Orthorexia Nervosa: A frequent eating disordered behavior in athletes

Eat Weight Disord. First online ahead of publication February 21, 2012 as DOI: 10.3275/8272

Orthorexia Nervosa: A frequent eating disordered behavior in athletes Running Title: Orthorexia nervosa in athletes Cristina Segura-García, MD, PhD1; Maria C. Papaianni, DPE1; Francesca Caglioti, MD1; Leonardo Procopio, MD1; Cristiano G. Nisticò, DPE1; Luca Bombardiere, DPE1; Antonio Ammendolia, MD2; Pasquale De Fazio, MD1; Laura Capranica, DPE3 1

Department of Health Sciences. University Magna Graecia of Catanzaro, Viale Europa, 88100Catanzaro (Italy). 2 Department of Medical and Surgical Sciences. University Magna Graecia of Catanzaro, Viale Europa, 88100-Catanzaro (Italy). 3 Department of Human Movement and Sport Science. University of Rome Foro Italico, Piazza Lauro De Bosis 15, 00135-Rome (Italy).

CORRESPONDING AUTHOR: Cristina Segura-García, MD, PhD, Aggregate Professor Dept. Health Sciences University Magna Graecia of Catanzaro Viale Europa Località Germaneto 88100-Catanzaro (ITALY) Cel. +39 3316718232 Tel. +39 0961712408/326/393 Fax. +39 0961774553 [email protected] Private address: Via Broussard 13 88100-Catanzaro (ITALY) Tel. +39 0961 742754 [email protected] DISCLAIMER: This is an un-copyedited author manuscript copyrighted by Editrice Kurtis. This may not be duplicated or reproduced, other than for personal use, without permission of the copyright owner. From the time of acceptance following peer review, the full text of this manuscript is made freely available by Editrice Kurtis at http://www.kurtis.it/ewd/en/list-preview.cfm. The final copyedited article will be available at the journal website at http://www.kurtis.it/ after publication on Eating and Weight Disorders. Editrice Kurtis disclaims any responsibility or liability for errors or omissions in this version of the manuscript or in any version derived from it. The citation of this article must include the following information: author(s), article title, journal title, year of publication, and DOI.

Received September 9, 2011;

accepted December 7, 2011

Copyright© 2012, Editrice Kurtis


ABSTRACT Striving for enhancing athletic performance many sportsmen undergo rigid dietary habits, which could lead to eating disorders (EDs) or Orthorexia Nervosa (ON), a psychopathological condition characterized by the obsession for high quality food. The aim of the study was to examine the occurrence of ON in athletes and to verify the relationship between ON and EDs. Five-hundredseventy-seven athletes and 217 matched controls were administered the following tests: ORTO-15, Eating Attitude Test 26 (EAT-26), Body Uneasiness Test (BUT) and Yale-Brown-Corner Eating Disorder Scale (YBC-EDS). High positivity to ORTO-15 (28%) and EAT-26 (14%) emerged in athletes, whereas a high rate of BUT positivity was evident among controls (21%). Multivariate logistic regression analysis revealed that independent predictors of ON are previous dieting, age, positivity to YBC-EDS, positivity to EAT-26, competition level, and number of YBC-EDS preoccupations and rituals. Sharing many features with both EDs and Obsessive-Compulsive Spectrum, ON represents a crossroad between these pathologic conditions and might compromise the health state of an athlete. Therefore, coaches should consider it important to detect symptoms of EDs and ON in their athletes. KEYWORDS: diet; eating disorders; obsessive-compulsive spectrum; orthorexia nervosa; sport.

Copyright© 2012, Editrice Kurtis


Introduction Regular physical activity and sport practice is essential for physical, mental, psychological and social development of the individual (1). Athletes represent an ‘ideal’ of health and physical perfection and a relevant proportion (40%) of European citizens declared to be regularly involved in sport and physical activities (2). Knowing that nutrition plays a crucial role for enhancing performance and recovery, reaching an ideal weight, shaping the body, and preventing physical pathologies, athletes tend to exert a great control over their diet without consulting sport nutritionists (3). Therefore, this population may be at high risk for Eating Disordered Behaviors (EDB) (4) and Eating Disorders (EDs) (5,6). In athletes, factors directly or indirectly related to EDB and EDs resulted high levels of sport competition (7), participation in judged sports (8) and in sports emphasizing a thin body (9) or muscle development (6), body dissatisfaction (7,8,10,11), and high degrees of self objectification (12). Furthermore, female athletes result more at risk of EDs with respect to their male counterparts (11). Recently, the eating behaviour characterized by exaggerated concerns on food quality has been described as orthorexia nervosa (ON), which represents a new emerging ED (13). Although the American Psychiatric Association does not consider ON a psychiatric disorder to be included in the DSM-IV TR (14), ON individuals eventually become completely dedicated to healthy eating, showing obsessive-compulsive symptoms regarding food choice and food preparation that lead to social isolation (15,16). Furthermore, ON could be considered as possible premorbid symptoms of a real ED (13). Although the search for extremely healthy eating habits could be regarded as a natural response of performance-oriented athletes, it could determine incorrect practices in physically active ON individuals. In fact a high risk of ON emerged in athletes involved in performing arts (17) and fitness activities (18). Thus, a serious concern should regard the detection of signs and symptoms of EDs and ON maladaptive eating behaviours in athletes. Therefore, the aim of this study is twofold: 1) to examine the frequency of occurrence of ON among athletes; 2) to verify the relationship between ON and EDs. It is hypothesized that ON is very frequent among people engaged in regular physical activity and that differences between ON and ED exist. Methods Participants The Ethical Committee of the University of Catanzaro approved the research protocol. From May 2009 to April 2010, 600 Italian athletes (age range: 16-45 yrs) were recruited for this study. According to literature (19) criterion for inclusion in the study was the individual’s involvement in competitive or vigorous fitness programmes (i.e., around 60% of time exercising >77% of individual maximum heart rate), consisting of a minimum of three 1.5-hour sessions per week for at least three years. Furthermore, age under 16 or over 45 years and diagnosis of psychiatric disorders as reported by athletes were considered exclusion criteria. Three-hundred-eighty-eight male (23.2±5.5 years) and 189 female (21.3±7.0 years) athletes signed an informed consent (respondents: 96.2%). The proportion of professional athletes was 64.6% for females and 66.5% for male athletes, respectively. Among female athletes, 15.3% were involved in judged sports (i.e., taekwondo, boxing, judo, body building), 41.3% in team sports (i.e., volleyball, basketball, and soccer) and 43.4% in fitness activities (i.e., aerobics and aquafitness). The relative picture for male athletes was 28.6%, 65.2%, and 6.2% for judged sports, team sports and fitness activities, respectively. From February 2011to April 2011, 250 sedentary controls were recruited among college and undergraduate students. Age under 16 or over 45, involvement in any sport or physical activity and diagnosis of psychiatric disorders were considered as exclusion criteria. One-hundred-thirty-eight males (23.6±6.3 years) and 79 females (21.3±2.9 years) respondents (86.8%) gave their informed consent and were enrolled in the study. Copyright© 2012, Editrice Kurtis


Anthropometric evaluation Participants, wearing light indoor clothing and no shoes, standing height to the nearest 0.1 cm and body weight to the nearest 0.1 kg, were measured using a portable stadiometer (Seca 220, GmbH & Co., Hamburg, Germany) and a balance scale (Seca 761, GmbH & Co., Hamburg, Germany), respectively. Measurements were carried out in the morning. Height and weight measures were used to calculate the participant’s body mass index (BMI, kg.m-2). According to the World Health Organization BMI cut-off points (20), participants were categorized into under-weight (BMI 20 were considered to be at risk of having a clinical disorder. Evaluation of the Body Dissatisfaction Body dissatisfaction was measured by the Body Uneasiness Test part A (BUT-A) (23), which consists of 34 items accounting for 5 dimensions: Weight Phobia (WP), related to the fear of being or becoming fat; Body Image Concerns (BIC), which identify worries related to physical appearance; Avoidance (A), related to body image-related avoidance behavior, Compulsive Self Monitoring (CSM), which relates to compulsive checking of physical appearance; and Depersonalization (D) which refers to feelings of detachment and estrangement towards the body. This instrument showed good psychometric properties, a satisfactory internal consistency, and significant test–retest correlation coefficients (0.90) (23). The average of the scores of all the items represents the Global Severity Index (GSI). A cut-off point GSI>1.2 was considered as index of clinically significant body uneasiness (Segura et al., 2010). Cronbach’s alpha coefficients in the present study were: GSI=0.89; WP = 0.84; BIC = 0.90; A =0.79; CSM = 0.82; and D =0.85. Evaluation of the Orthorexia Nervosa To identify ON subjects, the 15 multiple-choice ORTO-15 questionnaire for the diagnosis of orthorexia was used (24). The ORTO-15 items are designed within the framework of a four-step likert scale assessment (i.e., always, often, sometimes, or never), which reflects how individuals identify themselves with these expressions. Items that reflect an orthorexic tendency are scored 1 point, whereas 4 points are assigned to those showing normal eating habits. The questionnaire showed a good predictive capability also in verification with a control sample. In the present study the threshold to consider subjects positive to ORTO-15 has been set at a score