Archives of Psychiatric Nursing 32 (2018) 200–205

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

A Comparison of Eating Attitudes Between Vegans/Vegetarians and T

Nonvegans/Nonvegetarians in Terms of Orthorexia Nervosa☆
⁎
Pınar Çiçekoğlu , Güzin Yasemin Tunçay
Health Sciences Faculty of Çankırı Karatekin University, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: This descriptive study was performed to compare signs of orthorexia nervosa and eating habits and attitudes of
Orthorexia nervosa vegans/vegetarians and nonvegans/nonvegetarians. The study sample included 62 people, of whom 31 were
Eating habits vegan/vegetarian and 31 were nonvegan/nonvegetarian. Data were gathered with a personal characteristics
Vegan form, Orthorexia Nervosa Evaluation Scale-11, Eating Attitudes Test-40 and Maudsley Obsessive Compulsive
Vegetarian
Inventory. There were not any significant differences between scores for Orthorexia Nervosa Evaluation Scale-
Obsession
Compulsion
11, Eating Attitudes Test-40 and Maudsley Obsessive Compulsive Inventory (p > 0,05). As scores for
Orthorexia Nervosa Evaluation Scale-11 decreased, predisposition to orthorexia nervosa increased. Therefore,
although correlation coefficients were negative, they were considered positive. There was a significant, negative
relation between Eating Habits Test-40 scores and Orthorexia Nervosa Evaluation Scale-11 scores (r = −0.290,
p = 0.002) and between Maudsley Obsessive Compulsive Inventory scores and Orthorexia Nervosa Evaluation
Scale-11 scores (r = −0.319, p = 0.012). As poor eating habits and obsessive symptoms increased, so did or-
thorectic symptoms. In light of obtained results, it seems that people become vegan/vegetarian mainly for
ethical reasons and that veganism/vegetarianism is not associated with obsession of healthy eating.

Introduction eating for a few weeks cannot be considered as a disorder unless it

The word orthorexia in orthorexia nervosa (ON) is made up of the
words orthos (accurate, appropriate) and orexia (hunger or nutrition).
These words define excessive preoccupation with selection of healthy,
right food. Orthorexia, obsession with consumption of healthy food,
was first defined by Steven Bratman in 1997 to reveal that it is a variant
of anorexia nervosa (AN) (Gezer & Kabaran, 2013). The main char-
acteristic of ON is willingness to consume healthy food. A change in this
willingness into an excessive mental and behavioral action reminds
obsessive compulsive disorder (Brytek-Matera, 2012; Özenoğlu & Dege,
2015). The criterion for selection of food in individuals with ON is to
eat healthy food. They can prefer to be hungry to consume food which
they regard as unnatural and harmful to their health (Arusoğlu,
Kabakci, Köksal, & Merdol, 2008). They also feel anxious about mate-
rial and methods used for food preparation and refuse to consume
different types of food depending on their ingredients and methods of
preparation (Zamora, Bonaechea, Sanchez, & Rial, 2005) (Tables 1–6).
An individual can be thought to have ON based on two criteria:
- Persistence of healthy nutrition habits for a long time (healthy
becomes an obsession) (Dunn & Bratman, 2016),
- Presence of significant negative effects on life (thinking about food
to prevent stress, thinking about how food is prepared to prevent
negative feelings and spending most of the day by thinking about
food) (Dunn & Bratman, 2016).
Although ON is not included in Diagnostic and Statistical Manual of
Mental Disorders-V, 2013 (DSM-V 2013) by American Psychiatric As-
sociation (APA), researchers have focused their attention on it and
wondered whether it can be considered as a disorder (Duran, 2016;
Ergin, 2014).
Orthorectic individuals may depict obsessive tendencies. They may
have intrusive thoughts about food and health, feel extremely anxious
about dirt and contaminations and exhibit rituals like behavior while
preparing and eating food. The most important difference between
orthorexia and obsessive-compulsive disorder is that the content of
obsessions in orthorexia is perceived as ego-syntonic rather than ego-
dystonic (Koven & Abrey, 2015).
The groups at risk of ON reported in the literature are the ones with
high awareness about healthy eating like medical students (Fidan,

☆
The results of this study were presented as an oral presentation at the International Conference on Nursing (ICON-2017) on 16–18 March 2017.
⁎
Corresponding author.
E-mail addresses: pcicek78@hotmail.com (P. Çiçekoğlu), gyasemintuncay@gmail.com (G.Y. Tunçay).

https://doi.org/10.1016/j.apnu.2017.11.002
Received 27 March 2017; Received in revised form 29 August 2017; Accepted 2 November 2017
0883-9417/ © 2017 Elsevier Inc. All rights reserved.
P. Çiçekoğlu, G.Y. Tunçay Archives of Psychiatric Nursing 32 (2018) 200–205

Table 1 Table 4
Socio-demographic features of the participants. The distribution of MOCI, EAT-40 and ORTO-11 scores of the vegans/vegetarians and the
nonvegans/nonvegetarians according to results of Mann-Whitney U test.
Features Vegans/vegetarians Nonvegans/ Total
nonvegetarians Scales Features N Mean rank Sum of U p
ranks
N % N % N %
MOCI Vegan/vegetarian 31 29.69 920.50 424.5 0.429
Male 9 29.0 15 48.4 24 77.4 Nonvegan/ 31 33.31 1032.50
Female 22 71.0 16 51.6 38 122.6 nonvegetarian
Married 7 22.6 17 54.8 24 77.4 EAT-40 Vegan/vegetarian 31 35.19 1091.00 366.0 0.106
Single 24 77.4 14 45.2 38 122.6 Nonvegan/ 31 27.81 862.00
High school graduate 2 6.5 – – 2 6.5 nonvegetarian
University graduate 21 67.7 24 77.4 45 145.1 ORTO-11 Vegan/vegetarian 31 33.32 1033.00 424.0 0.423
Master degree 8 25.8 7 22.6 15 48.4 Nonvegan/ 31 29.68 920.00
Smoker 16 51.6 12 38.7 28 90.3 nonvegetarian
Nonsmoker 15 48.4 19 61.3 34 109.7
Taking alcohol 26 83.9 7 22.6 33 106.5
regularly Table 5
Not taking alcohol 5 16.1 24 77.4 29 93.5 The distribution of MOCI, EAT-40 and ORTO-11 scores by gender according to results of
Doing exercise 12 38.7 6 19.4 18 58.1 Mann-Whitney U test.
regularly
Not doing exercise 19 61.3 25 80.6 44 141.9 Scales Features N Mean rank Sum U P
BMI of lower than 5 16.1 3 9.7 8 25.8 of
18,5 kg/m2 ranks
(thin)
BMI of 18,5–24,9 kg/ 18 58.1 13 41.9 31 100.0 Vegan/ MOCI Male 9 11.67 105 60.0 0.094
m2 (normal vegetarian Female 22 17.77 391
weight) EAT-40 Male 9 23.72 213.5 29.5 0.001
BMI of over 25–29,9 7 22.6 12 38.7 19 61.3 Female 22 12.84 282.5
kg/m2 ORTO-11 Male 9 14.67 132 87.0 0.623
(overweight) Female 22 16.55 364
BMI of 30–34,9 (First 1 3.2 3 9.7 4 12.9 Nonvegan/ MOCI Male 15 14.50 217.5 97.5 0.379
degree obese) nonvege- Female 16 17.41 278.5
Total 31 100.0 31 100.0 62 100.0 tarian EAT-40 Male 15 20.50 307.5 52.5 0.006
Female 16 11.78 188.5
ORTO-11 Male 15 16.87 253 107.0 0.626
Table 2 Female 16 15.19 243
The distribution of vegan/vegetarian features of the participants.

Features N %
Table 6
Correlations between MOCI, EAT-40 and ORTO-11 scores.
Type of vegetarians Vegan 15 48.4
Vegetarian 16 51.6
Scales Correlation MOCI EAT-40 ORTO-11
Duration of veganism/ Since birth 5 16.1
vegetarianism 1–5 years 17 51.6 MOCI R 1 0.078 −319*
5–10 years 6 19.4 p – 0.547 0.012
> 10 years 4 12.9 n 62 62 62
Reasons for becoming a Ethical reasons 25 54.3 EAT-40 R 0.078 1 −0.290*
vegan/vegetariana Being against exploitation of animals 5 10.9 p 0.547 – 0.022
Political reasons 4 8.7
n 62 62 62
Disgust 5 10.9
ORTO-11 R − 0.319* − 0.290* 1
Other reasons (ecological, 7 15.2 p 0.012 0.022 –
conscientious, religious and being n 62 62 62
against sexism)

a
The participants had more than one response. Percentages are based on the number
of responses.
strict rules about eating. In this respect, vegans/vegetarians can be
thought to be at risk of ON. However, there have not been any studies
about the issue in the literature.
Table 3
The distribution of the scores for ORTO-11, EAT-40 and MOCI.

Veganism/vegetarianism
Scales Features N X ± S Min Max

MOCI Vegan/vegetarian 31 10.8 ± 5.3 4 32 The word vegetarian stems from the Latin word vegetus, which
Nonvegan/nonvegetarian 31 12.1 ± 6.5 2 24 means lively, healthy and alive (Vegetarian Club, 2015). International
EAT-40 Vegan/vegetarian 31 18.8 ± 8.3 7 43
Vegetarians Union (IVU) defined vegetarianism in 2011 as “consump-
Nonvegan/nonvegetarian 31 15.3 ± 7.4 4 36
ORTO-11 Vegan/vegetarian 31 27.7 ± 2.8 24 34 tion of food derived from plants only with or without animal products
Vegan/vegetarian 31 27.1 ± 3.4 19 35 like dairy products, eggs and honey” (Vegan and Vegetarian Association
of Turkey, 2016). Vegetarians eat grains, legumes, fruit, vegetables and
seeds. They do not eat meat from any animals, including red meat,
Ertekin, Işıkay, & Kırkpınar, 2010), doctors (Bağci Bosi, Çamur, & chicken and sea food (e.g. fish, lobster, crab and shrimps etc.)
Güler, 2007; Fidan et al., 2010) and dieticians (Asil & Sürücüoğlu, (Vegetarian Society, 2016).
2015; Gezer & Kabaran, 2013) and those placing great importance on Vegans are against the use of products tested on animals (cosmetics,
body image like performance actors (Aksoydan & Çamcı, 2009; Dalmaz detergents and toothpaste etc.). They do not consume soap containing
& Tekdemir Yurtdaş, 2015). The individuals adopting veganism/vege- animal fat and chocolate, cake and pasta containing milk. They do not
tarianism thought to have high awareness about healthy nutrition have go to circuses since animals are used there and do not watch films in

201
P. Çiçekoğlu, G.Y. Tunçay
which animals are used (Çetin, 2015; Frankie, 2005; Nuh'un Gemisinde
Veganizm Etiği [Veganism Ethics in Noah's Ark], 2014; Karabudak,
2008; Kınıkoğlu, 2015; Ongan & Ersoy, 2015; Pilis, Stec, Zych, & Pilis,
2014; Türkmen, 2015; Vegan & Vegetarian Association of Turkey,
2015; Vegetarian Society, 2016; Pilis et al., 2014).
Reasons for adopting veganism/vegetarianism, considered as not
only a type of nutrition but also a lifestyle, philosophy of life and a
bioethical approach, may vary. While some people prefer to become
vegans/vegetarians to be healthy, others adopt it only because they
think animal rights should be respected based on their ethical values.
There are also people adopting veganism/vegetarianism for ecological,
religious, cultural and taste related reasons. Some choose it for more
than one reason (VEBU, 2015; Vegetarian Society, 2016; Best, 2009;
Kıran, 2015; Pollan, 2009; Tunçay Son, 2016).
There have been numerous studies about nutrition in vegans/ve-
getarians and they have been shown to have better health status than
people eating meat. They have been reported to have lower blood
cholesterol levels and lower rates of cardiovascular diseases, obesity,
diabetes mellitus, arteriosclerosis and hypertension. They are less likely
to have cancer since they consume high amounts of legumes, walnuts,
hazelnuts, fruit, vegetables and grains. However, it is important to have
sufficient and balanced nutrition. Due to unbalanced nutrition, vege-
tarians, especially vegans can suffer from anemia, vitamin B12 defi-
ciency and osteoporosis Therefore, vegans may need iron, calcium, zinc
and vitamins B12 and D (Dyett, Rajaram, Haddad, & Sabate, 2014;
Karabudak, 2008; Kıran, 2015; Le & Sabaté, 2014; Orlich et al., 2015;
Pilis et al., 2014; Tantamango-Bartley, Jaceldo-Siegl, Fan, & Fraser,
2013; Yokoyama, Barnard, Levin, & Watanabe, 2014).
It is not sufficient to evaluate types of nutrition only by comparing
health status between vegans/vegetarians and nonvegans/non-
vegetarians. Further studies about the issue should focus on other fac-
tors likely to affect health such as ON (Michalak, Zhang, & Frank
Jacobi, 2016; Özyiğit, 2016).
Although DSM-V criteria do not involve ON yet, it is a nutritional
obsession, the frequency of which gradually increases and which more
frequently affects certain groups of people (Duran, 2016). Among risk
groups are women, adolescents, sportsmen/sportswomen, medical
students, health professionals and dieticians (Ergin, 2014). There has
been an interest in whether vegans and vegetarians can be included into
these risk groups and veganism/vegetarianism have been thought to be
associated with a nutrition disorder, especially ON.
The present study was performed to determine the frequency of ON
and eating attitudes in vegans/vegetarians and nonvegans/non-
vegetarians and whether vegans/vegetarians developed ON.
Methods
Study design
This study had a descriptive design and was carried out to reveal
orthorexia, obsession symptoms and eating habits in vegans/vegetar-
ians and nonvegans/nonvegetarians.
Study population and sample
The study population comprised vegans/vegetarians and non-
vegans/nonvegetarians older than 18 years. A purposeful sampling,
snowball sampling was used and individuals agreeing to participate in
the study were included into the sample. The sample was composed of
62 individuals, of whom 31 were vegan/vegetarian and 31 were non-
vegan/nonvegetarian.
Preparation and administration of data collection tools
Data were gathered in four steps between 1 June and 6 August
2016. In the first step, a questionnaire composed of questions about
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Archives of Psychiatric Nursing 32 (2018) 200–205
descriptive characteristics of the participants was utilized. In the second
step, Orthorexia Nervosa Evaluation Scale-11 (ORTO-11) was used to
calculate the risk of ON. In the third step, Eating Attitudes Test-40
(EAT-40) was employed to reveal eating behavior and attitudes and
signs of possible abnormalities in eating behavior. In the final step,
Maudsley Obsessive Compulsive Inventory (MOCI) was utilized. The
study was announced and vegans/vegetarians were contacted through
social networking sites. When they accepted to participate in the study,
their e-mail addresses were requested. The data collection tools were
sent to the e-mail addresses. In addition, the study was announced in a
vegan/vegetarian café in Ankara and individuals agreeing to participate
in the study were also requested to complete the data collection tools.
The tools were filled in by randomly selected vegans/vegetarians and
nonvegans/nonvegetarians.
Orthorexia Nervosa Evaluation Scale-11 (ORTO-11)
ORTO-11 is a self-rating scale developed by Steven Bratman and
composed of 10 questions to determine signs of AN. It was revised by
Donini, Marsilli, Graziani, Imbriale, and Canella (2005) from Italy;
some statements were replaced by new ones and expressions in some
other statements were changed. Finally, the scale included 15 questions
directed towards evaluating a tendency to ON (Dalmaz & Tekdemir
Yurtdaş, 2015). It was adapted into Turkish by Arusoğlu in 2006 and
named ORTO-11 (Arusoğlu, 2006). Higher scores for the scale show a
decreased risk of ON. Although correlation coefficients were negative in
the present study, they were considered as positive and evaluations
were made accordingly because as scores for the scale decrease, ten-
dency to ON increases. Items were written in Simple Present Tense and
scored on a four-point scale. They were about obsessive behavior of the
participants related to selection, purchase, preparation and consump-
tion of food they considered as healthy and Cronbach's alpha was found
to be 0.62. Some of the questions in the scale can be exemplified as in
the following: item 3. Is the taste of food more important than the
quality when you evaluate food?; item 5. Does the thought about food
worry you for more than 3 h a day?; item 8. Do you think that eating
healthy food changes your life-style (frequency of eating out, friends,
…?) (Gezer & Kabaran, 2013).
Maudsley Obsessive Compulsive Inventory (MOCI)
MOCI is utilized to determine type and prevalence of obsessive
compulsive symptoms. The original inventory was developed by Erol
and Savaşır (1988) to evaluate various obsessive-compulsive symptoms.
It included 30 true-false items. It had four subscales: checking, cleaning,
slowness and doubting. The alpha coefficients for the subscales were as
follows: 0.70 for checking, 0.66 for cleaning, 0.31 for slowness and 0.56
for doubting. The total score for the inventory was 30. Its test-re-test
reliability coefficient was 0.80 and its internal consistency coefficient
was reported to range from 0.60 to 0.87 (Erol & Savaşır, 1988).
The inventory was adapted to Turkish by Erol and Savaşır. Seven
items about thinking were added to the Turkish version, which was
composed of 37 true-false items. Although its internal consistency
coefficient was 0.44 at first, it changed into 0.81 for 30 items after some
items were rewritten and 0.86 for 37 items. Each marked item is as-
signed the score one. Only item 11 is scored in the reverse order. The
total score is calculated by adding the scores for each item. The total
score for the inventory is 37 and high scores for the inventory indicate
severe obsessive-compulsive symptoms. MOCI was utilized in this study
to measure the prevalence of obsessive-compulsive symptoms. Some of
the items in the inventory are as in the following: item 2. I often think
about unpleasant things and have difficulty in getting rid of these
thoughts from my mind; item 22. I check some things more than once;
item 37. Sometimes I'm obsessed with unimportant thoughts and they
disturb me for days (Erol & Savaşır, 1988).
Eating Attitudes Test-40 (EAT-40)
EAT-40 was developed by Savaşır and Erol (1989) to measure eating
P. Çiçekoğlu, G.Y. Tunçay
disorder symptoms. The validity and the reliability of the Turkish
version of the test were achieved by Savaşır and Erol (1989) and its test-
re-test reliability was reported to be 0.65. It is a 6-point Likert scale and
responses to items in the scale range from “always” to “never”. For
items 1, 18, 19, 23, 27 and 39, the responses “sometimes”, “rarely” and
“never” are assigned the points one, two and three respectively and
other responses are scored zero. The total score, obtained by adding
points for each item, may range from zero to 120. It is directly pro-
portional to an eating disorder. A score 30 and above suggests a risk of
an eating disorder. Cronbach alpha of the original scale based on Kuder-
Richardson formula was 0.79 and its construct validity coefficient was
0.87. The test-retest reliability coefficient of the Turkish version was
0.65 and its reliability coefficient based on Kuder-Richardson formula
was 0.70. These findings indicated that the internal consistency of the
scale was acceptable. Some of the items in the test are as follows: item
1. I enjoy eating; item 14. I feel extremely guilty for eating; item 31. I
think food controls my life (Savaşır & Erol, 1989).
Data analysis
Data were analyzed with Statistical Package Program for Social
Sciences. Descriptive characteristics of the participants were presented
by using percentages and mean values. Kolmogorov-Smirnov test was
used to determine whether scores for ORTO-11, EAT-40 and MOCI had
a normal distribution. Since the scores were not normally distributed,
(p < 0.05), Mann-Whitney U test was utilized to determine differ-
ences. Spearman correlation analysis was made to reveal correlations
between scores for the scales (Büyüköztürk, 2008).
Results
The mean age, height and weight of the vegans/vegetarians were
32.7 ± 5.6 years, 167.4 ± 9.1 cm and 63.5 ± 12.5 kg respectively.
The mean age, height and weight of the nonvegans/nonvegetarians
were 34.4 ± 8.1 years, 169.5 ± 8.2 cm and 72.5 ± 15 kg respec-
tively. The body mass index (BMI) of most of the participants ranged
from 18,5 to 24,9. They had a normal weight.
The study included 15 vegans and 16 vegetarians. Out of 31 vegans/
vegetarians, 16.1% had been vegan/vegetarians since their birth and
51.6% had been vegan/vegetarian for 1–5 years. Fifty-four-point 3% of
the vegans/vegetarians had adopted their lifestyle for ethical reasons.
Other reasons were opposition to exploitation of animals and political
opinions. A very small number of the participants had adopted ve-
ganism/vegetarianism due to their religious beliefs and opposition to
sexism.
Of 31 nonvegans/nonvegetarians included in this study, 83.9% did
not have a vegan/vegetarian relative, but 12.9% had a vegan/vege-
tarian friend and 3.2% had a vegan/vegetarian spouse. Of all the
nonvegans/nonvegetarians, 80.6% did not answer the question “What
do you think about veganism/vegetarianism?”, 12.9% commented that
veganism/vegetarianism could cause health problems and 6.4% re-
ported that this lifestyle was against the nature of humans and that they
had prejudices.
The mean scores of the vegans/vegetarians and the nonvegans/
nonvegetarians for ORTO-11 were 27.7 ± 2.8 and 27.1 ± 3.4 re-
spectively.
The mean scores for signs of obsession were higher in the non-
vegans/nonvegetarians (12.1 ± 6.5) than those of the vegans/non-
vegetarians (10.8 ± 5.3).
The mean EAT-40 score was 18.8 ± 8.3 in the vegans/vegetarians
and 15.3 ± 7.4 in the nonvegans/nonvegetarians.
There was not a significant difference in attitudes to eating, ob-
sessive symptoms and orthorexia scores between the vegans/vegetar-
ians and the nonvegans/nonvegetarians (p > 0.05). The mean scores
showed that the nonvegans/nonvegetarians had more obsessive symp-
toms (U = 425.5, p > 0.05) and were more orthorectic (U = 366.0,
203
Archives of Psychiatric Nursing 32 (2018) 200–205
p > 0.05) than the vegans/vegetarians.
ON scores and obsessive symptoms did not significantly differ be-
tween the vegans/vegetarians and the nonvegans/nonvegetarians in
terms of gender, marital status, age, BMI, education and doing exercise
(p ≥ 0.05).
Attitudes to eating significantly differed between genders in both
the vegans/vegetarians and the nonvegans/nonvegetarians (U = 29.5
for vegans/vegetarians, p < 0.05; U:307.5 for nonvegans/non-
vegetarians, p < 0.05). Considering mean ranks, the males had a
higher risk of eating disorders.
There was a significant negative relation between EAT-40 scores
and ORTO-11 scores (r = − 0.290, p = 0.022). This indicates that as
disruption in attitudes to eating increases so does the severity of or-
thorectic symptoms.
Discussion
The present study was performed to determine the risk of ON and
eating behavior of vegans/vegetarians and nonvegans/nonvegetarians.
The mean scores of the vegans/vegetarians and the nonvegans/non-
vegetarians for ORTO-11 were 27.7 ± 2.8 and 27.1 ± 3.4 respec-
tively. Low scores for this scale show a tendency for orthorexia and high
scores indicate a decreased risk for this condition. The cut-off value of
ORTO-11 was reported to be 27 by Arusoğlu. Neither the vegans/ve-
getarians nor the nonvegans/nonvegetarians in this study seemed to
have avoided the risk of orthorexia completely. In a study by Aksoydan
and Çamcı (2009), the mean score for orthorexia was 37.9 ± 4.46.
Duran (2016) in a study on the students at a two-year university pro-
gram about health reported that they had a tendency for orthorexia
(26.9 ± 5.1). Ergin (2014) found that health professionals got
26.6 ± 0.21 for ORTO-11 and individuals not working as health pro-
fessionals got 26.3 ± 0.25 for the questionnaire. Several studies per-
formed to evaluate tendencies to orthorexia in Turkey have shown that
the prevalence of ON is 41.9% in dieticians (Asil & Sürücüoğlu, 2015),
45.5% in physicians (Bağci Bosi et al., 2007) and 43.6% in medical
students (Fidan et al., 2010). Acar Tek and Karaçil Ermumcu (2016) in
their study on health professionals found the prevalence of ON to be
higher than those reported in prior studies (75.8%). They reported that
it was especially higher among nurses (35.0%) and midwives (30.0%).
In the current study, MOCI was utilized to determine to what extent
the participants were obsessed with eating and what they did to prevent
this obsession (i.e. compulsions). The mean scores for signs of obsession
were higher in the nonvegans/nonvegetarians (12.1 ± 6.5) than those
of the vegans/nonvegetarians (10.8 ± 5.3). However, both groups had
far lower scores than the highest total obsession score of the scale (37).
It means that neither of the groups had a risk of obsessive compulsive
signs.
The mean score for MOCI was reported to be 21.1 ± 5.55 in female
nutrition and dietetics students by Gezer and Kabaran (2013),
14.37 ± 6.8 in individuals doing sports at a gym and 13.39 ± 7.9 in
individuals not doing sports by Dalmaz and Tekdemir Yurtdaş (2015)
and 14.7 ± 6.2 in students at a two-year university program about
health sciences by Duran (2016). Kazkondu (2010) compared ob-
sessive-compulsive disorders between female and male university stu-
dents. They showed that the female students got a significantly higher
score for obsession (17.31 ± 5.77) than the male university students
(14.96 ± 6.75). Conflicting with their finding, Özenoğlu and Dege
(2015) reported that the female university students got lower scores for
obsession (14.58 ± 6.45) than the male university students.
In the present study, the mean EAT-40 score was 18.8 ± 8.3 in the
vegans/vegetarians and 15.3 ± 7.4 in the nonvegans/nonvegetarians.
In a study by Ergin (2014), health professionals had 11.7 ± 8.37 for
EAT-40 and individuals not working as health professionals got
12.0 ± 8.03. Neither of them significantly differed in their scores for
ORTO-11 and EAT-40 (p > 0.05).
In the present study, there was not a significant difference in
P. Çiçekoğlu, G.Y. Tunçay
attitudes to eating, obsessive symptoms and orthorexia scores between
the vegans/vegetarians and the nonvegans/nonvegetarians
(p > 0.05). The mean scores showed that the nonvegans/non-
vegetarians had more obsessive symptoms (U = 425.5, p > 0.05) and
were more orthorectic (U = 366.0, p > 0.05) than the vegans/vege-
tarians.
Scores for EAT-40 are proportional to the degree of eating disorders.
An EAT-40 score of 30 poses a risk of eating disorders. In the present
study, the mean score of the vegans/vegetarians for EAT-40 was 35.19.
This suggests that they had a higher risk of eating disorders than the
nonvegans/nonvegetarians. Erol et al. found that the best predictors of
eating disorders were obsessive compulsive symptoms and BMI (Erol,
Toprak, & Yazıcı, 2002). It has been pointed out in the literature that
obsessive, perfectionist personalities can predispose to obsessive com-
pulsive disorder and eating disorders and that presence of obsessive
compulsive symptoms is a risk of eating disorders (Karayılan & Erol,
2012).
In a study performed to evaluate food preferences in individuals
with orthorectic tendencies, these individuals were found to have a
higher tendency to consume healthy food like vegetables, fruit and
whole grain products and visit stores selling healthy food more fre-
quently (Acar Tek & Karaçil Ermumcu, 2016). Vegans and vegetarians
can be also said to display similar behavior since there are not many
restaurants and stores supplying products for vegans and vegetarians in
Turkey.
One of the factors affecting health status of vegans/vegetarians can
be their reasons for adopting this lifestyle. According to research, health
behavior of vegans/vegetarians can change depending on their reasons
for selecting their lifestyle. The main reasons for adoption of veganism/
vegetarianism have been reported to be ethical, ecological and health
related factors. Individuals becoming a vegan/vegetarian for ethical
reasons consume more desserts and fat than those becoming a vegan/
vegetarian for health reasons. It can be suggested that the former group
of people can have poorer health status (Fox & Ward, 2008; Hoffman,
Stallings, Bessinger, & Brooks, 2013; Radnitz, Beezhold, & DiMatteo,
2015). In the present study, the main reason for becoming a vegan/
vegetarian was ethical factors. Therefore, it was not surprising that they
did not make attempts to exhibit healthy eating behavior.
In the current study, ON scores and obsessive symptoms did not
significantly differ between the vegans/vegetarians and the nonvegans/
nonvegetarians in terms of gender, marital status, age, BMI, education
and doing exercise (p ≥ 0.05). In a study by Dalmaz and Tekdemir
Yurtdaş (2015), the males had a higher rate of orthorectic tendencies.
Donini, Marsili, Graziani, Imbriale, and Canella (2004) also reported
that males had slightly more orthorectic symptoms. In a study on
medical students by Fidan et al. (2010) from Turkey, the prevalence of
orthorexia was higher among male students than in female students.
There are conflicting findings about the relation between tendency for
ON and gender. Although several studies have shown a higher pre-
valence of ON in males, recent studies have shown exactly the opposite.
Acar Tek and Karaçil Ermumcu stated that the females are two and half
times more likely to have ON (Acar Tek & Karaçil Ermumcu, 2016).
In the present study, attitudes to eating significantly differed be-
tween genders in both the vegans/vegetarians and the nonvegans/
nonvegetarians (U = 29.5 for vegans/vegetarians, p < 0.05; U:307.5
for nonvegans/nonvegetarians, p < 0.05). Considering mean ranks,
the males had a higher risk of eating disorders. Perceived body image
has changed in males in Western culture. In fact, they have had more
interest in their body image. Desire for being liked and for influencing
females, doing sports to look fit, disinformation on TV and poor nu-
trition due to heavy work schedules can be predictive of a risk for eating
disorders. This can suggest that attitudes to perceived body image
should be investigated in detail in terms of social perceptions of gen-
ders.
There was a significant negative relation between EAT-40 scores
and ORTO-11 scores (r = − 0.290, p = 0.022). This indicates that as
204
Archives of Psychiatric Nursing 32 (2018) 200–205
disruption in attitudes to eating increases so does the severity of or-
thorectic symptoms.
Aksoydan and Çamcı (2009) found a positive relation between at-
titudes to eating and orthorectic symptoms (r = −0.283). In other
words, as an eating disorder became severe, orthorectic symptoms in-
creased. Similarly, in a study by Duran (2016), there was a significant
negative relation between MOCI scores and ORTO-11 scores
(r = −0.319, p = 0.012). It seems that as obsessive symptoms increase
so does the degree of orthorectic symptoms. Arusoğlu (2006) stated that
a high rate of obsessive compulsive symptoms could be predictive of
orthorectic tendencies as suggested by the theoretical definition of or-
thorexia. Kazkondu (2010), Dalmaz and Tekdemir Yurtdaş (2015)
found that an increase in obsessive compulsive symptoms led to a rise in
ON symptoms. These findings support the idea that ON is an obsession
with healthy food.
Conclusions and recommendations
The present study revealed that the vegans/vegetarians' attitudes
towards eating did not have a risk of orthorexia and that they adopted
veganism/vegetarianism for ethical reasons, not for good health.
Further studies on ON should be performed in larger samples on dif-
ferent groups of individuals. Based on this finding, the following re-
commendations could be made.
✓ Presence of only few studies about the new concept ON underlines
the need for further studies on this issue. Since the present study was
conducted on a small sample with certain characteristics, the results
cannot be generalized. Therefore, studies using semi-structured in-
terviews and focus group interviews should be carried out to test
different variables in individuals found to have orthorectic tenden-
cies.
✓ ON and veganism/vegetarianism should be incorporated into cur-
ricula for candidates of health professionals (doctors, nurses, dieti-
cians etc.),
✓ First-line health care providers should routinely perform as many
screenings for eating disorders (anorexia, bulimia and orthorexia) as
other diseases and achieve treatment of individuals found to have
eating disorders in cooperation with other health professionals (like
psychologists and dieticians) by evaluating the severity of the dis-
orders,
✓ Obsessional anxieties should be detected in individuals with or-
thorectic tendencies and ON should be treated by taking account of
the fact that it is not only an eating disorder but also an obsessive-
compulsive disorder,
✓ The role of the news appearing in printed and visual media in de-
velopment of obsessions should not be disregarded and therefore,
the media should provide appropriate and sufficient guidance in
healthy eating behavior and different eating behavior like ve-
ganism/vegetarianism,
✓ Long-term studies should be performed to determine how veganism/
vegetarianism influences health in Turkey,
✓ The present study was carried out on a small sample in a small area.
It is necessary to include different risk groups into further studies to
obtain more reliable results.
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