Orthorexia nervosa: The relationship with obsessive-compulsive symptoms and eating attitudes among individuals with and without healthcare professionals

Abstract

BACKGROUND:

Today, individuals with eating disorders or orthorexia nervosa (ON) are increasing.

OBJECTIVE:

This study aimed to determine the association between ON, eating attitudes, and obsessive-compulsive symptoms among healthcare and non-healthcare professionals.

METHODS:

The present study was cross-sectional, and conducted by 310 healthcare, and non-healthcare professionals. Data on demographic characteristics, the Orthorexia Nervosa Evaluation Scale (ORTO-15), the Eating Attitudes Test-40 (EAT-40), and the Maudsley Obsessive-Compulsive Inventory (MOCI) were obtained by a questionnaire form. Additionally, the body weight and height of participants were taken to calculate the body mass index (BMI). Data were analyzed with SPSS statistical package 24.0.

RESULTS:

The ORTO-15 score of 30.3% of healthcare professionals and 27.1% of non-healthcare professionals were ≤40 (p: 0.616). The EAT-40 scores were found to be ≥30 in 7.7% of healthcare professionals and 4.5% of non-healthcare professionals (p: 0.081). According to the MOCI scores, the possibility of obsessive-compulsive symptoms was high in 29.7% of healthcare professionals (p < 0.001). There was a weak negative correlation between ORTO-15 and EAT-40 (r: –0.176, p: 0.002) and MOCI (r: –0.170, p: 0.003); and EAT-40 and MOCI (r:0.166, p: 0.03).

CONCLUSION:

Further studies are required to understand the relationship between ON and eating disorders that are included in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria.

Keywords

Orthorexia Nervosa eating attitudes obsessive-compulsive symptoms healthcare professionals Turkey

1 Introduction

Today, the thought of healthy nutrition is a growing trend when considering issues associated with health improvement. The number of individuals with eating disorders or orthorexia nervosa (ON) is increasing due to this reason. ON is strongly associated with the intake of healthy food, in addition to disturbing thoughts and excessive concerns about healthy food. Its incidence is gradually increasing [1, 2]. An individual with ON is obsessed with consuming “pure” food, feels anguish when eating unhealthy food, and spends too much time and money on thoughts and practices about diet [3, 4]. It is stated that this behavioral obsession generally affects the quality of life negatively [5]. As diet becomes the main attitude of life, the obsession can be associated with malnutrition, social isolation, and internal stress [6].

Individuals with ON maintain dependence on healthy eating by following a strict diet, counting calories, and showing unrealistic concerns about choosing, preparing, and consuming food. [1 , 7–9]. They control every food they consume excessively and examine the content (additives, substances, etc.) and nutritional values of the products they will buy [3]. Therefore, they will reject foods they are not familiar with and do not trust [3]. Obsession with healthy eating can affect their lives over time and cause deterioration in their social relationships [1 , 7–9]. Additionally, studies in healthy people showed that obsessive-compulsive symptoms are related to orthorexic tendencies [6 , 11].

Based on the literature, there is a link between eating disorders and obsessive-compulsive disease (OCD), and it was observed that excessive physical exertion, obsession with certain foods, or compulsive calorie counting is very similar to OCD in several respects [1 , 12]. For example, studies conducted on OCD patients, predominantly female patients, were at high risk of eating disorders [12, 13]. In another study, the Orthorexia Nervosa Evaluation (ORTO-15) and the Eating Attitude Test-26 (EAT-26) scales were used to determine ON and eating attitudes, respectively. It was found that higher EAT-26 scores were significantly related to lower ORTO-15 scores in the medical students in Lebanese [1]. A study conducted in Turkey determined that men had lower ORTO-15 scores than women and tended to have more orthorexic tendencies. It was observed that there was a weak negative correlation between ORTO-15 and the eating attitude test [7]. Additionally, it has been reported that there may be a genetic relationship between eating disorders and OCD [14]. However, orthorexia levels were not evaluated through clinic interviews, determined using a questionnaire in these studies. These scales are used for the first step in the screening process, require further evaluation by a specialist to confirm the diagnosis [1 , 12]. Suggestions for further prospects were to explore the association between overweight, body image, healthy eating in different populations.

There are no standardized diagnostic tools of ON due to the not including in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Additionally, its prevalence in Turkey is not known; it is estimated to be around 40% [15 –17]. The incidence of ON is high in women, adolescents, athletes, medical faculty students, healthcare professionals, and dietitians [3 , 15–18]. This study aimed to determine the relationship between ON, eating attitudes, and obsessive-compulsive symptoms among healthcare and non-healthcare professionals. The hypothesizes of the research were; (1) the sociodemographic characteristics of adults affect ON level, (2) working as a healthcare professional increases the risk of developing ON, (3) nutritional behaviors and obsessive symptoms have been associated with ON.

2 Methods

2.1 Sample and study procedure

This study was cross-sectional, and conducted in January-March 2017 by 155 healthcare professionals in state hospitals and 155 non-healthcare professionals in Istanbul. This study was performed in state hospitals in Şişli, selected by random sampling method. Şişli is a district with all socio-economic levels (high, medium, and low) [19]. For this reason, 3 state hospitals located in the Şişli district (3 state hospitals in total in this district), which has every economic income, were selected because it is thought to reflect the average of Turkey better. Because Turkey hosts individuals of all income levels. Additionally, the incidence of ON was found to be higher in studies conducted on high-income people in Turkey [15, 16].

The sample selection was analyzed by G-power analysis, and the study consisted of 210 individuals, with a prevalence of 20%, type 1 error rate α= 0.05, type 2 error rate β= 0.20, and test power 1- β= 0.80. Accordingly, a total of 320 individuals (160 healthcare professionals and 160 non-healthcare professionals) were included in the present study. Ten individuals (5 healthcare professionals and 5 non-healthcare professionals) did not complete the survey. Therefore, we excluded from the study. Healthcare professionals consisted of doctors, nurses, midwives, paramedics, technicians such as first and emergency aid, dental technicians, anesthesia, etc., and physiotherapists working in the field of health. Non-healthcare professionals were housewives, teachers, engineers, and persons working in the private sector other than healthcare (e.g. textile, accounting, marketing, sales consultant, photography, law, construction, etc.). Inclusion criteria were≥18 years of age and no other psychiatric disorders, and exclusion criteria were < 18 years of age, dieticians, and current psychiatric disorders. The prevalence of ON has begun to increase in individuals who have extreme opinions about healthy nutrition. Dieticians have received intensive education about nutrition during their undergraduate education [17]. Therefore, they are the profession that has the most knowledge on healthy nutrition. For this reason, we did not include dietitians in healthcare professionals. Additionally, individuals who have these psychiatric disorders (anorexia nervosa (AN), autism, major depressive disorders, anxiety, OCD, etc.) were positively associated with ON symptoms [9], so we excluded current psychiatric disorders during the study period. The psychiatric data of the participants were obtained from the hospital records. Additionally, it was questioned whether the participants had a psychiatric disorder or not during the study.

Written approval to use the document about demographic characteristics, their lifestyle and eating habits, the Orthorexia Nervosa Evaluation Scale (ORTO-15), the Eating Attitudes Test-40 (EAT-40), and the Maudsley Obsessive-Compulsive Inventory (MOCI) was secured. Ethical approval was obtained from the Noninvasive Clinical Research Ethics Committee (Approval number: 2016-24) at Istanbul Gelisim University. Written informed consent was obtained from all participants.

2.2 Measurements

The data was performed by a questionnaire form to participants using the face-to-face interview method. The form included general information such as age, gender, marital status, education level, physical activity, unhealthy habits such as smoking and using alcohol (assessed as yes or no), history of chronic disease (assessed as yes or no), access to nutritional information, defining of yourself as healthy (assessed as yes or no), history of dieting (assessed yes or no), and appearance evaluation (assessed as too thin, thin, a little overweight, and overweight), the ORTO-15, the EAT-40, and the MOCI. Additionally, the body mass index (BMI) (calculated as the body weight (kg)/height (m)²) [19] was calculated from participants’ self-reported body weight and height and classified according to the World Health Organization [21].

2.2.1 The orthorexia nervosa evaluation scale (ORTO-15)

The ORTO-15 Scale is a 15-item self-rating questionnaire developed by Donini to assess the orthorexic tendencies of individuals [6]. The Turkish version’s reliability and validity of ORTO-15 were determined by Arusoglu [22]. A maximum of 60 points and a minimum of 15 points can be obtained from the test. The score < 40 points is defined as orthorexic, whereas ≥40 is considered normal eating behavior [6]. The Cronbach alpha value for the present study was found 0.734.

2.2.2 The Eating Attitude Test (EAT-40)

The EAT-40 is a screening questionnaire, which was developed by Garner and Garfinkel, that is highly effective in identifying eating disorders [23]. The validity and reliability study of the Turkish version of EAT-40 was determined by Savasır and Erol [24]. EAT-40 is a 40-item, 6-point Likert-type scale rated between “Always” and “Never” [23]. The answers of items 1, 18, 19, 23, 27, and 39 are evaluated as 1 point to sometimes, 2 points to rarely, 3 points to never, the others to 0 points. The other items are evaluated as 3 points to always, 2 points to very often, 1 point to often, and others to 0 points. A score≥of 30 points is defined as high risk (abnormal eating behavior), 21 to 30 points to moderate risk, and < 21 points to low risk [23, 24]. The Cronbach alpha value for this study was found 0.743.

2.2.3 Maudsley Obsessive-Compulsive Inventory (MOCI)

The MOCI is a self-administered questionnaire with 30 true–false items for measuring the level of various obsessive symptoms [25]. The validity and reliability study of the Turkish version of MOCI was determined by Erol and Savasır by adding 7 more items [26]. A score≥of 18 points is defined as a high potential risk of OCD, 13 to 17 points to a possible risk of OCD, and≤12 points to normal [25, 26]. The Cronbach alpha value for the present study was found 0.867.

2.3 Statistical analysis

The study data were analyzed using SPSS 24.0 (Statistical Package for the Social Sciences, Inc.; Chicago, Illinois, United States). Descriptive statistics were presented as the mean±SD (standard deviation) and percentages. The Kolmogorov-Smirnov test was used to assess whether the data were normally distributed. To compare measured variables between healthcare professionals and non-healthcare professionals, the student’s t-test was used for those with normal distribution, and Mann-Whitney U-test was used for those without normal distribution. We used the chi-square test or Fisher’s exact test for analyzing categorical differences. Bivariate correlation coefficients (r) were determined using Pearson’s correlation coefficient since they had a normal distribution. Multiple regression analysis (stepwise multiple regression) was performed to determine the effect of independent variables on the dependent variable. P-value < 0.05 was considered statistically significant.

3 Results

A total of 34.2% of the participants were men, and 65.8% were women, and the mean age was 31.81±10.64 years. 78.7% of participants were currently working in a job. 85.2% of healthcare professionals and 74.8% of non-healthcare professionals were defined themselves as healthy (p: 0.033). Additionally, most participants (61.3%) accessed the nutritional information from mass media (p: 0.031). In total, 74.8% of participants had not dieting previously (Table 1).

Table 1
Demographic and other characteristics of the participants

Healthcare professionals (n = 155) Non-healthcare professionals (n = 155) Total (n = 310) p value

n % n % n %

Age 27.93±7.65 35.70±11.82 31.81±10.64 < 0.001^*

Gender 0.281

Men 58 37.4 48 31.0 106 34.2

Women 97 62.6 107 69.0 204 65.8

Marital status < 0.001^*

Married 48 31.0 89 57.4 137 44.2

Single 107 69.0 66 42.6 173 55.8

Working status < 0.001^*

Working 146 94.2 98 63.2 244 78.7

Not working 9 5.8 57 36.8 66 21.3

Chronic disease 0.263

Yes 41 26.5 51 32.9 92 29.7

No 114 73.5 104 67.1 218 70.3

Define yourself as healthy 0.033^*

Yes 132 85.2 116 74.8 248 80

No 23 14.8 39 25.2 62 20

Alcohol use 0.023^*

Yes 8 5.2 9 5.8 17 5.5

No 108 69.7 126 81.3 234 75.5

Sometimes 36 25.2 20 12.9 59 19.0

Cigarette use 0.677

Yes 35 22.6 40 25.8 75 24.2

No 108 69.7 106 68.4 214 69.0

Sometimes 12 7.7 9 5.8 21 6.8

Physical activity 1.00

Yes 25 16.1 26 16.8 51 16.5

No 130 83.9 129 83.2 259 83.5

Access to nutritional information 0.031^*

Mass media 89 57.4 101 65.2 190 61.3

Books/scientific reports 22 14.2 9 5.8 31 10.0

Dietitians 22 14.2 10 6.5 32 10.3

Doctors 2 1.3 5 3.2 7 2.3

Health clubs 2 1.3 3 1.9 5 1.6

Environment 15 9.7 20 12.9 35 11.3

Other 3 1.9 5 3.2 8 2.6

History of dieting 0.597

Yes 38 24.5 39 25.2 77 24.8

No 117 75.5 115 74.2 232 74.8

Appearance evaluation 0.120

Too thin – – 3 1.9 3 0.9

Thin 21 13.5 13 8.4 34 11.0

Normal 76 49.0 66 42.6 142 45.8

A little overweight 49 31.6 62 40.0 111 35.8

Overweight 9 5.8 11 7.1 20 6.5

	Healthcare professionals (n = 155)	Non-healthcare professionals (n = 155)	Total (n = 310)	p value
Age	27.93±7.65	35.70±11.82	31.81±10.64	< 0.001^*
Gender							0.281
Men	58	37.4	48	31.0	106	34.2
Women	97	62.6	107	69.0	204	65.8
Marital status							< 0.001^*
Married	48	31.0	89	57.4	137	44.2
Single	107	69.0	66	42.6	173	55.8
Working status							< 0.001^*
Working	146	94.2	98	63.2	244	78.7
Not working	9	5.8	57	36.8	66	21.3
Chronic disease							0.263
Yes	41	26.5	51	32.9	92	29.7
No	114	73.5	104	67.1	218	70.3
Define yourself as healthy							0.033^*
Yes	132	85.2	116	74.8	248	80
No	23	14.8	39	25.2	62	20
Alcohol use							0.023^*
Yes	8	5.2	9	5.8	17	5.5
No	108	69.7	126	81.3	234	75.5
Sometimes	36	25.2	20	12.9	59	19.0
Cigarette use							0.677
Yes	35	22.6	40	25.8	75	24.2
No	108	69.7	106	68.4	214	69.0
Sometimes	12	7.7	9	5.8	21	6.8
Physical activity							1.00
Yes	25	16.1	26	16.8	51	16.5
No	130	83.9	129	83.2	259	83.5
Access to nutritional information							0.031^*
Mass media	89	57.4	101	65.2	190	61.3
Books/scientific reports	22	14.2	9	5.8	31	10.0
Dietitians	22	14.2	10	6.5	32	10.3
Doctors	2	1.3	5	3.2	7	2.3
Health clubs	2	1.3	3	1.9	5	1.6
Environment	15	9.7	20	12.9	35	11.3
Other	3	1.9	5	3.2	8	2.6
History of dieting							0.597
Yes	38	24.5	39	25.2	77	24.8
No	117	75.5	115	74.2	232	74.8
Appearance evaluation							0.120
Too thin	–	–	3	1.9	3	0.9
Thin	21	13.5	13	8.4	34	11.0
Normal	76	49.0	66	42.6	142	45.8
A little overweight	49	31.6	62	40.0	111	35.8
Overweight	9	5.8	11	7.1	20	6.5

^*p < 0.05, the difference between healthcare professionals and non-healthcare professionals. Missing value was found in access to nutrition information and history of dieting, but percentages were calculated according to 310 participants.

The mean body weight of participants was 70.98±14.60 kg for healthcare professionals, and 65.68±12.14 kg in non-healthcare professionals (p: 0.001), whereas the mean height of participants, was found 167.45±88.30 cm and 168.15±9.09 cm, respectively. According to the BMI classification, 49.7% of healthcare professionals and 31% of non-healthcare professionals had obesity risk (p < 0.001) (Table 2).

Table 2

The mean and standard deviation values of anthropometric measurements of participants

	Healthcare professionals	Non-healthcare professionals	P value
	(n = 155)	(n = 155)
Body weight (kg)	70.98±14.60	65.68±12.14	0.001^*
Height (cm)	167.45±88.30	168.15±9.09	0.490
BMI (kg/m²)	25.25±4.77	23.19±3.70	< 0.001^*
BMI classification			< 0.001^*
< 25	78 (50.3)	107 (69.0)
≥25	77 (49.7)	48 (31.0)

^*p < 0.05, the difference between healthcare professionals and non-healthcare professionals, BMI: body mass index.

The mean ORTO-15, EAT-40, and MOCI scores in healthcare professionals were higher than non-health professionals (p: 0.002, p: 0.583, and p: 0.855, respectively). 23.9% of healthcare professionals and 21.3% of non-healthcare professionals were women in orthorexic, whereas these values were 6.5% and 5.8% in men, respectively (p: 0.002). According to the EAT-40 classification, 7.1% of women healthcare professionals and 15.5% of non-healthcare professionals were at moderate risk of eating disorders. These values were 4.5% and 2.6% for women in high-risk classification, respectively. Additionally, 19.4% of healthcare professionals and 9% of non-healthcare professionals were women who were at possible risk of OCD; when classification for the high possibility of OCD, these values were 20.6% and 13.5% in women, respectively (p < 0.001) (Table 3).

Table 3

Classification and the mean scores of ORTO-15, EAT-40, and MOCI in participants

	Non-healthcare	Healthcare	Total	P¹ value	P² value
	professionals	professionals	(n = 310)
	(n = 155)	(n = 155)
ORTO-15 score	37.84±4.37	38.11±3.61	37.98±4.00	0.002^*	0.469
ORTO-15 Classification				0.616	0.002^*
≤40 (orthorexic)	42 (27.1)	47 (30.3)	89 (28.7)
> 40 (normal)	113 (72.9)	108 (69.7)	221 (71.3)
EAT-40 Score	15.12±10.23	15.96±9.77	15.54±9.99	0.583	0.465
EAT-40 Classification				0.081	0.535
< 21 (low risk)	117 (75.5)	125 (80.7)	242 (78.1)
21– 30 (moderate risk)	31 (20.0)	18 (11.6)	49 (15.8)
≥30 (high risk)	7 (4.5)	12 (7.7)	19 (6.1)
MOCI score	10.90±6.56	14.93±6.12	12.92±6.65	0.855	< 0.001^*
MOCI Classification				< 0.001^*	0.609
0– 12 (normal)	106 (68.4)	57 (36.8)	163 (52.6)
13– 17 (possibility of obsessive-compulsive disorder)	19 (12.2)	52 (33.5)	71 (22.9)
≥18 (high possibility of obsessive-compulsive disorder)	30 (19.4)	46 (29.7)	76 (24.5)

^*p¹ < 0.05, the differences between healthcare professionals and non-healthcare professionals, p² < 0.05, the difference between genders in two groups, ORTO-15: Orthorexia Nervosa Evaluation Scale, EAT-40: Eating Attitude Test, MOCI: Maudsley Obsessive-Compulsive Inventory.

30.3% of healthcare professionals and 27.1% of non-healthcare professionals were orthorexic, and there were no statistical differences (p: 0.616). Under the EAT-40, 7.7% of healthcare professionals and 4.5% of non-healthcare professionals were at high risk of eating disorders (p: 0.081). Additionally, the high possible risk of OCD was found in 29.7% of healthcare professionals and 19.4% of non-healthcare professionals (p < 0.001) (Fig. 1).

Fig. 1

Classification of ORTO-15, EAT-40, and MOCI scores in participants (n: 310).

Table 4 shows the correlation analysis between ORTO-15, EAT-40, MOCI, and BMI. A weak negative correlation was found between EAT-40 and ORTO-15 (r: –0.176, p: 0.002) and MOCI (r: 0.166, p: 0.003). Additionally, there was a weak correlation between ORTO-15 and MOCI (r: –0.170, p: 0.003).

Table 4

Relationship between ORTO-15, MOCI, EAT-40 and BMI

	ORTO-15	MOCI	EAT-40	BMI
ORTO-15	–	r: – 0.170	r: – 0.176	r: 0.083
		p: 0.03^*	p: 0.002^*	p: 0147
MOCI	–	–	r: 0.166	r: 0.014
			p: 0.03^*	p: 0.800
EAT-40	–	–	–	r: – 0.010
				p: 0.865

^*p < 0.05, ORTO-15: Orthorexia Nervosa Evaluation Scale, EAT-40: Eating Attitude Test, MOCI: Maudsley Obsessive-Compulsive Inventory, BMI: Body Mass Index.

For the regression analysis, the relationship between ORTO-15 cut-off point and discrete data (healthcare or non-healthcare professionals, gender, alcohol use, smoking, dieting, health problem, physical activity, and weight satisfaction) was determined by using chi-square analysis, and the association with a cut-off point of ON and continuous variables (age, BMI, EAT-40 score, MOCI) score using Student’s t-test. Based on this analysis, a significant relationship was found between gender, EAT-40 score, MOCI score, and Orthorexia Nervosa. The stepwise regression analysis was used to examine the correlation between the ORTO-15 score and gender, EAT-40, and MOCI scores. The ORTO-15 score was considered as the dependent variable, and the others were used as the independent variables. The stepwise analysis of the linear regression was used to fully reveal the effective variables. The results of the stepwise regression analysis indicated that gender (β= –0.179), EAT-40 score (β= –0.130), and MOCI score (β= –0.129) were predictors of a weak preoccupation with participants (Table 5). Results of the regression analysis were statistically significant, F = 7.938, p < 0.001. These variables predicted 7% of the variance (R² = 0.072).

Table 5

Predictors of Orthorexia Nervosa using the regression analysis

	Unstandardized coefficients		Standardized coefficients						Rsquare Effect size
Parameters	B	SE	Beta	t	Sig	F	Sig	R
1 (constant)	39.980	0.674		59.360	< 0.001	9.917	0.002^a	0.177	0.031
Gender	– 1.490	0.473	– 0.177	– 3.149	0.002
2 (Constant)	41.028	0.759		54.029	< 0.001	9.190	< 0.001^b	0.238	0.056
Gender	– 1.532	0.468	– 0.182	– 3.274	0.001
EAT-40	– 0.064	0.022	– 0.159	– 2.869	0.004
3 (constant)	41.826	0.832		50.296	< 0.001	7.938	< 0.001^c	0.269	0.072
Gender	– 1.513	0.465	– 0.179	– 3.255	0.001
EAT-40	– 0.052	0.023	– 0.130	– 2.308	0.022
MOCI	– 0.077	0.034	– 0.129	– 2.277	0.023

^aPredictors: (Constant), Gender. ^bPredictors: (Constant), Gender, EAT-40. ^cPredictors: (Constant), Gender, EAT-40, MOCI. ^dDependent Variable: Orthorexia Nervosa.

4 Discussion

Some researchers continue to discuss ON among eating disorders and some of them have classified ON as an indication of OCD [8]. The present study contributed to the literature by evaluating the association between orthorexic tendencies, eating attitudes, and obsessive-compulsive symptoms. We found that orthorexic tendencies of healthcare professionals (30.3%) were higher than non-healthcare professionals (27.1%), and 29.7% and 19.4% were at high risk of OCD were found, respectively. According to the EAT-40, 7.7% of healthcare professionals and 4.5% of non-healthcare professionals were at high risk of eating disorders. The present study highlighted a growing tendency of ON, eating behavior disorders, and obsessive-compulsive symptoms among individuals, especially healthcare professionals in Turkey.

Eating disorders are more common in developed countries; however, evidence showed that the incidence of eating disorders is increasing rapidly among developing countries [27, 28]. Additionally, these prevalence are more common in healthcare professionals and students in the health field [3 , 15–18]. A study indicated that orthorexia tendency was higher, especially in nurses and obstetricians [29]. Our results showed that healthcare professionals were found more prone to orthorexic tendencies with 30.3%, and the majority of our participants (71.7%) were nurses.

Studies stated that gender [3 , 30], age [4, 31], BMI [2, 4], and education level [4] could be part of ON etiology. Some studies showed that women suffer from eating disorders and have abnormal eating attitudes than men [3 , 31], while others showed the opposite pattern [1, 4]. According to these studies, the incidence of ON in gender is still unclear. In the present study, 22.6% (n: 70) of women were orthorexic. These results may be clarified by the women who have healthier lifestyle behavior and are more affected by mass media than men [15]. Additionally, maintaining appropriate body weight is associated with BMI. The food selection to achieve the ideal body weight affects BMI [32]. Some studies found that ON symptoms are related to increased BMI [17 , 33], whereas other studies showed no significant relationship between ON and BMI [2 , 31]. In this study, we found that there are no statistical differences between ON and BMI. It is unclear the relationship between ON and BMI. However, the first symptoms of ON may be developed by overweight individuals who attempt to lose weight; due to that, these individuals attempt healthy eating patterns to lose weight or maintain their ideal weight [32].

According to the literature, ON tendencies and behaviors were dramatically associated with higher eating attitude disturbances. Studies found an inverse association between ORTO-15 and EAT-40 scores [1 , 35]. In this study, we found a weak negative correlation between ON and EAT-40. This was an expected result and meant higher ON tendencies and behaviors are related to higher eating attitude disturbances.

Although OCD and eating disorders seem two different disorders, both have similar symptoms [17]. A study indicated that eating disorders are complex disorders that comprise OCD [36]. Some studies showed that individuals with OCD are more prone to eating disorders [12, 37]. After the emergence of ON, which is thought to be one of the eating disorder disorders, various studies have investigated the association between OCD and ON, and found that orthorexic individuals have higher OCD symptoms [3 , 38]. In the present study, the prevalence of orthorexia tendencies and the mean MOCI scores in healthcare professionals were higher than non-healthcare professionals. 33.5% of them were at a possible risk of OCD, and 29.7% were at a high possibility risk of OCD. These values were 12.2% and 19.4% in non-healthcare professionals, respectively. Additionally, we found a weak negative correlation between MOCI, EAT-40 and ORTO-15.

Additionally, logistic regression was performed to determine the factors related to ON. According to our results, gender, EAT-40, and MOCI scores were associated with ON. As mentioned above, 28.7% of the participants tended to have orthorexia and 70 were women. However, our results indicated that a weak preoccupation with gender, abnormal eating behaviors, and risk of OCD. Additionally, these variables predicted only 7% of the variance.

The study had some limitations. Firstly, we used the questionnaire forms to diagnose ON, eating attitudes, and OCD, not through a clinical interview. Secondly, we used the ORTO-15 scale for ON, but some researchers suggest that the validity of the ORTO-15 in measuring ON is not accurate [10, 36].

5 Conclusion

The prevalence of ON is increasing day by day, and researchers continue to discuss whether ON is a specific disorder or a subtype of other eating disorders. According to our results, ON was more common in healthcare professionals, and these individuals have higher obsessive-compulsive symptoms and disturbed eating attitudes. However, the correlation analysis suggested a link between ON and eating disorders, not OCD. More studies are needed to understand the relationship between ON and eating disorders in the DSM-5 criteria. Additionally, ON and OCD have similar symptoms. Therefore, it is crucial that psychological counselling be supported by professionals and diet therapy in ON.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Funding

The authors report no funding.

Conflict of interest

The authors have no conflict of interest to report.

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