Aim: This study aimed to investigate the relationships between orthorexia nervosa (ON) and vocational education, gender, BMI, body perception, and self-esteem in university students. Method: The study was conducted on a total of 500 volunteer students studying in health and nonhealth departments of a state university. The Ortho-15 test, Maudsley Obsessive–Compulsive Symptom Test (MOCI), Coopersmith Self-Esteem Inventory, and Body Perception Scale (BPS) were administered to the students along with a questionnaire to determine their demographic characteristics.

Results: According to the Ortho-15 test score, it was determined that medical school students had the lowest scores, that is, the highest orthorexic tendencies. However, when the distribution of the groups in terms of ON prevalence according to the Ortho-15 cutoff score < 35 was examined, the frequency of orthorexic tendency was found to be higher in students studying in nonhealth faculties (38.4% vs. 61.6%; p < 0.05). The Ortho-15 test score of females (38.60 ± 3.87) was higher than that of males (37.53 ± 3.21) (p < 0.001). When those with and without ON tendency were compared in terms of test scores, a significant difference was found only in terms of MOCI scores. Obsessive symptom scores of those with orthorexic tendency (15.41 ± 6.63) were higher than those without ON (13.59 ± 6.40) (p < 0.05).There was no significant difference between the faculties in terms of CSEI scores. Furthermore, in our study, the decrease in MOCI and Ortho-15 scores as BMI increases indicates that obsessive symptoms decrease but orthorexic tendency increases as BMI increases.

Conclusion: It was thought that these results distinguish ON from other eating disorders and that ON may be more suitable for the Obsessive–Compulsive Disorder classification.

1. Introduction

Eating disorder (ED) is a disease picture in which disorders in eating attitudes and behaviors occur as a result of impaired body perception of the individual, and it is known that adolescents and young women are more susceptible to this disorder [1]. The etiology and neurobiology of EDs are not fully understood, but they are recognized as brain-based diseases with serious acute and long-term consequences when left untreated or ignored [2, 3].

Orthorexia nervosa (ON) was first defined by Bratman to refer to a pathological obsession with the desire to consume healthy food [4]. ON is classified as an unspecified feeding and eating disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) [5]. Unlike other eating disorders, ON emphasizes the desire to consume only pure and healthy foods [6, 7]. Orthorectectics pay attention to the health and purity of foods rather than their caloric value. It is similar to obsessive–compulsive disorder (OCD) in the sense that this desire occupies the mind and behavior excessively [8, 9]. As in other eating disorders, depression, anxiety, stress, obsessions and compulsions have been reported to accompany ON [10–12].

It has been reported that the prevalence varies from country to country, ranging from 6% in Italy to 88.7% in Brazilian dietetic students [13]. Studies using the Ortho-15 scale have shown that the prevalence ranges from 6.9% to 75.2% in the general population and can be as high as 90.6% in specific groups [13–15]. In a systematic review and meta-analysis, the overall prevalence of ON in the exercising population was 55.3% [16].

It is also not clear whether ON is more common in females or males. Similar contradictions remain regarding the effects of age, educational status, Body Mass Index (BMI), exercise, body dissatisfaction, and vocational training on ON prevalence [17, 18]. Professionals such as health professionals, artists, and athletes who are oriented toward nutrition and health due to their profession or education are estimated to be at higher risk for ON [19, 20]. Some researchers have even suggested that vegetarianism can be used to mask EDs and that ON is a new concept that is more common in the vegan population [21–23].

It is accepted that ON does not occur suddenly; it develops as a result of the continuous interaction of biological, psychological, and social dynamics over time [24]. Adolescence is a period in which many biopsychosocial changes occur. During this period, various adaptation problems can be observed in adolescents, many of whom continue their university education away from their families. Adaptation problems caused by biopsychosocial changes can also affect the nutrition of young people.

It is thought that ON may be common in females and university students receiving health education. However, the results of existing studies are undecided regarding the relationships of gender, vocational training, body image, and self-esteem with ON. Therefore, our study aimed to investigate the relationships between Orthorexia Nervosa and vocational education, gender, BMI, body perception, and self-esteem in university students.

2. Methods

2.1. Study Design

2.1.1. Research Type

This is a cross-sectional controlled study conducted with university students. The population of the study consisted of third and fourth grade students studying at Ondokuz Mayıs University (OMU) in the spring semester of 2015–2016. In this cross-sectional study where simple random sampling method was used, the sample size was calculated by G power analysis. Accordingly, the sample size was calculated as 500 people with 95% power and 5% error.

2.1.2. Selection of Participants

Students studying in the field of health constituted the study group, and students in nonhealth departments constituted the control group. The study group consisted of students from the Faculty of Medicine, Dentistry and Health Sciences (Nutrition and Dietetics, Nursing, and Midwifery Departments), which provides education in the field of health; students from the Faculty of Education, Faculty of Science and Letters, Faculty of Economics and Administrative Sciences (FEAS), and Faculty of Engineering, which provide education in nonhealth fields, formed the control group. All students who continued their active education in the 3rd and 4th grades of these faculties, did not have any chronic health problems, and agreed to participate in the study voluntarily were included in the study. Written informed consent was obtained from all participants. Those who did not volunteer and did not give written consent were not included in the study.

2.1.3. Data Collection Methods

In the study, a questionnaire form to determine the sociodemographic characteristics of the students, Ortho-15, Moudsley Obsessive–Compulsive Inventory, Coopersmith Self-Esteem Inventory and Body Perception Scale were used. Due to the emotional, physical and behavioral characteristics of ON, it is considered necessary to support the diagnosis with the Ortho-15 test and scales to determine eating attitude, mood and obsessive–compulsive behaviors [7, 25]. The study was conducted between January and March 2016. Students were reached in social areas on campus such as classrooms, canteens, and cafeterias. After being informed about the study, questionnaires were distributed to volunteer students and they were left to fill them out based on their own self-report at their own time. The questions in questionnaires were answered in approximately 15 min. The completed questionnaires were later received by the researchers.

2.1.3.1. Ortho-15 Scale

It is a 15-item self-assessment scale adapted from Bratman’s short questionnaire first developed in Italy for Latinos and designed to assess the tendency to ON. The items are written to be answered in the present tense in a 4-point format. In the scale, individuals are asked to indicate how often they feel as described in the items by marking one of the options “always,” “often”, “sometimes,” and “never.” Each item is rated with a maximum score of 1, 2, 3, and 4.

The items investigate individuals’ obsessive behaviors in selecting, purchasing, preparing, and consuming foods that they themselves consider healthy. A score of “1” was given to answers that were discriminatory criteria for orthorexia and a score of “4” was given to answers that showed a tendency toward normal eating behavior. A minimum of 15 and a maximum of 60 points can be obtained from the scale. A low score on the test indicates an orthorexic tendency. For the Ortho-15 test cutoff score, values < 40 and < 35 are used. It has been reported that values below 35 are more valuable for identifying those with orthorexic tendencies [26].

2.1.3.2. Moudsley Obsessive–Compulsive Inventory (MOCI)

The original inventory was developed by Hodgson and Rachman for the assessment of various obsessive–compulsive symptoms. Each correct item marked on the scale is given one point. Only the 11^th item is reverse scored. The total scores are determined by the numerical values obtained from each item. The highest values are 37 for total obsession score, 9 for controlling, 11 for cleaning, 7 for slowness, and 7 for suspicion [27].

2.1.3.3. Coopersmith Self-Esteem Inventory (CSEI)

The inventory, which consists of 50 items measuring attitudes toward oneself, was originally designed by Coopersmith to measure children’s self-esteem [28]. It was later modified by Ryden for use in adults. For each item, participants answer whether the statement presented is “like me” or “not like me.” Expected responses score 1 and other responses score 0. A high score means high self-esteem and a low score means low self-esteem [29].

2.1.3.4. Body Perception Scale (BPS)

This scale was developed by Secord and Jourard [30] and adapted into Turkish by Hovardaoğlu [31]. The form of the scale used in our country is a five-point Likert-type instrument consisting of 40 items (1 = I like it very much, 2 = I like it quite a bit, 3 = I am undecided, 4 = I do not like it very much, and 5 = I do not like it at all). The most positive statement receives one point and the most negative statement receives five points. The lowest score that can be obtained from the scale is 40 and the highest score is 200, and an increase in score means an increase in positive evaluation [31].

2.1.4. Statistical Evaluation

The data obtained were analyzed with t-test, single factor analysis of variance (ANOVA), chi-square (X²), and Pearson correlation tests in SPSS 22.0 Version of the SPSS program, and p < 0.05 value was considered significant.

2.1.5. Ethical Approval

Ethical approval of the study was obtained with the decision of OMU Clinical Research Ethics Committee dated 14.01.2016 and numbered KAEK 2016/12.

3. Results

A total of 500 students participated in the study. Of the students, 66% (320) were female and 34% (180) were male. There were 249 (49.7%) students in the study group and 251 (51.3%) students in the control group. The mean age was 21.21 ± 2.04 years; BMI was 22.42 ± 4.21 kg/m². According to BMI, 54.4% were in the normal range (18.5–24.9 kg/m²). The majority of the participants lived in dormitories (48.0%), slept 7–8 h (51.4%), and ate 3-4 meals a day on average (46.4%) (Table 1).

Table 1. Some demographic characteristics of the participants.

Variable	Study Group			Control Group
Variable	Number (n)			Number (n)
Age (year)	249	21.06 ± 2.00		251		21.36 ± 2.07
BMI (kg/m²)	249	22.34 ± 4.12		251		22.49 ± 4.31
Variable	Group	Study group		Control group		Total
Variable	Group	Number (n)	Percent (%)	Number (n)	Percent (%)	Number (n)	Percent (%)
Gender	Female	172	69.1	148	59.0	320	66.0
Gender	Male	77	30.9	103	41.0	180	34.0
Daily sleep duration	5-6 h	55	22.1	56	22.3	111	22.2
	7-8 h	145	58.2	112	44.6	257	51.4
	9-10 h	21	8.5	32	12.7	53	10.6
	Irregular	28	11.2	51	20.3	79	15.8
Where he/she lives	With his/her family	76	30.6	77	30.7	153	30.6
	With his/her relative	3	0.1	8	3.2	11	2.2
	In the dormitory	115	46.2	125	49.8	240	48.0
	In student housing	55	22.1	41	16.3	96	19.2
Number of daily meals	< 3 meals	58	23.3	76	30.3	134	26.8
	3-4 meals	122	49.0	110	43.8	232	46.4
	5-6 meals	16	6.4	8	3.2	24	4.8
	Irregular	53	21.3	57	22.7	110	22.0

Note: X, mean.
Abbreviations: BMI, body mass index; SD, standard deviation.

The mean Ortho-15 scale score was 38.22 ± 3.68; MOCI score was 13.85 ± 6.46; CSEI score was 18.18 ± 4.32; and BPS was 88.71 ± 25.27. When the mean test scores of the study and control groups were compared, the MOCI score was 13.25 ± 6.36 in the study group and 14.45 ± 6.50 in the control group and the difference was found to be significant (p < 0.05). The BPS score was 92.29 ± 25.85 in the study group and 85.17 ± 24.22 in the control group (p < 0.001). No significant difference was found between the groups in terms of Ortho-15 and CSEI scores.

The FEAS had the highest Ortho-15 score, while the Faculty of Medicine had the lowest Ortho-15 score (p < 0.05). Accordingly, the students of the Faculty of Medicine showed the highest orthorexic tendency. The mean MOCI score was highest in the Faculty of Education (15.22 ± 6.35) and lowest in the Faculty of Medicine (12.33 ± 5.15) and the difference between the faculties was found to be significant (p < 0.05). Accordingly, obsessive thoughts were most common among the students of the Faculty of Education. There was no significant difference between the faculties in terms of CSEI test scores. A significant difference was found between the faculties in terms of the scores of the BPS. Faculty of Dentistry students had the highest score (96.51 ± 24.44) and Faculty of Arts and Sciences students had the lowest score (79.16 ± 28.03) (p < 0.005). It was observed that the students who were most satisfied with their own bodies were the students from the Faculty of Dentistry since a high score on the BPS was considered positive.

As seen in Table 2, females had significantly higher MOCI, Ortho-15, and BPS scores than males, while their BMI values were lower. Since a low score on the Ortho-15 scale indicates that the individual is in an orthorexic tendency, the orthorexic tendency is higher in males.

Table 2. Comparison of test scores by gender.

Scale	Gender	Number	Mean	SD	t-test	p value
CSEI	Female	320	18.13	4.22	−0.333	0.739
CSEI	Male	179	18.26	4.50	−0.333	0.739

MOCI	Female	320	14.41	6.34	2.585	0.010
MOCI	Male	179	12.86	6.56	2.585	0.010

ORTO-15	Female	320	38.60	3.87	3.147	0.002
ORTO-15	Male	179	37.53	3.21	3.147	0.002

BPS	Female	320	91.02	23.56	2.756	0.006
BPS	Male	179	84.56	27.67	2.756	0.006

BMI (kg/m²)	Female	320	20.70	3.09	−14.557	≤ 0.001
BMI (kg/m²)	Male	179	25.50	4.21	−14.557	≤ 0.001

Abbreviations: BMI, Body Mass Index; BPS, Body Perception Scale; CSEI, Coopersmith Self-Esteem inventory; MOCI, Moudsley Obsesive–Compulsive Inventory; SD, standard deviation.

When the Ortho-15 scale cutoff score was taken as < 40, the prevalence of ON in the entire group was found to be 61.7%, and it was 56.2% versus 71.5% in females and males, respectively (p < 0.001) (Table 3).

Table 3. Distribution by gender in terms of orthorexic tendency (according to Ortho-15 scale cutoff score < 40).

			ON group		Total	X² test
			< 40	≥ 40	Total	X² test
Gender	Female	Number	180	140	320	11.312 SD = 1 p = 0.001
	Female	%	56.2	43.8	100.0
	Male	Number	129	51	180
	Male	%	71.5	28.5	100.0

Total		Number	309	191	500
Total		%	61.7	38.3	100.0

Note: X², Chi square.
Abbreviation: ON, orthorexia nervosa.

The BMI of those with orthorexic tendency (22.797 ± 4.279 kg/m²) was significantly higher than those without (21.807 ± 4.041 kg/m²) (t-test = 2.566; p < 0.05).

When the cutoff value of Ortho-15 score < 35 is taken, the rates of those with ON tendency in the study and control groups are given in Table 4. Accordingly, the prevalence of orthorexic tendency was higher in students receiving nonhealth education.

Table 4. Distribution of groups in terms of ON frequency according to Ortho-15 cutoff score < 35.

ON group	Groups				Explanation
	Study group		Control group
	N	%	N	%
< 35	28	38.4	45	61.6	X² = 4.401 SD = 1 p = 0.036
≥ 35	220	51.6	206	48.4	X² = 4.401 SD = 1 p = 0.036

Note: X², Chi square.
Abbreviations: ON, orthorexia nervosa; SD, standard deviation.

When those with and without ON tendency were compared in terms of test scores, a significant difference was found only in terms of MOCI scores (Table 5). The obsessive symptom scores of those with orthorexic tendency were higher than those without ON (p = 0.026). This result confirms that ON includes obsessions related to food and nutrition.

Table 5. Comparison of test scores of those with and without ON tendency according to Ortho-15 cutoff score < 35.

Scales	< 35 (there is ON)		≥ 35 (there is no ON)		t-test	p
Scales	X	SD	X	SD	t-test	p
BMI	23.13	4.50	22.30	4.16	1.560	0.119
MOCI	15.41	6.63	13.59	6.40	2.239	0.026
CSEI	18.67	3.45	18.09	4.45	1.060	0.290
BPS	84.88	22.82	89.36	25.64	−1.402	0.161

Note: X, mean.
Abbreviations: BMI, Body Mass Index; BPS, Body Perception Scale; CSEI, Coopersmith Self-Esteem Inventory; MOCI, Moudsley Obsesive–Compulsive Inventory; ON, orthorexia nervosa; SD, standard deviation.

The relationship between BMI and Ortho-15 score was investigated by Pearson correlation and an inverse relationship was found (r = −0.138; p = 0.002). The decrease in Ortho-15 score as BMI increases indicates that weight gain increases orthorexic tendency.

Pearson correlation revealed an inverse relationship between BMI and MOCI (r = −0.132; p = 0.003). The decreases in the MOCI score while BMI increases indicate that obsessive symptoms decrease while BMI increases.

A significant inverse relationship was found between the CSEI score and MOCI and Ortho-15 scores. This indicates that while self-esteem increases, obsessive symptoms decrease, but orthorexic tendencies increase. In other words, those with orthorexic tendencies have high self-esteem.

4. Discussion

In the study, the relationships between vocational education, gender, BMI, self-esteem, and body perception and ON in university students were investigated. ON, known as obsession with healthy eating, has not yet been defined as an ED. In addition, literature information regarding the effects of vocational training, BMI, gender, body image, and self-esteem is inconclusive. It is known that other defined EDs are more common in females, health education recipients, and health professionals, and their body image and self-esteem are lower. The findings of our study make a significant contribution to the literature by revealing the different characteristics of ON from other EDs.

In line with the data of our study, it was determined that there was a significant relationship between orthorexic tendency and gender in university students. The lower Ortho-15 test score in males indicates that the tendency to ON is higher in males. The study results of Çulhacık and Durat [32] and Yılmaz [33] support our study in this respect. On the contrary, there are also studies showing that the risk of ON is higher in women [34, 35]. In a systematic review, no significant differences were observed between females and males [36]. In the light of the studies on the subject, it is seen that ON can affect both genders. In a study examining the relationship of ON with demographic variables such as gender and BMI and self-esteem [37], a higher BMI for men was associated with more symptomatology for all ON components. However, there are also studies reporting that no significant relationship was found between BMI and Ortho-15 score averages [33]. In our study, the fact that the mean BMI of males was significantly higher than that of females may have contributed to the higher tendency for ON in males.

In this study, it was determined that the MOCI scores of female students were higher than the scores of males. Similarly, in a study conducted by Gezer and Yalvaç [38], MOCI scores of female students were higher than male students. On the contrary, there are studies showing that there is no significant difference between MOCI scores and gender [39, 40]. In a study investigating the relationship between ON and obsessive–compulsive disorder (OCD), almost all OCD subtypes were found to be largely associated with ON [41].

No significant difference was found between CSEI and gender in our study. Although some studies investigating the effect of gender difference on the self-esteem variable indicate that self-esteem is higher in men, others show that there is a similar pattern in men and women throughout life [42, 43]. One review found that gender and self-esteem are generally unrelated to ON [18].

When the relationship between the BPS and gender was examined, it was determined that the score of females was higher than the score of males. In some studies, it has been observed that male students’ body image scores are higher than female students [44, 45]. In a study investigating the role of body image in healthy orthorexia and ON, no significant difference was found between men and women in terms of healthy orthorexia and ON, although men scored significantly higher than women in all measures of positive body image [46]. A study investigating body perception and gender differences in adults showed that the distorted image of body weight was more common in men (45.3%) than in women (25.7%) [47]. While age, income, perceived health status, and health behaviors were significantly associated with distorted body weight perception in men, psychological factors were associated in women.

Body perception is one of the factors that play an important role in EDs. In adolescence, females’ attitudes toward being thinner increase with the influence of the media, while males’ desire to be more muscular and their efforts in this direction increase. In a study examining the relationship between body perception and BMI in university students, it was found that females perceived themselves to be overweight and males perceived themselves to be thinner; in addition, as the BMI value increased, the BPS score decreased in both genders [48]. Studies indicate that women want to be thinner than they are, while men want to be both thin and muscular. Studies reporting that ON is most commonly seen in men in sports science students with high levels of physical activity [49] confirm this. Increased muscle mass may also be linked to sociocultural messages such as attractiveness and looking strong in men. In our study, it was thought that the lower BPS score found in males may be related to their higher orthorexic tendencies. Low body image may have encouraged male students to eat healthy.

In the present study, the frequency of orthorexic tendency was found to be significantly higher in students who received education in nonhealth fields. Similarly, Kamarlı Altun, Keser, and Bozkurt [50] found a higher incidence of orthorexic behavior in students who did not study in the health field. Interestingly, one study found that the orthorexic tendency was lower in Nutrition and Dietetics students and girls [33]. It was concluded that health education increases the level of knowledge about nutrition as well as health and the ability to cope with related problems and, therefore, students in health-related departments were found to have a lower tendency to ON. Although Pehlivan et al. [51] reported that the majority of orthorectic individuals were inadequately health literate, the frequency of orthorexia was also high in those with adequate and excellent health literacy. He suggested that this dichotomy may be due to the fact that increased knowledge about health increases the likelihood of showing orthorexic behaviors.

In the present study, it was observed that the students of the Faculty of Education were more obsessive than the students of the Faculty of Medicine. Inadequate nutrition courses during medical education may have contributed to medical students’ lower knowledge and awareness of nutrition and thus a higher tendency toward ON. The fact that the ON tendency was the highest in the students of the Faculty of Medicine, while the MOCI scores were the lowest, was interpreted as the fact that they were able to cope with their obsessions thanks to the medical education they received. On the other hand, the highest MOCI scores among the students of the Faculty of Education were interpreted as a reflection of their internal anxiety in order to be appointed as a teacher.

When the MOCI, CSEI, and BPS scores of the study and control groups were compared, no significant difference was found between the groups in terms of CSEI scores. However, the mean MOCI score was found to be significantly higher in students studying in nonhealth fields, and the BPS score was significantly higher in students studying health education. In a similar study, it was reported that students studying in nonhealth-related faculties had higher MOCI scores [50]. Another study found that the higher the level of body self-image distortion, the greater the presence of unhealthy nutrition beliefs [52].

In a study conducted to determine the prevalence and predisposing factors of low self-esteem among university students with an average age of 22.2 ± 2.5 years in Southern Tunisia [53], the prevalence of students with low self-esteem was 29.5%. Living in an urban area, studying at a private university, having a low monthly income (< 2 minimum wage) and having a chronic disease were found to be the main risk factors for low self-esteem. Moreover, daily TV time of more than 4 h and lack of leisure time activities were significantly associated with a higher prevalence of low self-esteem. On the contrary, doing physical activity 3 times a week and high academic performance were found to be protective factors of low self-esteem.

In our study, a significant inverse relationship was found between BMI and MOCI and Ortho-15 scales. According to this result, as BMI increased, the scores obtained from the MOCI and Ortho-15 scale decreased. The decrease in the MOCI score as BMI increased indicates that obsessive symptoms decreased as BMI increased. The decrease in the Ortho-15 score as BMI increased indicates that the increase in body weight or obesity increases orthorexic tendency. In this case, it is clear that the possibility of an ED underlying the externalized obsession with healthy eating should also be considered.

However, the fact that there was no significant difference between those with and without orthorexic tendency in terms of self-esteem and body perception differentiates ON from EDs, while the fact that obsessive symptom scores were higher in those with orthorexic tendency indicates that ON is more prone to OCD.

The BMI values of those with orthorexic tendency were significantly higher than those without orthorexic tendency. This confirms that the main goal of orthorexic patients is not to lose weight and that they are obsessed with healthy food consumption. The MOCI scores of those with orthorexic tendency were higher than those without ON. This result confirms that ON includes obsessions about food and nutrition. Similarly, Lucka et al. [54] showed in their study that individuals with suspected orthorexia had a higher BMI and that there was no link between the severity of obsessive–compulsive predisposition and the risk of orthorexia. In another study [32], it was found that there was no significant difference between BMI and Ortho-15 scores in both genders, it was reported that there was a weak negative correlation between the Ortho-15 test and MOCI suspicion subscale in women, and there was no correlation between the Ortho-15 and MOCI total score and subscale mean score in men. On the contrary, Okumuşoğlu [55] emphasized that overweight individuals showed less orthorexic tendency than normal weight individuals. In another similar study [56], it was reported that there was no significant difference between BMI and Ortho-15. According to these results, it is seen that the relationship between BMI and orthorexic tendency is not consistent.

No significant difference was found between those with and without orthorexic tendency in terms of self-esteem and body perception in our study. Alkan et al. [57] reported that there was no statistically significant difference between the Ortho-11 mean score and body perception. In a different study [42], it was found that there was no significant difference between the Ortho-15 test score and self-esteem inventory. In contrast to the findings of our study, Ruiz and Quiles [58] reported a positive correlation between low self-esteem and orthorexic tendency. In a study investigating how anxiety and self-esteem affect orthorexic tendency in highly educated groups, self-esteem scores were lower and anxiety scores were higher in participants with ON tendency [10].

5. Conclusion

In our study, students studying in nonhealth departments were found to have higher obsessive symptom scores, lower body perception, and higher orthorectic tendency. This was interpreted as health education increases the level of knowledge and coping skills in nutrition-related issues as well as health and, therefore, the ON tendency was found to be lower in health departments. When compared by gender, males were found to have higher rates of ON tendency based on the cutoff score < 40. When the Ortho-15 cutoff score was < 40, the significantly higher BMI values of those with ON tendency suggest that the main goal of these patients was not to lose weight, while on the other hand, the condition masked by healthy eating behavior may have an underlying ED. Moreover, the decrease in Ortho-15 score with increasing BMI indicates that weight gain increases orthorexic tendency. In line with these findings, it seems more likely that ON is an OCD that manifests its effects in the field of food and nutrition. However, it is clear that more comprehensive studies are needed to determine whether ON is an eating disorder or an OCD.

6. Strengths and Limitations

6.1. Strengths

6.1.1. Use of Various Tests

The inclusion of validated and reliable tools such as the Ortho-15, MOCI, CSEI, and BPS strengthens the study’s methodology. This ensures more reliable and accurate results.

6.1.2. Diverse Participant Pool

Including students from both health and nonhealth departments allows for a comparison between different fields of study. This diversity helps in identifying the variations in ON prevalence across different academic disciplines.

6.1.3. Focus on Gender Differences

The examination of gender differences provides important insights into how ON affects males and females differently, offering a valuable contribution from a gender perspective.

6.1.4. Exploring the Connection With Obsessive Symptoms

By investigating the link between obsessive-compulsive symptoms and ON, the study suggests that ON may not only be an ED but also a condition associated with obsessive behaviors. This offers a fresh perspective on the classification of ON.

6.2. Limitations

6.2.1. Cross-Sectional Design

Since the study uses a cross-sectional design, it only captures data at one point in time, making it difficult to establish causality. For instance, it is unclear whether obsessive symptoms lead to ON or whether ON triggers obsessive behaviors.

6.2.2. Self-Reported Measures

The reliance on self-reported questionnaires might introduce biases, such as social desirability bias or inaccurate reporting, which can affect the validity of the results.

6.2.3. Limited Demographic Scope

The study is confined to students from a single university, limiting the generalizability of the findings. ON may present differently in populations with different socioeconomic backgrounds.

6.2.4. Weak Association With Body Perception and Self-Esteem

The study found weak or unclear results regarding the relationship between body perception, self-esteem, and ON. This suggests that further exploration is needed in these areas to better understand potential connections.

6.2.5. Reliability of Cutoff Scores

Using the Ortho-15 cutoff score of < 35 may be a limited measure for diagnosing ON. Different tools or diagnostic criteria could potentially yield different results, raising questions about the precision of the measurement.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

Aliye Özenoğlu: conceptualization (lead); writing the original draft (lead); methodology (lead); resources (lead); and reviewing and editing (equal). Cahit Erkul: resources (supporting); methodology (supporting); and reviewing and editing (equal). Kamil Alakuş: conceptualization (supporting); software (lead); formal analysis (lead); and reviewing and editing (equal).

Funding

No funding was received for this research.

Acknowledgments

Apart from the authors mentioned, no person or third party service provider contributed to the research or manuscript preparation process. Furthermore, no AI software was used in the manuscript preparation process, either partially or completely. It was prepared entirely originally by the authors.

Open Research

Data Availability Statement

The data used to support the findings of this study are available on request from the corresponding author.

References

1 Treasure J., Duarte T. A., and Schmidt U., Eating Disorders, The Lancet. (2020) 395, no. 10227, 899–911, https://doi.org/10.1016/S0140-6736(20)30059-3.
10.1016/S0140-6736(20)30059-3
PubMed Web of Science® Google Scholar
2 Zyoud S. H., Shakhshir M., Abushanab A. S. et al., Mapping the Landscape and Structure of Global Research on Binge Eating Disorder: Visualization and Bibliometric Analysis, World Journal of Psychiatry. (2022) 12, no. 7, 982–994, https://doi.org/10.5498/wjp.v12.i7.982.
10.5498/wjp.v12.i7.982
PubMed Web of Science® Google Scholar
3 Hay P., Current Approach to Eating Disorders: A Clinical Update, Internal Medicine Journal. (2020) 50, no. 1, 24–29, https://doi.org/10.1111/imj.14691.
10.1111/imj.14691
PubMed Web of Science® Google Scholar
4 Bratman S., Health Food Junkie, Yoga Journal. (1997) 136, 42–50.
Google Scholar
5 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Dsm-5, 2013, Amer Psychiatric Pub Inc, Washington, DC.
10.1176/appi.books.9780890425596
Google Scholar
6 Scarf J. R., Orthorexia Nervosa: An Obsession With Healthy Eating, Federal Practitioner. (2017) 34, no. 6, 36–39.
Google Scholar
7 Donini L. M., Barrada J. R., Barthels F. et al., A Consensus Document on Definition and Diagnostic Criteria for Orthorexia Nervosa, Eating and Weight Disorders. (2022) 27, no. 8, 3695–3711, https://doi.org/10.1007/s40519-022-01512-5.
10.1007/s40519-022-01512-5
PubMed Web of Science® Google Scholar
8 Pontillo M., Zanna V., Demaria F. et al., Orthorexia Nervosa, Eating Disorders, and Obsessive-Compulsive Disorder: A Selective Review of the Last Seven Years, Journal of Clinical Medicine. (2022) 11, no. 20, https://doi.org/10.3390/jcm11206134.
10.3390/jcm11206134
Web of Science® Google Scholar
9 Duradoni M., Gursesli M. C., Fiorenza M., and Guazzini A., The Relationship Between Orthorexia Nervosa and Obsessive Compulsive Disorder, European Journal of Investigation in Health, Psychology and Education. (2023) 13, no. 5, 861–869, https://doi.org/10.3390/ejihpe13050065.
10.3390/ejihpe13050065
PubMed Web of Science® Google Scholar
10 Yılmaz M. N. and Dundar C., The Relationship Between Orthorexia Nervosa, Anxiety, and Self-Esteem: A Cross-Sectional Study in Turkish Faculty Members, Bio Medical Central Psychol. (2022) 10, no. 1, https://doi.org/10.1186/s40359-022-00796-7.
10.1186/s40359-022-00796-7
Google Scholar
11 Strahler J. and Stark R., Perspective: Classifying Orthorexia Nervosa as a New Mental Illness-Much Discussion, Little Evidence, Advances in Nutrition. (2020) 11, no. 4, 784–789, https://doi.org/10.1093/advances/nmaa012.
10.1093/advances/nmaa012
PubMed Web of Science® Google Scholar
12 Awad E., Salameh P., Sacre H., Malaeb D., Hallit S., and Obeid S., Association Between Impulsivity and Orthorexia Nervosa/Healthy Orthorexia: Any Mediating Effect of Depression, Anxiety, and Stress?, Bio Medical Central Psychiatry. (2021) 21, no. 1, https://doi.org/10.1186/s12888-021-03594-4.
10.1186/s12888-021-03594-4
Google Scholar
13 Niedzielski A. and Kaźmierczak-Wojtaś N., Prevalence of Orthorexia Nervosa and Its Diagnostic Tools-A Literature Review, International Journal of Environmental Research and Public Health. (2021) 18, no. 10, https://doi.org/10.3390/ijerph18105488.
10.3390/ijerph18105488
Web of Science® Google Scholar
14 Dunn T. M., Gibbs J., Whitney N., and Starosta A., Prevalence of Orthorexia Nervosa is Less Than 1%: Data from a US Sample, Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. (2017) 22, no. 1, 185–192, https://doi.org/10.1007/s40519-016-0258-8, 2-s2.0-85014438925.
10.1007/s40519-016-0258-8
PubMed Web of Science® Google Scholar
15 Haddad C., Obeid S., Akel M. et al., Correlates of Orthorexia Nervosa Among a Representative Sample of the Lebanese Population, Eating and Weight Disorders. (2019) 24, no. 3, 481–493, https://doi.org/10.1007/s40519-018-0631-x, 2-s2.0-85059661726.
10.1007/s40519-018-0631-x
PubMed Web of Science® Google Scholar
16 Hafstad S. M., Bauer J., Harris A., and Pallesen S., The Prevalence of Orthorexia in Exercising Populations: A Systematic Review and Meta-Analysis, Journal of Eating Disorders. (2023) 11, no. 1, https://doi.org/10.1186/s40337-023-00739-6.
10.1186/s40337-023-00739-6
PubMed Web of Science® Google Scholar
17 Duran S., Çiçekoğlu P., and Kaya E., Relationship Between Orthorexia Nervosa, Muscle Dysmorphic Disorder (Bigorexia), and Self-Confidence Levels in Male Students, Perspectives in Psychiatric Care. (2020) 56, no. 4, 878–884, https://doi.org/10.1111/ppc.12505.
10.1111/ppc.12505
PubMed Web of Science® Google Scholar
18 McComb S. E. and Mills J. S., Orthorexia Nervosa: A Review of Psychosocial Risk Factors, Appetite. (2019) 140, no. 9, 50–75, https://doi.org/10.1016/j.appet.2019.05.005, 2-s2.0-85065427053.
10.1016/j.appet.2019.05.005
PubMed Web of Science® Google Scholar
19 Yazkan G. and Uğurlu N., The Relationship Between Orthorexia Nervosa Tendencies and OCD Symptoms in Healthcare Professionals, Journal of Psychiatric Nursing. (2022) 13, no. 1, 49–56.
Web of Science® Google Scholar
20 Athanasaki D., Lakoumentas J., Feketea G., and Vassilopoulou E., The Prevalence of Orthorexia Nervosa Among Greek Professional Dancers, Nutrients. (2023) 15, no. 2, https://doi.org/10.3390/nu15020379.
10.3390/nu15020379
Web of Science® Google Scholar
21 Sergentanis T. N., Chelmi M. E., Liampas A. et al., Vegetarian Diets and Eating Disorders in Adolescents and Young Adults: A Systematic Review, Children. (2020) 8, no. 1, https://doi.org/10.3390/children8010012.
10.3390/children8010012
PubMed Google Scholar
22 Brytek-Matera A., Interaction Between Vegetarian Versus Omnivorous Diet and Unhealthy Eating Patterns (Orthorexia Nervosa, Cognitive Restraint) and Body Mass Index in Adults, Nutrients. (2020) 12, no. 3, https://doi.org/10.3390/nu12030646.
10.3390/nu12030646
Web of Science® Google Scholar
23 Kalika E., Egan H., and Mantzios M., Exploring the Role of Mindful Eating and Self-Compassion on Eating Behaviours and Orthorexia in People Following a Vegan Diet, Eating and Weight Disorders. (2022) 27, no. 7, 2641–2651, https://doi.org/10.1007/s40519-022-01407-5.
10.1007/s40519-022-01407-5
PubMed Web of Science® Google Scholar
24 Douma E. R., Valente M., and Syurina E. V., Developmental Pathway of Orthorexia Nervosa: Factors Contributing to Progression from Healthy Eating to Excessive Preoccupation With Healthy Eating. Experiences of Dutch Health Professionals, Appetite. (2021) 258, no. 3.
Google Scholar
25 Sanzari C. M. and Hormes J. M., U.S. Health Professionals’ Perspectives on Orthorexia Nervosa: Clinical Utility, Measurement and Diagnosis, and Perceived Influence of Sociocultural Factors, Eating and Weight Disorders. (2023) 28, no. 1, https://doi.org/10.1007/s40519-023-01551-6.
10.1007/s40519-023-01551-6
PubMed Google Scholar
26 Mitrofanova E., Pummell E., Martinelli L., and Petróczi A., Does ORTO-15 Produce Valid Data for Orthorexia Nervosa? A Mixed-Method Examination of Participants Interpretations of the Fifteen Test Items, Eating and Weight Disorders. (2021) 26, no. 3, 897–909, https://doi.org/10.1007/s40519-020-00919-2.
10.1007/s40519-020-00919-2
PubMed Google Scholar
27 Hodgson R. J. and Rachman S., Obsessional-Compulsive Complaints, Behaviour Research and Therapy. (1977) 15, no. 5, 389–395, https://doi.org/10.1016/0005-7967(77)90042-0, 2-s2.0-0017724319.
10.1016/0005-7967(77)90042-0
CAS PubMed Web of Science® Google Scholar
28 Coopersmith S., The Antecedents of Self-Esteem, 1967, W. H. Freeman & Co, San Francisco.
Web of Science® Google Scholar
29 Ryden M. B., An Adult Version of the Coopersmith Self-Esteem Inventory: Test-Retest Reliability and Social Desirability, Psychological Reports. (1978) 43, no. 3_suppl, 1189–1190, https://doi.org/10.2466/pr0.1978.43.3f.1189.
10.2466/pr0.1978.43.3f.1189
Web of Science® Google Scholar
30 Secord P. F. and Jourard S. M., The Appraisal of Body Cathexis: Body Cathexis and the Self, Journal of Consulting Psychology. (1953) 17, no. 5, 343–347, https://doi.org/10.1037/h0060689, 2-s2.0-58149423435.
10.1037/h0060689
CAS PubMed Web of Science® Google Scholar
31 Hovardaoğlu S., Body Perception Scale, Journal of Psychiatry. (1992) 1, no. 1, 26–27.
Google Scholar
32 Çulhacık G. D. and Durat G., Correlation of Orthorexic Tendencies With Eating Attitude and Obsessive Compulsive Symptoms Ortorektik Eğilimlerin Yeme Tutumu Ve Obsesif Kompulsif Belirtilerle Ilişkisi, Journal of Human Sciences. (2017) 14, no. 4, 3571–3579, https://doi.org/10.14687/jhs.v14i4.4729.
10.14687/jhs.v14i4.4729
Google Scholar
33 Yilmaz F. Ç., Orthorexia and Eating Attitudes in Health Sciences Students, Nigerian Journal of Clinical Practice. (2023) 26, no. 4, 502–507, https://doi.org/10.4103/njcp.njcp_507_20.
10.4103/njcp.njcp_507_20
CAS PubMed Web of Science® Google Scholar
34 Gramaglia C., Gambaro E., Delicato C. et al., Orthorexia Nervosa, Eating Patterns and Personality Traits: A Cross-Cultural Comparison of Italian, Polish And Spanish University Students, Bio Medical Central Psychiatry. (2019) 19, no. 1, https://doi.org/10.1186/s12888-019-2208-2, 2-s2.0-85070826046.
10.1186/s12888-019-2208-2
Google Scholar
35 Parra-Fernández M. L., Onieva-Zafra M. D., Fernández-Martínez E., Abreu-Sánchez A., and Fernández-Muñoz J. J., Assessing the Prevalence of Orthorexia Nervosa in a Sample of University Students Using Two Different Self-Report Measures, International Journal of Environmental Research and Public Health. (2019) 16, no. 14, https://doi.org/10.3390/ijerph16142459, 2-s2.0-85070404135.
10.3390/ijerph16142459
Web of Science® Google Scholar
36 López-Gil J. F., Tárraga-López P. J., Soledad Hershey M. et al., Overall Proportion of Orthorexia Nervosa Symptoms: A Systematic Review and Meta-Analysis Including 30476 Individuals From 18 Countries, Journal of Global Health. (2023) 13, https://doi.org/10.7189/jogh.13.04087.
10.7189/jogh.13.04087
Google Scholar
37 Oberle C. D., Samaghabadi R. O., and Hughes E. M., Orthorexia Nervosa: Assessment and Correlates With Gender, BMI, and Personality, Appetite. (2017) 108, no. 1, 303–310, https://doi.org/10.1016/j.appet.2016.10.021, 2-s2.0-84992437355.
10.1016/j.appet.2016.10.021
PubMed Web of Science® Google Scholar
38 Gezer C. and Yalvac M., The Relation Between Eating Behaviours and Obsession Among University Students, Progress in Nutrition. (2018) 20, 429–437.
Web of Science® Google Scholar
39 Tanriverdi E. C. and Nas M. A., Obsessive-Compulsive Symptoms and Orthorexia Nervosa in Medical Students: A Web-Based, Crosssectional Study, JSMS. (2023) 2, no. 3, 91–99, https://doi.org/10.61745/jsmsau.1389233.
10.61745/jsmsau.1389233
Google Scholar
40 Çobanoğlu Z. and Akman M., Consideration of Healthy Eating Obsession (Orthorexia Nervosa) for Students Educated in Nutrition and Dietetics Department, Journal of Pharmacy and Pharmacology. (2021) 9, no. 2, 35–43, https://doi.org/10.17265/2328-2150/2021.02.001.
10.17265/2328-2150/2021.02.001
Google Scholar
41 Duradoni M., Gursesli M. C., Fiorenza M., and Guazzini A., The Relationship Between Orthorexia Nervosa and Obsessive Compulsive Disorder, European Journal of Investigation in Health, Psychology and Education. (2023) 13, no. 5, 861–869, https://doi.org/10.3390/ejihpe13050065.
10.3390/ejihpe13050065
PubMed Web of Science® Google Scholar
42 Özenoğlu A. and Ünal G., The Effect of Self-Esteem and Incidence of Orthorexia Nervosa Among University Students of Health Education, Journal of International Research in Medical and Pharmaceutical Sciences. (2016) 6, no. 4, 173–182.
Google Scholar
43 Ogihara Y., The Pattern of Age Differences in Self-Esteem is Similar Between Males and Females in Japan: Gender Differences in Developmental Trajectories of Self-Esteem From Childhood to Old Age, Cogent Psychology. (2020) 7, no. 1, https://doi.org/10.1080/23311908.2020.1756147.
10.1080/23311908.2020.1756147
PubMed Web of Science® Google Scholar
44 Abakay U., Alıncak F., and Ay S., Investigation of Body Perception and Assertiveness Levels of University Students, International Journal of Turkish Educational Sciences. (2017) 9, 12–18.
Google Scholar
45 Büyük E. T. and Özdemir E., The Relationship Between Body Perception and Eating Attitudes of High School Students, International Anatolia Academic Online Journal Health Sciences. (2018) 4, no. 2, 1–12.
Google Scholar
46 Anastasiades E. and Argyrides M., Exploring the Role of Positive Body Image in Healthy Orthorexia and Orthorexia Nervosa: A Gender Comparison, Appetite. (2023) 185, no. 6, https://doi.org/10.1016/j.appet.2023.106523.
10.1016/j.appet.2023.106523
PubMed Web of Science® Google Scholar
47 Song Y., Kwon M., and Kim S. A., Distorted Body Weight Perception and Its Gender Differences in Middle-Aged Adults: Population Based Study, BMC Public Health. (2020) 20, no. 1, https://doi.org/10.1186/s12889-020-8358-9.
10.1186/s12889-020-8358-9
Web of Science® Google Scholar
48 Önal S., Özer B. K., Sağır M. et al., Examination of the Relationship Between Body Perception and Body Mass Index Among University Students, Ankara University Faculty of Language, History and Geography Journal. (2019) 59, no. 1, 543–558.
Google Scholar
49 Malmborg J., Bremander A., Olsson M. C., and Bergman S., Health Status, Physical Activity, and Orthorexia Nervosa: A Comparison Between Exercise Science Students and Business Students, Appetite. (2017) 109, no. 2, 137–143, https://doi.org/10.1016/j.appet.2016.11.028, 2-s2.0-85002496983.
10.1016/j.appet.2016.11.028
PubMed Web of Science® Google Scholar
50 Kamarlı Altun H., Keser İ., and Bozkurt S., Comparison of Eating Attitudes and the Susceptibility to Orthorexia Nervosa of Students in Health-Related Fields and Those in Other Fields, Iranian Journal of Public Health. (2020) 49, no. 3, 495–502.
Web of Science® Google Scholar
51 Pehlivan E., Mete B., Fırıncı B., and Doğan E., Prevalence of Orthorexia Nervosa Among University Students and Its Relationship With Health Literacy, ESTUDAM Public Health Journal. (2019) 4, no. 2, 166–175.
Google Scholar
52 Elias M. C., Gomes D. L., and Paracampo C. C. P., Associations Between Orthorexia Nervosa, Body Self-Image, Nutritional Beliefs, and Behavioral Rigidity, Nutrients. (2022) 14, no. 21, https://doi.org/10.3390/nu14214578.
10.3390/nu14214578
Web of Science® Google Scholar
53 Ketata N., Ben Ayed H., Baklouti M. et al., Self-Esteem and University Students: Findings From a Multi-Center Study, The European Journal of Public Health. (2021) 31, no. 3, ckab165–593, https://doi.org/10.1093/eurpub/ckab165.593.
10.1093/eurpub/ckab165.593
Web of Science® Google Scholar
54 Łucka I., Janikowska-Hołoweńko D., Domarecki P., Plenikowska-Ślusarz T., and Domarecka M., Orthorexia Nervosa-A Separate Clinical Entity, A Part Of Eating Disorder Spectrum or Another Manifestation of Obsessive-Compulsive Disorder?, Psychiatria Polska. (2019) 53, no. 2, 371–382, https://doi.org/10.12740/pp/onlinefirst/85729, 2-s2.0-85055336128.
10.12740/PP/OnlineFirst/85729
PubMed Web of Science® Google Scholar
55 Okumuşoğlu S., The Relationship of Orthorexic Tendencies With Eating Disorder Tendencies and Gender in a Group of University Students, Curr Res Educ.(2017) 3, no. 3, 105–115.
Google Scholar
56 Dell′Osso L., Carpita B., Muti D. et al., Prevalence and Characteristics of Orthorexia Nervosa in a Sample of University Students in Italy, Eating and Weight Disorders. (2018) 23, no. 1, 55–65, https://doi.org/10.1007/s40519-017-0460-3, 2-s2.0-85034634274.
10.1007/s40519-017-0460-3
PubMed Web of Science® Google Scholar
57 Alkan Ş.B., Solak R., Gürbüz E. et al., Eating Behavior Disorders and Body Perception in Nutrition and Dietetics Department Students: A Cross-Sectional Study, Necmettin Erbakan University Faculty of Health Sciences Journal. (2019) 2, no. 2, 38–44.
Google Scholar
58 Ruiz Á. and Quiles Y., Prevalence of Orthorexia Nervosa in Spanish University Students: Relationship With Body Image and Eating Disorders, Anales De Psicología/Annals of Psychology. (2021) 37, no. 3, 493–499.
Web of Science® Google Scholar

All articles

The Relationship of Orthorexia Nervosa With Vocational Education, Gender, BMI, Body Perception, and Self-Esteem in University Students: A Controlled Study in a Turkish Sample

Abstract

1. Introduction

2. Methods

2.1. Study Design

2.1.1. Research Type

2.1.2. Selection of Participants

2.1.3. Data Collection Methods

2.1.3.1. Ortho-15 Scale

2.1.3.2. Moudsley Obsessive–Compulsive Inventory (MOCI)

2.1.3.3. Coopersmith Self-Esteem Inventory (CSEI)

2.1.3.4. Body Perception Scale (BPS)

2.1.4. Statistical Evaluation

2.1.5. Ethical Approval

3. Results

4. Discussion

5. Conclusion

6. Strengths and Limitations

6.1. Strengths

6.1.1. Use of Various Tests

6.1.2. Diverse Participant Pool

6.1.3. Focus on Gender Differences

6.1.4. Exploring the Connection With Obsessive Symptoms

6.2. Limitations

6.2.1. Cross-Sectional Design

6.2.2. Self-Reported Measures

6.2.3. Limited Demographic Scope

6.2.4. Weak Association With Body Perception and Self-Esteem

6.2.5. Reliability of Cutoff Scores

Conflicts of Interest

Author Contributions

Funding

Acknowledgments

Open Research

Data Availability Statement

References

References

Related

Information