The various facets of orthorexic eating behavior: five case reports of individuals with supposed orthorexia nervosa.

BACKGROUND: Orthorexia nervosa, defined as a fixation on eating healthy according to subjective criteria, is recently being discussed as another variant of disordered eating behavior. Further characteristics are rigid adherence to nutritional rules, anxieties and avoidance behavior in the context of eating as well as a focus on health, not on body shape or weight loss, which is supposed to differentiate orthorexic from other disordered eating behavior. Although diagnostic criteria have been suggested, they have rarely been used in case reports published to date. Hence, the aim of this study was to present five individuals with supposed orthorexia nervosa, using preliminary diagnostic criteria to assess their eating behavior. CASE PRESENTATION: The five cases (three females, two males) reveal the great variety of disordered eating behavior. Fear of unhealthy overweight (case A), supposed orthorexic eating behavior as a coping strategy for anorexia nervosa (case B), the exclusive consumption of animal products with a total exclusion of fruits and vegetables (case C), the fixation on exercise and athletic goals (case D) as well as a focus on a vegan diet and unprocessed foods (case E) are facets of orthorexia nervosa with varying degrees of impairment. CONCLUSIONS: It is concluded that orthorexia nervosa manifests itself in very different ways and that more research is needed in order to determine whether it could be a useful additional category of disordered eating behavior.

A consensus document on definition and diagnostic criteria for orthorexia nervosa.

PURPOSE: Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with "correct" eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included. METHODS: 47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A-Definition, Clinical Aspects, Duration; B-Consequences; C-Onset; D-Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants. RESULTS: 27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON. CONCLUSIONS: This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel. LEVEL OF EVIDENCE: Level V: opinions of expert committees.

No elevated levels of orthorexic eating behavior in a sample of adults with allergies and food intolerances.

PURPOSE: To compare orthorexic eating behavior in a sample of adults with and without self-reported allergies and food intolerances. METHODS: N = 52 individuals with and n = 102 individuals without self-reported allergies and food intolerances (80% with medical diagnosis; in total 74.6% female, 23.7% male; age: M = 28.13, SD = 11.96 years) completed an online survey with the Düsseldorf Orthorexia Scale and answered several questions regarding their allergies/intolerances. RESULTS: The groups did not differ in their orthorexic eating behavior. In the sample of individuals with allergies/intolerances, orthorexic eating behavior correlated with the perceived severity of the allergic symptoms and the number of consequences that the allergies had for eating behavior. CONCLUSIONS: In line with previous findings, orthorexic eating behavior does not seem to be elevated in individuals with allergies/intolerances. However, focusing on a healthy diet despite adverse food reactions and experiencing a number of allergy-related consequences for one's eating behavior might be associated with orthorexic eating behavior. LEVEL OF EVIDENCE: III, case-control analytic study.

An exploratory study of associations between the ICD-11 personality disorder model and eating pathology.

BACKGROUND: Recently, the International Classification of Diseases 11th Revision (ICD-11) has introduced a paradigm shift in personality disorder conceptualization. The novel ICD-11 personality disorder model comprises a dimensional assessment of personality dysfunction and five maladaptive personality trait domains. Maladaptive personality plays a central role in eating pathology. Yet, relations between the ICD-11 personality disorder model and eating pathology are, to date, unclear. Thus, this study aimed to explore the bivariate, incremental, and interactive associations of the ICD-11 personality disorder model components with eating pathology domains. METHODS: A predominantly female (85%) sample of 888 German-speaking community adults completed validated self-report measures of personality dysfunction, the ICD-11 personality trait domains, and five eating pathology domains (drive for thinness, bulimia, body dissatisfaction, orthorexia, binge eating). Bivariate and hierarchical regressions models were used to investigate bivariate, incremental, and interactive relations between the ICD-11 personality disorder model components and eating pathology. RESULTS: Personality dysfunction and the ICD-11 personality trait domains showed statistically significant bivariate relations with eating pathology. Additionally, personality dysfunction and most ICD-11 personality trait domains displayed incremental links with eating pathology. Finally, the relations of the ICD-11 personality trait domains with eating pathology were largely independent of the severity of personality dysfunction. CONCLUSIONS: This study indicated that all ICD-11 personality disorder model components are uniquely linked to eating pathology. Beyond maladaptive personality trait domains, the strong and incremental relations of personality dysfunction with eating pathology have potential implications for theory building. Further research using longitudinal designs is needed to evaluate causal links between the ICD-11 personality disorder model components and eating pathology.

The International Classification of Diseases 11th Revision (ICD-11) contains a novel personality disorder model. We explored how this model's components (i.e., personality dysfunction, five maladaptive personality traits) relate to eating pathology. The model components were significantly and complementarily related to a drive for thinness, bulimia, body dissatisfaction, orthorexia, and binge eating. Hence, the ICD-11 personality disorder model may potentially prove helpful in better understanding individual differences in eating pathology.

Validation of the Arabic version of the Dusseldorf Orthorexia Scale (DOS) among Lebanese adolescents.

BACKGROUND: Orthorexia Nervosa (ON) is defined as a pathological preoccupation characterized by obsessive beliefs and compulsive behaviors regarding 'pure' eating behaviors. Many scales have been established and display good results regarding reliability and validity measures, including but not limited to ORTO-R (revised version of ORTO-15), Eating Habits Questionnaire, Teruel Orthorexia Scale (TOS) and the Düsseldorf Orthorexia Scale (DOS). Among these, the DOS seems to be a promising measure for multiple reasons. The current paper aims to validate the DOS, a measure of ON, in a non-Western population of Lebanese adolescents. METHODS: This was a cross-sectional designed study, conducted between May and June 2020, which enrolled 555 adolescents (15-18 years old; 75.7% females). Due the coronavirus pandemic outbreak, the data were gathered through snowball sampling using an online questionnaire. The DOS, TOS and ORTO-R scales were used in this study to screen for orthorexic tendencies and behaviors. RESULTS: We tested four competing structural models of the DOS assessing its factorial validity. The results of the current investigation revealed that the one-factorial model is the best one to represent the structure of the questionnaire. We provided evidence for validity for the DOS through demonstrating that it correlates significantly with other measures of orthorexic behaviours (Teruel Orthorexia Scale and ORTO-R). Finally, we have gathered evidence that the orthorexic behaviours as measured by DOS are not associated with age (r = -.02; p = .589), household crowding index (r = .02; p = .578), and Body Mass Index (r = .04; p = .297). Yet, females as compared to males achieved higher scores (M = 20.07, SD = 6.38 vs M = 18.29, SD = 6.37; p = .005; d = .28). CONCLUSION: The Arabic version of the DOS seems to be a structurally valid and internally consistent questionnaire measuring orthorexic eating behavior in a sample of Lebanese adolescents. This tool may be useful for psychologists, psychiatrists, dietitians and other clinicians in the assessment and the treatment of the multidimensional nature of ON.

Psychometric evaluation of the French version of the Düsseldorfer Orthorexia Skala (DOS) and prevalence of orthorexia nervosa among university students.

PURPOSE: This study aimed at obtaining a French version of the DOS (F-DOS) and evaluating its psychometric properties in a sample of university students, then assessing the prevalence of orthorexic eating behavior among the participants. METHODS: The F-DOS was obtained using back translation, and then administered to 3235 university students (10.32% men, 89.67% women) with a mean age of 21.13 (SD = 2.23). The Eating Habits Questionnaire and Eating Attitudes Test were used to assess convergent and divergent validities, respectively. Confirmatory factor analysis was performed to explore the factor structure. RESULTS: Ordinal ⍵ of F-DOS was 0.87, indicating very good internal consistency. F-DOS and EHQ total scores were strongly correlated (rs = 0.74, p < 0.001), indicating very good construct validity. Factor analysis revealed a well-fitted one-factor model. Regarding Orthorexia Nervosa (ON) prevalence, according to DOS cut-off score, 3.28% of participants could be considered having ON, while an additional 11.31% could be at risk of developing ON. CONCLUSIONS: The F-DOS appears to be a valid and reliable instrument to assess orthorexic eating behavior. ON prevalence in college students appeared similar to Germany and lower than in the US. LEVEL OF EVIDENCE: Descriptive (cross-sectional) study, Level V.

Orthorexic eating behaviour, illness anxiety and dysfunctional cognitions characteristic of somatic symptom disorders in a non-clinical sample.

PURPOSE: To analyse the relation of illness anxiety, dysfunctional cognitions characteristic of somatic symptom disorders and orthorexic eating behaviour in a non-clinical sample. METHODS: N = 445 participants (n = 363 females) completed an online survey with the following questionnaires: the Düsseldorf Orthorexia Scale to measure orthorexic eating behaviour, the Attitudes Towards Body and Health Questionnaire to assess dysfunctional cognitions concerning the perception and interpretation of bodily sensations and the Multidimensional Inventory of Hypochondriacal Traits to measure illness anxiety. RESULTS: In the total sample, orthorexic eating behaviour was associated with the aforementioned variables to a very low extent. However, individuals with high levels of orthorexic eating behaviour (n = 19) displayed significantly higher levels of health habits and of perceptions of autonomic sensations, as well as higher levels of hypochondriacal worry and absorption than individuals with low levels of orthorexic eating behaviour (n = 19). CONCLUSIONS: Orthorexic eating behaviour is associated to some characteristic features of illness anxiety and dysfunctional cognitions characteristic of somatic symptom disorders. Future studies should investigate whether illness anxiety serves as a risk factor for the development of orthorexic eating behaviour. LEVEL OF EVIDENCE: III, case-control analytic study.

Orthorexic eating behavior in patients with somatoform disorders.

PURPOSE: Although anecdotal reports suggest a relation between orthorexic eating behavior and symptoms of somatoform disorders, this issue has not yet been investigated. The aim of this study was to compare orthorexic eating behavior and other characteristics of disordered eating behavior in patients with somatoform disorders to a sample of healthy controls. METHODS: 31 patients with somatoform disorders and 30 matched controls completed eight questionnaires, i.a., the Düsseldorf Orthorexia Scale, three scales of the Eating Disorder Inventory-2, Eating Attitudes Test-26, Multidimensional Inventory of Hypochondriacal Traits, Attitudes Towards Body and Health Questionnaire, and Screening for Somatoform Disorders. RESULTS: The patients displayed higher levels of orthorexic eating behavior, drive for thinness, body dissatisfaction, bulimia, and dieting than the control group. In both groups, orthorexic eating behavior was associated with higher levels of somatization in eating and health habits. The control group showed an association of orthorexic eating behavior with catastrophizing cognitions and the perceptual component of health anxiety. CONCLUSION: The results support the hypothesis of a connection between orthorexic eating behavior and somatoform disorders. However, patients with somatoform disorders do not seem to be at particular risk for orthorexia. Future studies should investigate causes for the relationship between orthorexic eating behavior and characteristics of somatoform disorders in samples of healthy individuals. LEVEL OF EVIDENCE: Level V, descriptive study with matched control group.

Orthorexic eating behavior and body dissatisfaction in a sample of young females.

PURPOSE: To analyze body dissatisfaction in relation to orthorexic eating behavior in a sample of young females to further investigate characteristic features of orthorexic eating behavior and its association with other eating disorders. METHODS: N = 197 young females (age: M = 29.59, SD = 10.85 years) completed an online survey with the following questionnaires: the Düsseldorf Orthorexia Scale to measure orthorexic eating behavior, the Eating Disorder Inventory-2 (EDI-2), measuring psychopathological aspects of disordered eating behavior, the Dresden Body Image Questionnaire (DKB-35) to measure five components of body image, and the Body Shape Questionnaire (BSQ), measuring body dissatisfaction. RESULTS: In the total sample, Pearson correlations revealed that orthorexic eating behavior was positively associated with drive for thinness and body dissatisfaction. An independent samples t-Test revealed that females with elevated levels of orthorexic eating behavior (n = 35) displayed higher levels of drive for thinness and body dissatisfaction and lower levels of self-acceptance in comparison to a randomized sample from the remaining females with low levels of orthorexic eating behavior (n = 35). According to a multiple regression analysis, drive for thinness and body dissatisfaction measured by the BSQ served as positive predictors for orthorexic eating behavior, whereas bulimia and body dissatisfaction measured by the EDI-2 served as negative predictors. CONCLUSIONS: Results reveal that orthorexic eating behavior is more closely related to psychopathological aspects of other eating disorders than previously assumed. Body dissatisfaction as another major feature of orthorexia nervosa should be taken into account in future studies. LEVEL OF EVIDENCE: III, case-control analytic study.

Orthorexic eating behavior in vegans is linked to health, not to animal welfare.

PURPOSE: This study aimed to analyze the association between the importance of several reasons to follow a vegan diet and the degree of orthorexic eating behavior in a sample of vegan individuals (N = 65, 53.8% women, age: M = 28.22 (SD = 9.13) years, BMI: M = 22.91 (SD = 3.44) kg/m2). RESULTS: The results reveal that orthorexic eating behavior is associated with the importance of the underlying motives health, esthetics and healing, whereas animal welfare, politics and ecology are not linked to orthorexia. CONCLUSION: Hence, this study reveals that a vegan lifestyle is not per se associated with orthorexic eating behavior, but rather that it varies with the underlying motivation for following a vegan diet.

Orthorexia nervosa and healthy orthorexia as new eating styles.

It was recently proposed that healthy orthorexia (HeOr) and orthorexia nervosa (OrNe) should be differentiated. The aim of the present study was to analyze whether the two dimensions of orthorexia can be considered new eating styles or basically equivalent to restrained eating behavior. Two samples of university students (sample 1, n = 460; sample 2, n = 509) completed the Teruel Orthorexia Scale (TOS), the Dutch Eating Behavior Questionnaire (DEBQ), and the Positive and Negative Affect Schedule (PANAS). Factor analysis with the TOS and DEBQ items together revealed an adequate fit for the preexisting five-factor solution (TOS: OrNe and HeOr; DEBQ: Restrained Eating, Emotional Eating, and External Eating). This result points out that these factors are conceptually distinguishable. Moreover, we tested whether the different eating styles presented different patterns of correlations with gender, body mass index (BMI), and age, and whether OrNe and HeOr predicted Positive and Negative Affect after controlling for Restrained, Emotional, and External Eating. Whereas Restrained and Emotional Eating were higher for women and increased with BMI in both samples, HeOr and OrNe presented much lower associations with these variables. OrNe was positively related to Negative Affect and negatively to Positive Affect, whereas HeOr was positively related to Positive Affect. Again, this result supports the assumption that OrNe is a new variant of disordered eating, whereas HeOr could possibly be seen as a protective behavior.

Psychometric properties of the Chinese version of the Düsseldorf Orthorexia Scale: prevalence and demographic correlates of orthorexia nervosa among Chinese university students.

PURPOSE: As there is no measure available in Chinese for assessing orthorexia nervosa (ON), and as the Düsseldorf Orthorexia Scale (DOS) has demonstrated to be a valid measure for such a purpose, the current study aimed to obtain a Chinese version of the DOS (C-DOS), to evaluate psychometric properties of the C-DOS in a sample of Chinese university students, and to explore the prevalence of ON among the participants. METHODS: According to standard procedures, the C-DOS was obtained and administered to 1075 mainland Chinese university students (52.7% female) recruited from two provinces in mainland China. To examine the factor structure of the C-DOS, the total sample was split into two halves, one for exploratory factor analysis, and the other for confirmatory factor analysis. The ordinal alpha and test-retest reliability were examined. Convergent and divergent validity was assessed by conducting Pearson correlation analyses between the C-DOS and other theoretically related/unrelated measures. Prevalence of ON was estimated based on the total score of the C-DOS with the cutoff value of 30. RESULTS: A three-factor structure was revealed for the C-DOS. The C-DOS showed good internal consistency with an ordinal alpha of 0.80, and it also had good test-retest reliability of 0.77. The total scores of the C-DOS had strong and statistically significant positive correlations with eating inflexibility, while the total scores had weak correlations with other eating disturbances. Strong measurement invariance across gender groups was also supported. The prevalence of ON was 7.8% with males showing higher rates of ON than females (10.6% vs. 5.3%). CONCLUSIONS: The Chinese version of the DOS (C-DOS) was psychometrically adequate for the sample of Chinese students. Given the high prevalence of ON found in the current study, more attention to ON, as well as further research and potential interventions, are warranted in China. LEVEL OF EVIDENCE: Descriptive (cross-sectional) study, Level V.

Psychometric evaluation of the English version of the Düsseldorf Orthorexie Scale (DOS) and the prevalence of orthorexia nervosa among a U.S. student sample.

PURPOSE: Recently, the concept of orthorexia nervosa (ON) as a potential new variant of disordered eating behavior has gained popularity. However, published prevalence rates appear to be questionable given the lack of validity of the available questionnaires. The Düsseldorf Orthorexie Scale (DOS) is a validated questionnaire only available in German to measure orthorexic behavior. METHODS: The DOS was translated into English using the back-translation process. Cronbach's alpha was used to establish internal consistency and an intra-class correlation coefficient was calculated to assess reliability. The Eating Habits Questionnaire (EHQ) was used to test construct validity and the Eating Disorders Inventory was used to test discriminant validity. Principal and confirmatory factor analyses were carried out to test the factor structure. The sample consists of 384 university students in the U.S. RESULTS: English (E)-DOS and EHQ were highly correlated (r = 0.76, p < .001) indicating very good construct validity. Cronbach's alpha coefficient reached 0.88, indicating very good internal consistency. Confirmatory factor analyses revealed a poorly fitted one-factor model, but good results for the standardized coefficients for the 10 items ranging between 0.52 and 0.82 were found. According to the E-DOS, 8.0% of the students exceeded the preliminary cut-off score, while an additional 12.4% would be considered being at risk of developing ON. CONCLUSIONS: The E-DOS appears to be a valid, reliable measure for assessing ON. The results revealed higher prevalence rates for orthorexic behavior among U.S. students compared to German students. Cultural aspects could play a role in those differences. LEVEL OF EVIDENCE: Descriptive study, Level V.

Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature.

AIM: In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote health. The pursuit of an "extreme dietary purity" due to an exaggerated focus on food may lead to a disordered eating behavior called "orthorexia nervosa" (ON). ON raises a growing interest, but at present there is no universally shared definition of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related psychometric instruments and provides research propositions and framework for future analysis. METHODS: The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last access on 07 August 2018), using "orthorexia", "orthorexia nervosa" and "obsessive healthy eating" as search terms, and filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from English. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed. RESULTS: The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation. Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid, extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diagnostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c) psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia Self-Test developed by Bratman were the most used psychometric tools. CONCLUSIONS: The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psychometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both research and clinical activity until now. LEVEL OF EVIDENCE: Level V, narrative review.

Orthorexic and restrained eating behaviour in vegans, vegetarians, and individuals on a diet.

PURPOSE: Orthorexic eating behaviour, restrained eating, and veganism/vegetarianism are food selection strategies sharing several characteristics. Since there are no studies investigating their interrelationships, aim of the present study was to analyse orthorexic and restrained eating behaviour in (1) a sample of vegans and vegetarians and (2) a sample of individuals on a diet to lose weight. METHOD: Division of samples according to pre-defined criteria in (1) vegans (n = 114), vegetarians (n = 63), individuals with rare meat consumption (n = 83) and individuals with frequent meat consumption (n = 91) and in (2) participants on a diet with dietary change (n = 104), without dietary change (n = 37) and a control group of individuals not on a diet (n = 258). Orthorexic eating behaviour was assessed with the Düsseldorfer Orthorexie Skala and restrained eating was assessed with the Restraint Eating Scale. RESULTS: Vegans and vegetarians do not differ in orthorexic eating behaviour, but both groups score higher in orthorexic eating behaviour than individuals consuming red meat. There are no differences regarding restrained eating. Individuals on a diet with dietary change score higher in both orthorexic and restrained eating, than individuals without dietary change and individuals not on a diet. CONCLUSIONS: Individuals who restrict their eating behaviour, either predominantly due to ethical reasons or with the intention to lose weight, display more orthorexic eating behaviour than individuals not limiting their food consumption. Further research is needed to investigate whether veganism, vegetarianism, or frequent dieting behaviour serve as risk factors for orthorexia. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Orthorexic eating behaviour as a coping strategy in patients with anorexia nervosa.

PURPOSE: Orthorexia nervosa is defined as the fixation on health-conscious eating behaviour and has recently been discussed as a new variant of disordered eating. The aim of the present study was to analyse orthorexic eating behaviour in an inpatient treatment sample of female anorexics to investigate the relation between anorexic and orthorexic eating behaviour. METHOD: Female anorexic patients with low (n = 29) and pronounced (n = 13) orthorexic eating behaviour as well as a matched control group composed of healthy females (n = 30) were compared with regard to several aspects of disordered eating, hypochondriacal traits, food consumption frequency and fulfilment of basic psychological needs in terms of eating. Orthorexic eating behaviour was assessed using the Düsseldorfer Orthorexie Skala. RESULTS: Fulfilment of basic psychological needs with respect to autonomy and competence is higher in anorexic individuals with pronounced orthorexic eating behaviour compared to patients with low orthorexic eating behaviour. Furthermore, patients with pronounced orthorexic eating behaviour state eating healthy food regardless of calorie content more often. No difference was found for hypochondriacal traits and eating disordered symptoms in general. CONCLUSIONS: Orthorexic eating behaviour enhances self-perception of eating behaviour as autonomous and competent, indicating that it might serve as a coping strategy in anorexic individuals. Further research is needed to investigate if this tendency in food selection strategy leads to positive effects in the long term.