The role of obsessive-compulsive symptoms and gender in the frequency of orthorexia nervosa in medical students: A web-based, cross-sectional study

doi:10.21203/rs.3.rs-2349930/v1

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The role of obsessive-compulsive symptoms and gender in the frequency of orthorexia nervosa in medical students: A web-based, cross-sectional study

https://doi.org/10.21203/rs.3.rs-2349930/v1

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Purpose: This study aimed to determine medical students' tendency to ON and investigate the role of obsessive-compulsive symptoms and gender on these attitudes.

Methods: This descriptive study was conducted with 822 medical students. The data were collected via an online survey. The sociodemographic information form, ORTO-11 scale and Maudsley Obsessive Compulsive Symptom (MOCS) Inventory were used as data collection forms.

Results: The average age of the students was 20.57±2,071 (18-32), and 50.7% (n=417) were female. Orthorexia tendency was detected 19%. A significant relationship was found between the ORTO-11 and MOCS scores of the students in the opposite direction (P=0.000). There was no significant difference between ORTO-11 and MOCS scores according to gender and years of training. Participants who did not eat at night, did not consume packaged food, looked at the expiration date and content of the food, and had regular meals had significantly lower ORTO-11 scores. There was no significant relationship between the mean body mass index of the students and their ORTO-11 and MOCS scores (P>0.05 for all).

Conclusion: The study results show that the tendency to ON is high in medical students. ON is more common in students with obsessive-compulsive symptoms, and interventions to correct obsessive-compulsive symptoms should also be planned in the fight against ON.

Level of evidence: Level V, cross-sectional, descriptive study

Medical student

orthorexia

obsessive compulsive symptom

Orthorexia nervosa (ON) is a pathological obsession with consuming healthy foods [1] Although it is quite natural for an individual to eat healthily, the behavior toward healthy eating has become obsessive in ON. This situation adversely affects individuals' health and quality of life [2, 3]. Orthorexia nervosa is not a diagnostic criterion in the DSM-5 but is considered an unidentified eating disorder [1].

Although ON has similar aspects to eating disorders such as anorexia nervosa and bulimia nervosa, orthorexic individuals are mainly concerned with the health of food, not its calories [1, 2]. It is crucial for orthorexic individuals that the food is pure and has no additives. These individuals control food exaggeratedly and are very strict about ingredients and expiration dates [3]. They examine food packaging at length and check whether there are any hormones, additives, carcinogenic substances or dyes. They spend most of their time researching the properties of the foods they will consume and preparing pure foods. This obsessive approach to healthy eating negatively affects the health of individuals with ON and may cause them to lose weight even though they do not actually calculate calories [3–6].

Orthorexic individuals often lead a life away from society because they do not eat food prepared by others. This situation limits their lives over time, negatively affects their social relationships, and reduces their quality of life [6] Sometimes behaviors that start as just a healthy diet can turn into ON over time [7]. The prevalence of ON in the population is between 6.9% and 57.6% [8–13].

The etiology of ON is complex and multidimensional. Psychological factors are crucial among them. Although there are aspects similar to known eating disorders, the desire to consume pure and healthy food is more critical in ON than the desire to lose weight. This desire, which initially started as a healthy eating behavior, turns into excessive mental and behavioral struggle over time. Thus, the desire to eat healthy food becomes obsessive and challenging. In these respects, it is similar to obsessive-compulsive disorder (OCD) [1, 8].

Obsessive-compulsive disorder is a disease that progresses with obsessions and compulsions and affects the individual's daily life. Obsessions are impulses, thoughts, or images that occur involuntarily, cause the individual to be agitated, alien to the self (ego-dystonic), and show repetitive features. Compulsions are actions that occur with these thoughts, and the person feels compelled to engage in these behaviors. Compulsions are first performed to prevent the discomfort caused by obsessions, but then the person becomes unable to control himself, and these repetitive actions cause distress to the person. Compulsions are mainly composed of behaviors and thoughts in response to obsession [9, 10].

Orthorexia nervosa has a pathological obsession, similar to obsessive-compulsive disorder. This pathological obsession leads to a unique lifestyle over time. Strict rules for dietary practices and intense anxiety are observed. When the adopted diet is violated, guilt and shame are seen. This results in stricter dietary practices [11]. It has been shown that obsessive-compulsive tendencies and perfectionism may be risk factors for orthorexia [8, 12].

It is predicted that people with ON disorder will gradually increase, and orthorexia will be a global public health problem. The university environment is a period in which the eating habits of young individuals are reshaped. Eating disorders are quite common in college-age teens. Especially in students who move to another city, orientation to fast-food foods, unbalanced or malnutrition can be seen in the adaptation to the new environment [5]. Determining the eating habits acquired during university that will likely last a lifetime is vital in preventing future problems [13].

It is thought that health and disease information may also affect orthorexic tendencies. It has been suggested that health professionals are a risk group for ON due to their increasing emphasis on healthy eating and the pressure to be role models in healthy living [14].

It has been suggested that medical students are also among the risk groups regarding ON [15]. It is essential to know the frequency of ON and the influential factors in students to intervene early. In addition, the fact that future doctors, who should be role models for healthy behaviors, are involved in ON behavior may give a wrong message to society about nutrition and should be worked to prevent it.

Medical schools are responsible for training adequate and competent physicians who know and respond to society's priority health problems and needs. Knowing the orthorexic attitudes of medical students, who are tomorrow's doctors, is vital for their health and professional role. Screening of students gives them a chance to be diagnosed on time and to intervene early if those orthorexic attitudes have occurred.

Understanding the relationship between orthorexic attitudes and obsessive-compulsive symptoms requires searching for and treating obsessive symptoms, especially in treatment-resistant ON cases. Studies evaluating the orthorexic attitudes of medical students are limited in our country [16]. To the best of our knowledge, there has not been a study investigating the orthorexic attitudes of medical students in our region for the last 12 years. This study aimed to evaluate the orthorexia attitudes of medical students and the role of gender and obsessive-compulsive symptoms in these attitudes.

Ethical Consent

The ethical permission required for the study was obtained from the Atatürk University Faculty of Medicine Clinical Research Ethics Committee (IRB Number: B.30.2.ATA.0.01.00/633, Number: 7/44). The study was conducted following the principles of the Helsinki Declaration, and informed consent was obtained from the participants.

Study Setting And Participants

This cross-sectional study was carried out with students of Atatürk University Faculty of Medicine between October and November 2022. The data were collected through an online survey. Students were informed about the purpose and scope of the study through class WhatsApp groups and emails. Then, the survey link was shared with the students, who were invited to participate. Information about the purpose of the study was also included at the beginning of the survey. Participation in the study was voluntary. The survey's first question was written as "I voluntarily agree to participate in the study", and the participants were asked to consent to this statement. Students who did not give their consent could not answer the survey questions. Thus, the online consent of the participants was obtained. The questionnaire was left open for answers for three weeks. During this time, the students were sent a reminder message three times, once every week. At the end of the specified period, the survey was terminated. Students who currently have a psychiatric illness, who use drugs, who do not volunteer and who do not give consent were excluded from the study. All students in grades 1–5 were included in the study (n = 1373). Nine hundred-eleven student volunteers responded to the survey. Thus, 66% of the population was reached. Nineteen questionnaires with outlier values and 16 questionnaires that were abandoned were excluded from the study. Data from 54 participants with a history of psychiatric illness were also extracted, and data from 822 students were analyzed (Fig. 1).

Measures

A three-part questionnaire was used as a data collection tool: 1) sociodemographic characteristics and nutritional habits, 2) the ORTO-11 scale, and 3) Maudsley Obsessive-Compulsive Symptom (MOCS) Inventory

Sociodemographic information form

The students were asked questions such as age, education year, height, weight, smoking and alcohol use status, sports status, weight perception, night eating status, regular eating status, where they ate lunch, how many meals a day they ate, where they stayed, whether they ate regularly, fast food consumption status, packaged food consumption, and eating at night. Body mass index (BMI) was calculated according to the height and weight values of the students. It was calculated by dividing weight by the square of height (weight (kg)/ height (m²) [17].

ORTO-11 Scale

The ORTHO-15 scale was first developed by Donnini et al [3]. During the adaptation of the scale to Turkish, four items with low internal reliability were removed from the scale. When the items' statistical characteristics were considered, it was decided that the scale could be brought to the best possible operability level with its 11-item form, and it was named ORTO-11[5]. The items on the scale consist of expressions that investigate the obsessive behaviors of individuals in selecting, purchasing, preparing food and consuming foods that they consider healthy. Scale items are answered according to the Likert system of 4 and are scored as always (1 point), often (2 points), sometimes (3 points) and never (4 points). For each item, 1 point reflects orthorexic tendency, and 4 points reflect normal eating behavior tendency. The total score is obtained by summing the points of all items. The score that can be obtained from the scale is between 11 and 44. Low scores on the scale indicate orthorexic tendency. A value of 40 was used as the cutoff value for ORTO-15, but no such cutoff value was reported for ORTO-11. Individuals participating in the study were divided into quarters according to their ORTO-11 scores. The cutoff point of the study was determined as 24 points in the 25th percentile, and below this value was evaluated as an orthorexic tendency. The Cronbach’s alpha value of the scale was found to be 0.62 [5]. In our study, Cronbach’s alpha was 0.61. In this study, the cutting point scale for the ORTO-11 scale was determined by the cutting point acquisition method in the study of Arusoğlu et al., who adapted it to Turkish [5]. Accordingly, an ON trend below 24 points and 24 points and above was considered normal.

Maudsley Obsessive Compulsive Symptom (MOCS) Scale

It is a self-assessment tool developed by Hodgson and Rachman (1977) to measure the type and prevalence of obsessive-compulsive symptoms. The original scale was developed with 30 items [18]. The scale was adapted to Turkish by Erol and Savaşır (1988). Seven more items related to obsessional thinking were added to the Turkish version, and a scale of 37 items was obtained. The Cronbach’s alpha value of the scale was 0.86 [19]. Every item on the scale is answered as yes or no. Each yes answer is given one point, and no is given zero points, adding up the points. High scores on the scale indicate the severity of obsessive-compulsive symptoms (OCS) [19]. In our study, Cronbach’s alpha was 0.87.

Statistical Analysis

Statistical data analysis was performed with the SPSS 20 statistical package program (SPSS Inc., Chicago, IL, USA). The Kolmogorov‒Smirnov test evaluated the suitability of the data to the normal distribution. Numerical variables are expressed as the mean and standard deviation, and categorical variables are expressed as numbers and percentages. The t-test was used in independent groups to evaluate two independent groups. The Mann‒Whitney U test was used in normal distribution groups in the data with normal distribution. ANOVA tests were used for normal distribution, and Kruskal‒Wallis tests were used for normal distribution compared to more than two groups. Backward stepwise model logistic regression analysis was used to evaluate the factors affecting orthorexia nervosa and OCS. When looking at the relationship between two quantitative variables, Pearson correlation analysis was used in those with normal distributions, and Spearman correlation analysis was used in those who did not show normal distribution. The reliability of the scales was tested with Cronbach's alpha coefficient. The statistical significance level was accepted as P < 0.05.

The average age of the students was 20.57 ± 2,071 (18–32), and 50.7% (n = 417) were female. Four hundred ninety-seven students (60.5%) described body perception as normal. A total of 69.8% of the students (n = 574) stated that they ate at night, and 92.6% (n = 761) consumed packaged foods. Two hundred forty-one (29.3%) were engaged in regular sports, and 51.7% (n = 425) consumed fast food more than once a week. Four hundred and fifty-seven 55.6% (n = 457) ate lunch in the school cafeteria. The students' sociodemographic characteristics, nutrition and lifestyle habits are shown in Table 1.

Table 1

Sociodemographic characteristics of students
Variables		Count (n)	Percent (%)
Sex	Female	417	50,7
Sex	Male	405	49,3
Education year	1	156	19,0
	2	165	20,1
	3	202	24,6
	4	185	22,5
	5	114	13,9
In your opinion, what is your body's perception?	Normal	497	60,5
	Slim	145	17,6
	Overweight	134	16,3
	Obes	46	5,6
Do you eat anything at night?	No	248	30,2
Do you eat anything at night?	Yes	574	69,8
Do you consume packaged foods?	No	61	7,4
Do you consume packaged foods?	Yes	761	92,6
Do you usually look at the expiration date of food?	No	195	23,7
Do you usually look at the expiration date of food?	Yes	627	76,3
Do you usually look at the content of food?	No	371	45,1
Do you usually look at the content of food?	Yes	451	54,9
Are your meals regular?	No	435	52,9
Are your meals regular?	Yes	387	47,1
Do you do sports regularly?	No	581	70,7
Do you do sports regularly?	Yes	241	29,3
Do you drink alcohol?	No	694	84,4
Do you drink alcohol?	Yes	128	15,6
Do you smoke?	No	651	79,2
Do you smoke?	Yes	171	20,8
Do you think you are eating healthily?	No	462	56,2
Do you think you are eating healthily?	Yes	360	43,8
Where are you staying?	Dormitory	408	49,6
	Alone at home	52	6,3
	At home with my friends	70	8,5
	At home with my family	292	35,5
How many meals do you eat per day?	One meal	17	2,1
	Two meal	339	41,2
	Three meal	377	45,9
	More than three meals per day	89	10,8
Where do you eat your lunch?	I don’t eat	90	10,9
	In the school cafeteria	457	55,6
	Restaurant	49	6,0
	In the Canteen	104	12,7
	At Home	122	14,8
How often do you consume fast food?	Once a week	194	23,6
	Less than once a week	203	24,7
	More than once a week	425	51.7

The average ORTO-11 score of the participants was 27.22 ± 4.27, and the average MOCS score was 14.72 ± 7.26.

Table 2

ORTO-11 and MOCS scores of students
	n	Mean ± SD	Min-max	Med
ORTO-11 score	822	27,22 ± 4,27	14–41	28
MOKS score	822	14,72 ± 07.26	1–36	14
^{SD standard deviation}
^{MOCS score Maudsley Obsessive Compulsive Symptom Score}

Relationship Between Orto-11 And Mocs Scores

There was an opposite and significant relationship between the students’ scores on the ORTO-11 and MOCS. (P = 0.000). Accordingly, the MOCS score increased as the ORTO-11 score decreased (Table 3).

Table 3

Correlation between ORTO-11 and MOCS scores.
			ORTO-11 Score	MOCS Score
Spearman's rho	ORTO-11 Score	Correlation Coefficient	1,000	-,253^**
	ORTO-11 Score	P		0,000
	MOCS Score	Correlation Coefficient	-,253^**	1,000
	MOCS Score	P	0,000
Correlation is significant at the 0.01 level (2-tailed). MOCS score** Maudsley Obsessive Compulsive Symptom Score

The relationship of ORTO-11 and MOCS scores with sociodemographic variables

There was no significant difference between the students' ORTO-11 and MOCS scores according to gender and school year (P > 0.05 for both, Table 4). Participants who did not eat at night, did not consume packaged food, looked at the expiration date and content of the food, and had regular meals had significantly lower ORTO-11 scores (P 0.02, 0.02, 0.01, 0.00, 0.00, respectively). There was no significant difference between the ORTHO-11 scores of students who smoked or did not drink alcohol and those who did not (P > 0.05). The ORTO-11 scores of the students who thought they were eating healthy were significantly lower than those of the students who did not think they were eating healthy (P = 0.02).

Table 4

The relationship of ORTO-11 and MOCS scores with sociodemographic variables
		ORTO-11 Score				MOCS Score
		Mean ± SD	Med	Min-max	P	Mean ± SD	Med	Min-max	P
Education year	1	27,25 ± 4.55	28	14–41	0.149	14.39 ± 7.23	13	1–36	0.756
	2	27.73 ± 4.01	28	14–38		14.76 ± 6.96	15	1–35
	3	26.97 ± 4.21	27	14–38		14.80 ± 6.79	15	1–36
	4	26.68 ± 4.21	27	15–38		15.15 ± 7.63	14	2–36
	5	27.71 ± 4.39	28	16–41		14.23 ± 7.99	13	1–36
Gender	female	27.36 ± 4.05	28	14–41	0.573	14.73 ± 7.30	14	1–36	0.963
Gender	male	27.06 ± 4.49	28	14–41	0.573	14.70 ± 7.23	14	1–36	0.963
Do you eat something at night?	no	26.74 ± 4.20	27	15–41	0.021	14.90 ± 7.01	13	1–36	0.130
Do you eat something at night?	yes	27.41 ± 4.29	28	14–41	0.021	15.00 ± 7.35	15	1–36	0.130
Do you consume packaged foods?	no	25.90 ± 4.85	26	17–35	0.023	14.39 ± 7.21	15	1–31	0.946
Do you consume packaged foods?	yes	27.32 ± 4.21	28	14–41	0.023	14.74 ± 7.27	14	1–36	0.946
Do you usually look at the expiration date of food?	no	27.86 ± 4.10	28	15–41	0.014	14.33 ± 7.31	14	1–36	0.491
Do you usually look at the expiration date of food?	yes	27.01 ± 4.31	27	14–41	0.014	14.83 ± 7.25	14	1–36	0.491
Do you usually look at the content of food?	no	28.16 ± 3.88	29	15–41	0.000	14.45 ± 6.73	14	1–35	0.656
Do you usually look at the content of food?	yes	26.44 ± 4.42	26	14–41	0.000	14.94 ± 7.67	14	1–36	0.656
Are your meals regular?	no	27.65 ± 4.27	28	15–41	0.004	14.74 ± 7.45	14	1–36	0.876
Are your meals regular?	yes	27.42 ± 4.22	27	14–36	0.004	14.69 ± 7.05	14	1–36	0.876
Do you do sports regularly?	no	27.66 ± 4.06	28	15–41	0.000	14.66 ± 7.20	14	1–36	0.957
Do you do sports regularly?	yes	26.13 ± 4.58	26	14–38	0.000	14.84 ± 7.42	14	2–36	0.957
Do you drink alcohol?	no	27.72 ± 4.17	28	14–41	0.770	14.53 ± 7.02	14	1–36	0.324
Do you drink alcohol?	yes	26.87 ± 4.78	28	14–36	0.770	15.70 ± 8.41	14	2–36	0.324
Do you smoke?	no	27.26 ± 4.14	28	14–41	0.821	14.29 ± 7.09	14	1–36	0.001
Do you smoke?	yes	27.01 ± 4.76	28	14–41	0.821	16.33 ± 7.70	17	2–36	0.001
Do you think you are eating healthily?	no	27.55 ± 4.16	28	15–41	0.025	14.84 ± 7.22	15	1–36	0.412
Do you think you are eating healthily?	yes	26.78 ± 4.38	27	14–38	0.025	14.56 ± 7.33	14	1–36	0.412

The students’ grade point average was 71.010 ± 11.45 (25–98), their average weight was 66,363 ± 13.44 (42–124), and their mean BMI was 22.92 ± 4.56. No significant correlation was found between grade point average and BMI, ORTO-11 and MOCS scores (P > 0.05 for all). While there was no significant relationship between the students’ perceptions of their bodies (thin, overweight, fat) and ORTO-11 scores, there was a significant relationship between them and their MOCS scores. Accordingly, the MOCS scores of the students who felt overweight and fat were higher than those who evaluated themselves as thin and normal (r = 0.104, P = 0.003; Fig. 2).

According to logistic regression analysis, it was 2.4 times higher in those who did not consume packaged food than in those who did not consume it, 0.5 times higher in those who controlled the content of the food than in those who did not and 0.4 times higher in those who did regular sports (Table 5).

Table 5

The probability of orthorexia nervosa according to various variables
		B	S.E.	P	OR	95% C.I.for OR
		B	S.E.	P	OR	Lower	Upper
Step 1^a	Gender	-0.17	0.19	0.36	0.83	0.57	1.23
	Do you eat something at night?	-0.08	0.20	0.66	0.91	0.60	1.37
	Do you consume packaged foods?	0.88	0.30	0.003	2.42	1.33	4.38
	Do you usually look at the expiration date of food?	-0.16	0.24	0.50	0.85	0.53	1.36
	Do you usually look at the content of food?	-0.56	0.21	0.008	0.56	0.37	0.86
	Are your meals regular?	-0.29	0.22	0.19	0.74	0.47	1.16
	Do you do sports regularly?	-0.71	0.20	0.001	0.48	0.32	0.73
	Do you eat breakfast regularly?	-0.08	0.22	0.71	0.92	0.59	1.42
	Do you think you are eating healthily?	0.05	0.23	0.80	1.05	0.67	1.66

Orthorexia nervosa is a new concept in the field of eating disorders. Studies to determine the prevalence of ON among medical students are limited [16]. In this study, obsessive-compulsive symptoms and the role of gender on the tendency to ON in medical students were investigated. While gender did not significantly influence the tendency to ON, the study results showed that obsessive-compulsive symptoms had a significant predictive effect. Accordingly, as the OCS of the students increases, their tendency to ON also increases.

In the current study, 19% of medical students were found to have a tendency to ON. This indicates that one out of every five students has a tendency to ON. Different results are given regarding the frequency of ON in studies. The prevalence of orthorexia in the study conducted with medical students in Turkey was reported as 43.6% [16] and as 45.5% in the study with assistant doctors [14]. In the study by Donini et al. in Italy, the ON frequency was 6.9% [8]. In two studies conducted in Italy, the prevalence of ON in athletes [20] 28% and in university students as [21]. In a study conducted in an athlete sample, the prevalence of ON was reported as 81%. These differences may depend on the characteristics of the group studied, the cultural characteristics, the differences in the measurement tools used, or the difference in the values accepted as the cutoff point.

In our study, the mean ORTO-11 score of the students was 27.22 ± 4.27, and the mean MOCS score was 14.72 ± 7.26. Students' ORTO-11 scores are similar to the results of a study with medical students in the same region 12 years ago [16]. Fidan et al. found a significant relationship between the age of the students and their ORTO-11 scores [16]. However, other studies did not find a statistically significant relationship between age and orthorexia scores [5, 22–25]. In a study conducted in an Italian sample, Donini et al. reported that the average age of the orthorexic group was higher [8]. In our study, there was no significant relationship between the students' ages and ON attitudes. The close age of the students who made up the study group may have impacted the results.

Regarding the effects of gender on ON, different results are reported in the literature. In Fidan's study, the ON frequency in boys was higher than in female students [16]. In the studies of Sanlier et al. and Arusoğlu et al., higher rates were found in women. It was reported that gender had a strong predictive effect on orthorexic attitudes [5, 26]. In another study conducted in Turkey, the frequency of diabetic patients and orthorexia was significantly higher in men [27]. In a study by Donini et al. in Italy, the tendency to ON was higher in men. This result was explained by the fact that men may have previously entered the influence of "body culture" in some societies [8]. In addition to cultural and social differences, the different measurement tools used may have been effective in these differences. Our study did not find a significant difference between the sexes regarding ON attitudes.

In the literature, conflicting results regarding the relationship between education level and ON are observed. Some studies have observed a higher tendency to ON in individuals with lower education levels. In a study conducted by Korinth et al., it was observed that the tendency to orthorexic decreased toward the last years of university education. In the studies of Aksoydan and Bosi, no significant relationship was found between orthorexic tendency and education level. In a recent study by Yeşilçayır et al. with individuals who exercised, the relationship between ON and education level was not determined. Our study did not find a relationship between education level and orthorexic attitudes. Additional studies are needed to reach definitive conclusions. The current study did not find a relationship between how students perceive their bodies (thin, overweight, fat) and ON tendencies. However, students who felt fat and overweight were significantly more likely to have obsessive-compulsive symptoms than other students.

Body mass index is an important variable related to eating disorders. BMI did not have a significant effect on orthorexic tendency. The information in the literature on this subject is contradictory. In addition to the studies reporting that BMI does not affect ON [5, 24, 27]. there are also studies reporting that orthorexic tendency is higher in those with more BMI [28, 29]. This may be related to the need for healthy nutrition or weight control of individuals who are overweight. Another study determined that participants who frequently controlled their weight had high ON tendencies [14]. In two separate studies conducted with medical doctors and medical students in Turkey, it was reported that those with low BMI had a higher tendency to ON [14, 16]. In another study, it was found that orthorexic tendencies decreased as BMI values increased [23].

The benefits of healthy eating for physical and mental health are many. However, this has become a very advanced obsession in individuals with ON. When this obsession exceeds a certain period, it can become a disorder that concerns the dimensions of personality and behavior [6]. In this respect, the relationship between ON and OCD is interesting. In the study of Arusoğlu et al. in Turkey, obsessive-compulsive symptoms were associated with the tendency to ON. It was understood that the group with high obsessive-compulsive symptoms showed more orthorexic tendencies. This finding was confirmed in our study. In the current study, we determined that students' tendency to ON had a significant association with obsessive-compulsive symptoms. As the students who participated in the study had obsessive-compulsive symptoms, the tendency to ON also increased.

Contrary to our findings, in the study conducted by Donini et al. in Italy, no relationship was found between orthorexic attitudes and OCS, which was explained by the difference in the measurement tools used [3]. In addition to the deterioration of health in eating disorders, it has been reported that problems such as difficulty in learning and decreased intelligence averages occur due to unbalanced nutrition [30]. Our study did not confirm this. We did not find a significant relationship between the average grade of the students participating in our research and their ORTO-11 scores. More comprehensive and long-term follow-up studies may be helpful in this regard. In our study, there was no difference in the tendency toward orthorexia between the students who smoke or drink alcohol and those who did not. Similar results were obtained in a study of performance artists [31]. Only one-third of the students who participated in our study exercised regularly. Strategies should be developed to encourage medical students to eat healthily and participate in sports. More than half of the students consumed fast food more than once a week, two-thirds perceived body weight as normal, and nine out of ten students consumed packaged food.

Students who did not eat at night did not consume packaged food, looked at the expiration date and content of food, had regular meals, thought they were eating healthily, and played sports had significantly more orthoretic attitudes than other students. In the study of Bossi et al., people stated that they examined label information when purchasing products and [14]. According to regression analysis, the tendency to ON was 2.4 times higher in those who did not consume packaged food, 0.5 times more in those who controlled the content of the food than in those who did not, and 0.4 times more in those who exercised regularly. These findings are consistent with orthorexic behaviors. The limited number of studies on orthorexia nervosa, a new concept, reveals the need for further investigation in high-risk groups. Medical students are at risk for eating disorders due to their age and health education. Considering medical students' public information and social roles, increasing their knowledge and awareness of the subject is crucial. Medical students who are physician candidates in the future should be aware of ON. Understanding the relationship between ON attitudes and obsessive-compulsive symptoms is vital for prevention and intervention approaches. For this, more large-scale and diverse sampling studies on ON are needed.

Considering the peer education roles of medical students, it should also be seen as an opportunity for them to educate those around them with the right information. For this reason, it may be helpful to include courses on nutrition in the education of the tip and for the students to take responsibility in social sensitivity projects and to inform society. Cultural differences should be considered when planning individual and community training, and measures should be taken to prevent medical students from becoming obsessions while giving healthy nutrition awareness.

Strengths and limits

There are some limitations of our study. First, it is a cross-sectional study conducted with students from a single medical school. This makes it difficult to generalize the results for medical students. Second, the obsessive-compulsive symptoms and orthorexic attitudes of the students were evaluated through scales. There were no face-to-face interviews, and the scales were scored according to the students' self-assessments. Third, the influence of time and training on the ON tendency was not assessed. Finally, medical students' attitudes could not be compared with those of students in different departments. Despite these limitations, the fact that it is one of the limited numbers of studies conducted in a large sample in the field and that there has been no other study evaluating orthorexic attitudes of medical students in our region for more than a decade makes our study strong.

In this study, the relationship between orthorexia nervosa and gender and obsessive-compulsive symptoms was investigated in a large sample, and it was seen that obsessive-compulsive symptoms had a substantial predictive effect on orthorexic attitudes. Gender did not affect orthorexic attitudes. As tomorrow's doctors, students should be provided with knowledge and awareness about ON from the early stages, and obsessive-compulsive symptoms should be sought and treated in students with ON. For future studies, we should compare different groups of students and recommend multicenter studies.

Orthorexia Nervosa is a pathological obsession with eating healthy and pure foods. Medical students are among the risk groups for ON.

Studies investigating the tendency to ON in medical students are limited. In this respect, this study contributes to the literature. Medical students have a high tendency to ON. Our study proved that there is a significant relationship between ON and OCS. Orthorexia is more common in those with OCS. The probability of ON was higher in students who did not consume packaged food compared to those who did, those who controlled the content of the food than those who did not, and those who exercised regularly compared to those who did not.

Acknowledgments: We would like to thank Assist. Prof. Dr. Kamber Kaşalı for his help in the study's statistical analysis. We want to thank Mustafa Çelik for his technical support in arranging the tables and graphics of the study and to thank the medical students who participated in the study.

Conflict of Interest: There is no conflict of interest between the authors.

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No competing interests reported.

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The role of obsessive-compulsive symptoms and gender in the frequency of orthorexia nervosa in medical students: A web-based, cross-sectional study

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Abstract

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Introduction

Methods

Ethical Consent

Study Setting And Participants

Measures

Sociodemographic information form

ORTO-11 Scale

Maudsley Obsessive Compulsive Symptom (MOCS) Scale

Statistical Analysis

Results

Relationship Between Orto-11 And Mocs Scores

The relationship of ORTO-11 and MOCS scores with sociodemographic variables

Discussion

Strengths and limits

Conclusion and recommendations

What is already known on this subject?

What Does This Study Add?

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References

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