The COVID-19 Pandemic Drives People to Orthorexia and Anxiety with the In uence of Social Media: A Cross-Sectional Study of 525 Adults in Semi-Quarantine

Background: The COVID-19 pandemic hit the world tremendously, causing an increased risk of eating and anxiety disorders. Increased social media exposure and obsession with healthy eating to minimize the risk of catching the COVID-19 may cause orthorexia and anxiety symptoms in individuals during pandemic. We aimed to assess the presence and interaction between orthorexia and anxiety symptoms during the first phase of the COVID-19 pandemic. We also determined the influences of social media and nutritional supplement use on orthorexic and anxiety symptoms. Methods We performed an online survey of individuals in COVID-19 quarantine (n = 525) using Google forms. We determined their orthorexia and anxiety symptoms using ORTO-11 and General Anxiety Disorder (GAD-7) questionnaire, respectively. We also assessed their nutritional supplement and social media use, and how these patterns were affected during the first phase of the COVID-19 pandemic. Results Higher orthorexia (67% in men, 83.2% in women) and anxiety (62.4% in men;95.4% in women) symptoms were detected in individuals in COVID-19 pandemic. Orthorexia symptoms were found positively associated with anxiety symptoms in both sexes. The time spent on social media to follow the COVID-19, health, and nutrition news were closely associated with higher orthorexic symptoms in both sexes, and higher anxiety symptoms in women (r=-0.638 in men;r=-0.560 in women, p < 0.001). The use of multivitamins and ß-glucan to mainly support immunity were linked to orthorexic symptoms in both sexes. Discussion The COVID-19 pandemic has detrimental influences on mental well-being that drove individuals into psychologic problems. Increased social media use to follow healthy eating news has also create an undesirable impact on orthorexic problems. Therefore, it is crucial to detect orthorexia and anxiety symptoms earlier and modulate daily behaviours during the pandemic in order to prevent long-term detrimental consequences.

exposure and nutritional supplement use with anxiety and healthy eating obsession. The ndings show that healthy eating obsession and anxiety are quite high in people who are semi-quarantined due to COVID-19. In addition, people who follow healthy nutrition and COVID-19 issues more on social media have more orthorexia problems and consume more multivitamin and B glucan supplements. Overall, the increase rate of anxiety and orthorexia symptoms may cause tremendous alteration on well -being. These ndings may bene t people by highlighting the fact that constant exposure to social media news about healthy eating and supplement suggestions during the pandemic can lead to undesirable consequences such as increasing anxiety and obsession with healthy eating and leading to unconscious use of nutritional supplements.

Background
The entire world has been faced with the Coronavirus (SARS-CoV-2 or COVID-19), a new epidemic that has hit millions of people catastrophically years after the u epidemic that broke out more than a century ago [1,2]. Considering the process of the disease, it has been observed that COVID-19 is transmitted faster than other types of coronavirus, and it can cause severe respiratory distress that requires treatment in intensive care [3,4]. In order to prevent the spread of the coronavirus, people had to stay in semiquarantine at home after the government and the Ministry of Health obligatory calls to "stay at home to stay safe" [5]. It has been stated that the prolongation of the stay at home, combined with the fear of getting the virus, affects the psychological well-being of people in quarantine and increases anxiety symptoms [6]. In a study conducted in the rst phase of the COVID-19 outbreak in China, it was reported that the pandemic caused moderate to severe paranoia and panic in Chinese people and approximately one-third of the participants had moderate to severe anxiety [7].
The coronavirus infection occurs in three phases in the body [8]. The asymptomatic incubation period, when the virus is sometimes not recognized, is de ned as the rst stage. The symptomatic period in which the virus is diagnosed but does not seriously affect the body is stated as the second phase, while the period when the virus load increases signi cantly and causes severe respiratory symptoms is de ned as the third phase. It is emphasized that the adaptive immune response that develops in the body in the rst two phases can change the disease process. It has been reported that in individuals with a strong adaptive immune response can eliminate the virus by preventing the disease from progressing to a severe period. [8,9]. Therefore, a healthy and balanced diet high in antioxidants and vitamins is of great importance in combating COVID-19 to strengthen immune functions. [9]. Although dietary guidelines in COVID-19 direct individuals to strengthen immunity naturally [10], it is observed that many people, with or without nutrition expertise, have made dietary recommendations on social media to increase immunity and direct people to use supplements to protect against COVID-19. However, it has been reported that the coronavirus utilizes the ACE-2 receptor as the main receptor in its entry into the lungs [11] and some nutritional supplements may cause detrimental effects on the COVID-19 process by increasing the number of these receptors [12,13]. In addition, cytokine storm is de ned as the overproduction of cytokines by the immune system, which usually occurs at the terminal stage of some viral diseases (SARS, MERS, SARS-CoV-2), and is considered partially responsible for the high mortality rates in infected individuals [14] The potential impact of nutritional supplements on cytokine storm is not fully elucidated [15]. Therefore, it is crucial to avoid the unconscious use of nutritional supplements to maintain health during the COVID-19. To our knowledge, the effect of nutritional advices stated on social media on individuals in semi-quarantine and the tendency of individuals to use nutritional supplements has not been investigated.
It was stated that the constant exposure to COVID-19 news on social media and the increasing virus spread has affected both mood and eating behaviours [9]. It is well-known that the symptoms of Orthorexia Nervosa (ON), one of the eating disorders known as healthy eating obsession, increase considerably with the follow-up of the news about healthy eating on social media [16]. However, it is not investigated whether individuals in semi-quarantine display orthorexic behaviours, such as obsessions about whether the food they buy is safe and healthy enough to protect their immunity.
Eating disorders and anxiety disorders are often described as comorbid psychiatric disorders [17]. To our knowledge, there is no data in the literature on the relationship between anxiety arising from semiquarantine and fear of catching the virus, and obsession with healthy eating.
We aimed to evaluate the presence of obsessive eating behaviours and general anxiety disorders and the use of nutritional supplements during the COVID-19 pandemic. In addition, we also investigated the impact of social media news on orthorexia and anxiety symptoms in individuals in semi-quarantine.

Study design
This study was a cross-sectional study conducted during the rst wave of COVID-19 (between 01-21 April 2020) during the government-imposed lockdown due to the COVID-19 outbreak.
This lockdown included weekend curfews, everyone except cargo and food workers worked from home, and the obligation to wear masks everywhere. Data was collected using a digital platform (Google forms) due to the eliminate the risk of face-to-face interviews. The researchers shared a link with the participants to access the study questionnaire, which they can ll out online. No incentives were used in this crosssectional study.

Sample Size Calculation
The power analysis was calculated based on the study conducted by Turner et al. [16], which was stated the rate of orthorexia nervosa in individuals using social media was 49%, and the estimation of this ratio for our study as 60 %. At least 348 adults were needed to be included into the study according to the G power software, based on a power of 80% and a reliability of 95%. At the end of the data collection, a total of 525 participants from 1021 people were enrolled to the study.

Participants
Participants were recruited through social networks (Facebook, Instagram, Twitter, WhatsApp), e-mail, and faculty websites of the researchers. All individuals over the age of 18 were allowed to participate in this study. Body mass index (BMI) was calculated using the following formula; [weight (kg).(height) -2 (m 2 )].
BMI that less than 18.5 is classi ed as underweight range, between 18.5 to < 25, as healthy range, between 25 to < 30, as overweight range, higher than 30 as obese range [18].

Questionnaire
The questionnaire consisted of 45 questions and three parts detailed below.
The rst part included the sociodemographic characteristics: age, sex, education level, smoking status, presence of any chronic disease, marital status, dietary practice.
The second part included questions about the use of social media and supplements during semiquarantine. Questions aimed to collect information about the use of nutritional supplements before and after COVID-19, whose recommendation and why they need to use them, which foods they believe are healthy to improve immunity. There were also questions regarding the time spent using social media, the applications they use, and how long they follow the news on COVID-19, health and nutrition on a daily basis.
The last part dealt with the determination of orthorexia and general anxiety disorders using the following scales described in detail.

Statistical Analysis
Statistical analyses were performed using the SPSS Software version 21. The variables were tested using visual (histogram, probability plot) and analytic (Kolmogorov-Smirnov/ Shapiro-Wilk's test) methods to determine if they are normally distributed. Descriptive results were presented as mean and standard deviation. In order to compare the differences between the sexes, the independent two sample t-test or the Mann-Whitney test was used, where appropriate. The Chi-square test or Fisher's exact test (when chisquare test assumptions do not hold due to low expected cell counts), where appropriate, was used to compare the proportions of education, occupation, presence of chronic diseases, and diet applied between sexes. The Wilcoxon test was used to verify differences in supplement use between before and the current pandemic period. As both ORTO-11 and time spent on per day using social media to read information related to the COVID-19, health and nutrition were normally distributed, the correlation coe cients and their signi cance were calculated using Pearson test. However, Spearman test was applied to calculate the correlation between GAD-7 scores and time spent on social media to read information related to the COVID-19, health and nutrition as GAD-7 scores were not normally distributed.
A multiple linear regression model was used to identify the impact of orthorexic behaviours on starting the supplement use during the COVID-19. A 5% type-1 error level was applied to infer statistical signi cance.

Participants
Descriptive characteristics of the participants age, weight, height, BMI, education level, occupation status, presence of any chronical diseases, smoking status and diet practice were presented in Table 1. No differences were observed in age, weight and height between sexes. Most of the participants were omnivorous (98.9% of men; 98.0% of women), highly educated, actively working and had no known chronic diseases.  ⊕ Independent two-sample t-test. ⊕⊕ Mann-Whitney U test. ⊕⊕⊕ Pearson chi-squared test. ⊕⊕⊕⊕ Fisher's exact test.

Presence of General Anxiety Disorder
Higher general anxiety symptoms ranging from mild to severe were detected in both sexes (62.4% of men; 95.4% of women) (Table 1). Women had higher general anxiety symptoms compared to men, with predominantly moderate levels (40.5%) (p < 0.001).

Interaction between orthorexia disorder and general anxiety disorder
Lower ORTO-11 scores were signi cantly associated with higher GAD-7 scores in both sexes (r=-0.4 in men; r=-0.2 in women; p < 0.05) (Fig. 1).  Effect of social media use on orthorexia disorder and general anxiety disorder

Social Media Use
The potential effects of social media on orthorexic and general anxiety symptoms were shown in Table 3.
Mean time participants spent on social media apps to track information about COVID-19, health and nutrition were negatively correlated with ORTO-11 scores in both sexes. On the other hand, GAD-7 scores of women were found to be positively linked with the time spent on social media to check for health and nutrition solutions for COVID-19. Determination of nutritional supplements use after COVID-19 Figure 2 represents the alteration in supplement use before and after COVID-19 according to the sex. The use of vitamin C, Beta glucan (ß-glucan), and Pelargonium Sidoides were signi cantly increased after COVID-19 outbreak in both sexes (p < 0.05). The utilization rate of multivitamin, zinc, black elderberry and propolis in women were signi cantly elevated after COVID-19 (p < 0.05). The use of Vitamin D in men was signi cantly increased after COVID-19 (p < 0.05).
Participants predominantly preferred to use nutritional supplements to improve their immunity (24.0 % of men; 32.9 % of women) (Fig. 3). Most of the participants started using nutritional supplements with "belief effect" (52.6 % of men; 50.3 % of women) (Fig. 4).
Tendency to supplement use according to presence of orthorexic symptoms Table 4 shows the multiple linear regression analysis of supplement utilization and orthorexia symptoms taking the ORTO-11 score as the dependent variable. The regression analysis showed that as the ORTO-11 scores decreased, multivitamin (R 2 = 0.377 in men; 0.055 in women) and ß-glucan (R 2 = 0.379 in men; 0.199 in women) utilization rates were increased in participants regardless of sex. In addition, the utilization rates of Pelargonium Sidoides (R 2 = 0.172), vitamin C (R 2 = 0.142) and D (R 2 = 0.199) were increased in parallel with the decrease in ORTO-11 scores in women.

Discussion
The purpose of the study is to investigate the interaction between orthorexia and general anxiety symptoms and the tendency to use nutritional supplements during the semi-quarantine period due to the COVID-19 pandemic. We also sought to the psychological impact of social media news about COVID-19 and nutrition. We achieved ve fundamental results: (1) A positive association was found between Orthorexia and generalized anxiety disorder symptoms, with the fact that these disorders were reasonably high in both sexes during the COVID-19 semi-quarantine; (2) Individuals in semi-quarantine spent an average of 52 minutes on social media seeking information about COVID-19, health and nutrition; (3) A signi cant positive link was observed between social media use and orthorexic symptoms in both sexes; (4) A positive interaction was obtained between general anxiety disorder symptoms and social media use; (5) Most people in semi-quarantine (an average of 51.6 %) decided to take supplements believing they support their immunity, and a positive interaction was observed between orthorexic symptoms and multivitamin and ß-glucan use in both sexes. A positive correlation was also found between orthorexia symptoms and the use of Pelargonium Sidoides, vitamin C, and D in women.
Our results suggest increased orthorexia (67.0 % in men and 83.2 % in women) and general anxiety disorder (62. 6  overlooked, as orthorexic behaviours and dietary restriction behaviours to avoid weight gain during the pandemic appear quite similar. As we found that general anxiety was closely related to orthorexia in both sexes, evaluating individuals identi ed as having general anxiety during COVID-19 pandemic in terms of the presence of orthorexia may be an effective strategy as it can provide early intervention to effectively manage the process. This strategy can be also recommended for early detection of general anxiety in the presence of orthorexia symptoms. To our knowledge, this is the rst study to investigate orthorexia and general anxiety disorder by questioning the use of social media and nutritional supplements. In line with other studies [25,29,33], we reported that nearly all participants (99.2 %) were constantly using social media. It has been shown that constant exposure to social media during the COVID-19 may have paramount effects on psychological state [25]. In a study evaluating the interaction between the social media use and orthorexia, Turner and Lefevre [16] reported that a signi cant interaction between orthorexia and social media use, and Instagram is the most commonly used application to follow a healthy eating environment. Similar results were obtained from our study indicating that Instagram was the most frequently used application for both sexes (73.2% in men, 89.9% in women). The signi cant interaction between social media use and orthorexia symptoms may be due to the higher exposure time to Instagram. Following or interacting with like-minded individuals using social media can lead to an echo chamber effect, which reinforces the correctness of their point of view regarding eating behaviours by constantly underlining common views [36]. In addition, the restrictions of nearly all outdoor activities and daily schedules during the pandemic led to intense exposure to news about COVID-19 and healthy eating on social media [29], thus increasing fears of contracting COVID-19, and rising the obsession about healthy eating.
We revealed that the main reason why individuals in COVID-19 pandemic chose to take nutritional supplements was to support their immunity. Rising concerns about healthy eating during the pandemic [37] may drive individuals to take these supplements to improve adaptive immunity to minimize the risk of contracting COVID-19. In addition, one of the major reasons why individuals increase their use of nutritional supplements without consulting any healthcare professional during the COVID-19 pandemic may also be the echo effect of social media. underlining that nutritional supplements, such as zinc, vitamins C, A, and D may be applied to improve immunity in case of any de ciency is detected.
Since the beginning of the pandemic, researchers particularly focused on the potential e ciency of vitamin D on COVID-19 infection due to its modulatory mechanisms on immunity by dampening the entry and replication of the coronavirus and attenuating proin ammatory cytokines and provoking production of anti-in ammatory cytokines to ght the virus [46]. A systematic review and meta-analysis by Bassatne et al. [44] has underlined that high quality studies are needed before implementing vitamin D supplementation to treat or prevent the infection, although there is a pattern between vitamin D de ciency and COVID-19 outcomes. All studies considered, even vitamin D supplementation is only recommended for people with low vitamin D status or limited access to sunlight [47]. Furthermore, the risks of taking high doses of vitamin D have also been highlighted due to potential harmful effects on health, especially in individuals with other health problems such as decreased kidney function [47]. Therefore, individuals should be cautioned that a detailed nutritional evaluation is necessary to determine if there is a nutritional de ciency before starting any nutritional supplements during the COVID-19 pandemic and that otherwise supplements may cause detrimental effects on health.
Our study has several strengths and limitations to consider. To our knowledge, this is the rst study to compare orthorexia nervosa and anxiety in relation with the use of social media and nutritional supplements. The use of an online survey enabled data to be collected from all over the country. We implemented the ORTO-11, the valid and reliable version of ORTO-15 in our country as it eliminates the false prediction of the disorder. It is crucial to apply a valid questionnaire since we are aware that one of the main reasons why orthorexia is not included in DSM-V is the psychometric limitations of the ORTO-15 questionnaire, such as lack of cultural adaptation, internal validity, and reliability.
Since there are no speci c diagnostic criteria for orthorexia in DSM-5 [48] and we cannot independently be con rmed the presence of eating disorders, we did not ask if they had been diagnosed with orthorexia or any eating disorders before. However, previous eating disorder history may elevate the exaggerated obsession about food and orthorexic behaviours during the COVID-19 pandemic.

Conclusion
The current results suggest that individuals in COVID-19 semi-quarantine have higher orthorexic and anxiety symptoms in both sexes. A meaningful interaction was observed between orthorexia and anxiety, and higher social media use was signi cantly associated with orthorexia nervosa in both sexes, and anxiety in women. More than half of the participants applied nutritional supplements to improve the immune response. We indicated that as orthorexia symptoms increased, both sexes administered more multivitamins and ß-glucan. In addition, a signi cant association was observed between orthorexic symptoms and the use of Pelargonium Sidoides, vitamin C and D in women. Overall, these ndings suggest that orthorexia and anxiety are closely related to each other, and health, nutrition and COVID-19related news on social media trigger these symptoms. In addition, the increase in the selfsupplementation without consulting the healthcare personnel may cause detrimental consequences on health. Therefore, individuals who are concerned or obsessed with healthy eating should be encouraged to consult a healthcare professional so that any psychological problems can be detected early before they cause long-term detrimental consequences. In addition, they should be informed about the undesirable impact of social media news and also encourage to decrease the time spend on social media. Subjects Committee and all participants consented to participating in the study.

Consent for publication
Not applicable.

Competing interests
The authors declare that they do not have any con icts of interest.
Authors' contributions ADL was the main writer of the paper, assisted with data interpretation, and gave nal approval of this version to be published. HKBG and EEÇ conducted the data analysis, critically reviewed the paper, and gave nal approval of this version to be published.

Funding
Not applicable.
Availability of data and materials Not applicable.

Figure 2
Page 25/26 Determination of the differences in nutritional supplement use before and during COVID-19 semiquarantine Figure 3 Difference in the use of nutritional supplements before and after COVID-19 according to sex