Orthorexia Nervosa: Examining the reliability and validity of two self-report measures and the predictors of orthorexic symptoms in elite and recreational athletes.

Objectives: Orthorexia nervosa (ON) is characterised by a pathological fixation on healthy eating. Athletes are at a greater risk of developing eating disorders (EDs) and since ON is sharing many features with EDs, is considered an emerging health concern as it might compromise athlete’s health and performance. Despite recent interest in orthorexia, there are still a lot of inconsistencies around ON and the sensitivity of the available instruments used to assess ON is questioned. The present study aimed to examine the psychometric properties of two self-reported measures of ON, to assess differences in ON between elite and recreational athletes, and to explore correlates of orthorexic scores among athletic individuals. Methods: Cross-sectional study of 215 athletes; 59 elite (mean age 26.71 ±6.83 years) and 156 recreational athletes (mean age 36.13 ± 14.33 years) completed the Teruel Orthorexia Scale (TOS), Eating Habits Questionnaire (EHQ), Short Form Food Frequency Questionnaire (SFFFQ), Eating Attitudes Test-26 (EAT-26), and the Hewitt-Flett Multidimensional Perfectionism Scale Short Form (HF-MPS-SF). Results: Exploratory factor analysis revealed two-factor structures for both the TOS and the EHQ. Elite athletes exhibited higher scores for ‘healthy orthorexia’ (HeOr) (p=.016), ‘knowledge of healthy eating’ (EHQ-Knowledge) (p=.038), diet quality score (DQS) (p=.013) and self-orientated perfectionism scores (p=.032) compared to recreational athletes. Multiple linear regression analysis revealed DQS to be a consistent and significant predictor of all ON symptoms (both TOS and EHQ). BMI was negatively associated with HeOr (β=-.21, p<.001). EAT-26 dieting, bulimia and oral subscales predicted ‘orthorexia nervosa’ (OrNe; smallest p=.015) and ‘problems associated with healthy eating’ (EHQ-Problems; smallest p=.012). Other-orientated perfectionism (OOP) was the only perfectionism construct to predict HeOr (β=.23, p<.01), EHQ-Knowledge (β=.34, p<.001), EHQ-Problems (β=.18, p<.01) and EHQ-Total (β=.27, p<.001). Conclusions: Findings suggest TOS is a reliable measure of ON symptomatology in athletes and further refinement of the EHQ is required. Improvements in assessment tools, study methodology and classification of athlete characteristics are required to advance our understanding of ON in athlete populations.