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

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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.
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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 [46]. 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 [1723]. 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, 2428]. 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
BratmansTest[8,4042], 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.
Authorscontributions
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; patientsinformed 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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... Several researchers believe that ON and AN should be treated as a continuum of the same psychopathological dimension with different degrees of nuisance [12,31]. Mac Evilly [32] suggested that ON should be considered to be a risk factor or an initial stage of ED development, rather than classifying it as a separate disease entity. ...
... Upon obtaining oral consent to take part in the study, the participants were informed of the aim and anonymity of the study and were instructed on how to complete the questionnaire. The inclusion criteria were age (i.e., young adults aged [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35], informed consent to participate, and no symptoms of eating disorders (confirmed by the EAT-26 questionnaire). The respondents were asked to complete the questionnaire during classes/lectures. ...
... The available literature points to a relatively higher prevalence of ON among students of health-related fields (e.g., nutrition, medicine, and nursing [3,19,[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][48][49][50][51][52][53][54][55]) or among representatives of medical professions (mostly dieticians and doctors [5,11,19,56,57]). Several studies note that due to the profile of their education, such students possess a greater knowledge relating to health, nutrition-related disorders, the rules of healthy dieting, and the consequences of not following these rules, which may be a potential risk factor of ON. ...
Article
Full-text available
The aim of the study was to determine the level of nutrition knowledge and diet quality, understood in terms of healthy and unhealthy eating habits, among young people with orthorexic tendencies. The participants were school students, university students, and those employed in the Lublin region (N = 473). The data were collected by means of a questionnaire. The participants were asked to provide socio-demographic data through filling in the ORTO-15 questionnaire and the Dietary Habits and Nutrition Beliefs Questionnaire (KomPAN). The participants obtained results ranging from 9.3 to 100 (M = 31.15; SD = 11.81) in the non-healthy diet index, from 0.4 to 78.6 in the pro-healthy diet index (M = 21.79; SD = 11.08), and from 0 to 23 in the domain of nutrition knowledge (M = 13; SD = 4.23). A variance analysis showed no significant differences between the pro-healthy diet index and the level of nutrition knowledge. The group with orthorexia obtained statistically higher results in the pro-healthy diet index. Those with a tendency toward orthorexia obtained statistically higher results in the non-healthy diet index. The variance analysis showed that the level of nutrition knowledge of those not focused on healthy foods was significantly lower than in the other groups. The results of the ORTO-15 questionnaire correlated negatively with the pro-healthy diet index and the level of nutrition knowledge, and positively with the non-healthy diet index. We concluded that: 1. the orthorexic group and the group with a tendency toward orthorexia could be characterized with a moderate intensity of a healthy diet and a low intensity of a non-healthy diet; and 2. the level of nutrition knowledge in the orthorexic group did not significantly differ from that of the other groups.
... Researchers most frequently use the ORTO-15 test to estimate the degree of orthorexia. However, more and more studies accuse it of over-diagnosing orthorexia and low psychometric value [7][8][9][10][11]. The ORTO-15 scale has also been criticized for insu cient internal consistency and uctuations in the alpha-Cronbach value [12,13]. ...
... Głównie jem żywność, którą postrzegam za zdrową. 9. My concern with healthy eating takes up a lot of my time. ...
Preprint
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Background Orthorexia nervosa (ON) is a concept introduced in 1997. It is defined as excessive concentration on healthy eating. Orthorexia can lead to health loss and disrupt the psychosocial functioning of a person. A significant and current research problem on nervous orthorexia is the lack of appropriate diagnostic tools. One of the promising tools for studying orthorexia behavior is the Teruel Orthorexia Scale (TOS). This scale allows distinguishing pathological orthorexia (Ne) from healthy orthorexia (He), defined as an interest in healthy eating free from psychopathology. There are still no tools to measure orthorexia-related behavior with good psychometric properties. Therefore, this study aimed to adapt and validate Teruel Orthorexia Scale (TOS) in Poland. Methods The research involved the evaluation of 680 questionnaires collected in a group of adult Poles (18-68 years old). The research was conducted in the period from June 2019 to March 2020. The diagnostic survey method was used to collect the data. The study used the TOS scale translated into Polish and the Polish adaptation of the ORTO-15 scale. The obtained results were statistically analyzed. The validation procedure included three primary methods: assessment of the discriminant power, reliability, and validity of the tool compared to the ORTO-15 scale. Results Almost all items of the validated scale achieved a satisfactory value of discriminant power >0.3. The individual TOS subscales were characterized by high reliability (TOS He = 0.87; TOS Ne = 0.78). The validity analysis of the validated tool consisting in correlating the obtained results with the results of the ORTO-15 questionnaire showed a significant correlation between the scales (healthy orthorexia r = -0.36; pathological orthorexia r = -0.19). Conclusions The Polish version of the TOS scale is a reliable and valuable tool for measuring orthorexia-related behavior in the Polish adult population.
... Some studies suggest that employees of sectors related to health and nutrition and students of related fields of study, such as dieticians or students of medicine, are particularly vulnerable [2,33], but some studies did not find such a relationship [1,26]. However, the studies conducted so far indicate that the most important risk factor for orthorexia is the present or past eating disorders, such as bulimia and anorexia [3,8,18]. The work of Turner and Lefevre shows that the risk of orthorexia is much more common among social media users, especially Instagram [34]. ...
Article
The term orthorexia nervosa (ON), presented in 1997 in Yoga Journal by Dr. Steven Bratman, sheds new light on the view on healthy eating habits. He showed that persistent thinking about nutrition does not necessarily have to be associated with anorexia or bulimia, and may turn into something so far unknown - obsessive control over the healthiest eating style, resulting in numerous self-imposed restrictions and in the long run, without appropriate therapy, leading to the deterioration of the current state of health. Orthorexia can have many consequences not only on mental health, but also on physical health. For this reason, the development of standard diagnostic and classification criteria for orthorexia nervosa is a priority. The problem of eating disorders should be the subject of epidemiological research, which will take into account demographic, cultural and socio-economic conditions appropriate for a given population, and will also take into account the pressure of factors related to the food market.
... One study assessed people with anorexia nervosa compared to controls in Italy and Poland, 78 and found that the Polish anorexia group (85.6%) and the Polish control group (82%) had a much higher orthorexia prevalence than both the Italian anorexia (60.9%) and control groups (46%). Another study looked at patients with anorexia and bulimia, 77 and found that the orthorexia prevalence was higher in anorexia patients (48%) compared to bulimia patients (33%). ...
Article
Full-text available
There is concern that use of restrictive therapeutic diets, such as those used in disorders of the gut-brain interaction (DGBI), may increase disordered eating. In this issue of Neurogastroenterology and Motility, Burton Murray et al. and Peters et al. both demonstrate a high prevalence of disordered eating in patients with gastrointestinal conditions, particularly those with DGBI. Given these findings, it is likely that orthorexia is common in this patient group, although this was not directly examined in these studies. Orthorexia nervosa is described as an obsessive and unsafe focus on eating foods perceived as healthy. This mini-review therefore focuses on orthorexia by conducting a scoping review, as per the PRISMA extension for scoping reviews, aimed to assess the prevalence of orthorexia, and associations between orthorexia and restrictive eating practices. While a wide range of orthorexia prevalence has been reported (0%-97%) across the 57 studies included, no studies assessed prevalence specifically in gastrointestinal conditions. Four of eight studies describing diseases associated with specific dietary patterns suggested that participants who followed a diet for "digestive issues" or "food intolerances" were at higher orthorexia risk. These results suggest that dietary modifications may be a factor contributing to orthorexia. Additionally, we provide a commentary on the clinical implications of the findings for gastrointestinal conditions including a clinical flow chart. Clinicians should consider if a restrictive diet is appropriate for individuals with DGBI and include screening for disordered eating prior to implementation of dietary modifications. Future prospective studies should evaluate orthorexia within this patient group.
... There is scarce and mixed literature on the weight status of individuals with ON (McComb and Mills, 2019). The current findings suggest that despite ON sharing features with anorexia nervosa (Gramaglia, 2017), women with ON may, if anything, tend to be heavier relative to women without ON. More research is needed to verify whether this is a reliable finding. ...
... Although ON is not formally present as a nosological category of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; [5]) or in other major classification of disorders, many publications have contributed to hypothesize diagnostic criteria [2,3,6,7] in order to consider ON a new psychopathological disorder. Literature highlights important overlaps between ON and the symptomatology of Eating Disorders (ED) [8][9][10][11]. There are moderate relationships between ON and obsessive-compulsive features [12,13]. ...
Article
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Background Pursuing a healthy diet is not a dysfunctional behavior, but dieting could be an important etiological factor for Orthorexia Nervosa (ON). The aim of this study was to investigate the role of diet in groups with high/low orthorexic tendencies. Moreover, some psychopathological characteristics associated with ON and maladaptive personality traits were investigated. Methods The sample consisted of three groups: two were on a diet and had high (HIGH-D; n = 52) or low (LOW-D; n = 41) orthorexic tendencies. The other was composed of people with high orthorexic tendencies not on a diet (HIGH; n = 40). Participants filled out self-report questionnaires to investigate orthorexic tendencies, eating disorders features, obsessive–compulsive symptoms, perfectionism, depressive/anxious symptomatology, and maladaptive personality traits. Results The HIGH-D group showed more orthorexic tendencies than the HIGH group. More maladaptive personality traits and anxiety symptoms have been highlighted in HIGH and HIGH-D groups. The HIGH group had more eating disorder characteristics than other groups. Only the HIGH-D group showed more depressive symptoms than the LOW-D group. Conclusions The features of HIGH and LOW-D groups suggest that diet alone could not explain ON, even if it could be a possible factor related to ON. Therefore, people with high orthorexic tendencies, psychopathological features, and maladaptive personality traits could be in a prodromic condition for disordered eating habits and deserve clinical attention.
... Despite its unofficial diagnosis, ON has spawned a vast body of statistical studies and the development of multiple orthorexia scales including the Bratman Orthorexia Test (Bundros, Clifford, Silliman, & Neyman Morris, 2016) and ORTO-15 (Dunn & Bratman, 2016), all attempting to define and assess risk factors for ON in different population groups. The status of ON as clinically unique disorder rather than a variant of other disorders has become a hot topic of debate among clinicians and health researchers across the globe (Gramaglia, Brytek-Matera, Rogoza, & Zeppegno, 2017). 'Established' characteristics of ON now include a growing concern about consuming only healthy food, the presence of high levels of selfdiscipline and a sense of moral superiority over people who consume junk food (Bratman, 7 Steven, 2000;Varga et al., 2013). ...
Chapter
In this chapter, we examine the construction of the proposed eating disorder orthorexia nervosa (ON), the politics around its potential inclusion in the DSM, the polemic between desirable healthy eating versus pathological or deviant eating and market interests underpinning the identification of new eating disorders.
... The prevalence of ON behaviors ranges from 7 to 57% in the general population, from 29 to 34.9% in recent Italian studies involving university students, and can be even higher in some "risk groups", such as healthcare professionals, dietitians, artistic performers, athletes, yoga practitioners, organic stores customers [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. This high variability may be influenced by cultural or diagnostic issues which can lead to an overestimation of ON actual prevalence [22][23][24]. There are several questionnaires and scales to measure ON, but the disagreement behind the conceptualization of ON greatly influences their heterogeneity [25,26]. ...
Article
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Purpose Orthorexia nervosa (ON) is an obsession for healthy and proper nutrition. Diagnostic criteria for ON are lacking and the psychopathology of ON is still a matter of debate in the clinical and scientific community. Our aim was to better understand the Italian clinical and scientific community’s opinion about ON. Methods Anonymous online survey for Italian healthcare professionals, implemented with the REDCap platform and spread through a multicenter collaboration. Information was gathered about socio-demographic, educational and occupational features, as well as about experience in the diagnosis and treatment of EDs. The main part of the survey focused on ON and its features, classification and sociocultural correlates. Results The survey was completed by 343 participants. Most responders (68.2%) considered ON as a variant of Eating Disorders (EDs), and 58.6% a possible prodromal phase or evolution of Anorexia Nervosa (AN). Most participants (68.5%) thought the next DSM should include a specific diagnostic category for ON, preferably in the EDs macro-category (82.1%). Moreover, 77.3% of responders thought that ON deserves more attention on behalf of researchers and clinicians, and that its treatment should be similar to that for EDs (60.9%). Participants thinking that ON should have its own diagnostic category in the next DSM edition had greater odds of being younger (p = 0.004) and of considering ON a prodromic phase of another ED, such as AN (p = 0.039). Discussion Our survey suggests that the scientific community still seems split between those who consider ON as a separate disorder and those who do not. More research is still needed to better understand the construct of ON and its relationship with EDs; disadvantages and advantages of giving ON its own diagnosis should be balanced. Level of evidence V (descriptive cohort study).
Article
Background In comparison to other eating problems, there is less information on healthy eating fixation (HEF) in the literature. Purpose Understanding the effects of previous family experiences, which have a multidimensional impact on the individual and on other eating disorders, is important to better comprehend the HEF. Methods The current study examined the relationships between HEF and previous family experiences as well as eating attitudes. It is a cross-sectional survey design with a convenience sample of 18–24-year-olds (n = 225) based on a quantitative analysis method. Results Except for “limited social activity,” a sub-factor significantly related to HEF, and “health and social problems,” a sub-factor significantly related to healthy orthorexia (HO), both HEF and HO did not significantly relate to past family life. The outcomes showed that the participants’ eating attitudes had a significant relationship with HEF (r = .57, p < .001) and HO (r = .23, p = .001). Discussion The findings suggest that people with HEF have disordered eating attitudes. Furthermore, practitioners should be aware that family factors may be a risk factor for orthorexia. Translations to Health Education Practice These results may help to educate and increase awareness among health educators and mental health professionals regarding the identification, treatment, and recovery of eating disorders and HEF.
Article
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Background: In recent years a new term in the field of eating behaviors has emerged, namely "orthorexia". This behavior is associated with significant dietary restrictions and omission of food groups. The aim of the present study is to estimate the possible correlations between orthorexia and eating disorders in young adults and adolescents. Methods: A systematic review of related articles in PubMed, Google Scholar, and PsycInfo was conducted up to 30 June 2021. Results: A total of 37 studies (16,402 subjects) were considered eligible for this systematic review. Significant correlations were observed in most of the studies between orthorexia and eating disorders. However, the majority of studies adopted a cross-sectional design. Conclusions: An association between and eating disorders emerged. Prospective studies seem necessary to investigate associations and succession of orthorexia and eating disorders over time.
Article
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Liliana Dell’Osso,1 Marianna Abelli,1 Barbara Carpita,1 Stefano Pini,1 Giovanni Castellini,2 Claudia Carmassi,1 Valdo Ricca2 1Psychiatry Section, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, 2Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy Abstract: Eating disorders have been defined as “characterized by persistence disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs health or psychosocial functioning”. The psychopathology of eating disorders changed across time under the influence of environmental factors, determining the emergence of new phenotypes. Some of these conditions are still under investigation and are not clearly identified as independent diagnostic entities. In this review, the historic evolution of the eating disorder concept up to the recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has been evaluated. We also examined literature supporting the inclusion of new emergent eating behaviors within the eating disorder spectrum, and their relationship with anorexia, autism, and obsessive–compulsive disorder. In particular, we focused on what is known about the symptoms, epidemiology, assessment, and diagnostic boundaries of a new problematic eating pattern called orthorexia nervosa that could be accepted as a new psychological syndrome, as emphasized by an increasing number of scientific articles in the last few years. Keywords: anorexia nervosa, autism spectrum disorders, eating disorders spectrum, obsessive–compulsive spectrum, orthorexia nervosa, DSM-5
Article
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Purpose: We investigated whether perfectionism, body image, attachment style, and self-esteem are predictors of orthorexia nervosa. Methods: A cohort of 220 participants completed a self-administered, online questionnaire consisting of five measures: ORTO-15, the Multidimensional Perfectionism Scale (MPS), the Multidimensional Body-Self Relations Questionnaire-Appearance Scale (MBSRQ-AS), the Relationship Scales Questionnaire (RSQ), and Rosenberg's Self-Esteem Scale (RSES). Results: Correlation analysis revealed that higher orthorexic tendencies significantly correlated with higher scores for perfectionism (self-oriented, others-oriented and socially prescribed), appearance orientation, overweight preoccupation, self-classified weight, and fearful and dismissing attachment styles. Higher orthorexic tendencies also correlated with lower scores for body areas satisfaction and a secure attachment style. There was no significant correlation between orthorexia nervosa and self-esteem. Multiple linear regression analysis revealed that overweight preoccupation, appearance orientation and the presence of an eating disorder history were significant predictors of orthorexia nervosa with a history of an eating disorder being the strongest predictor. Conclusions: Orthorexia nervosa shares similarities with anorexia nervosa and bulimia nervosa with regards to perfectionism, body image attitudes, and attachment style. In addition, a history of an eating disorder strongly predicts orthorexia nervosa. These findings suggest that these disorders might be on the same spectrum of disordered eating.
Article
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Investigating eating disorders and orthorexia nervosa, especially in the young population, is an important step in taking protective precautions and identifying disease. This study was carried out to determine the relationship of eating disorders and orthorexia nervosa to gender, BMI, and field of study in a population of university students in Turkey. In all, 900 university students aged 17–23 years participated in this study. EAT-40 and ORTO-15, which are validated instruments for the screening of participants with anormal eating behaviors and orthorexia nervosa, respectively, were used. There was not a significant difference in EAT-40 scores according to gender and BMI classification. However, EAT-40 scores were high among the students in social science. The number of orthorectic participants among women is higher than that among men, and ORTO-15 scores were not associated with BMI classification and field of study. A significant negative correlation was found between EAT-40 and ORTO-15 scores.
Article
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Purpose: Orthorexia nervosa, or pathological dieting based on being "healthy," has been of growing interest. Clinical data are limited to less than a half-dozen case studies reporting instances of medical problems due to healthful eating. However, more than a dozen studies using a measure to identify orthorexia, the ORTO-15, report very high prevalence rates in non-clinical samples. Point prevalence rates are reported from 6 % to nearly 90 %. Such variability could be due to cultural issues or psychometric problems with the instrument. This study examines prevalence rate of orthorexia in a US sample. Method: The ORTO-15 was administered to 275 US college students along with other questions regarding diet, exercise, and health. Results: While the ORTO-15 indicated a prevalence rate of 71 %, only 20 % of the sample endorsed a dietary practice of removing a particular food type (e.g. meat) from their diet. Those who endorsed following a vegan diet had the highest (less pathological) mean ORTO-15 score. Further, when classifying participants based on their seriousness about healthy eating and whether their diet had led to impairment in everyday activities and medical problems, less than 1 % of the sample fell into such a category. Conclusion: As in other countries, a large proportion of a non-clinical US sample scored in the orthorexia range on the ORTO-15. However, this instrument is likely unable to distinguish between healthy eating and pathologically healthful eating. Our estimate is that orthorexia nervosa like anorexia nervosa and bulimia nervosa, is not a common condition.
Article
The alternative food network (AFN) refers to connections between consumers, producers, and sellers of organic, local/regional, “sustainably grown,” and other artisanal and niche food not produced by the conventional system (Goodman & Goodman, 2007). Alternative foods are often viewed as the “right” consumption choice while conventional counterparts are positioned as ethically “wrong.” A moral positioning of food, avoidance of certain food groups, and anxiety elicited by food consumption choices bears similarities to disordered eating behaviors (Hesse-Biber, Leavy, Quinn, & Zoino, 2006), including a newly proposed eating syndrome, orthorexia nervosa (ON; Vandereycken 2011; Zamora, Bonaechea, Sánchez, & Rial, 2005). This study examines the relationship among engagement in the AFN, disordered eating behaviors, and special diets. We hypothesized that individuals with higher AFN engagement would be more likely report greater disordered eating behaviors as well as to follow a special diet. Adult men and women (N=284) completed a series of measures assessing engagement in the AFN and eating behaviors. We found that individuals with higher AFN engagement were more likely to report ON tendencies but not significantly likely to engage in other disordered eating behaviors. Individuals following a special diet were significantly more engaged in the AFN, more likely to report ON tendencies, and more likely to self-report an eating disorder. Our findings suggest that the most engaged consumers participate in the AFN for the purported benefits reaped by society and the environment, and not to moderate their consumption or mask disordered eating behaviors. Future research should prospectively explore associations between AFN engagement, ON and disordered eating behaviors, and special diets as well as consider the utility of incorporating AFN engagement into existing disordered eating prevention programs.
Article
The alternative food network (AFN) refers to connections between consumers, producers, and sellers of organic, local/regional, “sustainably grown,” and other artisanal and niche food not produced by the conventional system (Goodman & Goodman, 2007). Alternative foods are often viewed as the “right” consumption choice while conventional counterparts are positioned as ethically “wrong.” A moral positioning of food, avoidance of certain food groups, and anxiety elicited by food consumption choices bears similarities to disordered eating behaviors (Hesse-Biber, Leavy, Quinn, & Zoino, 2006), including a newly proposed eating syndrome, orthorexia nervosa (ON; Vandereycken 2011; Zamora, Bonaechea, Sánchez, & Rial, 2005). This study examines the relationship among engagement in the AFN, disordered eating behaviors, and special diets. We hypothesized that individuals with higher AFN engagement would be more likely report greater disordered eating behaviors as well as to follow a special diet. Adult men and women (N=284) completed a series of measures assessing engagement in the AFN and eating behaviors. We found that individuals with higher AFN engagement were more likely to report ON tendencies but not significantly likely to engage in other disordered eating behaviors. Individuals following a special diet were significantly more engaged in the AFN, more likely to report ON tendencies, and more likely to self-report an eating disorder. Our findings suggest that the most engaged consumers participate in the AFN for the purported benefits reaped by society and the environment, and not to moderate their consumption or mask disordered eating behaviors. Future research should prospectively explore associations between AFN engagement, ON and disordered eating behaviors, and special diets as well as consider the utility of incorporating AFN engagement into existing disordered eating prevention programs.
Article
Objective: Orthorexia nervosa (ON) is considered an eating disorder (ED), with an excessive fixation on the consumption of healthy food and an obsession with its biological purity. Since the adolescent period poses a risk for EDs, the aim of this study was to assess the prevalence of ON in a population of Polish urban adolescents and some possible contributory factors. Method: 1899 high school students, 992 girls and 907 boys aged 15-21 years were studied. Demographic and clinical data were collected using a validated questionnaire including information on preferred living choices, in the context of pro- and antihealth activities. The Polish version of the ORTO-15 questionnaire was used. Results: The mean value of the ORTO-15 was 39.2 ± 3.6 points, with no sex difference. The main factors connected with orthorexia, according to the 'Orthorexia 33.35 and 40' definitions were excess weight, sporting activities, out-of-school activities, smoking status, working parents and a high family income. Conclusions: This study, of a large number of adolescents, showed a prevalence of ON similar to that recorded in adult populations. Since factors predisposing to ON in adolescence differ from those for other eating disorders, it is not clear whether ON should be treated as a new form of ED.
Chapter
Introduction: Unhealthy fixation with healthy eating, called "orthorexia nervosa", was first developed by Bratman (1987) in the United States. Several studies investigated the prevalence of orthorexia nervosa in the general population but to our knowledge, there is no reported study involving the prevalence of orthorexia nervosa in people suffering from anorexia nervosa. Objective: The purpose of the present study was two-fold. The first purpose was to assess whether anorexia nervosa is related to orthorexia nervosa tendency. The second purpose was to determine whether there is a relationship between orthorexia nervosa, body image and eating attitudes in outpatients with anorexia nervosa. Methods: The sample consisted of 37 women diagnosed with anorexia nervosa (DSM-IV-TR, APA, 2000) and 48 women without a current eating disorder. We used the ORTO-15 test, the Multidimensional Body-Self Relations Questionnaire (MBSRQ) and the Eating Attitude Test (EAT-26). Results: Among all participants, 37.8% of outpatients with anorexia nervosa and 22.9% of women without eating disorders presented a tendency towards orthorexia nervosa based on the cut-off of 35 for the ORTO-15 test. In women with anorexia nervosa, symptoms of orthorexia nervosa were negatively related to dieting (r = -.612; p < .01), fitness orientation (r = -.481; p < .01), overweight preoccupation (r = -.402; p < .05) and self-classified weight (r = -.402; p < .05). Conclusion: The present study may increase psychological knowledge about eatingrelated problems and points out possible future research directions in eating psychology.
Article
Disordered eating is prevalent among college student populations, and Orthorexia Nervosa (ON) is being explored as a new type of eating disorder. There is currently no standardized ON diagnostic tool, and the majority of ON research has been conducted among European populations. The present study explored the Bratman Orthorexia Test (BOT) for ON diagnosis, and its relationship to validated tools for assessing disordered eating, body dysmorphic, and obsessive-compulsive tendencies among college students attending a western university. A convenience sample of 448 college students with a mean age of 22 years was recruited to complete an online survey that included the BOT, Eating Attitudes Test-26 (EAT-26), Body Dysmorphic Disorder Questionnaire (BDDQ), Obsessive Compulsive Inventory, Revised (OCI-R) and demographics. Spearman correlation, Mann-Whitney U, Kruskal-Wallis, chi-square, and multiple linear regressions were used for analyses. The average BOT score was 4.71, near the “health fanatic” range, with Hispanic/Latino subjects and overweight/obese students having significantly higher median BOT scores. Gender, age, and college major were not significantly associated with BOT score. Significant positive correlations were observed between total BOT and EAT-26 scores (r=.47, p<0.01), BOT and BDDQ scores (r=.25, p<0.01), and BOT and OCI-R scores (r=.19, p<0.01). ON tendencies may exist among college students and Hispanic/Latino and overweight/obese students may be at increased risk. Further research is needed to determine ON risk factors among diverse student populations in order to inform prevention and treatment approaches on college campuses.