Eat Weight Disord DOI 10.1007/s40519-014-0131-6
ORIGINAL ARTICLE
Prevalence of orthorexia nervosa among ashtanga yoga practitioners: a pilot study Jesus Herranz Valera • Patricia Acun˜a Ruiz • Borja Romero Valdespino • Francesco Visioli
Received: 23 April 2014 / Accepted: 8 May 2014 Ó Springer International Publishing Switzerland 2014
Abstract Purpose Orthorexia nervosa (ON, i.e., fixation on righteous eating) is a poorly defined disordered eating behavior that results from a pathological obsession with food, its purported nutritional value, composition, origin, etc. Methods We investigated the prevalence of ON in a local ashtanga yoga community, by using a validated questionnaire (ORTO-15) that sets a threshold of ON diagnosis at B40. Results Among the 136 respondents, the mean ORTO-15 score (which was normally distributed) was 35.27 ± 3.69, i.e., 86 % of respondents had an ORTO-15 score lower than 40 and no significant association with age or BMI was recorded. When we analyzed the differential distribution of orthorexia in our cohort, we recorded an association of ORTO-15 score and vegetarianism, i.e., the ORTO-15 score was lower among vegetarians. Conclusions The results of this pilot study should suggest ashtanga yoga teachers to avoid excessive reference to a healthy diet, which is natural component of yoga practice. Keywords Orthorexia nervosa Yoga Eating disorders Physical activity Vegetarianism
J. Herranz Valera F. Visioli (&) Laboratory of Functional Foods, IMDEA-Food, CEI UAM?CSIC, C/Faraday 7, 28049 Madrid, Spain e-mail: [email protected] P. Acun˜a Ruiz B. Romero Valdespino Ashtanga Yoga Madrid, Madrid, Spain Present Address: P. Acun˜a Ruiz Ashtanga Yoga Malaga, Malaga, Spain
Introduction The disordered eating behavior orthorexia nervosa (ON, i.e., fixation on righteous eating) is a complex combination of attitudes and beliefs [1] that results from a pathological obsession with food, its purported nutritional value, composition, origin, etc. [2]. ON is often long term and can have a significant impact on the individual, in terms of both life quality and nutritional status [3, 4]. Indeed, even though there are currently no clinical guidelines for this purported disorder, ON is being considered as detrimental to human health, because it brings about excessive focus on food, health, behavior, etc. [2]. It is noteworthy that ON does not necessarily concern weight loss or appearance, but it does connote phobic behaviors toward what is perceived as ‘‘unhealthful’’ food [2]. In particular, ON involves (a) the need to know every single ingredient of a given food item; (b) the need to program meals; (c) fear to ‘‘contaminate’’ the body; (d) disgust toward the ingestion of nonnatural substances; (e) continuous desire to detox/depurate; (f) self-deprecation when diet is not strictly followed; (g) repulse of people who follow different diets; (h) difficulty in establishing relations with people who do not share these views [1, 2]. Yoga’s popularity is increasing in Western countries: an informal poll estimated that over 20 million Americans practiced some yoga style in 2012 (http://www.yoga journal.com/press/yoga_in_america), i.e., 8.7 % of adults, an increase of 29 % over the previous 4 years. Of note, of current non-practitioners, 44.4 % of Americans call themselves ‘‘aspirational yogis’’—people who are interested in trying yoga. Even though the majority of people who practice yoga likely do so to become physically fit and for its alleged healthful effects, the yoga method often brings about lifestyle modifications that comprise healthier habits,
123
Eat Weight Disord
i.e., smoke cessation and purportedly nourishing diets, including veganism and vegetarianism [5–7]. Due to the potentially large long-term impact that yoga and associated lifestyle could have on public health [5], it is important to assess the several facets of yoga practice, including its effects on nutritional behaviors. Indeed, the first recorded reference to ON was in a lay publication, Yoga Journal [8]. In his paper, Bratman shares his own experience as well as that of others; moreover, he states that ‘‘The act of eating pure food begins to carry pseudo-spiritual connotations’’. Indeed, perfectionistic eating and religious/spiritual practices are often intertwined and examples of food prescription and prohibition can be found in many religious books such as the Bible, the Holy Koran, or the Upanishads. Bratman also expanded on the features of ON in his book ‘‘Health Food Junkies’’ [9]. Ashtanga is a physically challenging style of yoga [10], which requires self-discipline and repeated practice [11, 12]. Practitioners often modify their lifestyle to include healthier (or perceived so) behaviors such as smoke cessation, reduced alcohol consumption, preference for organic and vegetable-based food, etc. [13]. We hypothesized that ON would be highly prevalent in the ashtanga community and carried out an investigation in a local ashtanga yoga center, by using a validated questionnaire.
Methods A link to the validated ORTO-15 questionnaire [3] was created and distributed on-line to the 582 alumni of the Ashtanga Yoga Madrid center’s database (Madrid, Spain) along with questions on sex (male or female), age, weight, height, years of ashtanga practice, vegetarianism, veganism, and fasting habits (i.e., whether participants routinely fasted for 24 h). The questionnaire was anonymous and participants were given 15 days to complete it. One hundred and thirty-six, i.e., 23.36 % questionnaires were returned and analyzed. ON prevalence was assessed according to Donini et al. [3], where a cutoff of 40 was considered the best predictor. We would like to underscore that ashtanga yoga, albeit physically challenging, cannot and should not be considered a sport; therefore, the thresholds specific for athletes [14, 15] do not apply to our study. Statistical analyses Quantitative variables are described as mean ± standard deviation and categorical variables as frequencies. The normality of the distribution of the ORTO-15 was assessed and slight departures from normal distribution were observed; therefore, a two-sided Wilcoxon signed rank test
123
Table 1 Distribution of the variables by sex Variables
Male
Female
Age
39.87 ± 6.7
35.39 ± 6.47
BMI
22.31 ± 2.31
20.89 ± 2.14
Normal weight
42 (89.4)
84 (94.4)
Overweight
5 (10.6)
5 (5.6)
Years of practice
4.34 ± 3.34
4.27 ± 3.15
Vegetarian Yes
17 (36.2)
21 (23.6)
No
30 (63.8)
68 (76.4)
Vegan Yes No Fasting habit
4 (8.5)
3 (3.4)
43 (91.5)
86 (96.6)
Yes
12 (25.5)
16 (18.0)
No
35 (74.5)
73 (82.0)
Age, BMI and years of practice is described as mean ± SD. Vegetarian, vegan and fasting habit are described as frequencies and percentages
was used to test for significant differences in the ORTO-15 score in the groups of participants by sex, vegetarian, vegan and fasting habits [16]. Spearman correlation coefficient was used to examine the relationship between ORTO-15 and age, height, weight, BMI, and years of practice. The correlation coefficients were tested for being significantly different from 0. All statistical tests were twosided. A P value B0.05 was considered statistically significant in all the tests. The statistical analysis was carried out with R Software version 2.15.
Results Participants’ characteristics Respondents were as follows: mean age 36.96 ± 6.69 (range 20–55); mean weight 61.64 ± 9.82 kg (range 41–93); mean height 1.69 ± 0.08 m (range 1.50–1.98); mean BMI 21.4 ± 2.28 (range 14.03–27.68); 34.5 % males, 65.5 % females; 27.9 % vegetarians; 5.1 % vegans; 20.6 % fast on a regular basis. On average they have being practicing ashtanga yoga for 4.35 ± 3.22 years (range 1–15). The distribution of these variables by sex is detailed in Table 1. ON prevalence The mean ORTO-15 score was 35.27 ± 3.69, i.e., 86 % of respondents had an ORTO-15 score lower than 40 and no significant association with age or BMI was recorded
Eat Weight Disord Table 2 Spearman correlation analysis of ORTO-15 and continuous variables Correlation Age
0.061
Body mass index Years of yoga practice
P value (q = 0) 0.481
0.068
0.435
-0.028
0.750
Table 3 Distribution of ORTO-15 by sex, according to different thresholds Possible ON cases, n (%)
Possible non-ON cases, n (%)
Threshold ORTO-15 \35 M
19 (40.4)
28 (59.6)
F
40 (44.9)
49 (55.1)
Threshold ORTO-15 \40 M
41 (87.2)
6 (12.8)
F
76 (85.4)
13 (14.6)
M, males; F, females
Table 4 Distribution of ORTO-15 mean scores among subgroups Variable
n (%)
Mean ± SD
All
136
35.27 ± 3.69
P value
Sex M
47 (34.6)
35.43 ± 3.8
F
89 (65.4)
35.19 ± 3.66
Yes
38 (27.9)
34.26 ± 4.15
No
98 (72.1)
35.66 ± 3.45
0.947
Vegetarian 0.033
Vegan Yes
7 (5.1)
No
129 (94.9)
Fasting habit Yes No
35 ± 7.28
0.663
35.3 ± 3.45
28 (20.6)
34.29 ± 4.26
108 (79.4)
35.53 ± 3.51
0.162
Wilcoxon signed rank test M males, F females
(Table 2). A more restrictive threshold was also considered for this population: 43.4 % of respondents had an ORTO15 score lower than 35. Table 3 shows the distribution of ORTO-15 by sex with different threshold values [3]. Even though the prevalence of ON is lower when computed with the B35 threshold, we still recorded a high overall prevalence. However, the relative proportions of males vs. females were opposite between the two threshold values, i.e., 35 and 40. When we analyzed the differential distribution of orthorexia in our cohort, we only found an association between the ORTO-15 score and vegetarianism (Table 4), i.e., the ORTO-15 score was lower among vegetarians.
Discussion As ON was first hypothesized in a yoga setting [8], we sought to investigate its prevalence in an ashtanga yoga group. Indeed, the results show that *86 % of practitioners recruited from within an ashtanga school score below the ORTO-15 proposed threshold for ON [3]. Of note, this prevalence did not correlate with any personal parameter we assessed, such as sex, age, or BMI. Yet, we computed a significant lower ORTO-15 score among vegetarians (Table 4), who might—indeed—take particular care of their diet and might push their attention to it to potentially orthorexic limits. When the more restrictive threshold value of 35 was computed, over 43 % of participants fell below that value. This finding reinforces the notion that several ashtanga practitioners embrace diets over which they might obsess. As mentioned above, yoga practice is rapidly gaining popularity in the West [5, 6]: if we speculatively apply our results to the over 20 million Americans who practice yoga, a total of 17,200,000 US individuals might be concerned with ON. Of note, the percentage of potentially orthorexic individuals of our cohort is higher than that of previously reported studies [1, 17–20] and similar to that recorded among opera singers [20]. Indeed, proposed risk factors for ON include perfectionist personality [2, 21] and frequent physical exercise [1]: both features might be substantially prevalent in assiduous yoga practitioners. Of note, ashtanga yoga is not merely physical activity and comprises eight ‘‘limbs’’ [10]; the possibility that excessive attention paid by practitioners to diet and food quality—as part of the ashtanga system—emerges from this study. Among the limitations of this investigation, the possibility of self-selection bias is probably the major one. The questionnaire was distributed to a wide list of recipients and those who filled it out might have a keen interest in the nutritional and health aspects of ashtanga yoga. Moreover, the lack of significant correlation between duration of ashtanga practice and ORTO-15 score can be tentatively explained by early onset of disordered behavior (see above), but also by the fact that subjects who were already at risk of ON started practicing ashtanga yoga to complement a perceived healthy lifestyle. Also, we assessed the prevalence of ON by using the ORTO-15 questionnaire only and we cannot rule out the possibility that other methods would provide different results. Finally, we need to underscore that ON is still a poorly defined eating disorder and that the extent and precise nature of its impact on health is as yet to be clearly assessed [2]. Indeed, ON should be a matter of concern only when it has a significant negative impact on an individual’s life (thinking about food to avoid the stresses of life, thinking about how food is prepared to avoid negative emotions, thinking about food
123
Eat Weight Disord
the majority of each individual’s day). Several studies on large cohorts are needed to clarify the prevalence of ON and its patho-physiological consequences. The results of this pilot study (which might not be limited to the ashtanga style of yoga, even though this must be proven by ad hoc studies) should suggest—similarly to what was suggested for athletes [15]—yoga teachers to ease any eventual psychological pressure on maintaining a healthy diet, which is natural component of yoga practice [5, 7]. Future studies should expand to yoga styles other than ashtanga, to verify whether ON affects the whole yoga community, irrespective of schools and centers. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Mathieu J (2005) What is orthorexia? J Am Diet Assoc 105:1510–1512 2. Brytek-Matera A (2012) Orthorexia nervosa—an eating disorder, obsessive-compulsive disorder or disturbed eating habit? Arch Psychiatry Psychother 1:55–60 3. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C (2005) Orthorexia nervosa: validation of a diagnosis questionnaire. Eat Weight Disord 10:e28–e32 4. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C (2004) Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eat Weight Disord 9:151–157 5. Ross A, Friedmann E, Bevans M, Thomas S (2013) National survey of yoga practitioners: mental and physical health benefits. Complement Ther Med 21:313–323 6. Ross A, Friedmann E, Bevans M, Thomas S (2012) Frequency of yoga practice predicts health: results of a national survey of yoga practitioners. Evid Based Complement Altern Med 2012:983258
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7. Carim-Todd L, Mitchell SH, Oken BS (2013) Mind-body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug Alcohol Depend 132:399–410 8. Bratman S.: Original orthorexia essay. http://www.orthorexia. com/original-orthorexia-essay/, 1997 9. Bratman S, Knight D (2000) Health food junkies. Broadway books, New York 10. Jois SKP (2010) Yoga mala. North Point Press, New York 11. Varambally S, Gangadhar BN (2012) Yoga: a spiritual practice with therapeutic value in psychiatry. Asian J Psychiatr 5:186–189 12. Benavides S, Caballero J (2009) Ashtanga yoga for children and adolescents for weight management and psychological well being: an uncontrolled open pilot study. Complement Ther Clin Pract 15:110–114 13. Penman S, Cohen M, Stevens P, Jackson S (2012) Yoga in Australia: results of a national survey. Int J Yoga 5:92–101 14. Ramacciotti CE, Perrone P, Coli E, Burgalassi A, Conversano C, Massimetti G, Dell’Osso L (2011) Orthorexia nervosa in the general population: a preliminary screening using a self-administered questionnaire (ORTO-15). Eat Weight Disord 16:e127– e130 15. Segura-Garcia C, Papaianni MC, Caglioti F, Procopio L, Nistico CG, Bombardiere L, Ammendolia A, Rizza P, De Fazio P, Capranica L (2012) Orthorexia nervosa: a frequent eating disordered behavior in athletes. Eat Weight Disord 17:e226–e233 16. Butar F, Park J (2008) Permutation Tests for comparing two populations. J Math Sci Math Ed 3:19–30 17. Catalina Zamora ML, Bote Bonaechea B, Garcia Sanchez F, Rios Rial B (2005) Orthorexia nervosa. A new eating behavior disorder? Actas Esp Psiquiatr 33:66–68 18. Fidan T, Ertekin V, Isikay S, Kirpinar I (2010) Prevalence of orthorexia among medical students in Erzurum, Turkey. Compr Psychiatry 51:49–54 19. Arusoglu G, Kabakci E, Koksal G, Merdol TK (2008) Orthorexia nervosa and adaptation of ORTO-11 into Turkish. Turk Psikiyatr Derg 19:283–291 20. Aksoydan E, Camci N (2009) Prevalence of orthorexia nervosa among Turkish performance artists. Eat Weight Disord 14:33–37 21. Mac Evilly C (2001) The price of perfection. Nutr Bull 26:275–276
ORIGINAL ARTICLE
Prevalence of orthorexia nervosa among ashtanga yoga practitioners: a pilot study Jesus Herranz Valera • Patricia Acun˜a Ruiz • Borja Romero Valdespino • Francesco Visioli
Received: 23 April 2014 / Accepted: 8 May 2014 Ó Springer International Publishing Switzerland 2014
Abstract Purpose Orthorexia nervosa (ON, i.e., fixation on righteous eating) is a poorly defined disordered eating behavior that results from a pathological obsession with food, its purported nutritional value, composition, origin, etc. Methods We investigated the prevalence of ON in a local ashtanga yoga community, by using a validated questionnaire (ORTO-15) that sets a threshold of ON diagnosis at B40. Results Among the 136 respondents, the mean ORTO-15 score (which was normally distributed) was 35.27 ± 3.69, i.e., 86 % of respondents had an ORTO-15 score lower than 40 and no significant association with age or BMI was recorded. When we analyzed the differential distribution of orthorexia in our cohort, we recorded an association of ORTO-15 score and vegetarianism, i.e., the ORTO-15 score was lower among vegetarians. Conclusions The results of this pilot study should suggest ashtanga yoga teachers to avoid excessive reference to a healthy diet, which is natural component of yoga practice. Keywords Orthorexia nervosa Yoga Eating disorders Physical activity Vegetarianism
J. Herranz Valera F. Visioli (&) Laboratory of Functional Foods, IMDEA-Food, CEI UAM?CSIC, C/Faraday 7, 28049 Madrid, Spain e-mail: [email protected] P. Acun˜a Ruiz B. Romero Valdespino Ashtanga Yoga Madrid, Madrid, Spain Present Address: P. Acun˜a Ruiz Ashtanga Yoga Malaga, Malaga, Spain
Introduction The disordered eating behavior orthorexia nervosa (ON, i.e., fixation on righteous eating) is a complex combination of attitudes and beliefs [1] that results from a pathological obsession with food, its purported nutritional value, composition, origin, etc. [2]. ON is often long term and can have a significant impact on the individual, in terms of both life quality and nutritional status [3, 4]. Indeed, even though there are currently no clinical guidelines for this purported disorder, ON is being considered as detrimental to human health, because it brings about excessive focus on food, health, behavior, etc. [2]. It is noteworthy that ON does not necessarily concern weight loss or appearance, but it does connote phobic behaviors toward what is perceived as ‘‘unhealthful’’ food [2]. In particular, ON involves (a) the need to know every single ingredient of a given food item; (b) the need to program meals; (c) fear to ‘‘contaminate’’ the body; (d) disgust toward the ingestion of nonnatural substances; (e) continuous desire to detox/depurate; (f) self-deprecation when diet is not strictly followed; (g) repulse of people who follow different diets; (h) difficulty in establishing relations with people who do not share these views [1, 2]. Yoga’s popularity is increasing in Western countries: an informal poll estimated that over 20 million Americans practiced some yoga style in 2012 (http://www.yoga journal.com/press/yoga_in_america), i.e., 8.7 % of adults, an increase of 29 % over the previous 4 years. Of note, of current non-practitioners, 44.4 % of Americans call themselves ‘‘aspirational yogis’’—people who are interested in trying yoga. Even though the majority of people who practice yoga likely do so to become physically fit and for its alleged healthful effects, the yoga method often brings about lifestyle modifications that comprise healthier habits,
123
Eat Weight Disord
i.e., smoke cessation and purportedly nourishing diets, including veganism and vegetarianism [5–7]. Due to the potentially large long-term impact that yoga and associated lifestyle could have on public health [5], it is important to assess the several facets of yoga practice, including its effects on nutritional behaviors. Indeed, the first recorded reference to ON was in a lay publication, Yoga Journal [8]. In his paper, Bratman shares his own experience as well as that of others; moreover, he states that ‘‘The act of eating pure food begins to carry pseudo-spiritual connotations’’. Indeed, perfectionistic eating and religious/spiritual practices are often intertwined and examples of food prescription and prohibition can be found in many religious books such as the Bible, the Holy Koran, or the Upanishads. Bratman also expanded on the features of ON in his book ‘‘Health Food Junkies’’ [9]. Ashtanga is a physically challenging style of yoga [10], which requires self-discipline and repeated practice [11, 12]. Practitioners often modify their lifestyle to include healthier (or perceived so) behaviors such as smoke cessation, reduced alcohol consumption, preference for organic and vegetable-based food, etc. [13]. We hypothesized that ON would be highly prevalent in the ashtanga community and carried out an investigation in a local ashtanga yoga center, by using a validated questionnaire.
Methods A link to the validated ORTO-15 questionnaire [3] was created and distributed on-line to the 582 alumni of the Ashtanga Yoga Madrid center’s database (Madrid, Spain) along with questions on sex (male or female), age, weight, height, years of ashtanga practice, vegetarianism, veganism, and fasting habits (i.e., whether participants routinely fasted for 24 h). The questionnaire was anonymous and participants were given 15 days to complete it. One hundred and thirty-six, i.e., 23.36 % questionnaires were returned and analyzed. ON prevalence was assessed according to Donini et al. [3], where a cutoff of 40 was considered the best predictor. We would like to underscore that ashtanga yoga, albeit physically challenging, cannot and should not be considered a sport; therefore, the thresholds specific for athletes [14, 15] do not apply to our study. Statistical analyses Quantitative variables are described as mean ± standard deviation and categorical variables as frequencies. The normality of the distribution of the ORTO-15 was assessed and slight departures from normal distribution were observed; therefore, a two-sided Wilcoxon signed rank test
123
Table 1 Distribution of the variables by sex Variables
Male
Female
Age
39.87 ± 6.7
35.39 ± 6.47
BMI
22.31 ± 2.31
20.89 ± 2.14
Normal weight
42 (89.4)
84 (94.4)
Overweight
5 (10.6)
5 (5.6)
Years of practice
4.34 ± 3.34
4.27 ± 3.15
Vegetarian Yes
17 (36.2)
21 (23.6)
No
30 (63.8)
68 (76.4)
Vegan Yes No Fasting habit
4 (8.5)
3 (3.4)
43 (91.5)
86 (96.6)
Yes
12 (25.5)
16 (18.0)
No
35 (74.5)
73 (82.0)
Age, BMI and years of practice is described as mean ± SD. Vegetarian, vegan and fasting habit are described as frequencies and percentages
was used to test for significant differences in the ORTO-15 score in the groups of participants by sex, vegetarian, vegan and fasting habits [16]. Spearman correlation coefficient was used to examine the relationship between ORTO-15 and age, height, weight, BMI, and years of practice. The correlation coefficients were tested for being significantly different from 0. All statistical tests were twosided. A P value B0.05 was considered statistically significant in all the tests. The statistical analysis was carried out with R Software version 2.15.
Results Participants’ characteristics Respondents were as follows: mean age 36.96 ± 6.69 (range 20–55); mean weight 61.64 ± 9.82 kg (range 41–93); mean height 1.69 ± 0.08 m (range 1.50–1.98); mean BMI 21.4 ± 2.28 (range 14.03–27.68); 34.5 % males, 65.5 % females; 27.9 % vegetarians; 5.1 % vegans; 20.6 % fast on a regular basis. On average they have being practicing ashtanga yoga for 4.35 ± 3.22 years (range 1–15). The distribution of these variables by sex is detailed in Table 1. ON prevalence The mean ORTO-15 score was 35.27 ± 3.69, i.e., 86 % of respondents had an ORTO-15 score lower than 40 and no significant association with age or BMI was recorded
Eat Weight Disord Table 2 Spearman correlation analysis of ORTO-15 and continuous variables Correlation Age
0.061
Body mass index Years of yoga practice
P value (q = 0) 0.481
0.068
0.435
-0.028
0.750
Table 3 Distribution of ORTO-15 by sex, according to different thresholds Possible ON cases, n (%)
Possible non-ON cases, n (%)
Threshold ORTO-15 \35 M
19 (40.4)
28 (59.6)
F
40 (44.9)
49 (55.1)
Threshold ORTO-15 \40 M
41 (87.2)
6 (12.8)
F
76 (85.4)
13 (14.6)
M, males; F, females
Table 4 Distribution of ORTO-15 mean scores among subgroups Variable
n (%)
Mean ± SD
All
136
35.27 ± 3.69
P value
Sex M
47 (34.6)
35.43 ± 3.8
F
89 (65.4)
35.19 ± 3.66
Yes
38 (27.9)
34.26 ± 4.15
No
98 (72.1)
35.66 ± 3.45
0.947
Vegetarian 0.033
Vegan Yes
7 (5.1)
No
129 (94.9)
Fasting habit Yes No
35 ± 7.28
0.663
35.3 ± 3.45
28 (20.6)
34.29 ± 4.26
108 (79.4)
35.53 ± 3.51
0.162
Wilcoxon signed rank test M males, F females
(Table 2). A more restrictive threshold was also considered for this population: 43.4 % of respondents had an ORTO15 score lower than 35. Table 3 shows the distribution of ORTO-15 by sex with different threshold values [3]. Even though the prevalence of ON is lower when computed with the B35 threshold, we still recorded a high overall prevalence. However, the relative proportions of males vs. females were opposite between the two threshold values, i.e., 35 and 40. When we analyzed the differential distribution of orthorexia in our cohort, we only found an association between the ORTO-15 score and vegetarianism (Table 4), i.e., the ORTO-15 score was lower among vegetarians.
Discussion As ON was first hypothesized in a yoga setting [8], we sought to investigate its prevalence in an ashtanga yoga group. Indeed, the results show that *86 % of practitioners recruited from within an ashtanga school score below the ORTO-15 proposed threshold for ON [3]. Of note, this prevalence did not correlate with any personal parameter we assessed, such as sex, age, or BMI. Yet, we computed a significant lower ORTO-15 score among vegetarians (Table 4), who might—indeed—take particular care of their diet and might push their attention to it to potentially orthorexic limits. When the more restrictive threshold value of 35 was computed, over 43 % of participants fell below that value. This finding reinforces the notion that several ashtanga practitioners embrace diets over which they might obsess. As mentioned above, yoga practice is rapidly gaining popularity in the West [5, 6]: if we speculatively apply our results to the over 20 million Americans who practice yoga, a total of 17,200,000 US individuals might be concerned with ON. Of note, the percentage of potentially orthorexic individuals of our cohort is higher than that of previously reported studies [1, 17–20] and similar to that recorded among opera singers [20]. Indeed, proposed risk factors for ON include perfectionist personality [2, 21] and frequent physical exercise [1]: both features might be substantially prevalent in assiduous yoga practitioners. Of note, ashtanga yoga is not merely physical activity and comprises eight ‘‘limbs’’ [10]; the possibility that excessive attention paid by practitioners to diet and food quality—as part of the ashtanga system—emerges from this study. Among the limitations of this investigation, the possibility of self-selection bias is probably the major one. The questionnaire was distributed to a wide list of recipients and those who filled it out might have a keen interest in the nutritional and health aspects of ashtanga yoga. Moreover, the lack of significant correlation between duration of ashtanga practice and ORTO-15 score can be tentatively explained by early onset of disordered behavior (see above), but also by the fact that subjects who were already at risk of ON started practicing ashtanga yoga to complement a perceived healthy lifestyle. Also, we assessed the prevalence of ON by using the ORTO-15 questionnaire only and we cannot rule out the possibility that other methods would provide different results. Finally, we need to underscore that ON is still a poorly defined eating disorder and that the extent and precise nature of its impact on health is as yet to be clearly assessed [2]. Indeed, ON should be a matter of concern only when it has a significant negative impact on an individual’s life (thinking about food to avoid the stresses of life, thinking about how food is prepared to avoid negative emotions, thinking about food
123
Eat Weight Disord
the majority of each individual’s day). Several studies on large cohorts are needed to clarify the prevalence of ON and its patho-physiological consequences. The results of this pilot study (which might not be limited to the ashtanga style of yoga, even though this must be proven by ad hoc studies) should suggest—similarly to what was suggested for athletes [15]—yoga teachers to ease any eventual psychological pressure on maintaining a healthy diet, which is natural component of yoga practice [5, 7]. Future studies should expand to yoga styles other than ashtanga, to verify whether ON affects the whole yoga community, irrespective of schools and centers. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Mathieu J (2005) What is orthorexia? J Am Diet Assoc 105:1510–1512 2. Brytek-Matera A (2012) Orthorexia nervosa—an eating disorder, obsessive-compulsive disorder or disturbed eating habit? Arch Psychiatry Psychother 1:55–60 3. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C (2005) Orthorexia nervosa: validation of a diagnosis questionnaire. Eat Weight Disord 10:e28–e32 4. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C (2004) Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eat Weight Disord 9:151–157 5. Ross A, Friedmann E, Bevans M, Thomas S (2013) National survey of yoga practitioners: mental and physical health benefits. Complement Ther Med 21:313–323 6. Ross A, Friedmann E, Bevans M, Thomas S (2012) Frequency of yoga practice predicts health: results of a national survey of yoga practitioners. Evid Based Complement Altern Med 2012:983258
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