Eat Weight Disord (2017) 22:177–184
DOI 10.1007/s40519-016-0280-x
ORIGINAL ARTICLE
The interrelationship between orthorexia nervosa, perfectionism,
body image and attachment style
Marta A. Barnes1 • Marie L. Caltabiano1
Received: 21 January 2016 / Accepted: 25 March 2016 / Published online: 11 April 2016
Ó Springer International Publishing Switzerland 2016
Abstract
Purpose We investigated whether perfectionism, body
image, attachment style, and self-esteem are predictors of
orthorexia nervosa.
Methods A cohort of 220 participants completed a self-
administered, online questionnaire consisting of five mea-
sures: ORTO-15, the Multidimensional Perfectionism
Scale (MPS), the Multidimensional Body-Self Relations
Questionnaire-Appearance Scale (MBSRQ-AS), the Rela-
tionship Scales Questionnaire (RSQ), and Rosenberg’s
Self-Esteem Scale (RSES).
Results Correlation analysis revealed that higher orthor-
exic tendencies significantly correlated with higher scores
for perfectionism (self-oriented, others-oriented and
socially prescribed), appearance orientation, overweight
preoccupation, self-classified weight, and fearful and dis-
missing attachment styles. Higher orthorexic tendencies
also correlated with lower scores for body areas satisfac-
tion and a secure attachment style. There was no significant
correlation between orthorexia nervosa and self-esteem.
Multiple linear regression analysis revealed that over-
weight preoccupation, appearance orientation and the
presence of an eating disorder history were significant
predictors of orthorexia nervosa with a history of an eating
disorder being the strongest predictor.
Conclusions Orthorexia nervosa shares similarities with
anorexia nervosa and bulimia nervosa with regards to
perfectionism, body image attitudes, and attachment style.
& Marie L. Caltabiano
marie.caltabiano@jcu.edu.au
1 ideism) with a food and its source, which becomes
Psychology, College of Healthcare Sciences, Division of
Tropical Health and Medicine, James Cook University,
PO Box 6811, Cairns, QLD 4870, Australia
In addition, a history of an eating disorder strongly predicts
orthorexia nervosa. These findings suggest that these dis-
orders might be on the same spectrum of disordered eating.
Keywords Attachment
Body image
Eating disorder

Orthorexia nervosa
ORTO-15
Perfectionism
Introduction
The term orthorexia nervosa was introduced by Steven
Bratman in 1997 [1] to describe a ‘condition’ involving a
pathological, monoideistic fixation with healthy eating and
proper nutrition. Orthorexia nervosa has not yet been
clinically recognised as an eating disorder, and it has not
been included in the DSM-5 [2]. Although validated
diagnostic criteria for orthorexia nervosa have not been
established, certain clinical features of orthorexia nervosa
have been routinely described (and agreed upon) in the
literature [3–5]. Orthorexia nervosa is characterised by a
desire to consume a healthy diet (what is believed by the
sufferer to be healthy) [4]. Individuals suffering from
orthorexia nervosa eliminate from their diet food that is
perceived by them to be impure and unhealthy, and often
restrict or completely eliminate specific food groups such
as meat, dairy, grains, cooked food, and non-seasonal
produce [3]. It is important to note that their dietary regime
is not part of a medically prescribed diet [2].
Orthorexic individuals are driven by a desire to improve
their health and/or to prevent or treat an existing disease
[3]. The desire to consume healthy food is not a pathology
per se but the obsessive preoccupation (a form of mono-
nuanced, may lead to a pathological level of worry and
stress concerning food [5]. Orthorexic individuals spend a
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significant amount of time (more than 3 h per day) on
researching, analysing and preparing food [3]. The focus on
food in orthorexia nervosa resembles other better described
eating disorders—anorexia nervosa and bulimia nervosa
[6]. However, unlike in anorexia nervosa or bulimia ner-
vosa where the primary concern is quantity of food con-
sumed, orthorexia nervosa is characterised by a
preoccupation with the quality of food [4, 6].
Within the literature, there is an ongoing debate
regarding whether or not orthorexia nervosa should be
classified as being a distinct disorder [7], a variant of an
existing eating disorder or obsessive compulsive disorder
(OCD) [8]. Moreover, some researchers suggest that
orthorexia nervosa might be a precursor for, or a residual of
an eating disorder [6]. In a longitudinal study [6], the
prevalence of orthorexia nervosa among eating disorder
patients was higher compared to a non-clinical cohort.
Moreover, 3 years after the treatment was finished, the rate
of orthorexia nervosa increased from 28 to 58 % among
anorexics and bulimics. The authors [6] suggested that
orthorexia nervosa may be on the same spectrum as anor-
exia nervosa and bulimia nervosa, where patients switch
from an obsession with the quantity of food to an obsession
with its quality. It is also possible that a healthy diet may
serve as a socially acceptable method of weight control for
anorexic and bulimic individuals.
To date, there is limited systematic research on orthor-
exia nervosa; the literature being dominated by descriptive
and anecdotal data. Studies on orthorexia nervosa have
focused primarily on measuring the prevalence of the
condition in different countries [7, 9], and examining fac-
tors (age, gender, occupation, BMI) that may affect its
prevalence [4, 9]. These studies have generated inconsis-
tent results. Due to similarities between orthorexia nervosa
and anorexia nervosa, factors that have been implicated in
the development and maintenance of eating disorders
(body image, perfectionism, attachment style, self-esteem)
[10–12] could potentially be implicated in orthorexia ner-
vosa, and could contribute to our understanding of the
condition.
Perfectionism has been implicated in the psy-
chopathology of anorexia nervosa and bulimia nervosa
[12]. The literature suggests that individuals with orthor-
exia nervosa are also characterised by perfectionism (a
personality trait typified by the setting of excessively high
standards, expectations of flawlessness, and excessive
criticism of self and others) [5, 13]; however, studies
investigating the association between orthorexia nervosa
and perfectionism are limited. One study [14] reported a
significant positive correlation between perfectionism and
orthorexia nervosa. In orthorexia nervosa, individuals aim
to eat a ‘perfect’ diet, and they follow rigorous dietary
rules; therefore, it seems plausible that they may display
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Eat Weight Disord (2017) 22:177–184
perfectionist natures. Adherence to food rules has been
found to mediate the relationship between perfectionism
and an eating disorder [10].
Negative body image and internalization of the thin
ideal are central to eating disorders [15]. The literature
suggests that orthorexic individuals are not concerned with
weight loss, and they do not display negative body image
attitudes [3]—a feature observed among patients with
anorexia nervosa and bulimia nervosa [15]. A Polish study
which used the ORTO-15 to assess orthorexic tendencies in
normal weight females concluded that orthorexic individ-
uals were less concerned with becoming overweight, and
paid less attention to their appearance [16]. However, on
closer inspection, it appears that the results were misin-
terpreted as there was a negative correlation between the
ORTO-15 (low scores indicate more orthorexic tendencies)
and both appearance orientation and overweight preoccu-
pation, which would suggest that orthorexic tendencies
were associated with an increased preoccupation with
appearance and fears of becoming overweight. This is
consistent with research which found that fitness partici-
pants who displayed orthorexic tendencies showed inter-
nalization of a thin ideal as well as social physique anxiety
associated with body image dissatisfaction and disordered
eating [17]. As a caveat, it should be noted that Erikson
et al. [17] measured orthorexia nervosa using the BOT
scale which has not been validated; therefore, conclusions
from this study should be interpreted with caution.
Insecure attachment styles (preoccupied, dismissing,
and fearful) have been implicated in the development and
perpetuation of anorexia nervosa and bulimia nervosa [11,
18]. Currently, studies on the association between attach-
ment style and orthorexia nervosa are lacking.
Self-esteem has been found to be lower among indi-
viduals suffering from anorexia nervosa and bulimia ner-
vosa [19]. However, literature on orthorexia suggests that
the opposite is true—for orthorexics, self-esteem appears to
be higher than in non-orthorexics [3, 20]. For orthorexics,
positive self-esteem appears be due to maintaining a
healthy diet, and having control over their own desires [3].
The current study aims to add to the research base on
orthorexia nervosa by examining the relationship between
orthorexia nervosa and perfectionism, body image, attach-
ment style and self-esteem. The hypotheses are as follows:
1. High scores on self-oriented perfectionism will predict
high scores on orthorexia nervosa.
2. High scores on appearance orientation and overweight
preoccupation will predict high scores on orthorexia
nervosa.
3. High scores on fearful, avoidant and preoccupied
attachment styles will predict high scores on orthorexia
nervosa.
Eat Weight Disord (2017) 22:177–184
4. High self-esteem will be a predictor of orthorexia
nervosa.
5. History of an eating disorder will be a predictor of high
scores on orthorexia nervosa.
Methods
Participants
A cohort of 220 adults (males 46, females 174) participated
in the current study. A hundred and eighty participants
were first and second year psychology students at James
Cook University. In addition, respondents were recruited
from Facebook for a more heterogeneous sample and to
increase the sample size, though only 40 individuals
responded to the survey. Participants’ age ranged from 17
to 62 (M = 23.81, SD = 8.40). One hundred and seven-
teen participants indicated having a high school degree or
equivalent, 61 participants had a certificate or diploma, 27
participants had a bachelor degree, and 12 participants had
a postgraduate degree. A majority of respondents indicated
an absence of any food intolerance (n = 166), an absence
of a food allergy (n = 196) and an absence of a medically
prescribed diet (n = 213). Eighteen participants indicated
having a history of an eating disorder—bulimia nervosa or
anorexia nervosa.
Measures
Five questionnaires along with demographic data were
included in the study. In addition, participants were asked
to indicate whether they have any food intolerances, food
allergies or a medically prescribed diet that determines
their food intake; this would identify participants who may
follow a strict diet for medical reasons. Participants were
also asked to indicate whether they have ever suffered
from, or been diagnosed with, an eating disorder such as
anorexia nervosa or bulimia nervosa.
ORTO-15
To measure orthorexia nervosa, the ORTO-15 scale was
used. The ORTO-15 scale was developed by Donini et al.
[21], and was based on Bratman’s orthorexia test (BOT)
and obsessive and phobic personality items from the MMPI
scale. The ORTO-15 is a self-reported instrument consist-
ing of 15 multiple-choice questions on a four-point scale
(always, often, sometimes, never); the items of the scale
assess attitudes towards selecting, purchasing, preparing
and consuming healthy food. A sample item from the scale
is: ‘‘Do you think that consuming healthy food may
179
improve your appearance?’’ Lower scores are assigned to
answers indicating orthorexia, while higher scores are
given to answers suggesting an absence of the condition.
The final score is made up from the sum of scores with a
minimum a score of 15 and a maximum of 60.
In the original validation research [21] Cronbach’s alpha
was not reported while in the translated versions of the
ORTO-15 scale, researchers deleted items to increase the
scale’s internal consistency. A Cronbach’s alpha of .82 was
reported for the Hungarian version consisting of 11 items
(ORTO-11 Hu) [9], and a Cronbach’s alpha of .82 was
reported for the 9-item Polish version of ORTO-15 [16]. In
the present study, six items (items 1, 2, 8, 9, 13, 15) with a
negative item-total correlation were deleted to increase the
scale’s internal consistency (a = .18 using the 15 items).
The Cronbach’s alpha of the scale consisting of nine items
(items 3, 4, 5, 6, 7, 10, 11, 12, 14) was .73. An orthorexia
score ranging from 9 to 36 was created as a total of the
individual responses on the 4-point rating scale.
Multidimensional perfectionism scale (MPS)
The 45-item MPS [22] was used to assess three aspects of
perfectionism (self-oriented, others-oriented and socially
prescribed perfectionism). Each subscale consists of 15
items rated on a seven-point Likert scale ranging from
disagree to agree. A sample item from the scale is:
‘‘Everything that others do must be of top-notch quality’’.
Cronbach’s alpha in the current study was .90 for the self-
oriented perfectionism subscale, .88 for the others-oriented
perfectionism subscale, and .85 for the socially prescribed
perfectionism subscale.
Multidimensional body-self relations questionnaire-
appearance scale (MBSRQ-AS)
The 34–item MBSRQ-AS [23] questionnaire was used to
assess appearance related aspects of body image. The
MBSRQ-AS is a shorter version of the well validated
multidimensional body-self relations questionnaire
(MBSRQ). The MBSRQ-AS consists of five subscales: the
appearance evaluation subscale (AE), which assesses a
person’s satisfaction with his or her own appearance and
feeling of attractiveness or unattractiveness; the appearance
orientation subscale (AO), which assesses the importance
that one places on appearance; the overweight preoccupa-
tion subscale (OP), which assesses a person’s anxiety with
respect to their weight, dieting behaviours and eating
restraints; the self-classified weight subscale (SCW), which
assesses how a person evaluates and perceives their own
weight, and the body areas satisfaction subscale (BASS),
which assesses a person’s satisfaction with particular body
areas. Higher scores on the subscales indicate the presence
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of the construct. In the current study, the Cronbach’s alpha
was .89 for the AE subscale, .88 for the AO subscale, .81
for the OP subscale, .80 for the SCW subscale, and .88 for
the BASS subscale.
Relationship scales questionnaire (RSQ)
To assess participants’ attachment pattern, the relationship
scales questionnaire [24] was used. The RSQ consists of 30
items rated on a 5-point scale (from not at all like me to
very like me). Participants were asked to indicate the
degree of correspondence of each statement to their general
orientation to close relationships. The Cronbach’s alpha in
the current study was .61 for the secure attachment sub-
scale, .74 for the fearful attachment subscale, .66 for the
dismissing attachment subscale, .57 for the preoccupied
subscale.
Rosenberg self-esteem scale (RSES)
The RSES [25] was used to assess global self-esteem and
feelings of self-worth. The measure consists of 10 items
such as ‘‘I feel that I have a number of good qualities’’.
Each item is answered using a 4-point Likert scale
(strongly agree, agree, disagree, strongly disagree). Total
score is the sum of the scores for the ten items with higher
scores indicating a higher level of self-esteem. The Cron-
bach’s alpha in the current study was .92.
Procedure
The study was approved by the Human Research Ethics
Committee at James Cook University. The study was listed
on two websites: the university SONA system for psy-
chology students, and Survey Monkey for recruits from
Facebook. In return for voluntary participation in the study,
students received credit toward their psychology degree for
time spent completing the survey. Students received credit
by logging their profiles on the SONA system were all
studies are advertised. Once they selected a study they
wanted to participate in they were taken to the on-line
survey. No identifying information was requested on the
survey. Informed consent was obtained from all partici-
pants. Facebook participants were invited to click on a link
which took them to the survey; the participants were not
required to give any of their personal details and the survey
was not linked in anyway to their Facebook profile.
Statistical analysis
Quantitative analysis was conducted using version 22 of
SPSS statistical software. Prior to conducting statistical
analyses the assumptions of parametric statistics were
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inspected and no violations of normality observed. Pear-
son’s correlation coefficient (.05 level for significance) was
computed between all continuous variables and the main
dependent variable (ORTO-15 score). Multiple linear
regression was used to identify predictors of the ORTO-15
score. Categorical variables were converted to dummy
variables before inputting them into the regression model.
Independent variables were selected for inclusion into the
multiple regression model using a stepwise method which
excludes the predictor variable that contributes the least to
the prediction equation. The assumptions of multiple
regression including linearity of the relationship between
dependent and independent variables; independence of
errors; homoscedasticity; and normality of errors were
tested with no violations.
Results
Descriptive statistics
Descriptive statistics for continuous variables for the total
cohort (220 participants) are presented in the Table 1.
The mean score for the ORTO-15 (based on nine items)
was 22.71 (SD = 4.55). There was no significant differ-
ence on the ORTO-15 score between males (M = 23.87,
SD = 4.94) and females (M = 22.42, SD = 4.41),
t (218) = 1.95, p = .053. A one-way between groups
ANOVA revealed that there was a significant difference on
the ORTO-15 scores between individuals with different
educational levels, F (3, 213) = 3.03, p = .031.
A Hochberg post hoc comparison revealed that those with a
bachelor degree scored significantly more orthorexic
(M = 20.48, SD = 4.73) as compared with those having a
high school certificate (M = 23.28, SD = 4.35).
There was a significant difference on the ORTO-15
score between those with a history of an eating disorder
(M = 17.94, SD = 1.01) and those who indicated having
no previous history of an eating disorder (M = 23.37,
SD = 4.20), t (159) = -5.15, p \ .001. There was no
significant difference on the ORTO-15 score between those
with a food intolerance (M = 21.67, SD = 5.31) and those
without (M = 21.67, SD = 4.26), t (210) = -1.65,
p = .100, and no significant difference on ORTO-15 was
found between those who indicated having food allergies
(M = 22.45, SD = 4.85) and those indicating not having
any food allergies (M = 4.55, SD = .33), t (216) = -.28,
p = .778. Those with medically prescribed diets
(M = 21.83, SD = 6.85) did not differ significantly from
those without medically prescribed diets (M = 22.74,
SD = 4.50), t (217) = -.48, p = .633. These findings
indicate that ORTO-15 scores were not due to following a
strict diet for medical reasons, food intolerances or having
 Table 1 Correlation analysis for all continuous variables and descriptive statistics
Eat Weight Disord (2017) 22:177–184

ORTO Score (9 Item

Based)
Age
Self-Oriented
Perfectionism
Others-Oriented
Perfectionism
Socially Prescribed
Perfectionisms
Appearance
Orientation
Appearance
Evaluation
Overweight
Preoccupation
Self-Class
Body Areas
Satisfaction
Secure Attachment
Fearful Attachment
Preoccupied
Attachment
Dismissing
Attachment
Self-Esteem

Age .127
Self-Oriented -.365** -.003
**
Others-Oriented -.250 .090 .408**
Socially Prescribed -.238** -.129 .466** .299**
** **
Appearance Orientation -.444 -.031 .475 .287** .250**
Appearance Evaluation .054 -.014 .047 .110 .178** -.110
** ** ** **
Overweight Preoccupation -.502 .091 .322 .181 .297 .474** -.217*
** *
Self-Classified Weight -.203 .166 -.027 .033 .066 -.044 -.130 .440**
Body Areas Satisfaction .141* -.058 -.059 -.021 -.170* -.226* .844** .303* -.103
* * * **
Secure Attachment .146 -.032 -.043 -.006 -.208 -.172 .432 -.032 .182** .472**
** ** ** * ** **
Fearful Attachment -.230 -.031 .282 .034 .438 .161 -.098 .412 .328 -.081 -.092
* ** * **
Preoccupied Attachment .009 -.267 .067 -.125 .337 .027 -.005 .166 .212 .076 .095 .513**
** ** * * ** ** **
Dismissing Attachment -.203 .096 .276 .037 .167 .098 .147 .287 .353 .113 .282 .655** .225**
Self-Esteem .051 .100 .048 .091 .193** -.143* .633** .141* .089 .594** .684** .023 .138* .391
M 22.71 23.81 66.54 52.09 55.88 3.45 3.05 2.69 3.16 3.08 3.00 3.10 2.88 3.30 26.97
SD 8.42 4.55 15.37 11.82 12.88 .70 .92 1.06 .79 .85 .74 .98 .92 .83 7.47
* Correlation significant at level .05 (2-tailed)
** Correlation significant at level .001 (2-tailed)
181

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food allergies even though there may be overlap between
these groups.
Correlation analysis
A correlation matrix (Table 1) was produced to assess
bivariate relationships with Pearson’s correlation coeffi-
cient for all continuous independent variables and the
dependant variable (the ORTO-15 score). Key findings
from the correlation analysis were as follows: the ORTO-
15 score was significantly and negatively correlated with
self-oriented, others-oriented, socially prescribed perfec-
tionisms; and appearance orientation, overweight preoc-
cupation, self-classified weight, and fearful and
dismissing attachment styles. In addition, the ORTO-15
score was significantly and positively correlated with
body areas satisfaction, and secure attachment style. The
ORTO-15 score was not significantly correlated with self-
esteem.
Multiple linear regression
A multiple linear regression model was developed with
the ORTO-15 score as the dependent variable and four
independent variables which showed the highest correla-
tion with the ORTO-15 (self-oriented perfectionism,
appearance orientation, overweight preoccupation and
history of an eating disorder). The stepwise procedure
removed self-oriented perfectionism as it showed the
lowest R-squared value among the predictor variables.
The results of the stepwise multiple regression analysis
indicated that overweight preoccupation, appearance ori-
entation and history of an eating disorder accounted for
31.9 % of the variance in the ORTO-15 score, F (3,
157) = 25.99, p \ .001.
Higher scores for overweight preoccupation (b = -.32,
p \ .001) and appearance orientation (b = -.23,
p = .002) were linked to a lower ORTO-15 score. Fur-
thermore, history of an eating disorder (b = .20, p = .005)
was associated with a lower ORTO-15 score. The most
important predictor of orthorexia nervosa is having a his-
tory of an eating disorder; this is followed by appearance
orientation and overweight preoccupation, respectively
(See Table 2).
Table 2 Stepwise regression
Intercept/predictors
analysis to predict orthorexia
nervosa Intercept
Overweight preoccupation
Appearance orientation
History of eating disorder
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Discussion
The aim of the current study was to contribute to the literature
on orthorexia nervosa by examining the relationship of
orthorexia with factors that have been previously implicated
in other eating disorders such as anorexia nervosa and buli-
mia nervosa. Specifically, the potential association between
orthorexia nervosa, and perfectionism, body image, attach-
ment style, and self-esteem was investigated.
The first hypothesis—high self-oriented perfectionism
will be a predictor of high scores on orthorexia nervosa—was
not supported from the regression analysis. Self-oriented
perfectionism showed the lowest R-squared value among the
four predictor variables (with overweight preoccupation,
appearance orientation, a history of an eating disorder);
hence, it was removed in the stepwise procedure. Although,
self-oriented perfectionism was not a significant predictor of
the ORTO-15 score, there was a significant, moderate cor-
relation between self-oriented perfectionism and orthorexia
nervosa consistent with previous research [5].
The second hypothesis—high scores on appearance
orientation and overweight preoccupation will be predic-
tors of orthorexia nervosa—was supported. Higher scores
for overweight preoccupation and appearance orientation
were associated with more orthorexic tendencies, and both
appearance orientation and overweight preoccupation were
significant predictors of orthorexia nervosa. This is con-
sistent with research on female participants with orthorexic
tendencies [16]—lower scores on the ORTO-15 were
associated with greater focus on appearance and fear of
becoming overweight. Greater emphasis on appearance as
well as anxiety about being overweight has been observed
among anorexic and bulimic individuals [26]. These results
may suggest that an exaggerated focus on appearance and a
fear of becoming overweight might be hidden motives
behind the preoccupation with a healthy diet rather than a
fixation on health per se. However, overweight and obesity
are generally associated with poorer health [27]; therefore
orthorexics knowledgeable of the link between BMI and
health might associate overweight appearance with being
in poorer health; hence, driving their exaggerated focus on
appearance and fear of becoming overweight.
The third hypothesis—high scores on fearful, dismiss-
ing, and preoccupied attachment styles will be predictors of
B (95 % CI) b t p value
32.07 (20.71, 31.79) 20.90 \.001
-1.37 (-2.05, -.73) -.32 -4.10 \.001
-1.55 (-2.39, -.54) -.23 -3.19 .002
-2.88 (.91, 4.90) .20 -2.83 .005
Eat Weight Disord (2017) 22:177–184
orthorexia nervosa—was not supported. None of the
attachment styles were significant predictors of orthorexia
nervosa; however, the fearful, and the dismissing attach-
ment styles significantly and negatively correlated with the
ORTO-15 score. Although, these correlations were weak,
the direction of the correlation was consistent with what
has been observed in studies on other eating disorders [11,
18].
The fourth hypothesis—high self-esteem will be a pre-
dictor of orthorexia nervosa—was not supported. Self-es-
teem was not significantly correlated with, and was not a
significant predictor of orthorexia nervosa. This is incon-
sistent with the literature, which suggests that orthorexics
show an inflated sense of self-esteem [3].
The fifth hypothesis—history of an eating disorder will
predict high scores on orthorexia nervosa—was supported.
History of an eating disorder was a strong predictor of
orthorexia nervosa. This is consistent with research [6]
which reported that the prevalence of orthorexia nervosa
among patients with anorexia or bulimia was higher than in a
control group. Both anorexia and bulimia nervosa are asso-
ciated with an exaggerated focus on appearance and ‘fat
anxiety’ [26]. It is possible that, as previously suggested [6],
orthorexia nervosa is on the same spectrum as anorexia
nervosa and bulimia nervosa, where a person shifts between
these conditions; this might be driven by a fear of being
overweight. A healthy diet might serve as a socially
acceptable alternative for the unhealthy drive for thinness.
Earlier research [17] reported orthorexic tendencies were
associated with an internalization of the thin ideal and social
physique anxiety—both of which are associated with body
image dissatisfaction and disordered eating [15].
In the present study there was no significant difference
on the ORTO-15 score between males and females. This is
consistent with research [9, 16] which did not find a gender
difference on the ORTO-15. However, the finding is
inconsistent with research which has reported higher
prevalence of orthorexia for males [4], and research
reporting higher prevalence for females [17]. Nonetheless,
this comes with a caveat: a majority (79 %) of the partic-
ipants in the current study were females; therefore, this
result should be treated with caution. Individuals with a
tertiary qualification were found to score lower on the
ORTO-15 than those with a high school certificate, which
is inconsistent with research [4] which found a higher
prevalence among less educated individuals.
From the correlation results, the current study has found
that elevated perfectionism (self-oriented, others-oriented
and socially prescribed) was associated with greater
orthorexic tendencies. Perfectionism has been implicated in
the development and maintenance of eating disorders [10,
12]—and data from the current study suggests that per-
fectionism could be a potential risk factor for orthorexia
183
nervosa. Furthermore, perfectionism is implicated in
adherence to strict food rules which has a mediating effect
between self-oriented perfectionism and eating disorders
[10]. A key feature of orthorexia nervosa is adherence to
strict dietary rules [1, 3, 13]; this might be a manifestation
of a person’s perfectionism in relation to food (having strict
dietary rules), as well as a person’s perfectionist views on
appearance (appearance orientation and overweight
preoccupation).
Limitations
Due to some limitations of the study the findings need to be
interpreted with caution. The size and homogeneity of the
sample preclude generalisations to populations more
heterogeneous for age, gender, education and different
ethno-cultural backgrounds. Another limitation concerns
the nature of self-reported data. Given that the ORTO-15
questions relate to healthy eating habits, the participants
might have been inclined to give socially desirable
answers, even though they could not be identified.
Lastly, the study only used the ORTO-15 scale to detect
orthorexic tendencies. Although, the preliminary validation
shows that the scale has good predictive validity [21] the
internal consistency of the ORTO-15 has been criticised
[5]. Some research has reported high Cronbach alphas
using the ORTO-15 [28]. In the present study, the internal
consistency of the ORTO-15 scale that included all 15
items was very low (Cronbach’s alpha of .18); therefore,
six items had to be removed to increase the internal con-
sistency of the scale to .73. Generalizability of the present
findings using the reduced ORTO-15 scale needs to be
taken into consideration when comparing the findings to
other studies [28] which have used the full ORTO-15 scale.
A recent US prevalence study concluded that the ORTO-15
may have validity problems as it seems to detect healthy
eating (as measured by endorsement of statements that
healthy eating is important and that one’s diet is healthier
than others) rather than pathological restriction [7]. The
ORTO-15 was unable to detect differences between groups
who either had or did not have clinically significant indi-
cators of pathology such as ‘medical issues secondary to
dieting’ or ‘social conflict due to dietary choices’ [7].
Moreover, the ORTO-15 could not detect subgroup dif-
ferences based on diet (e.g., Vegan) or exercise [7].
Conclusions
This study was the first to investigate orthorexia nervosa in
Australia as most previous studies have been conducted in
Europe. In addition, the present study was the first to assess
123
184
the relationship between orthorexia nervosa, multidimen-
sional perfectionism and attachment style. The current
findings indicate that a history of an eating disorder,
overweight preoccupation, and appearance orientation are
significant predictors of orthorexia nervosa. Future
research could potentially benefit from a replication of this
study by focusing on a clinical sample—a cohort of indi-
viduals meeting the ‘criteria’ for orthorexia nervosa. In
addition, investigations involving larger and more hetero-
geneous cohorts will add to the research base on orthorexia
nervosa.
Compliance with ethical standards
Conflict of interest Both authors declare that they have no conflict
of interest.
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all indi-
vidual participants included in the study.
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