Abstract
Objective
Celiac disease (CD) is a systemic autoimmune disorder requiring lifelong gluten exclusion, which may inadvertently foster disordered eating patterns. This study examined orthorexic traits in patients with CD and explored its association with anxiety and depressive symptoms.
Methods and measures
A cross-sectional study included 156 biopsy-confirmed patients with CD and 182 controls. Assessments included the Orthorexia Nervosa Inventory (ONI), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI).
Results
Of the 338 participants, 255 were female (75.4%). ONI total score and all ONI subscale scores (behaviors, emotions, and impairments) were significantly higher in the CD group. Similarly, BDI and BAI scores were significantly higher in the CD group. ONI total scores showed a significant positive correlation with BDI (r = 0.38; p < 0.001) and BAI scores (r = 0.42; p < 0.001). In hierarchical regression analyses, CD status emerged as the strongest predictor of orthorexic traits, while anxiety symptoms and age remained significant independent predictors.
Conclusion
Orthorexic traits were significantly higher in individuals with CD and were associated with increased psychological distress. These findings suggest that the rigid dietary requirements of CD management may be associated with orthorexic tendencies in some individuals, highlighting the importance of integrating nutritional and psychological support into routine clinical follow-up.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12888-026-08335-z.
Keywords: Celiac disease, Anxiety, Depression, Dieting, Orthorexia, Healthy eating
Introduction
Celiac disease is a chronic immune-mediated disorder triggered by gluten ingestion in genetically susceptible individuals and characterized by inflammation and villous atrophy of the small intestinal mucosa. The cornerstone of treatment is lifelong adherence to a strict gluten-free diet, which remains the only effective therapy for preventing disease-related complications and promoting mucosal recovery [1, 2]. Symptoms in celiac disease can include abdominal pain, bloating, diarrhea, constipation, exhaustion, weight loss, and vitamin deficiencies. In addition to gastrointestinal symptoms, neurological, psychological, and cutaneous symptoms are becoming increasingly common [3]. Adhering to a gluten-free diet can help repair intestinal damage and alleviate or eliminate symptoms [4]. However, the difficulty of maintaining such a strict diet may be related to intense psychological stress [5]. Recent research has increasingly highlighted the association between celiac disease and various psychological difficulties, including anxiety, depression, and disordered eating behaviors [6–8]. The prevalence of eating disorders in individuals with gastrointestinal diseases ranges from 13% to 55%, compared to 3% to 21% in the healthy population [9]. Previous studies have reported an increased frequency of anorexia nervosa and bulimia nervosa in patients with celiac disease [10–12].
Orthorexia nervosa (ON), which means “proper appetite,” is a pathological obsession with healthy food. While it may initially seem to be a beneficial behavior for maintaining health, it often has the opposite effect [13]. Orthorexia affects 6.9% of the general population and 35%-57.8% of high-risk groups, depending on diagnostic cut-off criteria, tools used, and cross-cultural, regional, and gender differences [14]. Although not yet officially recognized as a psychiatric condition, orthorexia is frequently associated with severe impairment. What begins as an effort to achieve optimum health through diet may escalate to malnourishment, social isolation, and a poor quality of life. For ON, four consensus diagnostic criteria have been proposed. Criterion A consists of a preoccupation with healthy nutrition and rigid adherence to a restrictive ‘healthy’ diet (which the individual believes to be healthy and pure), as well as severely avoiding things perceived to be unhealthy. Criterion B includes violations of stringent dietary guidelines that produce considerable emotional suffering as well as feelings of guilt, shame, and/or anxiety. Criterion C considers physical impairments where nutritional deficits could result in considerable weight loss, malnutrition, and/or physical health issues. Criterion D includes psychosocial abnormalities in social, vocational, and/or academic functioning that may result from other diagnostic criteria [15]. Orthorexia has received little attention from the scientific community compared to other types of disordered eating, even though this behavioral pattern is regularly noticed by eating disorder specialists.
Dietary restriction for medical reasons is recognized as a risk factor for eating disorders and orthorexia [16]. The necessity for a gluten-restricted diet in celiac disease may provide a suitable ground for the development of ON. Recent research has shown that the frequency of above-threshold orthorexia traits in women with celiac disease is 32% [17]. While the ORTO-15 scale was used in this research, it has been suggested that the scale may not adequately assess orthorexia as it does not encompass the four consensus criteria currently accepted for the disorder. Moreover, the study did not include a control group.
While individuals with celiac disease must adhere to a strict gluten-free diet for medical reasons, it is important to distinguish this necessary restriction from pathological eating behaviors such as ON. Orthorexia is not defined simply by avoidance of specific foods, but by an excessive preoccupation with healthy eating, rigid dietary rules beyond medical necessity, emotional distress when dietary rules are violated, and measurable psychosocial impairment [15, 18]. In contrast, gluten avoidance in celiac disease is a targeted intervention with the explicit clinical goal of preventing immune mediated intestinal damage and systemic complications [1, 2]. Thus, gluten avoidance per se should not be interpreted as orthorexic pathology. This study assesses orthorexia nervosa tendencies in patients with celiac disease using the Orthorexia Nervosa Inventory (ONI). It examines patterns of excessive, obsessive, and potentially dysfunctional eating behaviors that may resemble orthorexia, beyond the medical necessity of gluten avoidance. Additionally, the study investigates the relationship between orthorexic traits and anxiety and depression, which are common psychiatric comorbidities in celiac disease. We hypothesized that individuals with celiac disease would demonstrate higher levels of orthorexia traits compared to the control group and that increased orthorexic symptomatology would be associated with higher levels of anxiety and depressive symptoms.
Materials and methods
Participants and procedure
A total of 338 participants were included in the study. The study included 156 seropositive and biopsy-confirmed patients with celiac disease and 182 control participants. The mean age of the celiac disease and control groups was 25.5 years (SD = 11.0) and 26.5 years (SD = 8.25), respectively.
Participants with celiac disease were recruited from patients under follow-up at the Gastroenterology Department of Baskent University Ankara Hospital. The diagnosis of celiac disease had been previously established and was confirmed through medical record review documenting serological positivity and biopsy-confirmed intestinal damage.
The control group consisted of individuals recruited from the general population through convenience sampling. Control participants were selected to achieve a similar age and gender distribution to the celiac disease group. Participants were screened to exclude diagnosed celiac disease and other gastrointestinal disorders. Participants younger than 18 years or older than 65 years were excluded from the control group.
Inclusion criteria for the celiac disease group were age ≥ 18 years and a previously established diagnosis of celiac disease confirmed by serological testing and intestinal biopsy. Exclusion criteria included severe neurological disorders, active psychotic disorders, cognitive impairment interfering with questionnaire completion, or refusal to provide informed consent. Additionally, participants younger than 18 years or older than 65 years were excluded from the celiac disease group. The flowchart of the participant inclusion process is presented in Fig. 1.
Fig. 1.
Flowchart of participant recruitment and inclusion in the study
All participants were invited for a face-to-face assessment conducted by the research team. During this meeting, participants were informed about the study procedures and provided written informed consent. Sociodemographic information was collected, and participants completed standardized self-report questionnaires under researcher supervision, including the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Orthorexia Nervosa Inventory (ONI). Body mass index (BMI) was calculated as weight (kg) divided by height squared (m²). In addition, psychiatric comorbidity was assessed based on participants’ self-reports. Participants were asked whether they had any psychiatric disorder and, if applicable, to specify the diagnosis. No structured clinical interview was conducted. Lifetime or current eating disorders, including anorexia nervosa, were not specifically assessed. Ethical approval was obtained from the Research Ethics Committee of Baskent University (approval no: KA22/375), and the study was conducted in accordance with the Declaration of Helsinki. The study was designed as a cross-sectional study. Data collection was conducted between November 2022 and February 2024.
Materials
Beck Depression Inventory (BDI)
The BDI is a self-rating scale developed by Beck et. al. [19]. The BDI consists of 21 multiple-choice items that assess various cognitive, emotional, and physical symptoms associated with depression. Individuals rate the intensity of their depressive symptoms over the past two weeks, with response options ranging from 0 to 3. The total score can range from 0 to 63, with higher scores indicating more severe depressive symptoms. It has been updated in 1996, and this version has been extensively evaluated for its psychometric properties, including reliability, validity, and factor structure. Kapci et al. (2008) conducted validity and reliability investigations in our country. The internal consistency as measured by Cronbach’s alpha for the nonclinical and clinical groups were 0.90 and 0.89 respectively; test–retest stability was also high (r = 0.94) [20]. Cronbach’s alpha reflects the degree of internal consistency among the items, with higher values indicating greater reliability.
Beck Anxiety Inventory (BAI)
The BAI is a self-rating scale developed by Beck et al. to assess the severity of anxiety symptoms reported by individuals [21]. It consists of 21 items. Participants rate the severity of each symptom on a scale of 0 to 3. The scores are combined to produce a total score ranging from 0 to 63, with higher scores indicating higher anxiety levels. Ulusoy et al. conducted Turkish reliability and validity studies [22]. Cronbach’s alpha coefficient was 0.93. Cronbach’s alpha reflects the degree of internal consistency among the items, with higher values indicating greater reliability.
Orthorexia Nervosa Inventory (ONI)
The ONI was developed by Oberle et al. (2021) to reliably assess ON symptomatology [18]. It includes a sufficient number of items to evaluate each of the four consensuses ON diagnostic criteria and items designed to better distinguish non-pathological healthy eating. The inventory contains 24 questions in a four-point Likert structure (1 = not at all true, 4 = very true). It has three subscales: behavior, impairment, and emotions. A higher score indicates a greater level of ON symptomatology. Turkish validity and reliability were performed by Kaya and colleagues [23].
Statistical analysis
Data were analyzed using IBM SPSS Statistics version 24.0 (IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test assessed the normality of continuous data. The student’s t-test was used for groups where continuous variables were normally distributed, and the Mann-Whitney U test was used for non-normally distributed variables. Correlation analyses were performed with Pearson or Spearman tests, depending on the data distribution. A hierarchical multiple regression analysis was performed to examine factors associated with orthorexia symptom severity. Age, gender, BMI, and the presence of comorbid chronic illness were entered in the first step. Anxiety and depressive symptoms were entered in the second step, and celiac disease status was entered in the final step. Changes in explained variance (ΔR²) were evaluated at each step. Standardized regression coefficients (β) were reported. Multicollinearity was assessed using tolerance and variance inflation factor (VIF) values. Tolerance reflects the proportion of variance in a predictor that is not explained by other predictors, whereas VIF indicates the extent to which the variance of a regression coefficient is inflated due to multicollinearity. Lower tolerance values and higher VIF values indicate greater multicollinearity, which may reduce the stability and interpretability of regression estimates. In general, tolerance values below 0.10 and VIF values above 10 are considered indicative of potentially problematic multicollinearity. P values less than 0.05 were considered statistically significant.
Results
Two hundred fifty-five of the participants were female (75.4%). Sociodemographic variables and comparisons between groups are presented in Table 1. There were no statistically significant differences in terms of age, gender, marital status, employment status, education level, and psychiatric illness history in the family between the celiac disease and control groups. Based on self-reported data, panic disorder (27.2%) was the most frequently reported psychiatric diagnosis in the celiac disease group, whereas generalized anxiety disorder (25.0%) was most frequent in the control group. Comorbid chronic illnesses were more common in the celiac disease group than in the control group (e.g., arterial hypertension, hypothyroidism, rheumatoid arthritis, and migraine).
Table 1.
Sociodemographic variables and comparison between groups
| CD(n = 156) | CG(n = 182) | χ²/t | p-value | |
|---|---|---|---|---|
| Gender | 0.34 | 0.5 | ||
| Female | 120 (76.9%) | 135 (74.2%) | ||
| Male | 36 (23.1%) | 47 (25.8%) | ||
| Age (Mean ± SD) | 25.5 ± 11.0 | 26.5 ± 8.25 | -1.19 | 0.2 |
| Marital Status | 0.12 | 0.7 | ||
| Married/partnered | 56 (35.9%) | 62 (34.1%) | ||
| Single/separate/widowed | 100 (64.1%) | 120 (65.9%) | ||
| Employment Status | 1.36 | 0.2 | ||
| Employment | 63 (40.4%) | 85 (46.7%) | ||
| Unemployment | 93 (59.6%) | 97 (53.3%) | ||
| Education level | 0.14 | 0.7 | ||
| Primary and High School | 30 (19.2%) | 38 (20.9%) | ||
| University and above | 126 (80.8%) | 144 (79.1%) | ||
| Psychiatric illness | 0.10 | 0.7 | ||
| Yes | 33 (21.2%) | 36 (19.8%) | ||
| No | 123 (78.8%) | 146 (80.2%) | ||
| Comorbid chronic illness | 29.50 | < 0.001 | ||
| Yes | 63 (40.4%) | 26 (14.3%) | ||
| No | 93 (59.6%) | 156 (85.7%) | ||
| Psychiatric illness in the family | 0.03 | 0.8 | ||
| Yes | 25 (16.0%) | 28 (15.4%) | ||
| No | 131 (84.0%) | 154 (84.6%) |
Notes: CD: Celiac Disease; CG: Control Group ; SD = Standard deviation; χ² = chi-square test; t = independent samples t-test
A comparison of ONI total, BDI, and BAI scores between the groups is presented in Table 2. ONI total scores as well as all ONI subscale scores (behaviors, emotions, and impairments) were significantly higher in the celiac disease group compared with the control group. Additionally, BDI and BAI scores were significantly higher in the celiac disease group (p < 0.001 for both comparisons). Based on the established cut-off scores, the proportion of individuals with moderate-to-severe depressive symptoms (BDI score > 18) and moderate-to-severe anxiety symptoms (BAI score > 15) was also significantly higher in the celiac disease group (p < 0.001) [24, 25]. However, BMI was significantly lower in the celiac disease group than in the control group (p < 0.001).
Table 2.
Comparison of ONI, BDI, BAI, and BMI Between the Celiac Disease and Control Groups
| Variable | CD(n = 156) | CG(n = 182) | χ²/t/Z | p-value | Cohen’s d | |
|---|---|---|---|---|---|---|
| ONI total | 56.6 ± 14.5 | 39.7 ± 12.5 | 11.32 | < 0.001 | 1.25 | |
| ONI behaviors | 25.3 ± 6.5 | 16.5 ± 5.3 | 13.07 | < 0.001 | 1.48 | |
| ONI emotions | 11.3 ± 4.1 | 8.7 ± 3.5 | 6.22 | < 0.001 | 0.68 | |
| ONI impairments | 20.2 ± 6.8 | 14.5 ± 5.6 | 8.35 | < 0.001 | 0.91 | |
| BDI scores | 18.5 ± 11.8 | 11.8 ± 9.9 | 5.62 | < 0.001 | 0.61 | |
| BAI scores | 20.6 ± 15.0 | 11.1 ± 10.7 | 6.54 | < 0.001 | 0.73 | |
| Moderate-to-severe depressive symptoms | 22.09 | < 0.001 | - | |||
| Yes | 80 (51.3%) | 48 (26.4%) | ||||
| No | 76 (48.7%) | 134 (73.6%) | ||||
| Moderate-to-severe anxiety symptoms | 26.77 | < 0.001 | - | |||
| Yes | 87 (55.8%) | 51 (28.0%) | ||||
| No | 69 (44.2%) | 131 (72.0%) | ||||
| BMI (kg/m 2 ) | 21.3 (IQR:5.03) | 23.3 (IQR:6.08) | -4.41 | < 0.001 | - | |
Notes: Values are presented as mean ± SD, median (IQR), or n (%), as appropriate. CD = celiac disease; CG = control group; ONI = Orthorexia Nervosa Inventory; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; BMI = body mass index ; χ² = chi-square test; t = independent samples t-test; Z = Mann–Whitney U test
Correlation analysis was performed between continuous variables. In the correlation analysis, the ONI total score was significantly positively correlated with the BDI score (r = 0.38; p < 0.001). Simultaneously, the BAI score was significantly positively correlated with the ONI total score (r = 0.42; p < 0.001). Furthermore, ONI behaviors, ONI impairments, and ONI emotions subscales of the ONI scale were positively associated with BDI and BAI scores. The body mass index of the participants was found to be significantly positively correlated with age (r = 0.39; p < 0.001) (Table 3). Additionally, separate correlation analyses for the celiac disease and control groups are presented in Supplementary Table S1 and Supplementary Tables S2, respectively.
Table 3.
Correlation Analysis
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
|---|---|---|---|---|---|---|---|
| 1.ONI total | - | ||||||
| 2.ONI behaviors | 0.91*** | - | |||||
| 3.ONI impairments | 0.89*** | 0.67*** | - | ||||
| 4.ONI emotions | 0.85*** | 0.67*** | 0.73*** | - | |||
| 5.BDI score | 0.38*** | 0.20*** | 0.47*** | 0.38*** | - | ||
| 6.BAI score | 0.42*** | 0.28*** | 0.48*** | 0.40*** | 0.71*** | - | |
| 7. Age | 0.05 | 0.07 | 0.03 | 0.01 | -0.14** | -0.10 | - |
| 8.BMI | -0.11* | -0.14* | -0.10 | -0.04 | -0.14* | -0.15** | 0.38*** |
Notes: ONI = Orthorexia Nervosa Inventory; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; BMI = body mass index; *p < 0.05, **p < 0.01, ***p < 0.001
A hierarchical multiple regression analysis was conducted to examine whether celiac disease status was independently associated with orthorexic traits. The results are presented in Table 4. In the first step, demographic and health-related variables (age, gender, BMI, and comorbid chronic illness) were entered, explaining 10.7% of the variance in orthorexic traits (R² = 0.11, p < 0.001). In the second step, anxiety and depressive symptoms were added, significantly increasing the explained variance (ΔR² = 0.16, p < 0.001). In the final step, celiac disease status was included and accounted for an additional 12.8% of the variance (ΔR² = 0.13, p < 0.001). In the final model, celiac disease status (β = 0.40, p < 0.001), anxiety symptoms (β = 0.25, p < 0.001), and age (β = 0.10, p = 0.04) were significant predictors of orthorexic traits. Additionally, collinearity diagnostics were performed, and all predictor variables had acceptable tolerance (tolerance = 0.42–0.95) and variance inflation factors (VIF = 1.03–2.38).
Table 4.
Hierarchical Multiple Regression Analysis Predicting Orthorexic Traits (ONI Total Score)
| Predictors | Step 1 | Step 2 | Step 3 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| β | SE | t | β | SE | t | β | SE | t | |
| Age | 0.03 | 0.09 | 0.49 | 0.12 | 0.06 | 2.30* | 0.10 | 0.08 | 2.04* |
| Gender | 0.07 | 1.94 | 1.41 | 0.03 | 1.78 | 0.67 | 0.06 | 1.62 | 1.24 |
| BMI | -0.14 | 0.20 | -2.46* | -0.10 | 0.19 | -1.93 | -0.01 | 0.17 | -0.11 |
| Comorbid chronic illness | 0.28 | 1.91 | 5.20*** | 0.12 | 1.86 | 2.38* | 0.04 | 1.74 | 0.76 |
| BDI scores | 0.15 | 0.10 | 2.22* | 0.11 | 0.09 | 1.69 | |||
| BAI scores | 0.31 | 0.08 | 4.34*** | 0.25 | 0.08 | 3.75*** | |||
| Celiac disease status | 0.40 | 1.53 | 8.36*** | ||||||
| R 2 | 0.11 | 0.27 | 0.39 | ||||||
| △R2 | 0.11 | 0.16 | 0.13 | ||||||
Note: ONI: Orthorexia Nervosa Inventory, BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; BMI = body mass index
Coding of gender: 0 = male, 1 = female
Coding of comorbid chronic illness: 0 = no, 1 = yes
Coding of celiac disease status: 0 = non-celiac control, 1 = celiac disease
β = standardized regression coefficient; SE = standard error
*p < 0.05, **p < 0.01, ***p < 0.001
Discussion
In our study, orthorexia traits in patients with celiac disease were screened using the ONI scale, and the relationship of these traits with anxiety and depression was investigated. The results revealed that, compared to healthy controls, celiac disease patients experience traits of ON more frequently. The behavior of adhering to a rigid diet and the associated stress may be linked to an increase in psychiatric comorbidities [26–28].
The frequency and severity of anxiety and depression have been reported to be higher in patients with celiac disease than in healthy controls [29, 30]. Similarly, our findings indicate significantly higher levels of both depression and anxiety in patients with celiac disease compared with the control group. The associations between ONI scores and both anxiety and depression indicate moderate relationships, suggesting that emotional distress is an important correlate of orthorexic traits in individuals with celiac disease. In contrast, BMI showed significant negative correlations with ONI total scores, BDI, and BAI scores; however, these associations were small in magnitude. According to Cohen’s criteria, these values correspond to small effect sizes, indicating limited clinical relevance despite statistical significance. Additionally, the positive correlation between age and BMI is consistent with expected trends in adult populations [31]. It is known that anxiety and depression in patients with celiac disease reduce their quality of life and impair dietary compliance [32]. Anxiety and depression rates have been reported to decrease after dietary compliance improves [33, 34]. On the other hand, the association between orthorexic traits and anxiety suggests a heightened concern for health and fear of contamination in patients with celiac disease. Anxiety likely reinforces these rigid dietary patterns as a coping strategy to prevent potential health risks, which in turn sustains and exacerbates orthorexic tendencies.
Although adherence to a gluten-free diet may be associated with improvements in mental health outcomes such as reduced anxiety and depressive symptoms, patients have reported feelings of isolation due to their dietary restrictions [35, 36]. Women, in particular, reported that dietary adherence prevented them from socializing and that they had to miss out on essential aspects of life [34]. Another study examined the impact of celiac disease on daily life and found that patients felt more isolated and invisible [36]. Similarly, patients with celiac disease have reported that they avoid socializing due to their diet, and anxiety about the diet causes maladaptive eating disorders [30]. While adherence to a gluten-free diet may have beneficial effects on psychological well-being through biological mechanisms, it may also contribute to psychological distress by limiting social participation. In the present study, higher ONI scores were associated with increased levels of anxiety and depression. This finding is consistent with previous literature suggesting that the psychosocial burden of dietary restrictions may contribute to stress and vulnerability to anxiety and depressive symptoms in patients with celiac disease. This finding is consistent with the literature and may indicate that the deterioration of the patient’s social cohesion due to their diet is associated with more intense stress and a predisposition to anxiety and depression [37–39]. Accordingly, stricter dietary adherence may be linked to increased perceived stress related to dietary management and, to some extent, depressive symptoms [38–40]. Beyond physical complications and nutritional concerns, clinicians should also consider the impact of dietary management on patients’ social functioning during follow-up. Addressing psychosocial difficulties within a multidisciplinary framework may improve overall patient outcomes.
Critically, the increased orthorexic tendencies in the celiac population represent more than just strict adherence to a gluten-free diet. Orthorexia involves a pathological layer of cognitive obsession and emotional strain that extends beyond necessary medical precautions, ultimately leading to functional impairments in the patient’s daily and social life [13].
The rigorous dietary vigilance necessitated by celiac disease can, perhaps inadvertently, cultivate cognitive patterns that mirror those found in ON. Given the constant requirement to scrutinize ingredients and mitigate contamination risks, patients often operate under a state of heightened food-related anxiety. While these behaviors are initially adaptive, they risk evolving into a more rigid, maladaptive preoccupation with food purity that extends beyond the clinical requirements of a gluten-free diet [5, 13, 32].
A critical issue in interpreting the present findings is the conceptual overlap between adaptive dietary behaviors required for the management of celiac disease and maladaptive orthorexic traits. Strict dietary control in celiac disease is medically necessary and is often associated with substantial practical and psychosocial burden, including concerns about food contamination, limited food availability, financial constraints, and social restrictions. Although these behaviors may resemble orthorexic patterns at a behavioral level, they primarily reflect the demands of disease management. However, because the ONI captures behavioral, emotional, and impairment-related aspects of eating, some degree of overlap between disease-related dietary burden and orthorexic symptomatology cannot be excluded. Therefore, elevated ONI scores in this population should be interpreted with caution, as they may partially reflect the burden of managing a chronic dietary condition rather than exclusively maladaptive eating pathology.
Symptoms of anorexia are known to increase morbidity in celiac disease [41]. Like anorexia, orthorexia is characterized by perfectionism, high levels of anxiety, and a need for control. Individuals with orthorexia and anorexia are driven by a desire for achievement, viewing even minor deviations from their diet as failures. Both conditions often involve a lack of insight, with patients unable to recognize the negative impact of their behaviors on their functionality [42, 43]. However, in orthorexia, patients may experience excessive, intrusive thoughts about food and health at inappropriate times, along with intense anxiety about contamination, resembling obsessive behaviors [44]. The stress associated with these conditions is considered a predisposing factor for anxiety and depression. In celiac disease, physical distress resulting from non-adherence to dietary restrictions can exacerbate these symptoms and increase stress. The co-occurrence of orthorexic traits and celiac disease may be associated with more adverse psychological outcomes.
The regression analysis indicated that the model explained a moderate proportion of the variance in orthorexic symptoms, which is consistent with the multifactorial nature of orthorexic symptomatology in patients with celiac disease. Although anxiety and disease status emerged as significant predictors, a substantial proportion of variance remained unexplained, suggesting that additional factors such as personality traits, cognitive rigidity, nutritional beliefs, and sociocultural influences may also contribute to orthorexic tendencies [45, 46].
Importantly, in the final regression model, the BDI lost statistical significance, whereas the BAI remained a significant predictor. This pattern suggests that anxiety may represent a more relevant psychological correlate of orthorexic traits than depressive symptoms in this population. One possible explanation is that orthorexic behaviors are more closely related to anxiety-driven processes such as heightened health concerns, need for control, and intolerance of uncertainty. This interpretation is consistent with previous literature reporting stronger associations between orthorexia and anxiety than with depression, although findings remain heterogeneous [47, 48]. Overall, these findings suggest that anxiety may play a particularly relevant role in the psychological profile associated with orthorexic traits in individuals with celiac disease, while depressive symptoms may have a more indirect or context-dependent association.
The ONI is the first assessment tool for orthorexia that includes elements of physical impairment, a component that academics and clinicians agree is essential to the disorder [18]. Our study’s strength lies in being the first to thoroughly assess orthorexia traits in patients with celiac disease using the ONI and to explore the association between these symptoms and anxiety and depression. However, the relatively small sample size limits the generalizability of the findings, and future studies with larger cohorts are warranted. A key limitation of this study is the lack of objective data on dietary adherence. Given that strict adherence to a gluten-free diet is medically required in celiac disease, the interpretation of orthorexic traits should be made cautiously in this context. Elevated ONI scores in this population may therefore reflect, at least in part, the burden of necessary dietary restrictions rather than exclusively orthorexic pathology. Future research should incorporate validated measures of dietary adherence and include subgroup analyses to better elucidate these relationships. Another limitation is the cross-sectional design, which precludes conclusions regarding causal or temporal relationships. The psychological symptoms and orthorexic traits may be bidirectional. For example, while better adherence to a gluten-free diet may reduce anxiety and depressive symptoms through improved physical health, individuals with lower psychological distress may also be better able to maintain dietary compliance. Longitudinal studies are therefore needed to clarify these pathways.
Finally, the absence of structured clinical interviews for eating disorders and the lack of information on disease duration should be acknowledged. Although orthorexic traits were assessed using a validated self-report instrument, some overlap between disease-related dietary vigilance and maladaptive eating attitudes cannot be excluded. This may have contributed to an overestimation of orthorexic traits in this population. Future studies should employ longitudinal designs to clarify the causal relationship between orthorexic tendencies and psychiatric symptoms in patients with celiac disease.
Additionally, research incorporating measures of dietary adherence, social functioning, and stress may provide a more comprehensive understanding of the psychosocial factors contributing to orthorexia traits in this population.
Conclusion
Although celiac disease requires strict dietary management, individuals with celiac disease may exhibit higher levels of orthorexic traits. The findings suggest that both dietary management and the psychological burden associated with strict dietary control should be considered during clinical follow-up. Addressing these aspects may contribute to improved quality of life and overall functioning in patients with celiac disease, as well as better recognition of associated psychological distress.
Supplementary Information
Below is the link to the electronic supplementary material.
Abbreviations
- ON
Orthorexia Nervosa
- ONI
Orthorexia Nervosa Inventory
- BDI
Beck Depression Inventory
- BAI
Beck Anxiety Inventory
- BMI
Body Mass Index
Author contributions
JH: Conceptualization, Methodology, Data Curation, Formal Analysis, Writing – Original Draft, Project Administration. YHA: Conceptualization, Writing – Review & Editing, Supervision. BÖ: Investigation, Data Curation, Resources. ÜD: Resources, Methodology, Writing – Review & Editing. All authors read and approved the final manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for the study was obtained from the Baskent University School of Medicine Human Research Ethics Committee (KA22/375). The research was conducted in compliance with the ethical standards established in the1964 Declaration of Helsinki and its subsequent updates. All participants gave informed consent before the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.