpersonal Effects Scale for Orthorexia

Orthorexia nervosa (ON) is a disorder characterized by dietary restrictions and an obsessive focus on "healthy" eating. The present study analyzes two aspects of ON. One related to the inner experiences of the individual (intrapersonal). The other concerns the impact of ON on interpersonal relationships (interpersonal). The developed scale was named the Intra- and Interpersonal Effects Scale of Orthorexia (IIESO). The analysis showed an average correlation between the INTER and INTRA factors (r = 0.46). Both the INTER and INTRA scales correlated strongly with both subscales of the TOS but weakly with the ORTO-R score. Females obtained higher scores on the INTER scale (p < 0.01), while no differences were shown for the INTRA subscale or the overall scale score (p < 0.01). Subjects using supplements had higher mean scores on the INTER and INTRA subscales and for the total score. Among the analyzed results, the greatest strength effect was shown for the total score on the IIESO scale (INTER+INTRA) and the TOS scale. The questionnaires used to date have not distinguished between behaviors from interpersonal and intrapersonal perspectives. Research on these dimensions could expand our knowledge of the disorder and refine diagnostic criteria.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Greek adaptation of the Teruel Orthorexia Scale (TOS) in adults from the Republic of Cyprus: A bidimensional model may not be universal

The Teruel Orthorexia Scale (TOS) is a 17-item instrument designed to assess distinct facets of Orthorexia Nervosa (ON) and Healthy Orthorexia (HO). While a bidimensional model of TOS scores has been supported in diverse national and linguistic groups, the psychometric properties of the TOS have not been previously assessed in Greek-speaking populations. To rectify this, we assessed the psychometric properties of a novel Greek translation of the TOS in a sample of adults from Cyprus. A total of 1248 respondents (710 women, 538 men) completed the Greek TOS, as well as previously validated measures of perfectionism, obsessive-compulsive symptomatology, eating restriction, negative affect, and appearance evaluation. Our results showed that a bidimensional model of the TOS had less-than-adequate fit when modelled using both confirmatory factor analysis and exploratory structural equation modeling (ESEM). Conversely, both exploratory factor analysis and ESEM supported extraction of a 3-factor model consisting of a HO facet and separate components of emotional orthorexia and cognitive-social orthorexia. This 3-factor model showed a lack of measurement bias (measurement invariance across gender identity and lack of differential item functioning as function of age and body mass index), but there were differences in latent factor means as function of respondent age and body mass index. The 3-factor model showed adequate evidence of construct validity, with the latent emotional orthorexia and cognitive-social orthorexia facets showing significant and moderate associations with the additional constructs measured in the survey. Broadly speaking, these findings support the psychometric properties of a 3-factor model of the Greek TOS, but also suggest that the bidimensional model of the TOS may not have universal applicability. We encourage further assessments of factorial validity in other national and linguistic contexts.

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.

The Risk of Orthorexia and the Prevalence of Emotional Eating Behaviours among Polish Military Flying Personnel in Relation to Body Mass Index (BMI) and Sociodemographic Factors

BACKGROUND

Proper nutrition has a positive impact on health. Paradoxically, excessive preoccupation with healthy eating may lead to the emergence of abnormal eating behaviours and increase the risk of developing disorders. The aim of this study was to assess the risk of orthorexia (ON) and the prevalence of emotional eating (EE) in military flying personnel of the Polish Air Force in relation to BMI and sociodemographic factors.

METHODS

This study included 760 soldiers (including 60 females) taking part in the National Health Programme 2021-2025. The ORTO-15 questionnaire and EEQ were used to assess the risk of ON and EE.

RESULTS

The risk of ON occurred in 28.9% of military flying personnel and was significantly more frequent in soldiers with a normal weight (46.4%), under 40 years of age (42.7%), and with higher education (42.7%). The prevalence of EE was found in approximately 12.3% of the respondents and was significantly more common in soldiers with diagnosed obesity (17.5%), women (21.7%), and soldiers with higher education (13.6). Other sociodemographic variables did not differentiate the results of the ORTO-15 questionnaire and EEQ.

CONCLUSIONS

The obtained results indicate that the problem of eating disorders also occurs in military populations. The necessity of continuing research in this area is discussed.

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.

The relationship between orthorexia nervosa and cyberchondria levels in nurses: A cross-sectional study

PURPOSE

The study was conducted with the aim of investigating the relationship between orthorexia nervosa and cyberchondria levels among nurses.

METHODS

This cross-sectional study was conducted with 399 nurses through face-to-face interviews. The data were collected using a participant information form, the Cyberchondria Severity Scale, and the Orthorexia Nervosa-11 scale (ORTO-11).

RESULTS

The mean score of the nurses' cyberchondria severity scale was 73.95 ± 18.53, while the mean score of the Orthorexia Nervosa-11 scale was 28.23 ± 4.76. In the study, a low negative correlation was found between the cyberchondria and orthorexia nervosa levels (p < 0.05).

CONCLUSIONS

The increase in the level of cyberchondria among nurses increases the risk of orthorexia nervosa. Therefore, it is recommended that nurses receive proper nutritional education and psychosocial support to reduce their tendency towards orthorexia nervosa and cyberchondria.

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.

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).

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.

Relationship between disgust and orthorexia nervosa and psychometric properties of the Italian Dusseldorf orthorexia scale in a general population sample

BACKGROUND

It remains unclear among clinicians and researchers whether orthorexia nervosa (ON) is a part of the obsessive-compulsive disorder spectrum or eating disorders. Disgust seems to be a shared psychopathological factor in these clinical presentations, indicating a potentially crucial role in ON. On the other hand, numerous psychometric tools have been developed to evaluate ON. The Dusseldorf Orthorexia Scale (DOS) was recently validated in an Italian sample. However, the study's primary limitation was that the scale was only administered to undergraduate university students. This study aimed to investigate the psychometric properties (including factorial structure, reliability, and measurement invariance conditional on sex) of the Italian version of the DOS (I-DOS) on a sample from the general population. Additionally, the study sought to determine the nomological validity of the I-DOS by examining its relationship with disgust sensitivity.

METHODS

A sample of 521 participants took part in this study and completed a battery that assessed ON and disgust sensitivity. To assess the I-DOS structure, reliability, and measurement invariance we respectively conducted confirmatory factor analysis (CFA), computed McDonalds's omega, and performed hierarchical series of multigroup CFAs. Then, we tested the relationship between ON and disgust sensitivity.

RESULTS

CFA confirmed the unifactorial model of I-DOS and it respected the configural, metric, and strict invariance while a partial scalar invariance was achieved. It also showed good reliability with an omega of 0.87. In addition, we found a positive relationship between ON and disgust sensitivity, thus confirming the nomological validity of I-DOS.

CONCLUSIONS

Our findings suggest that the Italian version of the Dusseldorf orthorexia scale (I-DOS) exhibits strong psychometric properties and can be an effective instrument for assessing ON in a general population sample. Notably, the most significant and innovative outcome was the positive correlation between ON and disgust sensitivity. As disgust has been linked to other clinical presentations, this preliminary result could serve as a foundation for future research exploring this phenomenon in greater detail.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Maternal Bonding as a Protective Factor for Orthorexia Nervosa Risk in Dietetics Students

This study aimed to determine the prevalence of the risk of orthorexia nervosa (ON) in dietetics students in Greece, and its relationship with diet, risk of eating disorder (ED), body mass index (BMI), body image flexibility, and parental attachment. The participants were 132 dietetics students, with a mean age of 22.94 ± 3.5 years, who completed a series of questionnaires that recorded sociodemographic, clinical, and anthropometric characteristics; adherence to the Mediterranean diet (MedDiet); ON indicators as determined by the ORTO-15 questionnaire; body image flexibility, with the Body Image-Acceptance and Action Questionnaire (BI-AAQ-5); the risk for ED as assessed using the EAT-26; anxiety level according to the STAIT 6 instrument; and recollection of their parents' attitudes towards them during the first 16 years of life, with the Parental Bonding Instrument (PBI). ON risk appeared to be significantly associated with BMI (p = 0.002), exercise frequency (p = 0.023), anxiety level (p = 0.002), risk of ED (p < 0.001), body image inflexibility (p < 0.001), and inversely with the affectionate constraint of maternal bonding (p = 0.036). In conclusion, disordered eating behaviors and body shape concerns are prevalent among dietetics students, with parental attachment to the mother influencing their occurrence. Identification of potential ON and development of prevention mechanisms during childhood could help eliminate these concerns and improve the lives of dietetics students.

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.

Orthorexia nervosa and type 1 diabetes: results of a cross-sectional study

AIM

Orthorexia nervosa (ON) is a condition characterized by an excessive importance attributed to the intake of healthy foods. This study was aimed at investigating the prevalence of ON in subjects with type 1 diabetes (T1D) compared to control subjects.

METHODS

Patient with T1D using either flash glucose monitoring or continuous glucose monitoring were enrolled. For the selection of control group, each patient was asked to indicate one non-diabetic subject of their same sex and approximate age among colleagues at work and school. Patients and controls completed the following questionnaires: ORTO-15, Dusseldorf Orthorexie Scale (DOS), Eating Disorder Examination Questionnaire (EDE-Q) and Brief Symptom Inventory (BSI). The principal outcome was the prevalence of ON among T1D and control subjects.

RESULTS

We enrolled 44 patients with T1D aged 39.7 ± 15.7 years, with BMI 24.3 ± 4.3 kg/m², and mean HbA1c 53.5 [49-57] mmol/mol. Control subjects were similar to T1D with respect to sex, age and BMI. Thirty-two [72%] and 29 [65%] subjects among patients and controls, respectively, had ORTO15 < 40 (between-group p = 0.48). Two (4.5%) and zero subjects among patients and controls, respectively, had DOS ≥ 30 (p = 0.29). Median scores of DOS, but not of ORTO-15, were significantly higher in patients than in controls. None of the metabolic variables showed a correlation with psychometric tests in T1D.

CONCLUSION

Although the prevalence of ON was not significantly higher in T1D than in controls, patients with T1D showed higher scores of some, but not all, tests assessing orthorexia, without any significant correlation with metabolic parameters.

Global Scientific Trends on Healthy Eating from 2002 to 2021: A Bibliometric and Visualized Analysis

Diet has been recognized as a vital risk factor for non-communicable diseases (NCDs), climate changes, and increasing population, which has been reflected by a rapidly growing body of the literature related to healthy eating. To reveal a panorama of the topics related to healthy eating, this study aimed to characterize and visualize the knowledge structure, hotspots, and trends in this field over the past two decades through bibliometric analyses. Publications related to healthy eating between 1 January 2002 and 31 December 2021 were retrieved and extracted from the Web of Science database. The characteristics of articles including publication years, journals, authors, institutions, countries/regions, references, and keywords were assessed. The analyses on co-authorship, co-occurrence, and co-citation were performed and network visualization maps were constructed by VOSviewer. Major subdomains identified by bibliometrics were further discussed and analyzed. A total of 12,442 articles on healthy eating were identified. Over the past two decades, the annual global publications increased from 71 to 1764, showing a nearly 25-fold growth. The journal Nutrients published the most articles and The American Journal of Clinical Nutrition possessed the highest citations. The United States, Harvard University, and Hu, Frank B. were identified as the most productive and influential country, institution, and author, respectively. The co-occurrence cluster analysis of the top 100 keywords formed four clusters: (1) the food insecurity environment for youths highlighting the necessity and significance of implementing healthy eating in early life; (2) sustainable advantages of the Mediterranean diet; (3) the importance of an overall healthy lifestyle optimization leveraged by eHealth; (4) the challenges during the course of healthy eating against obesity, which are prominent in reflecting the knowledge structure, hotspots, and trends. Moreover, COVID-19, orthorexia nervosa, sustainability, microbiota, food insecurity, and e-health are identified keywords that represented the latest high-frequency keywords and indicated the emerging frontiers of healthy eating. This study indicates that the number of publications on healthy eating will increase in the future and that healthy dietary patterns and clinical applications of healthy eating will be the next hotspots in this research field.

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

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

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.

A Systematic Review of Clinical Psychophysiology of Obsessive-Compulsive Disorders: Does the Obsession with Diet Also Alter the Autonomic Imbalance of Orthorexic Patients?

(1) Background: A new mental illness is attracting the attention of researchers and mental health professionals. Orthorexia nervosa (ON) is a possible new mental disorder, the main symptom of which is an obsessive and insecure focus on healthy foods and consequent compulsive behaviors. There is a common consensus among researchers that ON is considered partly overlapping with obsessive-compulsive disorders (OCDs). (2) Methods: MEDLINE and Scopus were searched for articles published in the last 10 years regarding the psychophysiological aspects of OCD and ON. Eight studies met the eligibility criteria. The inclusion criteria encompassed adults diagnosed with OCD and/or ON. However, only studies involving OCD patients were found. (3) Results: Some research groups have shown that OCD disorders can be considered among anxiety disorders because they are characterized by anxious hyper activation. Other research, however, has shown profiles characterized by low psychophysiological reactivity to stressful stimuli. Despite this, there seems to be a consensus on the poor inhibition abilities, even when activation is low, and the dissociation between cognitive and psychophysiological activation emerged. (4) Conclusions: However discordant, some points seem to bring the researchers to agreement. In fact, there is consensus on conducting a multidimensional assessment that can measure all of the aspects of suffering (cognition, emotion, and behavior) and highlight the poor body-mind integration. This clinical approach would make it possible to propose interventions aimed at treating some mental illnesses such as food obsession that can paradoxically impair the psychophysical balance. Nevertheless, the applied systematizing approach to existing studies on ON is very much needed for better understanding of the psychophysical nature of this new mental illness and its implications for prevention and treatment.

Orthorexia nervosa in gay men-the result of a spanish-polish eating disorders study

BACKGROUND

The purpose of this exploratory study was to identifying demographic factors and unique predictors of ON e.g., the use of pre-exposure prophylaxis (PrEP), the use of social media and the Grindr ® dating application among a sample group of Spanish and Polish identifying gay men.

METHODS

The study was conducted in Poland and Spain between March and June 2021 using questionary: ORTO-15. Data was collected using a three-section self-administered questionnaire. The first section contained demographic data, the second part was the Polish and Spanish version of the Orto-15, and the third part was the Polish and Spanish version of the EAT-26.

RESULTS

Total enrollment was 394 gay men. In regression proportional hazards single model, significant predictors of ON were: age (OR = 0.964, 95% CI, 0.944-0.984), BMI (OR = 0.895, 95% CI, 0.848-0.944), staying in an informal relationship compared to being single (OR = 2.138, 95%CI, 1.225-3.732), occasional use of Pre-exposure Prophylaxis (OR = 4.667, 95%CI, 1.186-18.362) and use of the Grindr application (OR = 5.312, 95%CI, 3.373-8.365). Instagram users had lower risk of ON (OR = 0.479, 95%CI, 0.279-0.822). The multivariate analysis showed that Grindr usages (OR = 4.72; 95%CI, 2.89-7.72) correlated with higher risk of ON. Higher BMI (OR = 0.913, 95%CI, 0.861-0.98) and daily use of Pre-exposure Prophylaxis (OR = 0.142, 95%CI, 0.03-0.674) is associated with lower risk of ON.

CONCLUSIONS

The most important predictors of orthorexia nervosa in gay men are: low BMI and the use of Grindr. The effect of daily usage of PrEP is associated with lower risk, and occasional use is associated with increased risk, of orthorexia nervosa.

Healthy orthorexia vs orthorexia nervosa: associations with body appreciation, functionality appreciation, intuitive eating and embodiment

PURPOSE

Current conceptualizations and measures of orthorexia nervosa may not be accurately distinguishing between the healthy vs pathological pursuit of a healthy diet, leading to very high prevalence rates and risking the pathologizing and stigmatizing of healthy eating more generally. Recent research has identified healthy orthorexia as a novel construct conceptually distinct from orthorexia nervosa, which represents the non-pathological pursuit of a healthy diet. In light of the strong body of evidence supporting the role of positive body image in eating behavior, the current study aimed to examine the associations between healthy orthorexia, orthorexia nervosa, intuitive eating and indices of positive body image.

METHODS

The current study employed a cross-sectional design. An online community sample (N = 835; 62% women; M_age = 40.24, SD = 14.45) completed self-report questionnaires including the Teruel Orthorexia Scale, Body Appreciation Scale-2, Functionality Appreciation Scale, Intuitive Eating Scale-2, and Experience of Embodiment Scale.

RESULTS

Intuitive eating and indices of positive body image were significantly positively associated with healthy orthorexia and inversely associated with orthorexia nervosa. A hierarchical multiple regression analysis found that intuitive eating and indices of body image were uniquely associated with 13.3% of the variance of healthy orthorexia above and beyond that accounted for by orthorexia nervosa. Intuitive eating moderated the relationship between healthy orthorexia and orthorexia nervosa.

CONCLUSION

The findings of this study provide support for intuitive eating and indices of positive body image as worthy of further exploration as important factors which distinguish between healthy orthorexia and orthorexia nervosa.

LEVEL OF EVIDENCE

V, descriptive study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level V (descriptive cross-sectional study).

Associations between Orthorexia Nervosa, Body Self-Image, Nutritional Beliefs, and Behavioral Rigidity

Possible correlations between orthorexic self-reports, unhealthy nutritional beliefs, behavioral rigidity related to following rules, and distortion of body self-image were investigated. In total, 246 university students of both sexes, from different areas of knowledge, answered a sociodemographic form, the Ortho-15, the Body Shape Questionnaire, the Rigidity Scale, and a Nutritional Beliefs Form. Orthorexic self-reports were observed in 73 men and 106 women. A positive correlation was found between females and orthorexic self-reports (p = 0.036), and severe distortion of body self-image (p = 0.002) and between the latter, the behavioral rigidity scale (p2 = 0.189; p = 0.001), and female sex (p2 = 0.245; p < 0.000). In the logistic regression, women were 1.83 times more likely to present orthorexic behaviors than men. The creation of prevention and treatment strategies aimed at women is suggested and it recommended that studies investigating whether the presence of orthorexic self-reports is a risk factor for the development of eating disorders are carried out.

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.

A comparative study of orthorexia between premenopausal, perimenopausal, and postmenopausal women

PURPOSE

Studies suggested that menopause is a period of vulnerability for disordered eating behaviors, but whether menopause could be linked to orthorexia nervosa (ON) remains unexplored.

METHODS

A sample composed of 709 women aged between 30 and 71 years (mean age = 43.08 years, SD = 9.24) answered self-administered questionnaires assessing ON (Düsseldorfer Orthorexia Skala, DOS), body image, self-esteem, and psychopathological symptoms. The sample included a Premenopause group of 441 women reporting regular menses, a Perimenopause group of 94 women reporting the recent onset of amenorrhea or menstrual irregularities, and a Postmenopause group of 174 women reporting amenorrhea of natural onset for more than 12 months.

RESULTS

Group comparison using analysis of covariance with age as covariate showed that ON scores were statistically higher in the two groups of participants dealing with menopause (Peri- and Postmenopause) when compared with women not yet concerned by menopause (Premenopause). A Kendall's tau-b correlation performed between the menopausal status (Pre, Peri, or Postmenopause) and DOS categories (No ON; At risk of ON; Presence of ON) showed a weak but statistically significant positive correlation between the menopausal group and DOS categories (tau-b = 0.136, p < 0.001). In addition, Fisher's exact tests indicated that the percentages of participants in the "At risk of ON" and "Presence of ON" categories were statistically higher in the Postmenopause group in comparison with the Premenopause group (p < 0.001). Depressive symptoms were statistically higher in the Peri- and Post-groups, while anxiety symptoms were stronger in the Peri-group when compared with the Pre-group.

CONCLUSIONS

This study shows an increase of ON in women concerned with menopause, suggesting the existence of a relationship between menopause and ON. Further studies are necessary to identify factors involved in this association.

LEVEL OF EVIDENCE

Descriptive (cross-sectional) study, level V.

The dark triad moderates the association between orthorexia nervosa and relationship (dis)satisfaction

PURPOSE

Past research has revealed a link between orthorexia nervosa (ON) and relationship dissatisfaction, which has in turn been found to be correlated with the Dark Triad traits. The current study investigated the association ON has with seeking out relationships and with relationship satisfaction, while also assessing a potential moderating effect of the Dark Triad.

METHODS

Recruited from Reddit forums, 788 adults (74% female, 67% White, 63% aged 25-30 years) completed an online survey with the Orthorexia Nervosa Inventory (ONI), Short Dark Triad (SD3), and Relationship Assessment Scale (RAS).

RESULTS

Greater ON symptomatology was associated with greater levels of all aspects of the Dark Triad (Machiavellianism, narcissism, and psychopathy), as well as with lower levels of relationship satisfaction (among those in committed romantic relationships) and a lower likelihood of seeking new romantic relationships (among single participants). A regression analysis revealed that the Dark Triad moderated the association between ON and relationship satisfaction, whereby this association was not significant at high levels of the Dark Triad.

CONCLUSION

The current research highlights that at low and medium levels of the Dark Triad, greater ON symptomology is associated with lower levels of satisfaction in romantic relationships.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Orthorexia nervosa, mindful eating, and perfectionism: an exploratory investigation

PURPOSE

Research has drawn associations between Mindful Eating (ME) and perfectionism in the aetiology and treatment of eating disorders (ED), but understanding into the relationship between these factors and Orthorexia nervosa (ON) is limited. The purpose of this research is to explore the relationship between perfectionism, ME, and ON.

METHOD

Participants (n = 670) completed the Düsseldorf Orthorexia scale, the Mindful Eating Behavior scale, and the Big-Three Perfectionism scale Short-form, to reveal the relationship between ON, ME, and perfectionism. The relationship was assessed using correlational and regression analyses.

RESULTS

A positive association was observed between perfectionism and ON. Moreover, perfectionism demonstrated a significant negative correlation with three out of four ME facets, with "eating without distraction" displaying the highest correlation. The "eating with awareness" facet of ME demonstrated a significant relationship with ON, in a negative direction. An unexpected relationship was observed between the focused eating facet of ME and ON, with a positive association being found. A further regression analysis revealed both perfectionism and ME to predict orthorexic tendencies.

CONCLUSION

These findings identify a relationship between ON, ME, and perfectionism. It offers suggestion for the complexity of ME, and how it should be recognised by its different components, estimating a differential predictability and estimation of ON. Further research is required to clarify the direction of causality in the relationships observed, to inform the clinical diagnoses and intervention of ON.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

V, Cross-sectional descriptive study.

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

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

Sinful Foods: Measuring Implicit Associations Between Food Categories and Moral Attributes in Anorexic, Orthorexic, and Healthy Subjects

Recently, neurocognitive studies have shown that food categorization is sensitive to both the properties of the food stimuli (e.g., calorie content) and the individual characteristics of subjects (e.g., BMI, eating disorders) asked to categorize these stimuli. Furthermore, groups of patients with eating disorders (ED) were described as relying more on moral criteria to form food categories than were control subjects. The present studies built on these seminal articles and aimed to determine whether certain food properties might trigger moral categories preferentially in subjects suffering from ED and in the general population. Using a Go/No-Go Association Task, Study 1 focused on the extent to which food categories are laden with moral attributes in ED patients compared to control subjects. Study 2 was a follow-up with a different design (an Implicit Association Test), another food variable (calorie content), and two non-clinical subgroups (orthorexic and healthy control subjects). Results revealed for the first time implicit associations between food variables cueing for energy density and moral attributes in the general population, the population suffering from anorexia nervosa, and subjects suffering from disordered eating such as orthorexia nervosa. These findings suggest that moralization of food is a pervasive phenomenon that can be measured with methods reputed to be less vulnerable to self-presentation or social desirability biases.

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.

Lifestyle-Related Risk Factors of Orthorexia Can Differ among the Students of Distinct University Courses

Orthorexia nervosa (ON) is defined as the excessive attention on healthy eating, and studies especially focused on food quality ON prevalence in university students can be extremely variable. The objective of this study is to investigate whether there was a difference in ON risk between health-scientific, economic-humanistic, sport sciences and dietetics and nutrition students, and to evaluate if lifestyle-related ON risk factors (dieting, physical activity, drugs and supplements use) could have an impact in different ways in determining ON risk among students attending these four programs. Participants were recruited at the University of Pavia and received a two-section questionnaire including demographic and lifestyle information and the ORTO-15 questionnaire. A total of 671 students (54% F e 46% M) completed the questionnaire (median age 21.00 (IQR 20.00−23.00), median BMI 21.77 kg/m2 (IQR 20.06−23.66 kg/m2)). The 31.2% had ORTO-15 test scores < 35, and were considered at risk of having ON. No differences were found in ON risk among the students attending the four university courses. Dieting was confirmed as the major ON risk factor for health-scientific, economic-humanistic and sport sciences students. The type of sport practiced was an important determinant of ON risk only for the economic-humanistic course, while supplements use was statistically different between sport sciences students with or without ON. Our findings may suggest that lifestyle-related risk factors of orthorexia can differ among the students of distinct university courses, but these results need to be supported by further longitudinal and prospective studies.

Dietary Behavior and Risk of Orthorexia in Women with Celiac Disease

Evidence points to a link between celiac disease and eating disorders. Although with the current limited knowledge, orthorexia cannot be formally recognized as an eating disorder, some features are similar. This study is the first to examine individuals with celiac disease in terms of the prevalence of risk of orthorexia. Participants were 123 females diagnosed with celiac disease. The standardized ORTO-15 questionnaire was used to assess the risk of orthorexia. In this study, eating habits and physical activity were assessed. The effect of celiac disease on diet was self-assessed on a 5-point scale. Taking a score of 40 on the ORTO-15 test as the cut-off point, a risk of orthorexia was found in 71% of individuals with celiac disease, but only in 32% when the cut-off point was set at 35. There was a positive correlation between age and ORTO-15 test scores (rho = 0.30). In the group with orthorexia risk, meals were more often self-prepared (94%) compared to those without risk of orthorexia (78%) (p = 0.006). Individuals at risk for orthorexia were less likely to pay attention to the caloric content of food (46%) relative to those without risk of orthorexia (69%) (p = 0.001). For 64% of those at risk for orthorexia vs. 8% without risk had the thought of food that worried them (p = 0.001). Given the survey instrument for assessing the prevalence of orthorexia and the overlap between eating behaviors in celiac disease and orthorexia, the prevalence of orthorexia in celiac disease cannot be clearly established. Therefore, future research should focus on using other research tools to confirm the presence of orthorexia in celiac disease.

The Mediating Role of Orthorexia in the Relationship between Physical Activity and Fear of COVID-19 among University Students in Poland

Previous research showed that the COVID-19 pandemic has a significant impact on the wellbeing and lifestyle of populations worldwide, including eating and physical activity (PA) patterns. The present study aims to examine the mediating effect of orthorexia on the relationship between PA and fear of COVID-19. A sample of 473 university students from Poland of a mean age of 22 years (M = 22.04, SD = 2.90, 47% of women) participated in the cross-sectional online survey study. Continuous variables were measured using the Fear of COVID-19 Scale (FCV-19S) and the Test of Orthorexia Nervosa (TON-17), while categorical variables divided participants into the physically active and inactive group regarding WHO criteria (150 min per week). Weak gender differences were found. Active people showed lower fear of COVID-19 and higher orthorexia scores than those inactive. Orthorexia was found as a suppressor variable, which increases the negative predictive value of PA on fear of COVID-19. The model of cooperative suppression explained 7% of FCV-19S. The mechanism of mediation showed that health-related behavior could help reduce fear of COVID-19, but caution is necessary for people with addictive behavior tendencies. Universities should support university students by offering programs focused on increasing healthy lifestyles and improving wellbeing.

Obsessed with Healthy Eating: A Systematic Review of Observational Studies Assessing Orthorexia Nervosa in Patients with Diabetes Mellitus

Orthorexia nervosa (ON) is an unspecified feeding or eating disorder (USFED) characterized by an exaggerated, unhealthy obsession with healthy eating. Τypical eating disorders (EDs) and USFEDs are common among patients with diabetes mellitus (DM), which complicates metabolic control and disease outcomes. The present systematic review summarizes the evidence on the prevalence of ON symptomatology among patients with DM. PubMed, Web of Science, Scopus, and grey literature were searched, and relevant observational studies were screened using the Rayyan software. The quality of the studies was assessed using the appraisal tool for cross-sectional studies (AXIS) and the Newcastle–Ottawa scale (NOS). Out of 4642 studies, 6 fulfilled the predefined criteria and were included in the qualitative synthesis. Most studies relied on the ORTO-15 or its adaptations to identify ON among patients with DM. No apparent sex or age differences exist regarding the prevalence of ON symptoms. None of the studies compared the prevalence of ON in patients with type 1 and type 2 DM. Most of the research was of average to good methodological quality. In conclusion, patients with DM often exhibit ON tendencies, although research is still limited regarding the etiology or mechanistic drivers behind ON and the characteristics of patients with a dual ON–DM diagnosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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