Abstract
Young adulthood is a sensitive phase that comes with many developmental tasks. Successful mastery of these challenges is crucial not only for long-term physical and mental health. A positive relationship with one's own body and associated healthy dietary and behavioral patterns are essential building blocks for healthy adolescence and adult life. But being overly concerned with healthy food may lead to decreased quality of life and negative (mental) health outcomes. This study was conducted via a cross-sectional online questionnaire including the Düsseldorfer Orthorexieskala(DOS), the WHO Quality of Life BREF and questions about life style and nutritional habits. We investigated the prevalence of ON and its relationship with different aspects of quality of life and lifestyle factors (sport and nu trtional habits) in a sample of young adults in Austria. No significant difference in the DOS-scores of male and female participants were found and no significant difference between students and non-students. High DOS-scores significantly impair all three domains of QoL. We did not find a significant relationship between high DOS-scores and taking nutritional supplements or being vegan, vegetarian or omnivore. Participants with high DOS-scores spent significantly more hours per week with sport/exercising.
Author Contributions
Academic Editor: Sasho Stoleski, Institute of Occupational Health of R. Macedonia, WHO CC and Ga2len CC
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2023 Verena Steiner-Hofbauer, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have declared that no competing interests exist.
Citation:
Introduction
Adolescents and young adults are in a sensitive transitional phase in which important developmental tasks must be mastered. Successful mastery of these challenges is crucial not only for long-term physical and mental health, but also for economic success and interpersonal relationships throughout the lifespan. Failure to successfully overcome these challenges is a major cause of mental illness 1. Adolescents and young adults, especially young women, are particularly at-risk of developing eating disorders. In Austria, 31% of all females aged 10 to 18 might be affected. A study based on nationally representative US survey data found the highest annual prevalence at age 21, with initial onset mostly before the age of 25 2. In the "growing up" phase, independence and personal responsibility also develop with regard to important health-related behavior patterns 3. A positive relationship with one's own body and associated healthy dietary and behavioral patterns are essential building blocks for healthy adolescence and adult life. Healthy nutritional habits are not only associated with better physical well-being but also with increased mental health and well-being 4. However, an obsession towards healthy foods may cause negative outcomes in physical and mental health as well as overall quality of life. The concept of Orthorexia Nervosa (ON) describes this phenomenon of the obsession towards the quality rather than the quantity of food. It includes very particular rules about the origin, processing, and/or preparation of foods 5. Consuming foods that do not comply with these rules can cause feelings of guilt, fear and worries. ON leads to avoidance of certain foods or categories of foods and therefore can cause malnutrition and unintentional weight loss. ON is not recognized as a distinct eating disorder but ON may also impair the overall quality of life (QoL), social relations and psychological well-being 6. The prevalence of ON may be correlated with the educational status, knowledge about nutrition, and health consciousness. Some studies found an increased prevalence among university students 6, 7, but prevalence estimates for Austria are not available to date.
Therefore, the aims of this study are to investigate the prevalence of ON and its relationship with different aspects of quality of life and lifestyle factors (sport and nutritional habits) in a sample of young adults in Austria.
Method / Material
Recruitment and Procedure
The study was conducted via a cross-sectional online questionnaire with three main parts. The whole survey took approximately 20 minutes. Participants were recruited via a panel distribution of the Österreichische Gallup-Institut GmbH. All participants gave informed consent at the beginning of the questionnaire by ticking a box indicating their consent. The questionnaire could only be started with given consent. Participation was voluntary.
Materials
The first part of the questionnaire covered sociodemographic questions such as age, gender, height and weight. The second part covered quality of life via the WHO Quality of Life BREF-questionnaire 8 as well as the ON-questionnaire Düsseldorfer Orthorexieskala(DOS). We used the WHOQOL domains physical (PHYS), psychological (PSYCH) and social (SOC), with higher scores indicating higher quality of life on a scale of 0 to 100. DOS scores of 30 or higher are considered as clinically relevant, scores of 25 or higher indicate a tendency towards orthorectic eating behavior. The third part included questions about life style, nutritional style and supplement consumption.
Analysis
For statistical analysis, SPSS 28.0.1.0 was used (IBM Corp., 2021). We compared the mean values of all variables between female and male participants as well as students and non-students. We conducted Pearson correlations to analyze significance and compute the correlation coefficients between WHOQOL scores (physical, psychological and social) of participants with DOS scores. Chi² tests were used to assess the relationship between DOS-scores (high: >=25, low: <25) and nutrition style (vegan, vegetarian, omnivorous) as well as DOS-scores (high: >=25, low: <25) and the intake of nutritional supplements (Yes, No). A two-sample t-test was performed to compare the mean hours of sport per week in participants with high (≥ 25) and low DOS-scores (<25).
Results
Participants
Our purposive sample consisted of a total of 400 participants between 18 and 30 years (mean age: 24.92 years, SD = 3.51). Mean Body-Mass-Index (BMI) in the sample was 23.28 (SD=4.19). 115 participants identified as male, 282 as female, 3 as non-binary. 0.9% of male and 4.6% of female participants were vegan, 6.1% of male and 16% of female participants were vegetarian. The 3 non-binary participants were excluded from all gender specific analysis. 81.5% of our sample had a high school diploma (Matura) or a university degree. The sample consisted of 183 employed people, 32 workers, 19 school students, 19 currently unoccupied people and 17 people with “other occupations”. 130 persons were students of different disciplines, 78% of them were female. Table 1
Table 1. Mean values and standard deviations of BMI, DOS-scores, QoL physical, psychological and social domain, hours per week invested in sport (exercise).| Female (n=282)Mean (SD) | Male (n=115)Mean (SD) | Non-Students (n=270)Mean (SD) | Students (n=130)Mean (SD) | |
| BMI | 22.67 (4.01)** | 24.78 (4.22)** | 23,50 (4.48) | 22.85 (3.49) |
| DOS | 18.18 (5.33) | 18.70 (6.07) | 18.66 (5.72) | 17.62 (5.12) |
| WHOQOL-Phys. | 72.39 (15.97) | 73.01 (17.38) | 73.60 (17.22) | 74.59 (14.32) |
| WHOQOL-Psych. | 65.68 (16.53) | 64.82 (20.26) | 64.80 (19.08) | 66.76 (14.14) |
| WHOQOL-Soz. | 66.96 (20.95)** | 58.91 (22.40)** | 61.81 (21.91)* | 68.97 (20.73)* |
| Sport (h/week) | 3.09 (3.55) | 3.67 (3.82) | 3.00 (3.59)* | 3.79 (3.68)* |
Prevalence of ON
Overall, 3% (n=12; 4 male, 8 female, two of them students) of our sample had 30 or more points in the DOS questionnaire, indicating clinically relevant orthorexia nervosa symptoms. Overall, 16.3% showed values of 25 or higher indicating a tendency towards orthorectic eating behavior. 22.6% of male and 13.8% of female participants as well as 18.5% of the students had 25 or more points in the DOS questionnaire.
DOS-Scores and Different Aspects of Quality of Life, BMI and Age
Correlations between 3 different domains of qualitiy of life, measured by the WHOQOL, and DOS-scores can be found in Table 2. All three aspects of quality of life are significantly and negatively correlated with DOS-sores.
Table 2. Correlation coefficients and p-Values between DOS-scores, QoL Domains, BMI and age.| r | p | |
| BMI | .08 | .09 |
| Age | .02 | .65 |
| Quality of Life PSYCH | -.14 | .005* |
| Quality of Life PHYS | -.19 | < .001** |
| Quality of Life SOC | -.14 | .007* |
DOS-Scores and Nutrition Style
A Chi-Square test of Independence was performed to assess the relationship between DOS-scores (high: >=25, low: <25) and nutrition style (vegan, vegetarian, omnivorous). There was no significant relationship between the two variables, X2(df, 2) = 2.43, p = .30.
DOS-Scores and Nutrition Supplements
A Chi-Square test of Independence was performed to assess the relationship between DOS-scores (high: >=25, low: <25) and the intake of nutritional supplements (Yes, No). There was no significant relationship between the two variables, X2(df, 1) = 1.50, p = .22.
DOS-Scores and Sport
A two-sample t-test was performed to compare the mean hours of sport per week in participants with high (≥ 25) and low DOS-scores (<25). There was a significant difference in hours of sport per week between high DOS-scores (>=25) (m = 5.26 h, SD = 5.19) and low DOS-scores (<25) (m = 2.87, SD =3.11); t(73.14) =3.60, p = <.001. Participants with high DOS-scorers spending significantly more hours on sport per week.
Discussion
We investigated the prevalence of ON and its relationship with different aspects of quality of life and lifestyle factors (sport and nutritional habits) in a sample of young adults in Austria.
We found no significant difference in the DOS-scores of male and female participants, and no significant difference between students and non-students. High DOS-scores significantly impair all three domains of QoL. We did not find a significant relationship between high DOS-scores and taking nutritional supplements or being vegan, vegetarian or omnivore. Participants with high DOS-scores spent significantly more hours per week with sport/exercising.
In several studies, the prevalence of ON is reported between 3% and 6.9% in the general population 9, 10. ON was reported to show a higher prevalence in people with higher BMI 11. Findings on gender differences in the prevalence of ON are contradictory, in contrast to many other eating disorders that show a distinctly higher prevalence in women 12. Strahler et al. report a higher tendency towards pathologically healthy eating in women 6. Another group suspected to be at risk for developing ON are university students with a prevalence 8% and up to 12.4% being at risk of developing ON 13. Differences in prevalence according to age could not be clearly established 12.
In our study we did not find significant differences in DOS-scores neither between female and male participants nor between the students and non-students’ group. More than 80% of our sample are highly educated, therefore it could be considered that high education has a higher predictive value for ON than being a university student 14. DOS-scores did not significantly correlate with BMI and age, but it must be taken into account that about 80% of our sample had a BMI of 25 or lower and that our age range was only between 18 and 30 years. Therefore, we have a relatively young sample with overall low BMI scores. The overall prevalence of ON estimated with the DOS was 3% and therefore in line with the results of other studies 9, 10. 16.3% of our sample may be at risk of developing orthorectic eating behavior. With 22.6% of male and 13.8% of female participants, more men seem to be at risk. Ab Hamid et al explain a similar finding in their study with a particular eagerness of men to maintain body shape 15.
ON can have a negative impact on physical and mental health and it can lead to social problems. ON can lead to malnutrition caused by a narrowed food pallet resulting in vitamin deficiencies or thyroid and gonadal dysfunction, amenorrhea, and menstrual disturbances 16, 17, 18. Furthermore, ON poses a risk for developing obsessive compulsive disorders (OSD) and other eating disorders. Studies also found tendencies towards excessively high demands on themselves and harsh criticism themselves 19, 20, 21. ON can cause disturbances in social interactions by avoiding social events that include eating or through the narrowed interest and activities related to food and eating 22, 23. Our data shows that high values in the DOS-questionnaire are negatively correlated with all three domains of quality of life; physical, psychological, and social. Other studies found similar negative relations between ON and quality of life 15, 24. Vegan and vegetarian diets are associated with ON in different studies 5, 10. In our sample, we could not find a connection between high values in the DOS-questionnaire and vegan or vegetarian diet. ON may also be associated with other health related aspects of life like exercising 25 and health knowledge and health consciousness 14, 26. We tested if DOS-scores are associated with the hours exercising and the tendency to take nutritional supplements as a particular form of health-conscious behavior. In line with the results of a review and meta-analysis of Strahler et al 25, we found a significant correlation between the hours of exercise per week but no difference in taking supplements.
Conclusion
Careful and conscious selection of foods and viewing nutrition as part of a healthy lifestyle is not a pathological behavior. But thinking too much about food and nutrition, executing extreme dietary restrictions, harsh self-criticism, and an impaired social life due to strict dietary rules can be a sign of possible ON. Even if ON is not an official diagnosis according to DSM or ICD, it impairs health and quality of life in those affected. There is a need for research regarding ON and its differences and similarities with other eating disorders as well as regarding risk and protective factors. More knowledge about ON could lead to improved diagnostic and screening tools. This might be an important preventive measure to detect and treat ON in early stages.
Declaration of interest
We have no conflict of interest to declare.
References
- 1.M C Nelson.et al.,Emerging Adulthood and College-aged Youth: An Overlooked Age for Weight-related Behavior Change.Obesity. 16(10), 2205-2211.
- 2.Z J Ward.et al.,Estimation of Eating Disorders Prevalence by Age and Associations With Mortality in a Simulated Nationally Representative. , US Cohort.JAMA Network Open 2(10), 1912925-1912925.
- 3.Zeiler M.et al.,Prevalence of Eating Disorder Risk and Associations with Health-related Quality of Life: Results from a Large School-based Population Screening.European Eating Disorders Review. 24(1), 9-18.
- 4.Walther J.et al.,Nutrition, lifestyle factors, and mental health in adolescents and young adults living in. , Austria.Int J Adolesc Med Health 26(3), 377-86.
- 5.Brytek-Matera A.et al.,Strict health-oriented eating patterns (orthorexiceatingbehaviours) and their connection with a vegetarian and vegan diet.Eat Weight Disord. 24(3), 441-452.
- 6.Strahler J, Stark R, Orthorexia.nervosa: Verhaltensauffälligkeit oder neue. , Störungskategorie?Suchttherapie 20(01), 24-34.
- 7.Malmborg J.et al.,Health status, physical activity, and orthorexia nervosa: A comparison between exercise science students and business students.Appetite. 2017-109.
- 9.Barthels F, Meyer F, Pietrowsky R, Die.Düsseldorfer Orthorexie Skala–Konstruktion und Evaluation eines Fragebogens zur Erfassung ortho-rektischen Ernährungsverhaltens.Zeitschrift Fur Klinische Psychologie Und Psychotherapie. 2015-44.
- 10.Luck-Sikorski C.et al.,Is orthorexic behavior common in the general public?A large representative study. in Germany.Eat Weight Disord 24(2), 267-273.
- 11.C D Oberle, R O Samaghabadi, M E.Hughes,Orthorexia nervosa: Assessment and correlates with gender, BMI, and personality.Appetite. 2017-108.
- 12.Gkiouleka M. (2022) et al.,Orthorexia Nervosa in Adolescents and Young Adults: A Literature Review.Children. , (Basel)
- 13.C A.et al.,Psychometric evaluation of the English version of the DüsseldorfOrthorexieScale (DOS) and the prevalence of orthorexia nervosa among a U.S. student sample.Eating and Weight Disorders -. , Studies on Anorexia, Bulimia and Obesity 24(2), 275-281.
- 14.Hyrnik J.et al.,The assessment of orthorexia nervosa among 1899 Polish adolescents using the ORTO-15 questionnaire.International. , Journal of Psychiatry in Clinical Practice 20(3), 199-203.
- 15.Hamid Ab, R M.. et al.,The Orthorexia Nervosa and Quality of Life among Health Sciences Students.Environment-Behaviour Proceedings Journal 2018-3.
- 16.Misra M, A.Klibanski,Anorexia Nervosa and Its Associated Endocrinopathy. in Young People.Hormone Research in Paediatrics 85(3), 147-157.
- 17.K D Cashman, Vitamin.D in childhood and adolescence.Postgraduate. , Medical Journal 83(978), 230-235.
- 18.R M Moroze.et al.,MicrothinkingAbout Micronutrients: A Case of Transition From Obsessions About Healthy Eating to. Near-Fatal “Orthorexia Nervosa” and Proposed Diagnostic Criteria.Psychosomatics 56(4), 397-403.
- 19.Dell'Osso L.et al.,Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive-compulsive spectrum.Neuropsychiatr Dis Treat. 2016-12.
- 20.M A Barnes, L M.Caltabiano,The interrelationship between orthorexia nervosa, perfectionism, body image and attachment style.Eating and Weight Disorders -. , Studies on Anorexia, Bulimia and Obesity 22(1), 177-184.
- 21.S E McComb, J S Mills, Orthorexia.nervosa: A review of psychosocial risk factors.Appetite. 2019-140.
- 22.L M Donini.et al.,Orthorexia nervosa: A preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon.Eating and Weight Disorders -. , Studies on Anorexia, Bulimia and Obesity 9(2), 151-157.
- 23.C B, Hardan-Khalil K, Gibbs K, Orthorexia.Nervosa: A Review of the Literature.Issues. in Mental Health Nursing 38(12), 980-988.
- 24.Sfeir E.et al.,Binge eating, orthorexia nervosa, restrained eating, and quality of life: a population study. in Lebanon.Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity 26(1), 145-158.