Nevin Sanlier
Zeynep Bengisu Ejder
Elif Yildiz Kaya†- Department of Nutrition and Dietetics School of Health Sciences, Ankara Medipol University, Ankara, Türkiye
Background: The obsession with healthy eating, as well as clinical eating disorders and health anxiety, is becoming increasingly common worldwide. Health anxiety, characterised by undue relevance about one’s health and reinforced by perfectionism, is a significant problem requiring intervention in individuals with orthorexia nervosa (ON) and other eating disorders.
Objective: This study was conducted to examine the relationship between orthorexia nervosa, eating disorder and health anxiety in adults.
Methods: A total of 654 people (M = 211, F = 443) aged 19–50 answered sociodemographic questions and three instruments: the Orthorexia Nervosa Scale (ORTO-R), Clinical Impairment Assessment (CIA) and Short Health Anxiety Inventory (SHAI-18).
Results: Significant positive correlations were observed between ORTO-R and CIA (r = 0.461), ORTO-R and SHAI-18 (r = 0.364), and CIA and SHAI-18 (r = 0.429) (all p = 0.000). Regression analyses showed reciprocal associations: higher CIA and SHAI-18 scores were related to higher ORTO-R scores (β = 0.350 and β = 0.203, respectively; Adjusted R2 = 0.266), and higher ORTO-R and SHAI-18 scores were related to higher CIA scores (β = 0.316 and β = 0.262, respectively; Adjusted R2 = 0.338). Similarly, both ORTO-R and CIA predicted SHAI-18 (β = 0.213 and β = 0.305, respectively; Adjusted R2 = 0.228).
Conclusion: In conclusion, it was shown that ON, clinical eating disorder, and health anxiety were significantly related to each other. This finding may contribute to the development of public health communication strategies that promote balanced and evidence-based health behaviors.
1 Introduction
The obsession with healthy eating, as well as clinical eating disorders and health anxiety, is becoming increasingly common worldwide. Health anxiety, characterized by undue relevance about one’s health and reinforced by perfectionism, is a significant problem requiring intervention in individuals with orthorexia nervosa (ON) and other eating disorders (Sirri et al., 2020). There is ongoing debate regarding the diagnostic criteria for ON, and the diagnosis has two core criteria: an obsessive focus on “healthy” eating and compulsive behavior and preoccupation that negatively impact clinically (Dunn and Bratman, 2016; Cena et al., 2019). Psychosocial risk factors play a significant role in the emergence and progression of ON and other eating disorders (McComb and Mills, 2019; Strahler, 2020; Rossi et al., 2024), and individuals may exhibit symptoms of anxiety and depression (Strahler et al., 2022). In fact, as conceptualized by Duradoni et al. (2023), in ON, the purity of food is valued above anything else, including deleterious health effects (e.g., an extremely restrictive diet). Researchers suggested that people with ON are anxious about not eating healthy, compulsively plan and prepare healthy meals, and feel superior to others when it comes to choosing healthy foods (Duradoni et al., 2023).
Beliefs about health anxiety are significant predictors of orthorexic symptoms, and it is thought that individuals with high health anxiety may be at higher risk of developing ON (Rossi et al., 2024; Duradoni et al., 2023; Barthels et al., 2021; Chace and Kluck, 2021; Novara et al., 2021a; Greville-Harris et al., 2022). Those with severe anxiety symptoms may exhibit greater levels of emotional eating, uncontrolled eating, and resistance to eating behaviors (Cifuentes et al., 2022). While at first glance, this obsession with healthy eating may seem harmless and can control an individual’s life over time (Zickgraf et al., 2019). While some individuals may perceive their obsession with healthy eating as a positive lifestyle choice (Pontillo et al., 2022; Zagaria et al., 2022; Levin et al., 2023; Tan et al., 2023), for others, healthy eating habits support psychological well-being and when this interest reaches the level of obsession, it can negatively affect mental health (Strahler et al., 2018; Barlow et al., 2024).
Eating disorders can affect an individual’s psychosocial functioning. Individuals’ excessive scrutiny of their body shape and weight can have significant negative effects on their ability to establish and sustain interpersonal relationships (Chace and Kluck, 2021). Some studies have found that individuals with ON have higher anxiety, stress, and lower life satisfaction (Rossi et al., 2024; Strahler et al., 2022; Meier et al., 2020; Novara et al., 2021b). Individuals with eating disorders, such as fear of weight gain and dietary restriction, exhibit significant impairments in clinical and physical health, emotional, and social functioning (Meier et al., 2020; Novara et al., 2021b). However, the relationship between clinical eating disorders and ON remains unclear (Zickgraf et al., 2019). ON is reported to be more common in individuals with a history of eating disorders, restrictive diets, or body dissatisfaction (Novara et al., 2021b). Eating-related clinical disorders are closely related to the rigid, prescriptive, and inflexible structures of orthorexia nervosa (Zickgraf et al., 2019; Zagaria et al., 2022). The potential mediating role of health anxiety in the relationship between an obsession with healthy eating and clinical eating disorders can be explained by the cognitive and emotional processes underlying these variables. Individuals with high health anxiety tend to interpret bodily cues as threatening and develop behavioral control strategies to prevent illness. One of the most common forms of these control strategies is over-structuring one’s diet and focusing on foods perceived as ‘safe’, a process that underlies a preoccupation with healthy eating. Over time, this excessive control can result in a loss of eating flexibility, increased avoidance behaviors and the development of restrictive eating patterns. This, in turn, can result in the emergence or exacerbation of symptoms of a clinical eating disorder. Therefore, it is hypothesised that health anxiety plays a mediating role as an emotional and cognitive trigger in the continuum from healthy eating obsession to clinical disorder.
The boundaries between orthorexia nervosa, health anxiety and eating disorders remain unclear (Strahler et al., 2018). Existing literature emphasizes the need to address excessive health concerns and perfectionistic tendencies in both the prevention and clinical interventions for orthorexic tendencies (Greville-Harris et al., 2022; Barlow et al., 2024; Novara et al., 2021b). In recent years, it has been demonstrated that an obsession with healthy eating is not unique to certain societies but can manifest in a similar way across cultures. Studies conducted in various countries, including Poland, Spain, Germany, China and India, have revealed that this obsession is shaped by social norms, media representations, body ideals and health discourses. Furthermore, longitudinal studies conducted during and after the period of the pandemic indicate that increased health anxiety can reinforce individuals’ tendency to exercise excessive control over their food choices. However, existing literature shows that models addressing obsession with healthy eating, BMI, health anxiety and clinical eating disorder symptoms together are limited. Therefore, this study aims to expand upon and update the existing literature in a cross-cultural context by examining these variables within the same model.
In recent studies, the concept of healthy eating has evolved beyond physical health to encompass psychological and behavioral aspects. This phenomenon, referred to in the literature as ‘healthy eating obsession/orthorexia-like tendencies’, has been found to differ according to various demographic characteristics, particularly age, gender, level of education, and sociocultural factors (Donini et al., 2022; Gleaves et al., 2020). Therefore, this study predicts that obsession with healthy eating will differ based on these variables. Furthermore, research has shown that an obsession with healthy eating can manifest alongside symptoms of clinical eating disorders and is particularly associated with restrictive eating patterns and control-oriented behaviors (Strahler, 2021). It is also recognised that health anxiety can play a regulatory and triggering role in an individual’s eating behaviors and that perceived health threats can lead to excessive efforts to control eating behaviors (Mosewich et al., 2022). Consequently, this study anticipates positive correlations between health anxiety, healthy eating obsession, and clinical eating disorder symptoms.
The aim of this study was to examine the relationship between orthorexia nervosa, clinical eating disorders, and health anxiety in adults and adolescents.
The hypotheses of the study are presented in Figure 1.
Figure 1. Visual overview of all hypothesis. H1, hypothesis 1; H2, hypothesis 2; H3, hypothesis 3; H4, hypothesis 4; H5, hypothesis 5; H6, hypothesis 6.
Hypothesis 1: Healthy eating obsession varies by demographic characteristics.
Hypothesis 2: Healthy eating obsession is associated with clinical eating disorder.
Hypothesis 3: Health anxiety is associated with healthy eating obsession.
Hypothesis 4: BMI is associated with healthy eating obsession.
Hypothesis 5: BMI is associated with clinical eating disorder.
Hypothesis 6: Clinical eating disorder is associated with health anxiety.
2 Materials and methods
2.1 Study design
The study was a cross-sectional study, and data were collected between March 2023 and January 2024.
2.2 Study population
The study included 654 volunteers (211 males, 443 females) aged 19–50.
2.2.1 Inclusion criteria
• Individuals aged >19 and <50.
• Those without chronic diseases.
• Those who agreed to participate in the study.
2.2.2 Exclusion criteria
• Pregnant and breastfeeding individuals.
• Individuals aged <19 and >50.
• Those taking medication for psychological reasons.
• Those with chronic illnesses.
• Those who declined to participate in the study.
2.3 Study setting and duration
• Study period: April 2023–December 2023.
• Study location: Data were collected via a questionnaire and face-to-face interviews.
2.4 Sample size and sampling method
2.4.1 Sampling size calculation
Before starting the study, a power analysis was conducted using G*Power 3.1.9.7 to determine the number of individuals to be included in the sample. For this purpose, information obtained from similar previous studies (Awad et al., 2021) was used as a reference. The analysis assumed alpha (a) = 0.05, effect size (d) = 0.5, and power (1-b) = 0.95, which indicated a required sample of (N = 176). Our final sample (n = 654) exceeds this requirement. We chose d = 0.5 based on previous research in the field that reported medium effect sizes (Cohen, 1988).
2.4.2 Sampling strategy
The study included 654 volunteers (211 males, 443 females) aged 19–50. A pilot study was initially conducted with 40 participants. Minor modifications were made to address unclear or ineffective questions and wording. The study flowchart is shown in Figure 2. A pilot study was initially conducted with 40 participants. Minor adjustments were made to address unclear or ineffective questions and wording. The study flowchart is shown in Figure 2. Data were collected via a survey and face-to-face interviews. Each participant signed an informed consent form in accordance with the Declaration of Helsinki. Volunteers were seated in a quiet and comfortable position to allow them to easily complete the survey, which took approximately 20 min to complete.
Figure 2. Participant flow chart throughout the study.
Participants were recruited through a convenience sampling method. This approach was chosen due to the accessibility of the target population and the feasibility of in-person data collection. Although convenience sampling limits the generalizability of the findings, it is widely used in psychological research when probability sampling is not feasible.
2.5 Data collection procedures
The data collection tools used in the study are grouped under four main sections;
(1) General information (4 questions).
(2) Orthorexia Nervosa Scale (ORTO-R) (6 items).
(3) Clinical Impairment Assessment (CIA) (16 items).
(4) Short Health Anxiety Inventory (SHAI-18) (18 items).
(5) Anthropometric measurements.
2.5.1 General information
Demographic information of the patients, such as age, education level, gender, and marital status, was collected.
2.5.2 Anthropometric measurements
The researchers measured the body weight and height of all participants. These measurements were then recorded on a questionnaire. Body mass index (BMI) was calculated using the formula body weight (kg)/height (m2). Calculations were evaluated according to the World Health Organization’s BMI classification (2025). Participants were categorized as healthy body weight (18.5 ≤ BMI ≤ 24.9 kg/m2), overweight, and obese (≥25.0 kg/m2) (World Health Organization, 2025). Although BMI was included as a predictor in the present model, this index does not account for body composition or metabolic characteristics, which limits its precision as an indicator of health status.
2.5.3 Orthorexia nervosa scale (ORTO-R)
This scale consists of six items (Rogoza and Donini, 2021). It is a revised version of the 15-item ORTO-15 scale developed by Donini et al. (2005), which has shown an unstable factor structure across different populations. Participants respond using a 5-point Likert-type scale of “never,” “rarely,” “sometimes,” “very often,” and “always.” There is no cut-off point for this scale. Individuals are not classified as having ON based on their ORTO-R scores. Therefore, this scale cannot provide information on prevalence or incidence. Rather, scores obtained from the scale are used for comparison between groups. Although the ORTO-R has shown some psychometric instability and limitations in assessing the prevalence of orthorexia nervosa it was chosen in the present study because it remains the most widely used instrument for assessing orthorexic tendencies.
2.5.4 Clinical impairment assessment (CIA)
This scale is a 16-item self-report measure focusing on the past 28 days designed to measure the severity of psychosocial impairment associated with eating disorder features. It was developed as a measure of functional impairment in the areas of life that are typically affected by eating disorders. These areas include mood, self-concept, cognitive function, job performance and interpersonal function (Bohn and Fairburn, 2008). No study was found on the validity and reliability of the CIA in Turkish. The CIA consists of three subscales to capture clinical impairment in specific field: personal, cognitive and social. Participant responses are rated on a 4-point Likert scale (not at all = 0, a little = 1, a little = 2, a great deal = 3) (Bohn and Fairburn, 2008; Bohn et al., 2008). The CIA overall score is calculated as a intensity index (ranging from 0 to 48). Higher scores indicate bigger force of clinical impairment.
2.5.5 Short health anxiety inventory (SHAI-18)
This inventory comprises 18 items designed to assess health anxiety, regardless of physical health status. These items estimate an individual’s concern about their health, cognizance of somatic sensations and/or changes, and awed consequences of having an illness (Salkovskis et al., 2002). The Turkish validity and reliability of SHAI-18 was made by Aydemir et al. (2013). The scale is assessed using a 4-point Likert scale (never = 0, sometimes = 1, often = 2, almost always = 3). Scores range from 0 to 54 and consist of two subscale scores. Items 1–14 (range 0–42) address health-related anxiety, and items 15–18 (range 0–12) address negative consequences of being ill. Higher scores indicate beliefs about negative consequences of illness and greater health anxiety (Reas et al., 2010).
Although the CIA and SHAI-18 assess distinct constructs, both instruments capture anxiety-related functional impairment, which may partly explain the observed associations.
2.6 Data analysis and missing data handling
The data were analyzed using IBM SPSS Statistics 22. Categorical variables were used in the interpretation of the findings. Percentages and distributions were calculated and mean and standard deviation were calculated for quantitative variables. Assessment of data normality was performed through the Shapiro–Wilk test. For normally distributed data, the Independent Samples t-test was used to compare two groups in terms of quantitative variables. The correlation between quantitative variables was analyzed using the Pearson method. Multiple regression analysis was performed for the dependent variables ORTO-R, CIA, and SHAI-18. Prior to conducting multiple regression analyses, assumptions were checked. The residuals were normally distributed, scatterplots suggested homoscedasticity, and collinearity diagnostics indicated no multicollinearity (Tolerance > 0.20; VIF < 5). A significance level of p < 0.05 was used in all analyses.
3 Ethical considerations
Ethics approval was received for this study from the University Health Sciences Non-Interventional Research Ethics Committee with decision number 37, dated 03/30/2023. The study was carried out in accordance with the Declaration of Helsinki. Participants were informed about the purpose and procedures of the study. Written consent informed consent was obtained from all the participants involved in the study. The study posed no risks to participants, and participants were free to withdraw at any time without any consequences.
4 Results
Among the participants, 67.7% were female and 32.3% were male. Most of them (51.8%) were between the ages of 32 and 50, and 53.2% were married. The majority of participants were undergraduates (88.2%), 58.3% (n = 381) had a healthy body weight, and 41.7% (n = 273) were slightly overweight or obesity (see Table 1).
Table 1. Characteristics of the 654 participants included in this study.
Cronbach’s alpha coefficients for the scales used in the study, ORTO-R, CIA and SHAI-18, are presented in Table 2. Cronbach’s alpha for ORTO-R was 0.800, CIA was 0.950 and SHAI-18 was 0.910.
Table 2. Cronbach’s alpha values of ORTO-R, CIA and SHAI-18 scales.
Table 3 presents the mean (X̄) and standard deviation (SD) scores for ORTO-R, CIA, and SHAI-18, categorized according to the participants’ demographic characteristics. ORTO-R scores were higher in undergraduate (16.5 ± 5.24) (p = 0.035) and in those with slightly overweight/obesity (17.4 ± 5.55) (p = 0.000). The CIA score was higher in female participants (12.4 ± 11.31) than in male participants (8.5 ± 10.36) (p = 0.000), in those in the 18–31 age group (12.9 ± 11.47) than in those in the 32–50 age group (9.52 ± 10.62) (p = 0.000), in single participants (13.10 ± 11.63) than in married participants (9.4 ± 10.44) (p = 0.000), in undergraduates (11.5 ± 11.24) than in high school graduates or below (8.1 ± 10.02) (p = 0.008, 0.000), singles (21.7 ± 10.99) (p = 0.016) and undergraduates (20.9 ± 11.00) (p = 0.035).
Table 3. Arithmetic mean and standard deviation (SD) values of ORTO-R, CIA, and SHAI-18 scores according to participants’ demographic ınformation (n = 654).
Age showed a small positive correlation with BMI (r = 0.384, p = 0.000), while it was negatively correlated with CIA (r = −0.220, p = 0.000) and SHAI-18 (r = −0.162, p = 0.000). BMI was positively correlated with ORTO-R (r = 0.183, p = 0.000) and CIA (r = 0.122, p < 0.01). Significant positive correlations were also observed between ORTO-R and CIA (r = 0.461, p = 0.000), ORTO-R and SHAI-18 (r = 0.364, p = 0.000), as well as between CIA and SHAI-18 (r = 0.429, p = 0.000) (Table 4; Figures 3A–C).
Table 4. Correlation analysis between participants’ age, BMI, ORTO-R, CIA, and SHAI-18 scale scores (r).
Figure 3. (A–C) Relationship between ORTO-R, CIA and SHAI-18 total scores. ORTO-R, orthorexia nervosa scale; CIA, clinical impairment assessment; SHAI-18, short health anxiety inventory-18.
Table 5 displays the findings of the multiple linear regression analyses for the participants’ ORTO-R, CIA, and SHAI-18 scores.
Table 5. Multiple linear regression analysis of ORTO-R, CIA and SHAI-18.
Increases in BMI (standardized β = 0.141, p = 0.000, Adjusted R2 = 0.266), CIA (standardized β = 0.350, p = 0.000, Adjusted R2 = 0.266), and SHAI-18 (standardized β = 0.203, p = 0.000, Adjusted R2 = 0.266) were associated with increases in ORTO-R. Decreases in female gender (standardized β = 0.087, p = 0.016, Adjusted R2 = 0.338) and age (standardized β = −0.140, p = 0.002, Adjusted R2 = 0.338) and increases in BMI (standardized β = 0.154, p = 0.000, Adjusted R2 = 0.338), ORTO-R (standardized β = 0.316, p = 0.000, Adjusted R2 = 0.338) and SHAI-18 (standardized β = 0.262, p = 0.000, Adjusted R2 = 0.338) were associated with increases in CIA. Increases in ORTO-R (standardized β = 0.213, p = 0.000, Adjusted R2 = 0.228) and CIA (standardized β = 0.305, p = 0.000, Adjusted R2 = 0.228) were associated with increases in SHAI-18.
5 Discussion
Behaviors associated with ON may result in emotional, cognitive, and social outcomes that adversely affect individuals’ daily functioning. Eliminating foods perceived as “unhealthy” may lead to nutrient deficiencies and weight loss Although ON and healthy eating may appear alike at first glance, ON is characterized by rigid dietary rules, whereas healthy eating promotes flexibility and diversity in food choices. In healthy eating, occasional indulgence is accepted without feelings of guilt, whereas ON is marked by adverse emotional responses when one strays from self-imposed dietary standards (Cena et al., 2019; Mitrofanova et al., 2025). An excessive focus on healthy eating, in combination with psychological characteristics like perfectionism (Barlow et al., 2024; Novara et al., 2021b), is consistently associated with increased health anxiety and eating disorder symptoms (Levin et al., 2023; Tan et al., 2023; Donini et al., 2022; Yılmaz and Dundar, 2022).
The relationship between orthorexia and gender is inconsistent. While some studies report no significant gender difference (McComb and Mills, 2019; Barlow et al., 2024; Yılmaz and Dundar, 2022), one study also reports that orthorexia symptoms may be more common in women (Zagaria et al., 2023). It has also been reported that tendencies toward healthy eating are similar between men and women, but the tendency toward healthy eating is more pathological in women (Strahler et al., 2022). There are also studies reporting higher orthorexic tendencies in women, but no significant gender effect or a higher risk in men with higher BMI (Zagaria et al., 2023; Hallit et al., 2021; Sanlier et al., 2016; Oberle et al., 2017). In the current study, ORTO-R did not differ by gender (p > 0.05) (Table 3). Clinical eating disorders are linked to a higher risk among women (Gramaglia et al., 2019). In this study, the CIA score was found to be higher in female participants (12.4 ± 11.31) (p < 0.001) (Table 3). Health-related anxiety is reported to be twice as common in women as in men (Jahrami et al., 2019). In the present study, female had significantly higher SHAI-18 scores (21.6 ± 10.52) compared to male (18.6 ± 11.63) (p < 0.05) (Table 3). Conversely, another study reported no statistically significant gender difference in SHAI-18 scores (Kris-Etherton et al., 2021). This difference observed between men and women may vary according to social roles, suggesting that in some traditional societies, men are not as obsessed with body weight as women.
Young people’s nutritional sensitivities may make them particularly susceptible to ON due to the frequency of eating disorders (Pontillo et al., 2022; Alshayea, 2020). Studies have indicated that eating disorders are most common between the ages of 12–35 (Barlow et al., 2024; Zickgraf and Barrada, 2022; de Vos et al., 2017). In contrast to this result, another study reported no significant age-related difference in ON prevalence (Luck-Sikorski et al., 2019). In the present study, ON was not significantly related to age (p > 0.05) (Table 3). Clinical eating disorders are linked to a heightened risk among young individuals (Reynolds, 2018). Findings of another study revealed no age-related variation in clinical eating disorders among young men and women (Argyrides et al., 2020). In this study, participants aged 18–31 had higher CIA scores (12.9 ± 11.47) (p < 0.001) (Table 3). Although no difference was found in the SHAI-18 score according to age in another study (He et al., 2022), this study found it to be higher in the 18–31 age group (21.9 ± 10.51) (p < 0.05) (Table 3). This may suggest that young age is a factor that increases health anxiety and that young people are more sensitive to these issues (Arnáez et al., 2019).
The impact of marital status is not emphasized or remains secondary in prior studies (McComb and Mills, 2019; Albery et al., 2022; Escolar-Llamazares et al., 2023; Witaszek et al., 2023). In this study, single individuals had higher CIA (13.10 ± 11.63) and SHAI-18 scores (21.7 ± 10.99) than married individuals (Table 3). Another study reported that individuals with higher education levels have more knowledge about a healthy lifestyle and a higher prevalence of ON (Reivan Ortiz et al., 2025). In this study, the ORTO-R score was found to be higher in university graduates (16.5 ± 5.24) (p < 0.001) (Table 3). Clinical eating disorders are associated with an increased risk, particularly among university students (He et al., 2022). This study also found that it was higher in university graduates (11.5 ± 11.24) (p < 0.05) (Table 3). In this study, the SHAI-18 score was found to be higher in university graduates (20.9 ± 11.00) (p < 0.05) (Table 3), suggesting that education level and knowledge accumulation may lead to an increase in health anxiety. Another study reported that university graduates were more anxious about health-related information (Gkiouleka et al., 2022).
The study conducted by Łucka et al. (2025) on two cohorts of young adults in Poland demonstrated that orthorexic tendencies co-occur with anxiety and disordered eating symptoms and vary substantially across different socio-cultural contexts. These findings support the view that ON is a heterogeneous construct and highlight the importance of considering demographic and cultural factors when interpreting orthorexia-related outcomes.
It is thought that individuals with high BMI may be more prone to clinical impairment by causing deterioration in physical functioning and, due to the limitations caused by this condition, deterioration in social functioning (Myrick and Willoughby, 2019). Studies support a positive relationship between increased BMI and ON (Zickgraf and Barrada, 2022; Sahlan et al., 2022). It is thought that the deterioration in body image experienced by obese individuals may make them more obsessed with health. Furthermore, some studies have found no relationship between BMI and ON (Reynolds, 2018; Abdullah et al., 2020). Orthorexia can sometimes occur as a distinct pattern without body image concerns (Barlow et al., 2024; Zickgraf and Barrada, 2022; Chard et al., 2019). Clinical eating disorders are associated with an increased risk of developing high BMI (He et al., 2022). Similar studies have also associated higher BMI with higher CIA, suggesting that increased BMI brings with it many undesirable health risks (Reivan Ortiz et al., 2025; Łucka et al., 2024). One study found that BMI is not a simple indicator of weight but rather a clinical risk indicator (Dudzikowska et al., 2025). In this study, BMI was positively correlated with ORTO-R (r = 0.183, p < 0.001) and CIA (r = 0.122, p < 0.05) (p < 0.001) (Table 4).
According to Chace and Kluck (2021), orthorexia symptoms were significantly and positively associated with health anxiety, which emerged as an important predictor of the condition. Levin et al. (2023) observed a stronger association between orthorexia subprofiles, health anxiety, and BMI among university students. This suggests that the relationship between ON and health anxiety may be moderate, and that health preoccupation may lead to orthorexic behaviors beyond those seen in traditional eating disorders (Strahler et al., 2022; Barlow et al., 2024; Novara et al., 2021b). Studies support the view that ON is more closely related to eating disorders than obsessive-compulsive disorder. However, the moderate strength of these associations suggests that ON may be a distinct clinical entity (Novara et al., 2021b; Vaz et al., 2020). Another study found strong associations between orthorexia and health anxiety (Kris-Etherton et al., 2021), and the effect of SHAI-18 on ORTO-R was similar to this study (p < 0.001) (Table 5).
Individuals may feel superior to others by comparing their own lifestyles and eating habits with those of others through perfectionist behaviors related to healthy eating (Atchison and Zickgraf, 2022). This can lead to an unhealthy mindset based on healthy eating habits (Argyrides et al., 2020). Generally, when the pursuit of healthy eating becomes rigid and obsessive, leading to significant health problems and influenced by factors such as anxiety, perfectionism, and health controllability, a “dark side” can occur (Strahler et al., 2022; Chace and Kluck, 2021; Greville-Harris et al., 2022; Barlow et al., 2024).
This study demonstrates that an obsession with healthy eating, health anxiety and symptoms of an eating disorder may be linked through shared processes of anxiety and control. As health anxiety increases, individuals may be more likely to engage in heightened regulation and restriction of their eating behaviors in an effort to “protect their health.” This pattern may be associated with higher levels of orthorexic tendencies, which in turn are linked to elevated eating-disorder–related symptoms. In the Turkish context, societal expectations regarding body image and the social significance of sharing food can exacerbate the emotional impact of ON. It should also be noted that ON has behavioral, cognitive and emotional dimensions. From a clinical perspective, early screening for ON in individuals with high health anxiety is recommended. From a public health perspective, nutritional messages should emphasise flexibility and balance.
These results emphasize the connection between orthorexic behaviors and clinical eating disorders in relation to health anxiety. Findings from the current study suggest that health anxiety is associated with orthorexic tendencies as well as risk for clinical dysfunction related to eating behaviors.
In addition to the observed associations between health anxiety, orthorexic tendencies, and eating-disorder–related impairment, several psychological mechanisms may help explain these relationships. Elevated health anxiety may be linked to rigid, perfectionistic standards around “clean” eating, increased cognitive control over food choices, and difficulties regulating emotions factors that can reinforce orthorexic and disordered eating patterns. Impulsivity may further contribute to fluctuations between rigid restriction and loss of control (Strahler et al., 2022; Barlow et al., 2024; Sanseverino et al., 2025). Although these mechanisms were not measured in the present study, future research incorporating perfectionism, cognitive control, impulsivity, and emotion-regulation styles may clarify the pathways connecting health anxiety with orthorexia and eating-related psychopathology.
5.1 Strengths and limitations
Because our study was conducted in major cities, it is inappropriate to generalize to the entire country. Additionally, the cultural characteristics of the Turkish context, where food has strong social and emotional meaning and appearance norms are more publicly emphasized, may influence how healthy eating behaviors are expressed. Therefore, cultural specificity should be considered when interpreting the findings. Furthermore, the cross-sectional nature of this study, rather than its longitudinal nature, is a limitation. This design does not allow for the establishment of a causal relationship between the variables. Future studies employing longitudinal or experimental designs could more accurately determine the temporal sequence of ON, health anxiety and clinical eating disorder symptoms. ON, clinical eating disorders, and health anxiety can be influenced by psychological and demographic factors, and the short timeframe for clarifying these differences and their long-term effects is another limitation. Another limitation concerns the diagnostic controversies surrounding the ORTO-R. Recent literature has questioned its construct validity and its ability to distinguish clearly between adaptive, health-oriented eating patterns (“healthy orthorexia”) and maladaptive, impairment-related orthorexic behaviors (Gkiouleka et al., 2022). As orthorexia is increasingly understood as a heterogeneous phenotype, elevated ORTO-R scores in our sample may reflect a combination of these distinct dimensions, which should be considered when interpreting the findings. Furthermore, variables such as depression, perfectionism and mindfulness, which are known to affect both anxiety and eating behavior, were not measured and may act as potential confounders, influencing the observed relationships. Varying diagnostic criteria make it difficult to assess associations. According to traditional Turkish practices, most men are reluctant to answer questions in these types of surveys. Therefore, the number of men is lower than the number of women. Additionally, as all measures were based on self-report questionnaires, there is a possibility of response bias and social desirability effects, particularly with regard to sensitive behaviors such as eating patterns and anxiety levels. The unequal representation of male and female volunteers among the participants may represent a selection bias, preventing our results from being generalized to the entire population, gender, age group, and education level.
In this study, adjusted R2 values rather than eta-squared were used to evaluate model fit. This indicates that additional factors may influence the observed associations. Moreover, significant demographic differences in variables such as age, sex, and marital status suggest that these characteristics may act as potential confounders in the model. Future research would benefit from the use of interaction terms or multilevel models to better account for demographic variability.
6 Conclusion
Health anxiety plays a decisive role in eating behaviors, shaping food choices and negatively impacting individuals’ quality of life. This situation points to a multidimensional risk environment that can threaten not only individuals’ physical health but also their psychological well-being. This study demonstrates a significant relationship between ON, clinical eating disorders, and health anxiety. The positive correlations observed between variables suggest that individuals’ excessive preoccupation with healthy eating may increase with health anxiety. Our results support the notion that ON is not merely an obsession with healthy eating but is instead associated with eating-disorder–related symptoms. Our study found that CIA and SHAI-18 scores were higher in women than in men, suggesting a greater association with anxiety, low self-esteem, and other eating disorder symptoms in women. Consequently, the current study found health anxiety, obsession with healthy eating, and clinical eating disorders to be risk factors. Health anxiety may be associated with individuals’ food choices and with higher levels of eating-disorder–related symptoms, both of which are linked to lower quality of life. Further studies examining the role of various variables in conjunction with health anxiety will be an important step toward a more comprehensive understanding of the causes and consequences of ON and other eating disorders. In future research, longitudinal or intervention-based designs could be used to clarify the causal relationships between these variables and observe how these patterns evolve over time. Additionally, cross-cultural and experimental studies could contribute to determining whether these relationships are universal or influenced by cultural contexts.
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
Ethics statement
This study protocol was reviewed and approved by the Non-Interventional Research Ethics Committee of University (approval number 37, dated March 30, 2023). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.
Author contributions
NS: Methodology, Supervision, Writing – original draft, Writing – review & editing, Investigation, Visualization. ZJ: Data curation, Investigation, Methodology, Writing – original draft, Visualization. EK: Data curation, Investigation, Methodology, Visualization, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Acknowledgments
The authors would like to thank all the participants in this study. They are sincerely appreciated for their helpful and wholehearted cooperation. We would like to thank the graduate students (BYT, SAA, and EDY) who supported the data collection.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: nutrition, orthorexia nervosa, clinical impairment, health anxiety, adult
Citation: Sanlier N, Ejder ZB and Kaya EY (2025) The relationship between healthy eating obsessions, clinical eating disorder, and health anxiety: the dark side of the pursuit of healthy eating. Front. Psychol. 16:1705064. doi: 10.3389/fpsyg.2025.1705064
Edited by:
Costela Lacrimioara Serban, Victor Babes University of Medicine and Pharmacy, RomaniaReviewed by:
Omer Horovitz, Tel-Hai College, IsraelMirko Duradoni, Unimercatorum University, Italy
Marta Kopańska, University of Rzeszow, Poland
Copyright © 2025 Sanlier, Ejder and Kaya. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Nevin Sanlier, bmV2aW50ZWtndWxAZ21haWwuY29t
†ORCID: Nevin Sanlier, orcid.org/0000-0001-5937-0485
Zeynep Bengisu Ejder, orcid.org/0000-0001-7231-8497
Elif Yildiz Kaya, orcid.org/0000-0003-3350-4777