Orthorexia nervosa, eating patterns and personality traits: A cross-cultural comparison of Italian, Polish and Spanish university students

Abstract

Background:
The amount of research about orthorexic attitudes and behaviours has increased in the last five years, but is still mainly based on descriptive and anecdotal data, yielding a variety of prevalence data and inconsistent results. The interplay between socio-cultural context and orthorexia has been poorly investigated and is still far from being understood.

Method:
Multicentre, cross-sectional study involving Italian (N = 216), Polish (N = 206) and Spanish (N = 242) university students, assessed through a protocol including informed consent, socio-demographic and anamnestic data sheet and self-administered questionnaires (ORTO-15, Eating Attitudes Test- 26 [EAT-26], Temperament and Character Inventory [TCI]).

Results:
Higher prevalence of orthorexia (as described by the ORTO-15 cutoff) was found in Poland. Female gender, Body Mass Index (BMI), current Eating Disorder, dieting, EAT-26 score ≥ 20 and low/medium Persistence were associated with orthorexia in the whole sample. The cross-cultural comparison showed several differences among the three subgroups of students.

Conclusions:
The associations found between orthorexic attitudes, self-reported current eating disorder, BMI and adherence to a dieting need to be supported by further research. The differences among students from the three countries seem to suggest a possible rolve for cultural elements in the construct of orthorexia.

Full text

R E S E A R C H A R T I C L E Open Access
Orthorexia nervosa, eating patterns and
personality traits: a cross-cultural
comparison of Italian, Polish and Spanish
university students
Carla Gramaglia
1,2
, Eleonora Gambaro
1,2
, Claudia Delicato
2
, Marco Marchetti
3
, Marco Sarchiapone
3
,
Daniela Ferrante
2
, María Roncero
4
, Conxa Perpiñá
4,5
, Anna Brytek-Matera
6
, Ewa Wojtyna
7
and
Patrizia Zeppegno
1,2*
Abstract
Background: The amount of research about orthorexic attitudes and behaviours has increased in the last five years,
but is still mainly based on descriptive and anecdotal data, yielding a variety of prevalence data and inconsistent
results. The interplay between socio-cultural context and orthorexia has been poorly investigated and is still far
from being understood.
Method: Multicentre, cross-sectional study involving Italian (N= 216), Polish (N= 206) and Spanish (N= 242)
university students, assessed through a protocol including informed consent, socio-demographic and anamnestic
data sheet and self-administered questionnaires (ORTO-15, Eating Attitudes Test- 26 [EAT-26], Temperament and
Character Inventory [TCI]).
Results: Higher prevalence of orthorexia (as described by the ORTO-15 cutoff) was found in Poland. Female gender,
Body Mass Index (BMI), current Eating Disorder, dieting, EAT-26 score ≥20 and low/medium Persistence were
associated with orthorexia in the whole sample. The cross-cultural comparison showed several differences among
the three subgroups of students.
Conclusions: The associations found between orthorexic attitudes, self-reported current eating disorder, BMI and
adherence to a dieting need to be supported by further research. The differences among students from the three
countries seem to suggest a possible rolve for cultural elements in the construct of orthorexia.
Keywords: Orthorexia nervosa, Eating patterns, Personality traits, Cross-cultural comparison
Highlights
The interplay between socio-cultural context and
orthorexia has been poorly investigated and still
needs to be better understood.
The associations found between orthorexic attitudes,
self-reported current eating disorder, BMI and
dieting may be explained by the great attention paid
to the individual responsibility for health, typical of
Western societies.
Differences in the frequency of orthorexic attitudes
and behaviors among the Italian, Polish and Spanish
samples can be related to the role of gastronomic
culture, Mediterranean diet, convivial and social
value attributed to eating and main approaches
aimed at improving one’s health.
Background
Eating styles and behaviors have always been and are still
currently deeply shaped by the context where people
live, encompassing cultural, social and environmental
© The Author(s). 2019 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.
* Correspondence: patrizia.zeppegno@med.uniupo.it
1
Psychiatry Ward, Maggiore della Carità University Hospital, Novara, Italy
2
Department of Translational Medicine, Institute of Psychiatry, Università del
Piemonte Orientale, Novara, Italy
Full list of author information is available at the end of the article
Gramaglia et al. BMC Psychiatry (2019) 19:235
https://doi.org/10.1186/s12888-019-2208-2
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

factors [1]. For instance, Western societies have long
been influenced by theoretical constructs on the purity of
the body obtained through food restrictions, in a mind
over matter framework that extends from classical culture
and early Christian beliefs to contemporaneity [2].
In contemporary society, the interest in the body and
the will to keep it healthy have become “obsessive”and
sometimes leading to eating behaviors based on the
compulsive search for natural and “pure”foods [3]. Re-
cently, a new health consciousness", called “healthism”
[4] suggests that health can be accomplished in an un-
problematic way through individual discipline and con-
duct, mainly by doing regular exercise and healthy
eating [5]. Further context-related elements which have
gained importance and become an important part of this
phenomena over the last years [6,7] include the mass-
media and the Internet.
The concept of orthorexia nervosa (ON) defined as as
a persistent fixation on healthy eating [8] has developed
in this cultural and temporal context. Currently, though
ON is not classified as a formal diagnostic category and
its grading is still a matter of debate [9], several sugges-
tions have been made about it being a distinct subtype
of the Avoidant/Restrictive Food Intake Disorder
(ARFID) described by the Diagnostic and Statistical
Manual of Mental Disorders [10], sharing features with
anorexia nervosa (AN) [11] or overlapping with obses-
sive-compulsive disorder [2]. While Dunn and Bratman
[8] pointed out that ON could be considered as a dis-
tinct condition, the current state of research does not
allow the final categorization of ON as a separate mental
disorder [12]. Actually, despite the increase in the
amount of research about this topic in the last five years
[11,13], the literature on ON is still mainly represented
by descriptive and anecdotal data, often with inconsist-
ent results [14], and its prevalence in the general popula-
tion has been recently estimated to be less than 1% [8].
Regarding the shared features between ON and AN,
there are cognitive fixation on nutrition, perfectionism,
high anxiety and need to exert control, achievement
orientation, guilt over food transgressions, value adher-
ence to dieting as a marker of self-discipline, limited
insight, cognitive rigidity, denial of the functional im-
pairments associated with disorder [9]. Therefore, it is
likely, but not yet consistently supported by the existing
literature, that some AN features, including personality
traits, could be involved in the development and main-
tenance of ON as well [12,15].
The personality correlates of ON have been addressed
only by a few studies. Higher levels of neuroticism [16],
narcissism and perfectionism [17] were described in in-
dividuals with ON -related tendencies, cognitions, be-
haviors, and feelings. A recent study [18], performed
with a widely used assessment tool for personality, i.e.
the Temperament and Character Inventory (TCI) [19],
has investigated personality traits in ON individuals,
showing high Harm Avoidance, high Self-Trascendence
and low Self-Directedness. According to these dimen-
sions, an “orthorexic personality”has been described as
characterized by excessive preoccupation and shyness in
social situations, combined with the desire to be perfect
and to feel accepted [18]. Further conclusions of this
study suggested that strictly planned, excessively “pure”
dieting would result from an intense need for control
and as a compensation of poor self-esteem and feelings
of ineffectiveness in managing harmful events [18].
According to these premises, we identified three main
areas of interest: 1) a deeper understanding of the
orthorexia construct, considering its possible and cur-
rently debated relation with full-blown eating disorders;
2) the investigation of the personality correlates of
orthorexic attitudes and behaviors; 3) the role of the cul-
tural context on orthorexia.Regarding the first area,
there is still much inconsistency in the existing litera-
ture. A previous study [20] by our research group inves-
tigated orthorexia in a sample of patients with a clinical
diagnosis of eating disorders, showing that more patho-
logical ON attitudes and behaviors (as measured by the
ORTO-15 test) were related to lower degrees of disor-
dered eating (as assessed with the Eating Attitudes Test-
26). While another study has supported a negative cor-
relation between ON and disordered eating patterns
[21], others (using the Bratman Orthorexia Test and the
Eating Habits Questionnaire, respectively) found in-
creased ON features corresponding to more severely dis-
ordered eating behaviors (particularly calories restriction
and weight concerns) [2].
As far as personality is concerned, considering its role
in eating disorders [22], the widespread use of the TCI
and the familiarity we have with this assessment tool
[23,24], we decided to include it in our research.
Last, the interplay between socio-cultural context and
ON has been poorly investigated. We already addressed
this topic in a previous study [20] involving Italian and
Polish females with AN and healthy controls. Less
orthorexic features, as assessed with the ORTO-15,
emerged in the Italian than in the Polish samples (both
AN and healthy control group). Research involving non-
clinical populations of students have reported a wide
variability in the prevalence of orthorexic attutides and
behaviors, being up to 68.55% in Polish University stu-
dents [26], and57.6% in a previous Italian study [25].
Therefore, the aim of the present study was: 1) to as-
sess the prevalence of orthorexic attitudes and behav-
iours (as measured by the ORTO test; later on referred
to in the text as ON, for the sake of conciseness) in a
sample of university students enrolled in different Euro-
pean countries (Italy, Poland and Spain); 2) to investigate
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 2 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

the association between ON, socio-demographic fea-
tures, eating patterns (measured with the EAT-26) and
personality traits (assessed with the TCI) within the
whole sample; and 3) to investigate the possible cross-
cultural differences in ON and eating patterns in the
three samples, subdivided according to nationality.
We put forward the hypothesis that ON prevalence
and the differences in eating patterns could reflect eating
habits in Italy, Poland and Spain as a mirror of cultural
normative pressures.
Methods
Study design
Multicentre, cross-sectional study analyzing the ON
construct, eating habits and personality traits in a sam-
ple of European university students from Italy, Poland
and Spain. We recruited a convenience sample, based on
previous collaboration among some of the authors (P.Z.
and C.G., A.B.M., M.R.). Each of these authors proposed
the research protocol to the students attending their
University courses (different types of university courses
were involved, as detailed below, thus ensuring a good
representativity of the University population), whowere
assessed with a protocol including informed consent,
socio-demographic and anamnestic data sheet and self-
administered questionnaires.
Sample
The sample was composed by Italian, Polish and Spanish
university students enrolled by the Psychiatry Institute,
Department of Translational Medicine, Università del
Piemonte Orientale at the Faculty of Medicine and
Nursing Sciences, in Novara, Italy; by the Psychology
Faculty of Katowice at different universities in Silesia,
Lower Silesia, Lesser Poland and Mazovia regions (phil-
osophy, dietetics, psychology, sociology students) in
Poland; and by psychology students from the Faculty of
Ciencias Sociales y Humanas of the Universidad de
Zaragoza, in Teruel, Spain, and from the Faculty of Psy-
cholgy, Universitat de València, in Valencia, Spain. Re-
cruitment took place from January 1st 2016 to
December 31st 2017. No inclusion/exclusion criteria
were applied. Students were approached during lesson
time (hence it was not possible to retrieve the exact
number of those approached, nor that of those who de-
clined); they were explained the study protocol and
asked about their willingness to participate and to pro-
vide their informed written consent. In case they ac-
cepted to take part in the study, they were e-mailed a
link with the study protocol, allowing anonymous com-
pilation. The data sheet gathered information about gen-
der, age, ethnicity, marital status, weight and height (in
order to allow the calculation of BMI), use of substances
and/or alcohol, cigarette smoking, sporting activity,
dieting, use of nutritional supplements and past or
current ED diagnosis. All the information gathered was
self-reported, including that about anthropometric mea-
sures and ED diagnosis.
Assessment
Participants were assessed with the following question-
naires: ORTO-15 [26,27]; Eating Attitudes Test-26
(EAT-26) [28]; Temperament and Character Inventory
(TCI) [19,29].
Orto-15
The ORTO-15 is a self-administered scale developed in
2004 by Donini and coworkers, modeled on the Bratman
test [30,31]. It is the most frequently used tool for the
assessment of orthorexic symptoms in various popula-
tions [26,32,33], even though it is clearly not a diagnos-
tic tool.
The ORTO-15 was developed in Italian [26] and later
translated in other language. Several studies have elimi-
nated one or more of its items, based on confirmatory
analyzes and the adequacy of the instrument [34].
ORTO-15 scores range between a minimum of 15 and a
maximum of 60, with lower scores corresponding to more
pathological behaviors. Two cut-offs for orthorexic behav-
iors have been proposed: < 40 (sensitivity 100%, specificity
73.6%, positive predictive value 17.6%, negative predictive
value 100%) and< 35 (sensitivity 86.5%, specificity 94.2%,
negative predictive value 94.1%) [28,35].
The Polish version of the ORTO-15 has a maximum
score of 36 and adopts a 24-points threshold cut-off [25].
Since our study involved samples recruited in Italy,
Poland and Spain, the cutoff of 35 was used for Italy and
Spain, and the cutoff of 24 for Poland, to identify pos-
sible ON, as described in the literature [36]: therefore,
students were classified dichothomically, as scoring
under or above the specific cutoff scores.
Eating attitudes Test-26 (EAT-26)
The EAT-26 is the most common self-report measure
assessing symptoms and concerns typical of EDs [27].
The scale consists of 26 items and includes three basic
dimensions: dieting (which reflects restricting intake of
high caloric foods and preoccupation with body image/
shape), bulimia and food preoccupation (which describes
thoughts regarding food, binging and self-induced
vomiting) and oral control (which is about the ability to
regulate food intake and perceived pressure from others
to gain weight). Albeit it is not a diagnostic tool, it has
been suggested that the EAT-26 might identify cases at
risk for EDs clinical spectrum [37]. A score of 20 or
higher on the EAT-26 indicates a high level of concern
about dieting, body weight or problematic eating behav-
iors. The questionnaire has been validated and translated
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 3 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

into Italian [37], Polish [38], and Spanish [39] and used
extensively in clinical settings as well as in the general
population.
Temperament and character inventory (TCI)
Developed by Cloninger [19], it is a self-report scale
consisting of 240 questions with yes/no answers. It is
based on the biopsychosocial personality theory devel-
oped by Cloninger and assesses individual differences in
the seven basic dimensions of Temperament and Char-
acter, including four temperamental dimensions (Novelty
Seeking [NS] mediated by dopamine; Harm Avoidance
[HA] mediated by serotonin; Reward Dependence [RD]
mainly mediated by norepinephrine; Persistence [P] me-
diated by glutamate) and three character dimensions
(Self-Directedness [SD], Cooperativeness [C], Self-tran-
scendence [ST]). The Temperament and Character In-
ventory-Revised (TCI-R) [29] allows graded answers
from 1 (absolutely false) to 5 (absolutely true) on a
Likert scale. The questionnaire has been validated and
translated into Italian [40], Polish and Spanish [28] and
used extensively in clinical settings as well as in the gen-
eral population. Due to availability reasons, the TCI was
used in Italy and Poland, while the TCI-R was used in
Spain. To overcome the possible problems entailed by
the different scoring methods of the scales used, we
adopted the cutoffs described in the literature [19].
Scores in each temperament and character dimension
were thus classified accordingly as low (low/very low
scores); medium (medium-low/medium/medium-high
scores); high (high/very high scores).
Ethics
The study was approved by the local ethics committees
(Comitato Etico Interaziendale, Novara, Italy, protocol
UNI-ORTO, no. 1/2014; University of Silesia in Kato-
wice Human Research Ethics Committee, no. 14/2015;
Comité Ético de Investigación en Humanos de la Uni-
versitat de València, no. H1409824786250). All proce-
dures performed in the study were in accordance with
The Code of Ethics of the World Medical Association
(Declaration of Helsinki). Participation was anonymous
and informed written consent was obtained from partici-
pants. No fee or reimbursement was offered for partici-
pation in the study.
Statistical analyses
To quantify categorical variables, frequency distribution
tables were constructed for categorical variables and
mean and standard deviation were calculated for con-
tinuous variables.
Univariable and multivariable logistic regression
models were used to study the association between the
study variables and the presence of ON (as measured by
an ORTO-15 score below the cutoff). Odds ratios and
95% confidence intervals (95% CI) were calculated. The
significance of each individual variable was assessed
using the likelihood ratio test (LRT). The Kruskal-Wallis
test was used to evaluate the difference in continuous
variables between the groups of students from Italy,
Poland and Spain and for categorical variables the asso-
ciation with the nationality was evaluated by the chi-
square test or Fisher test.
Ap-value < 0.05 was considered statistically significant.
Statistical analyses were performed with STATA v14.
Results
Descriptive analysis
We enrolled 664 university students, 216 in the Italian
University, 206 in the Polish University, 242 in the Spain
University. The percentage of females was 72.29%, and
the sample mean age was 24.02 years (SD: 4.94; 17–54);
99.70% (N= 662) were Caucasian. Regarding marital sta-
tus, 85.39% were unmarried (N= 567), 13.55% married
(N= 90) and 0.90% (N =6) divorced (1 unkown).
The mean BMI was 22.24 kg/m
2
(SD: 3.66; min 15.78,
max 39.06). Sport activity was practiced by 56.93% of
the students (N= 378); dieting and food supplements
use were reported by 12.20% (N= 81) and 16.42% (N=
109) of the sample. Current and past EDs were self-re-
ported by 6.48% (N= 43), 3.01% (N= 20) of the students,
respectively.
Regarding questionnaire scores in the whole sample,
the mean EAT-26 scores were 5.04 ± 6.06 for Dieting,
1.78 ± 2.93 for Oral Control, 0.99 ± 2.23 for Bulimia and
Food Preoccupation; the total EAT-26 score was 7.89 ±
9.51. ORTO-15 and EAT-26 scores dichotomized ac-
cording to scoring below or above the respective cutoff,
and TCI scores classified in low, medium, high accord-
ing to the mean value of each dimension (as described
in the methods section) are reported in Table 1for the
whole sample.
Univariable and multivariable logistic regression:
associations between ORTO-15 scores, the variables
assessed and questionnaire scores (EAT-26, TCI)
The results of the univariable and multivariable logistic
regression analyses performed to assess the association
of ON (as described by an ORTO 15 score below the
cutoff; dependent variable in the multivariable analysis)
with the self-report variables gathered from participants
and questionnaire scores (EAT-26 and TCI) (independ-
ent variables in the multivariable analysis) are reported
in Table 2and Table 3, respectively.
Details about the descriptive data of the self-report
variables and questionnaire scores with a statistically sig-
nificant association with the ORTO-15 score are re-
ported in Table 4.
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 4 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Comparison among the Italian, Polish and Spanish
samples
The results of the statistical analyses performed to com-
pare the Italian, Polish and Spanish samples are reported
in Table 5. While no statistically significant result was
found from the chi-suqare comparison of those scoring
higher/lower that the EAT-26 cutoff, the Kruskal-Wallis
comparison of the EAT-26 total mean scores in the three
countries yielded the following result: it was higher in
the Italian than in the Polish and Spanish Sample
(9.56 ± 12.28; 8.52 ± 8.18; 5.87 ± 7.11; p= 0.0001).
Discussion
Descriptive analysis
The first aim of the present study was to investigate the
prevalence of ON (as suggested by an ORTO-15 score
below the cutoff) in a sample composed by 664 univer-
sity students enrolled in Italy (N= 216), Poland (N=
206) and Spain (N= 242).
The ORTO-15 score suggested ON in more than a
third of the whole sample of students (score < cutoff in
37.05%). The quite high value we found is consistent
with reports from previous studies with the same assess-
ment tool, which reported a prevalence of ON up to
more than 50% in university students from different
countries [41–43]. More specifically, some at-risk groups
have been described, including students attending uni-
versity courses focused on nutrition (Dietetics) [44,45]
and body care (Exercise and Sport Sciences) [45]), as
well as in medical students and residents [32,46].
Anyway, the interpretation of the result about ON
prevalence is currently difficult, because ON is not a
clinical diagnosis and the ORTO-15 is far from being a
diagnostic tool. Moreover, the possible implications of
ON for the general population still need to be better
understood (for instance, eating healthy may be desirable
until it does not become clinically impairing).
Overall, although more studies on ON are required, in
our sample the prevalence of ON, self-reported current/
previous EDs (6.48 and 3.01%, respectively), and the per-
centage of students scoring above the EAT-26 cutoff (sug-
gestive of high-risk for EDs, 8.43%), suggest that attention
should be paid to eating-related problems in university stu-
dents, and that psychoeducational interventions targeting
this topic may be warranted also for this population [47].
Associations between orthorexia nervosa, the variables
assessed and questionnaire scores (EAT-26, TCI)
The second objective was to investigate the association
between ON, socio-demographic features, eating pat-
terns (measured with the EAT-26) and personality traits
(assessed with the TCI) within the whole sample.
The univariable analyses shown an increased risk of
ON in female students, with higher BMI values, self-
Table 1 ORTO-15, EAT-26 and TCI in the whole sample (Italian,
Polish and Spanish students)
Questionnaire N %
ORTO 15
Score < cut-off 246 37.05
Score > cut-off 418 62.95
EAT-26
Score ≥20 56 8.43
Score < 20 608 91.57
TCI
Novelty Seeking (mean score)
Low/very low 137 20.63
Medium-low/medium/medium-high 332 50.00
High/very high 183 27.56
Missing 12 1.81
Harm Avoidance (mean score)
Low/very low 69 10.39
Medium-low/medium/medium-high 332 50.00
High/very high 250 37.65
Missing 13 1.96
Reward Dependence (mean score)
Low/very low 247 37.20
Medium-low/medium/medium-high 306 46.08
High/very high 98 14.76
Missing 13 1.96
Persistence (mean score)
Low/very low 252 37.95
Medium-low/medium/medium-high 293 44.13
High/very high 106 15.96
Missing 13 1.96
Self-Directedness (mean score)
Low/very low 288 43.37
Medium-low/medium/medium-high 296 44.58
High/very high 69 10.39
Missing 11 1.66
Cooperativeness (mean score)
Low/very low 325 48.95
Medium-low/medium/medium-high 259 39.01
High/very high 69 10.39
Missing 11 1.66
Self-Transcendence (mean score)
Low/very low 361 54.37
Medium-low/medium/medium-high 246 37.05
High/very high 43 6.48
Missing 14 2.11
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 5 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

reporting themselves as dieting and having a current ED,
and in those scoring above the EAT-26 cutoff.
The multivariables analyses confirmed an increased
risk of ON in females and in students self-reporting
themselves as dieting. An increased likelihood of ON
was found also in students with low or medium Persist-
ence (as measured by the TCI).
Regarding gender, while it is widely acknowledged that
the prevalence of EDs like AN has a male to female ratio
1:9 [48], gender differences in ON are still a matter of
debate; results are inconsistent across studies [9,49],
and some did not even show any significant gender
difference [25,32,42].
Literature findings are inconsistent also about the rela-
tionship between ON and BMI. In the current research,
the likelihood of ON increased with higher BMI values.
Some studies have not found any significant relationship,
while others described an increasing trend of ON with
increasing BMI values [32]; no study has found yet a
negative correlation between BMI and orthorexia. None-
theless, the low OR does not allow to draw clear conclu-
sions about the clinical relevance of this association.
Students who declared to be dieting were more likely
to display ON than those who were not following a diet.
ON has already been described as being more frequent
in individuals who strictly adhere to dieting habits, but
once again results are inconsistent and another study
[50] failed to identify any correlation between being diet-
ing and ON.
Last, there was a higher risk of ON in students
who self-reported having a current ED at the time of
assessment, but not in those with a self-reported his-
tory of EDs. Furthermore, in the current study we
also found a positive correlation between ON and
high risk of EDs as suggested by an EAT-26 score
above the cutoff.
Table 2 Univariable analysis: associations between ON (ORTO-15 score < cutoff), the self-report variables assessed, EAT-26 and TCI
scores
ORTO-15 < cutoff (ORTO-15 > cut-off reference) N Odds ratio 95% Confidence Interval p-value
Females 663 1.71 1.18–2.47 0.004
Age 664 0.99 0.96–1.03 0.724
Marital Status, Unmarried 663 1.21 0.76–1.94 0.426
BMI 659 1.05 1.00–1.09 0.040
No Sport Activity 664 1.24 0.90–1.70 0.192
Dieting 664 2.67 1.66–4.28 0.000
Food Supplements 664 1.42 0.94–2.15 0.099
Self-report current ED 664 3.10 1.63–5.87 0.001
No self-report past ED 664 0.58 0.24–1.41 0.229
EAT-26
Score ≥20 664 2.89 1.65–5.06 0.000
TCI
%
NS low and medium 652 0.94 0.66–1.34 0.746
HA low and medium 651 1.03 0.74–1.43 0.846
RD low and medium 651 1.48 0.93–2.36 0.100
P low and medium 651 2.13 1.32–3.44 0.002
SD low and medium 653 1.05 0.62–1.76 0.859
C low and medium 653 1.13 0.67–1.90 0.659
ST low and medium 650 1.55 0.78–3.09 0.208
= reference: high
P-values set in boldface indicate statistical significance
Table 3 Multivariable logistic regression model for variables predicting ON (ORTO-15 score < cutoff) (only statistically significant
results are shown)
ORTO-15 < cutoff (ORTO-15: > cut-off reference) N Odds ratio 95% Confidence Interval p-value
Female 650 1.52 1.03–2.25 0.036
Dieting 650 2.52 1.55–4.10 0.000
P low and medium 650 1.95 1.19–3.19 0.008
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 6 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

The relationship between ON and EDs is complex and
still far from being thoroughly understood. Afive-fold in-
crease in the risk of having ON was identified in individ-
uals with a disordered eating behavior compared to those
with normal eating attitudes [21], and a frequent comor-
bidity, either current or lifetime (from 28 to 53% in a 3-
year follow-up study), has been described between ON
and EDs [35,36]. Orthorexia can precede the onset of an
ED, or it can represent its evolution in the phase of remis-
sion and recovery, representing a condition with the “ad-
vantage”of making the invidual with an ED feels once
again accepted and part of society; this is one reason why
ON can be described as “a disease masked by virtue”[3].
Moreover, EDs have been identified as risk factors for
ON by some authors [34], while others have found EDs
and weight concern as negative predictors of ON [36,
51]. Also, we cannot exclude that in some cases incon-
sistent results in the literature could be due to the use of
different instruments, which may likely measure differ-
ent facets of orthorexia [52].
Despite the intrinsic limitations of self-report informa-
tion about previous/current ED, and those retrieved from
the EAT-26 scoring, overall, from our results described
above and from the inconsistency of those available in the
existing literature, it emerges the importance of fully de-
fining the construct and implications of ON, and its pos-
sible relation with EDs, in order to better understand how
to approach it in a more scientifically sound way.
An interesting result was found regarding the correl-
ation between ON and personality features as assessed
by the TCI. ON was more likely in students with low
and medium scores on the P scale of the TCI than in
those with high P scores. Persistence reflects the cap-
acity for perseveration, determination and constancy in
spite of frustration and fatigue, and predicts resistance
to the extinction of behavior in the face of intermittent
reinforcements [19]; it is usually characterized by high
scores in typical descriptions of AN, restricter sybtype
[53]. To date, only one study has investigated personality
traits in ON with the TCI [24], finding a profile charac-
terized by high HA, low SD and high ST, while no sig-
nificant result emerged regarding P. The “orthorexic
personality”has been previously described as character-
ized by an excessive preoccupation that shows itself with
shyness in social situations, combined with the desire to
be perfect and to feel accepted. In this context, “pure”
dieting would result from an intense need for control to
compensate for low self-esteem, feelings of ineffectiveness
and inability to manage harmful events [18]. The low P
we found in ON subjects may reflect a poor ability in
adopting appropriate coping strategies to finalize ac-
tion in everyday life. While this result, again, is diffi-
cult to contextualize given the shortage of available
studies in the literature, further research about the
personality features of ON individuals are warranted
to identify possible targets for psychoeducational and
Table 4 Descriptive data of the statistically significant associations between ORTO-15 score (> or < cutoff), self-report variables and
questionnaire scores in the whole sample
ORTO-15 score > cutoff
% (N)
ORTO-15 score < cutoff
% (N)
62.95 (418) 37.05 (246)
Gender
Male 31.34 (131) 71.58 21.14 (52) 28.42
Female 68.42 (286) 59.58 78.86 (194) 40.42
Missing 0.24 (1) 100 0.00 0.00
Dieting
YES 8.13 (34) 41.98 19.11 (47) 58.02
NO 91.87 (384) 65.87 80.89 (199) 34.13
Self-reported current ED
YES 3.83 (16) 37.21 10.98 (27) 62.79
NO 96.17 (402) 64.73 89.02 (219) 35.27
EAT-26
Score ≥20 5.26 (22) 39.29 13.82 (34) 60.71
Score < 20 94.74 (396) 65.13 86.18 (212) 34.87
TCI Persistence
Low and medium mean score 78.71 (329) 60.37 87.80 (216) 39.63
High mean score 19.38 (81) 76.42 10.16 (25) 23.58
Missing 1.91 (8) 61.54 2.03 (5) 38.46
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 7 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

also therapeutic interventions (such as perfectionism,
need for control, etc.).
Comparison among the Italian, Polish and Spanish
samples
The third aim of our study was to highlight any cross-
cultural difference in eating attitudes (as measured by
the EAT-26) and ON in the three sub-groups of students
(notwithstanding the limitations of the comparability of
the different university populations recruited in the three
countries due to the convenience sampling procedure).
Differences among the three subgroups were found for
all the self-reported information we gathered. While less
Polish students reported practicing physical/sport activ-
ity, they were more frequently dieting and using food
supplements (e.g. vitamins), compared to their peers in
Italy and Spain.
A few studies are available about eating habits in
Polish university students [54,55]; with more detail, a
recent research found almost a third of the studied
population following restrictions in the type and
amount of food intake [56], consistent with our find-
ings on dieting.
To contextualize these results (dieting, use of food
supplements), it should be considered that in Poland, in
recent decades, economic and political changes have had
a significant impact on the lifestyle of various social
groups, especially on young people, including university
students [56].
Regarding self-reported current and past ED, the only
students declaring a current ED belonged to the Polish
sample, and the higher rate of students with a self-re-
ported history of ED was found in the Polish sample, as
well, even though no actual difference in the BMI of stu-
dents belonging to the three subgroups emerged. While
all this information is intrinsically limited by its self-re-
port nature, we cannot exclude that a different percep-
tion of EDs may underlie these findings.
Table 5 Comparison among the Italian, Polish and Spanish sample: socio-demographic, clinical information, EAT-26 and ORTO-15
questionnaires scores
Italian sample
% (N)
Polish sample
% (N)
Spanish sample
% (N)
P
32.53 (216) 31.02 (206) 36.45 (242)
Gender
Males 26.77 (34) 22.97 12.14 (25) 16.89 36.78 (89) 60.14 < 0.0001
Females 73.23 (93) 21.78 87.86 (181) 42.39 63.22 (153) 35.83
Sport Activity
Yes 63.43 (137) 36.24 47.57 (98) 25.93 59.09 (143) 37.83 0.003
No 36.57 (79) 27.62 52.43 (108) 37.76 40.91 (99) 34.62
Dieting
Yes 1.85 (4) 4.94 21.84 (45) 55.56 13.22 (32) 39.51 < 0.0001
No 98.15 (212) 36.36 78.16 (161) 27.62 86.78 (210) 36.02
Food Supplements
Yes 19.91 (43) 39.45 25.24 (52) 47.71 5.79 (14) 12.84 < 0.0001
No 80.09 (173) 31.17 74.76 (154) 27.75 94.21 (228) 41.08
Self-reported current ED
Yes 0.00 (0) 0.00 20.87 (43) 100.00 0.00 (0) 0.00 < 0.0001
No 100.00 (216) 34.78 79.13 (163) 26.25 100.00 (242) 38.97
Self-reported past ED
Yes 2.31 (5) 25.00 5.83 (12) 60.00 1.24 (3) 15.00 0.02
No 97.69 (211) 32.76 94.17 (194) 30.12 98.76 (239) 37.11
ORTO-15
Score < cut-off 30.09 (65) 26.42 66.50 (137) 55.69 18.18 (44) 17.89 < 0.0001
Score > cut-off 69.91 (151) 36.12 33.50 (69) 16.51 81.82 (198) 47.37
EAT-26
Score ≥20 7.87 (17) 30.36 11.17 (23) 41.07 6.61 (16) 28.57 0.21
Score < 20 92.13 (199) 32.73 88.83 (183) 30.10 93.39 (226) 37.17
P-values set in boldface indicate statistical significance
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 8 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

The opposite trend was found for sport activity prac-
ticed by students in the three subgroups, which was less
frequent in the Polish sample (only in the Polish sample
the percentage of students who did not practice sports
was more than 50%). Nonetheless, another study, in-
volving a different population of university students
(from medical/scientific studies rather than humanities
faculties as in the current one) showed that the major-
ity of Polish students rated their activity level as
medium (68.5%) and high (25.3%) and that 80.5% of fe-
male students and 74.3% of men practiced active sports
every day [54].
Despite inconsistencies and gaps in the available litera-
ture, and the limitations of our results, it will certainly
be interesting to better understand whether cultural
background differences among the three countries exist
in terms of what students consider a healthy lifestyle
and in how they believe it can be achieved.
To our knowledge, in the last years in Poland good
consumer practices have gained greater popularity (for
example in the control of the composition of food
products) and healthy eating has become the most im-
portant among the strategies aimed at improving one’s
state of health [57].
On the other hand, Italy has a widely recognized cul-
ture about eating and nutrition and the Mediterranean
diet has long been praised for its general health benefits
and a strong attention paid to taste [58]; a similar situ-
ation is found in the Northeast (Basque Country) re-
gion of Spain.
Good consumer practices, control of the composition
of food products and the belief that healthy dieting is
the most important approach for the improvement of
ones’health could explain the high percentage of ON
found in the Polish sample. On the other hand, it is
likely that the lowest frequency of ON and attitudes
found in the Spanish sample depends on an enogastro-
nomic culture that includes the Mediterranean diet style,
similar to the Italian one, but with an even stronger con-
vivial and social value of the meal.
Moreover, since the importance attributed to convivi-
ality and to the eating-related social dimension could
penalize orthorexic individauls, we cannot exclude that
our results depend on under-reporting on behalf of stu-
dents. A clearer definition of ON and its diagnostic cri-
teria, and further studies using clinical interview and
assessment rather than self-report information will
allow a more comprehensive approach to the intriguing
topic of the impact of socio-cultural differences on the
ON construct.
Limitations
Some limitations of the current study should be under-
scored. As already stated, an assessment based on self-
administered questionnaires entails problems in terms of
realibility and possible underestimation/overestimation.
The ORTO-15 Questionnaire does not allow to make a
diagnosis of ON, and has intrinsic limitations already de-
scribed by the scientific literature [59], with contradictory
results regarding its psychometric properties, including
construct validity [9,60–63].
The possible problems due to the convenience sam-
pling procedure and to different cut-offs and scoring
methods of the scales used in the three countries
have been overcome as described above in the
methods section.
On the other hand, a strength of the study is that it
represents the first one in the scientific literature specif-
ically focused on the comparison of three countries as
far as ON and eating patterns are concerned.
Conclusions
The positive association between ON, a self-reported
current ED, presence of food psychopathology as sug-
gested by the EAT-26 score, BMI and adherence to a
dieting that emerged in the present study needs to be
supported by further research in order to better under-
stand the relationship between ON and ED. The current
knowledge suggests that ON tendencies are observed in
those who expect benefits for their health, society and
the environment, deriving from food, but may also be
found in individuals who may rather try to disguise dis-
ordered eating attitudes with a more socially acceptable
eating habit [8,19,64].
Regarding the differences in the frequency of ON
found among the Italian, Polish and Spanish samples, we
cannot exclude that a role is played by gastronomic cul-
ture, Mediterranean diet, convivial and social value at-
tributed to eating and main approaches aimed at
improving one’s health typical of each socio-cultural
context.
Further studies with consistent and sound methodo-
logical approaches will help to shed light on the several
gaps that still exist in this field of research, including
that about whether ON is mediated by socio-cultural
factors and to what extent.
Abbreviations
AN: Anorexia Nervosa; ARFID: Avoidant/Restrictive Food Intake Disorder;
BMI: Body Mass Index; C: Cooperativeness; DSM-5: Diagnostic and Statistical
Manual of Mental Disorders; EAT-26: Eating Attitudes Test-26; ED: Eating
Disorder; HA: Harm Avoidance; NS: Novelty Seeking; OCD: Obsessive
Compulsive Disorder; ON: Orthorexia nervosa; P: Persistence; RD: Reward
Dependence; SD: Self-Directedness; ST: Self-Transcendence;
TCI: Temperament and Character Inventory
Acknowledgements
Not applicable.
Authors’contributions
CG, PZ contributed to the conception, design and methodology of the
study; EG, CD, MR, CP, ABM, EW collected data; DF performed the statistical
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 9 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

analysis; CG, EG, CD drafted the manuscript; all the authors critically revised
the manuscript for important intellectual content, and contributed to its final
version. All authors read and approved the final manuscript.
Funding
The author(s) received no specific funding for this work.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
Approval for the research was obtained by the local ethics committees
(Comitato Etico Interaziendale, Novara, Italy, protocol UNI-ORTO, no. 1/2014;
University of Silesia in Katowice Human Research Ethics Committee, no. 14/
2015; Spain Comité Ético de Investigación en Humanos de la Universitat de
València, no. H1409824786250). All procedures performed in the study were
in accordance with The Code of Ethics of the World Medical Association
(Declaration of Helsinki). Participation was anonymous and informed written
consent was obtained from participants. No fee or reimbursement was of-
fered for participation in the study.
Consent for publication
Not applicable.
Competing interests
Carla Maria Gramaglia currently acts as an Editorial Board member for BMC
Psychiatry. All other authors declare that they have no competing interests.
Author details
1
Psychiatry Ward, Maggiore della Carità University Hospital, Novara, Italy.
2
Department of Translational Medicine, Institute of Psychiatry, Università del
Piemonte Orientale, Novara, Italy.
3
Department of Medicine and Health
Sciences, University of Molise, Via DeSantis, 86100 Campobasso, Italy.
4
Departamento de Personalidad, Evaluación y Tratamientos Psicológicos.
Facultad de Psicología, Universitat de València. Av. Blasco Ibáñez, 21. 46010
Valencia, Spain.
5
CIBER Fisiopatología Obesidad y Nutrición (CIBERobn),
Instituto Salud Carlos III, Madrid, Spain.
6
Katowice Faculty of Psychology,
SWPS University of Social Sciences and Humanities, Katowice, Poland.
7
Institute of Psychology, University of Silesia, Katowice, Poland.
Received: 15 April 2019 Accepted: 10 July 2019
References
1. Healy D. From fasting saints to anorexic girls: the history of self-starvation.
Walter Vandereycken, Ron van Deth. London: Athlone Press, 1994. Irish
Journal of Psychological Medicine. Cambridge University Press; 1995;12(1):
41–2.
2. Bundros J, Clifford D, Silliman K, Morris MN. Prevalence of orthorexia
nervosa among college students based on Bratman’s test and associated
tendencies. Appetite. 2016;101:86–94.
3. Daniele MT, Pinto M, Manna V. Il cibo come droga Un approccio integrato
ai disturbi del comportamento alimentare nel XXI secolo. Collana di
Psicoterapia e Psicoanalisi Edizioni Alpes. 2016:85–95.
4. Crawford R. Healthism and the medicalization of everyday life. Int J Health
Serv. 1980;10(3):365–88.
5. Håman L, Barker-Ruchti N, Patriksson G. Lindgren E-C. Orthorexia nervosa:
An integrative literature review of a lifestyle syndrome Int J Qual Stud
Health Well-Being. 2015;10:26799.
6. Abbate-Daga G, Marzola E, Gramaglia C, Brustolin A, Campisi S, De-Bacco C,
Amianto F, Fassino S. Emotions in eating disorders: changes of anger
control after an emotion-focused day hospital treatment. Eur Eat Disord
Rev. 2012;20(6):496–501.
7. Dunn, TM, Bratman, S. On orthorexia nervosa: a review of the literature and
proposed diagnostic criteria. Eat Behav. 2016;21:11–17.
8. Koven NS, Abry AW. The clinical basis of orthorexia nervosa: emerging
perspective. Neuropsychiatry Dis Treat. 2015;11:385–94.
9. Moroze RM, Dunn TM, Holland JC, Yager J, Weintraub P. Microthinking
about micronutrients: a case of transition from obsession about healthy
eating to near-fatal "orthorexia nervosa" and proposed diagnostic criteria.
Psychosomatics. 2014;56:397–403.
10. Barthels F, Meyer F, Huber T, Pietrowsky R. Orthorexic eating behaviour as a
coping strategy in patients with anorexia nervosa. Eat Weight Disord. 2017;
22(2):269–76.
11. Barthels F, Meyer F, Pietrowsky R. Orthorexic eating behavior. A new type of
disordered eating. Ernahrungs Umschau. 2015;62(10):156–61.
12. Cuzzolaro M, Donini LM. Orthorexia nervosa by proxy? Eat Weight Disord.
2016;21(4):549–51.
13. Barnes MA. Caltabiano ML. The interrelationship between orthorexia
nervosa, perfectionism, body image and attachment style Eat Weight
Disord. 2017;22(1):177–84.
14. Dell’Osso L, Abelli M, Carpita B, Pini S, Castellini G, Carmassi C, Ricca V.
Historical evolution of the concept of anorexia nervosa and relationships
with orthorexia nervosa, autism, and obsessive–compulsive spectrum.
Neuropsychiatr Dis Treat. 2016;12:1651–60.
15. Forester DS. Examining the relationship between orthorexia nervosa and
personality traits (unpublished master's thesis). Stanislaus, CA: California
State University; 2014.
16. Oberle CD, Samaghabadi RO, Hughes EM. Orthorexia nervosa: assessment
and correlates with gender, BMI, and personality. Appetite. 2017;108:303–10.
17. Kiss-Leizer M, Rigo A. People behind unhealthy obsession to healthy food:
the personality profile of tendency to orthorexia nervosa. Eat Weight Disord.
2018;24(1):29–35.
18. Cloninger CR, Przybeck TR, Svrakic DM, Wetzei RB. The temperament and
Character Inventory (TCI): a guide to its developement and use. In: Center for
Psychobiology of personality. St Louis, Missouri: Washington Univeristy; 1994.
19. Gramaglia C, Brytek-Matera A, Rogoza R, Zeppegno P. Orthorexia and
anorexia nervosa: two distinct phenomena? A cross-cultural comparison of
orthorexic behaviours in clinical and non-clinical samples. BMC Psychiatry.
2017;17(1):75.
20. Sanlier N, Yassibas E, Bilici S, Sahin G, Celik B. Does the rise in eating
disorders lead to increasing risk of orthorexia nervosa? Correlations with
gender, education, and body mass index. Ecol Food Nutr. 2016;55(3):266–78.
21. Scarff JR. Orthorexia nervosa: an obsession with healthy eating. Fed Pract.
2017;34(6):36–9.
22. Gaudio S, Dakanalis A. Personality and eating and weight disorders: an
open research challenge. Eat Weight Disord. 2018;23(2):143–7. https://doi.
org/10.1007/s40519-017-0463-0.
23. Fassino S, Amianto F, Gramaglia C, Facchini F, Abbate DG. Temperament
and character in eating disorders: ten years of studies. Eat Weight Disord.
2004;9(2):81–90.
24. Brytek-Matera A, Donini LM, Krupa M, Poggiogalle E, Hay P. Orthorexia
nervosa and self-attitudinal aspects of body image in female and male
university students. J Eat Disord. 2015; 24; 3:2.
25. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C. Orthorexia
nervosa: Validation of a diagnosis questionnaire. Eat Weight Disord. 2005;
10(2):e28–32.
26. Brytek-Matera A, Fonte ML, Poggiogalle E, Donini LM, Cena H. Orthorexia
nervosa: relationship with obsessive-compulsive symptoms, disordered
eating patterns and body uneasiness among Italian university students.
Eating Weight Disord. 2017;22(4):609–17.
27. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test:
psychometric features and clinical correlates. Psychol Med. 1982;12(4):871–8.
28. Gutiérrez-Zotes JA, Bayón C, Montserrat C, Valero J, Labad A, Cloninger CR,
Fernández-Aranda F. Inventario del Temperamento y el Carácter-Revisado
(TCI-R). Baremación y datos normativos en una muestra de población
general. Actas Esp Psiquiatr. 2004;32(1):8–15.
29. Heiss S, Coffino JA, Hormes JM. What does the ORTO-15 measure?
Assessing the construct validity of a common orthorexia nervosa
questionnaire in a meat avoiding sample. Appetite. 2019 Apr 1;135:93–9.
30. Bratman S. Orthorexia vs theories of healthy eating. Eat Weight Disord.
2017;22(3):381–5.
31. Aksoydan E, Camci N. Prevalence of orthorexia nervosa among turkish
performance artists. Eat Weight Disord. 2009;14(1):33–7.
32. Fidan T, Ertekin V, Işikay S, Kirpinar I. Prevalence of orthorexia among
medical students in Erzurum. Turkey Compr Psychiatry. 2010;51(1):49–54.
33. Varga M, Dukay-Szabó S, Túry F, van Furth EF. Evidence and gaps in the
literature on orthorexia nervosa. Eat Weight Disord. 2013;18(2):103–11.
34. Segura-Garcia C, Ramacciotti C, Rania M, Aloi M, Caroleo M, Bruni A,
Gazzarrini D, Sinopoli F, De Fazio P. The prevalence of orthorexia nervosa
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 10 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

among eating disorder patients after treatment. Eat Weight Disord. 2015;
20(2):161–6.
35. Brytek-Matera A, Krupa M, Poggiogalle E, Donini LM. Adaptation of the
ORTHO-15 test to polish women and men. Eat Weight Disord. 2014;19(1):
69–76.
36. Dotti A, Lazzari R. Validation and reliability of the Italian EAT-26. Eat Weight
Disord. 1998;3(4):188–94.
37. Rogoza R, Brytek-Matera A, Garner D. Analysis of the EAT-26 in a non-clinical
sample. Vol 2, Archives of Psychiatry and Psychotherapy. 2016:54–8.
38. Castro J, Toro J, Salamero M, Guimerá E. The eating attitudes test: validation
of the Spanish version. Evaluación Psicológica. 1991;7(2):175–89.
39. Vespa A, Ottaviani M, Fossati A, Giulietti MV, Spatuzzi R, Meloni C, Fabbietti
P, Spazzafumo L, Rozsa S, Cloninger RC. Validation of the Italian translation
of the revised temperament and character inventory--TCI-140--in adult
participants and in participants with medical diseases. Compr Psychiatry.
2015 May;59:129–34.
40. Zakrzewska M, Samochowiec J, Rybakowski F, Hauser J, Pełka-Wysiecka J.
Polska wersja Inwentarza Temperamentu i Charakteru (TCI): analiza
rzetelności. Psych Pol. 2001;35:455–65.
41. Brytek-Matera A. Healthy eating obsession in women with anorexia
nervosa: a case control study. In: Gramaglia C, Zeppegno P, editors.
New developments in anorexia nervosa research. New York: Nova; 2014.
p. 39–50.
42. Ramacciotti CE, Perrone P, Coli E, Burgalassi A, Conversano C, Massimetti G,
Dell’Osso L. Orthorexia nervosa in the general population: a preliminary
screening using a self-administered questionnaire (ORTO-15). Eat Weight
Disord. 2011;16(2):e127–30.
43. Jahrami H, Sater M, Abdulla A, Faris MA, AlAnsari A. Eating disorders risk
among medical students: a global systematic review and meta-analysis. Eat
Weight Disord. 2018 May;21.
44. Kinzl JF, Hauer K, Traweger C, Kiefer I. Orthorexia nervosa in dieticians.
Psychother Psychosom. 2006;75(6):395–6.
45. Bo S, Zoccali R, Ponzo V, Soldati L, De Carli L, Benso A, Fea E, Rainoldi A,
Durazzo M, Fassino S, Abbate-Daga G. University courses, eating problems
and muscle dysmorphia: are there any associations? J Transl Med. 2014 7;12:
221.
46. Bağci Bosi AT, Camur D, Güler C. Prevalence of orthorexia nervosa in
resident medical doctors in the faculty of medicine (Ankara, Turkey).
Appetite. 2007 Nov;49(3):661–6. https://doi.org/10.1186/s12967-014-0221-2.
47. Yager Z, O’Dea JA. Prevention programs for body image and eating
disorders on University campuses: a review of large, controlled
interventions. Health Promot Int [Internet]. 2008;23(2):173–89. Available
from. https://doi.org/10.1093/heapro/dan004.
48. Keller MF, Konradsen H. Orthorexia in young fitness participants. Klinisk
Sygepleje. 2013;27:63–71.
49. Karakus B, Hidiroglu S, Keskin N, Karavus M. Orthorexia nervosa tendency
among students of the department of nutrition and dietetics at a university
in Istanbul. North Clin Istanb. 2017;4(2):117–23.
50. McInerney-Ernst EM. Orthorexia nervosa: real construct or newest social
trend? Dissertation: University of Missouri-Kansas City; 2011. Retrieved from
https://mospace.umsystem.edu/xmlui/bitstream/handle/10355/11200/
McInerneyErnstOrtNerRea.pdf?sequence=1
51. Barrada JR, Roncero M. Bidimensional Structure of the Orthorexia:
Development and Initial Validation of a New Instrument. analesps [Internet].
10Apr.2018 [cited 13Apr.2019];34(2):283–291.
52. Fassino S, Pierò A, Levi M, Gramaglia C, Amianto F, Leombruni P, Abbate
Daga G. Psychological treatment of eating disorders. A review of the
literature. Panminerva Med. 2004;46(3):189–98.
53. Jakubiec D, Kornafel D, Cygan A, Górska-Kłęk L, Chromik K. Lifestyle of
students from different universities in Wroclaw. Poland Rocz Panstw Zakl
Hig. 2015;66(4):337–44.
54. El Ansari W, Stock C, Mikolajczyk RT. Relationships between food
consumption and living arrangements among university students in four
European countries - A cross-sectional study. Nutr J [Internet]. 2012;11(1):28.
55. Galinski G, Lonnie M, Kowalkowska J, et al. Self-reported dietary restrictions
and dietary patterns in polish girls: a short research report (GEBaHealth
study). Nutrients. 2016;8(12):796.
56. CBOS (Centrum Badania Opinii Społecznej). Zachowania żywieniowe
Polaków. Nr 115/2014. Warszawa; 2014. http://www.cbos.pl/SPISKOM.POL/2
014/K_115_14.PDF.
57. Schwingshackl L, Missbach B, König J. Hoffmann G adherence to a
Mediterranean diet and risk of diabetes: a systematic review and meta-
analysis. Public Health Nutr. 2015;18(7):1292–9.
58. Missbach B, Hinterbuchinger B, Dreiseitl V, Zellhofer S, Kurz C, König J. When
eating right, is measured wrong! A validation and critical examination of the
ORTO-15 questionnaire in German. PLoS One. 2015;10(8):e0135772.
59. Missbach B, Dunn TM, König JS. We need new tools to assess Orthorexia
Nervosa A commentary on “Prevalence of Orthorexia Nervosa among
College Students Based on Bratman’s Test and Associated Tendencies
Appetite. 2017; 108:521–524.
60. Cena H, Barthels F, Cuzzolaro M, Bratman S, Brytek-Matera A, Dunn T, Varga
M, Missbach B, Donini LM. Definition and diagnostic criteria for orthorexia
nervosa: a narrative review of the literature. Eat Weight Disord. 2019;24(2):
209-46. https://doi.org/10.1007/s40519-018-0606-y.
61. Moller S, Apputhurai P, Knowles SR. Confirmatory factor analyses of the
ORTO 15-, 11- and 9-item scales and recommendations for suggested cut-
off scores. Eat Weight Disord. 2019;24(1):21–8.
62. Roncero M, Barrada JR, Perpiñá C. Measuring orthorexia nervosa:
psychometric limitations of the ORTO-15. Span J Psychol. 2017 Sep 20;
20:E41.
63. Brytek-Matera A, Gramaglia CM, Gambaro E, Delicato C, Zeppegno P. The
psychopathology of body image in orthorexia nervosa. Journal of
Psychopatology. 2018;24(3):133–41.
64. Rich E, Holroyd R, Evans J. In: Evans J, Davies B, Wright J, editors. Hungry to
be noticed: young women, anorexia and schooling. London: Routledge:
body knowledge and control: studies in the sociology of physical education
and health; 2004. p. 173–90.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Gramaglia et al. BMC Psychiatry (2019) 19:235 Page 11 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com