Orthorexia and anorexia nervosa: Two distinct phenomena? A cross-cultural comparison of orthorexic behaviours in clinical and non-clinical samples

Abstract

Background
Orthorexia nervosa (ON) is defined as pathological healthful eating. The aim of this study was to investigate whether there is any difference in orthorexic behaviours between clinical and non-clinical groups, and in different cultural contexts. .

Methods
Recruitment involved both female patients with anorexia nervosa (AN) and healthy controls (HC) from Italy and Poland (N = 23 and N = 35 AN patients; and N = 39 and N = 39 HCs, in Italy and Poland, respectively). Assessment of orthorexic behaviours was performed with the ORTO-15 test.

Results
Statistically significant differences were found between Italian women in the AN and HC group, whereas no difference between Polish women in the AN and HC group was found. Both Italian groups scored significantly higher than the Polish ones on the ORTO-15.

Conclusions
Differences have been found between the Italian and Polish samples, both in the percentage of individuals with orthorexic behaviours as suggested by an ORTO 15 score below the cutoff, and in the mean ORTO 15 scores in the AN and HC groups, suggesting cross-cultural differences in orthorexic behaviours, whose meaning is currently difficult to understand.

Full text

R E S E A R C H A R T I C L E Open Access
Orthorexia and anorexia nervosa: two
distinct phenomena? A cross-cultural
comparison of orthorexic behaviours
in clinical and non-clinical samples
C. Gramaglia
1*
, A. Brytek-Matera
2
, R. Rogoza
3
and P. Zeppegno
1
Abstract
Background: Orthorexia nervosa (ON) is defined as pathological healthful eating. The aim of this study was to
investigate whether there is any difference in orthorexic behaviours between clinical and non-clinical groups,
and in different cultural contexts. .
Methods: Recruitment involved both female patients with anorexia nervosa (AN) and healthy controls (HC) from
Italy and Poland (N= 23 and N= 35 AN patients; and N= 39 and N= 39 HCs, in Italy and Poland, respectively).
Assessment of orthorexic behaviours was performed with the ORTO-15 test.
Results: Statistically significant differences were found between Italian women in the AN and HC group, whereas
no difference between Polish women in the AN and HC group was found. Both Italian groups scored significantly
higher than the Polish ones on the ORTO-15.
Conclusions: Differences have been found between the Italian and Polish samples, both in the percentage of
individuals with orthorexic behaviours as suggested by an ORTO 15 score below the cutoff, and in the mean ORTO
15 scores in the AN and HC groups, suggesting cross-cultural differences in orthorexic behaviours, whose meaning
is currently difficult to understand.
Keywords: Anorexia nervosa, Orthorexia, Culture, ORTO-15
Background
Orthorexia nervosa (ON) is defined as an exaggerated,
obsessive, pathological fixation on healthy food, eating
healthy, or rather health-conscious eating behaviours [1–
3]. The literature is not unequivocal about whether ON is
an eating disorder (at all), a variant of a currently recog-
nized eating disorder (ED), such as the avoidant/restrictive
food intake disorder, or a different disorder [4–6]. Similar-
ities and possible overlaps have been suggested with the
spectrum of obsessive-compulsive, eating, or somatoform
disorders [5, 7, 8]. Orthorexia shares issues with disturbed
eating/nutrition attitudes as shown by excessive focus on
food-related topics [9, 10], strict diet [11], perfectionism
[12], co-occurrence of anxiety, need of control [13],
stiffness of behaviour and rituals related to preparation
of meals [14, 15]. In individuals with ON, the most
characteristic features of anorexia nervosa (AN) and
bulimia nervosa (BN) are absent, namely excessive pre-
occupation with losing weight, extreme fear of gaining
weight and body size overestimation [12, 16]. Reports
from the literature are far from being consistent, none-
theless a high frequency of occurrence of orthorexic
behaviours in patients with EDs has been described,
and eating related disturbances may play the role of risk
factors for orthorexia, although the reverse is also
possible [17–23]. Overall, despite increasing research
efforts, there is still a dearth of empirical data regarding
the relation between AN and orthorexia.
* Correspondence: carla.gramaglia@gmail.com;
carla.gramaglia@med.uniupo.it
1
Psychiatry Institute, Dipartimento di Medicina Traslazionale, Università del
Piemonte Orientale, Via Solaroli n° 17, 28100 Novara, Italy
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Gramaglia et al. BMC Psychiatry (2017) 17:75
DOI 10.1186/s12888-017-1241-2
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Reports are not unequivocal also as far as the cor-
relation between eating pathology (as measured for
instance with the Eating Attitudes Test) and orthor-
exia (as measured with the ORTO-15 test) is con-
cerned [17, 24–28]. Moreover, while orthorexia entails
both a fixation, i.e. a mental process, and specific be-
haviours, the ORTO-15 test, especially when using a
score of 40 as threshold value, likely measures the latter
(healthy eating behaviours) rather than the first (fixations
and obsessive traits) [3, 29].
The aim of the present research was to assess the
possible overlap between orthorexia, measured with the
ORTO-15 test, and AN. For this purpose, we assessed a
sample of female patients under treatment for a diagno-
sis of AN, and a sample of female healthy controls
(HCs) from the general population. The second aim
was to assess the possible cross-cultural differences in
orthorexic behaviours between Italian and Polish
women, both with and without a diagnosis of AN. For
this purpose, the same research procedure was carried
on in two culturally different countries –Italy and
Poland.
Methods
Patients with a diagnosis of AN according to DSM-5
criteria [30] were recruited both in Italy (Psychiatry
Institute, Università del Piemonte Orientale, AOU
Maggiore della Carità, Novara), and in Poland (the
Polish National Center for Eating Disorders, Wroclaw)
(N=23 and N= 35, respectively), as well as HCs from
the general population (N= 39, both in Italy and
Poland). All groups included individuals aged > 18 years,
who voluntarily took part in the study after informed
consent was obtained. The need for approval from the
local ethics committee was waived since the study did
not entail anything beyond standard and everyday clin-
ical practice.
The ORTO-15 test [3, 29] was used as a measure
of orthorexic behaviours. The ORTO-15 is composed
of 15 items with closed multiple-choice answers (“al-
ways”,“often”,“sometimes”,“never”). Items investigate
the obsessive attitude of the individuals in choosing,
buying, preparing and consuming food they consider
to be healthy. A score equal to 1 for each item corre-
sponds to an orthorexic tendency in the eating behav-
iour, while a score equal to 4 points indicates normal
eating habits. Higher scores suggest normal eating
habits; a cutoff of 40 or 35 points has been suggested.
We used the 40-points cutoff, which according to
Donini and coworkers [29] allows the identification of
symptoms consistent with orthorexia nervosa with a
sensitivity of 100.0%, a specificity value of 73.6%, a
positive predictive value of 17.6% and a negative pre-
dictive value of 100%. In our study we used both the
Italian and Polish [31] validated versions of the
questionnaire.
Statistical analyses were performed using Chi-square
test and parametric t tests for independent sample to
test the study hypotheses; statistical significance level
was set at p-value <0.05. All analyses were performed
with SPSS v.22 [32].
Results
Mean age and BMI of AN and HCs from both coun-
tries are reported in Table 1, as well as the percentage
of individuals scoring under the ORTO-15 cutoff (i.e.
with orthorexic tendencies). No difference was found
with the Chi-square test in the percentage of subjects
scoring under the ORTO-15 cutoff when comparing
Italian AN and Italian HC (p= .263), or when compar-
ing Polish AN and Polish HC (p= .670). On the con-
trary, the percentage of individuals with orthorexic
behaviours as described by an ORTO-15 score below
the cutoff was different between Italian AN and Polish
AN (p= .031) and between Italian and Polish HC (p
= .001). Descriptive statistics and normality distribution
testofORTO-15scoresintheANandHCgroupsare
presented in Table 2. Data in all studied samples as di-
vided by country were normally distributed, except for
the Italian AN group, likely due to the small number of
patients included. Nonetheless, since both kurtosis and
skewness in all samples did not exceed 1, parametric
statistics were used for the analyses.
The results of the t-tests are presented in Table 3.
First, groups recruited in the same nation were com-
pared. The statistical difference between Italian AN and
HC groups was found at the boundary of the accepted
threshold, whereas no differences between Polish women
in the AN and HC group was found. Second, women in
the AN and HC groups were compared, independently.
The Italian groups scored significantly higher than the
Polish ones, both for AN and HC group.
Discussion
Italian patients were older than Polish ones; regrettably
data about illness duration were not available, although
it is likely that the Italian AN group included patients
Table 1 Mean age, mean BMI, and % of individuals scoring under
the ORTO-15 40-points cutoff
Sample Mean age
(years)
Mean BMI
(Kg/m
2
)
% scoring under the
ORTO-15 40-points cutoff
Italian AN 30.39 16.36 60.9%
Italian HC 34.41 22.69 46%
Polish AN 22.97 17.21 85.6%
Polish HC 23.00 21.69 82%
Gramaglia et al. BMC Psychiatry (2017) 17:75 Page 2 of 5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

with a more severe and enduring ED, as suggested also
by the lower BMI values.
In the current Italian HC sample, 54% scored 40 or
aboveattheORTO-15,suggestingthepresenceof
orthorexic behaviours in 46% of the sample, consistent
with a previous study performed in Italy and reporting
a prevalence of orthorexia nervosa of 57.6% (40-point
threshold, ORTO-15), or 21% (35-point threshold,
ORTO-15) [19].
Surprisingly, in the Polish HC sample the percentage
of those scoring 40 or above (i.e. those with no ortho-
rexic tendencies) was only 18%, with 82% of the sample
self-reporting orthorexic behaviours as described by the
ORTO-15 test. Mean scores under the 40-points cutoff
[33], and percentages up to 68.55% of orthorexic behav-
iours measured with the ORTO-15 [34] have been de-
scribed in Poland.
Differences in the mean score at the ORTO-15 were
found between AN and HC groups in Italy, but not in
Poland. Whether there is an overlap or not between AN
and orthorexic behaviours, and whether this is also me-
diated by cultural factors should be further assessed by
studies involving larger samples.
The Chi-square differences in the percentage of ortho-
rexic behaviours suggested by an ORTO-15 score below
the cutoff, and the finding of higher ORTO-15 mean
scores in Italian women than in Polish ones, independent
of belonging to either the AN or the HC group, suggest
cross-cultural differences in orthorexic attitudes and be-
haviours. Their meaning is currently difficult to under-
stand, considering the lack of data about this issue. These
differences are likely due to culture-related discrepancies
in the approach to food and health concept. Italy has a
widely-acknowledged culture about eating and nutri-
tion, and the Mediterranean diet has long been praised
for its benefits for overall health [35, 36], but has a
strong focus on taste as well. In Poland, in the last ten
years, good consumer practices have gained a slightly
greater popularity (e.g. checking the composition of
foodstuffs). For Poles, healthy eating is the most im-
portant among various activities aimed at improving
their own state of health; eight out of ten adults report
eating healthy, and most Poles assess their diet as
balanced [37]. This may explain the high percentage of
people scoring under the ORTO-15 cutoff, i.e. self-
reporting orthorexic behaviours.
Further studies are warranted to assess whether health-
ism or Alternative Food Networks (AFN) play a role in
the differences between Italian and Poles. Healthism is a
concept proposed to discuss and contextualize orthorexia,
which would be an advocate for healthy eating to pursue a
better health [38]. Orthorexic tendencies have been de-
scribed in people actively engaged in AFN [39], but while
most people are likely to do so for the benefits that this
would bring to society, health and environment, currently
it cannot be excluded that a small number of individuals
may rather try to disguise disordered eating attitudes be-
hind these socially acceptable (and even laudable) habits.
Limitations of this study are the relatively small sample
size, which may hinder the generalizability of the current
results, and the intrinsic flaws of the ORTO-15. As far
as the former is concerned, regrettably it is a shared
problem of most studies in the field of orthorexia [18].
As for the latter, recently it has been claimed that new
tools are necessary for the assessment of orthorexia, in
consideration of the limits of both the ORTO-15 and
Bratman’sTest[8,40–42], which tend to overestimate
its prevalence. While the ORTO-15 is still the most
used instrument by the studies in this field, we can-
not exclude the possibility that other assessment tools
would yield different results. Moreover, the ORTO-15
alone is not a diagnostic tool, and regrettably in this
study neither a measure of personality features was
available [3] nor the suggested diagnostic criteria for
ON [2, 43] were used.
Last, since this was a naturalistic study based on vol-
untary participation, the samples in Poland and Italy
were not age matched. Therefore, we cannot exclude
that some of the differences we found depend on age
issues.
Conclusions
In the current sample, orthorexic behaviours did not over-
lap with AN in the Italian samples, and seemed to be in-
fluenced by cultural issues. Further studies are warranted
to assess whether orthorexia is just a variant of individuals’
Table 2 Descriptive statistics and normality distribution test of
ORTO-15 scores in the AN and HC groups (bold is for statistically
significant results)
Sample NM SD Kurtosis Skewness Kolmogorov-Smirnov
normality test
p
Italian AN 23 37.21 1.15 –0.97 –0.07 0.20 .024
Italian HC 39 39.41 0.50 0.61 0.31 0.12 .191
Polish AN 35 34.37 0.83 –0.88 –0.20 0.13 .166
Polish HC 39 35.36 0.58 –0.74 –0.21 0.10 .200
Table 3 Comparison of the mean ORTO-15 score in AN and
HC groups divided by country (bold is for statistically significant
results)
Group 1 Group 2 t
(df)
p
Italian AN Italian HC –2.00
(60)
.049
Polish AN Polish HC –0.98
(72)
.325
Polish AN Italian AN –2.06
(56)
.044
Polish HC Italian HC 5.31
(76)
.001
Gramaglia et al. BMC Psychiatry (2017) 17:75 Page 3 of 5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

ways of approaching eating and nutrition, or something
different, and to disentangle the meaning of cultural dif-
ferences in its prevalence.
Abbreviations
AFN: Alternative Food Networks; AN: Anorexia nervosa; BN: Bulimia nervosa;
ED: Eating disorder; HCs/HC: Healthy controls; ON: Orthorexia nervosa
Acknowledgements
not applicable.
Funding
No funding was received for this research.
Availability of data and materials
The datasets used and analysed during the current study available from the
corresponding author on reasonable request.
Authors’contributions
CG. and PZ. designed the study project. CG. and ABM. collected data and
drafted the manuscript. RR. performed statistical analyses. PZ. critically revised
the manuscript. All the Authors read and approved the final draft of the
manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
not applicable.
Ethics approval and consent to participate
The need for approval from the local ethics committee (Comitato Etico
Interaziendale, Novara, Italy; SWPS University of Social Sciences and
Humanities Human Research Ethics Committee, Katowice, Poland) was
waived since the study did not entail anything beyond standard and
everyday clinical practice; patients’informed consent was obtained.
Author details
1
Psychiatry Institute, Dipartimento di Medicina Traslazionale, Università del
Piemonte Orientale, Via Solaroli n° 17, 28100 Novara, Italy.
2
SWPS University
of Social Sciences and Humanities, Katowice Faculty of Psychology, Katowice,
Poland.
3
University of Cardinal Stefan Wyszyński, Warsaw, Poland.
Received: 24 November 2016 Accepted: 15 February 2017
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