Associations between Orthorexia Nervosa symptoms and executive functioning in physically active adults

Abstract

This study examined the relationships between core executive functioning (EF) domains (working memory, inhibition, and cognitive flexibility) and both healthy orthorexia and orthorexia nervosa in physically active adults. Participants were 342 adults (50.9% women; mean age = 23.40, SD = 5.62) who exercised regularly. They completed the Adult Executive Functioning Inventory, the Cognitive Flexibility Inventory, and the Teruel Orthorexia Scale. Pearson correlations and two-step multiple regression analyses controlling for demographic variables were conducted. Results showed that orthorexia nervosa was positively associated with working-memory difficulties and negatively associated with cognitive flexibility, while inhibition was not a significant predictor. Executive functioning variables did not significantly predict healthy orthorexia after controlling for demographics. Overall, the findings highlight the relevance of executive functioning in orthorexia nervosa and suggest that cognitive remediation approaches targeting cognitive rigidity and working memory may be beneficial in reducing maladaptive health-focused eating behaviors.

Keywords

exercise behavior cognitive processing activity eating behavior adults body mass index eating disorders

Introduction

Orthorexia, derived from the Greek words orthos (“correct”) and orexis (“appetite”), has been conceptualized as a distinct eating style characterized by an intense concern with consuming healthy foods. While an interest in proper nutrition is not inherently problematic (Barthels et al., 2019), research indicates that such behaviors can evolve into maladaptive forms, most notably orthorexia nervosa, which is marked by rigid dietary rules, avoidance of foods perceived as unhealthy, and excessive preoccupation with the sourcing and preparation of meals (Barrada and Roncero, 2018; Barthels et al., 2019; Bratman, 1997; Donini et al., 2005). Orthorexia nervosa is associated with distress, anxiety, functional impairment, and comorbid mental health difficulties such as obsessive–compulsive disorder, depression, and other disordered eating patterns (Messer et al., 2023; Zagaria et al., 2022). More broadly, disordered eating behaviors, including anorexia nervosa, bulimia nervosa, binge eating disorder, and emerging conditions like orthorexia nervosa, have attracted growing attention due to their significant health, psychological, and social consequences (American Psychiatric Association, 2013). These concerns have been further intensified by the pervasive influence of media-driven ideals and the rise of unrealistic body standards on social media, which contribute to the increasing prevalence and severity of disordered eating across diverse populations (Holland and Tiggemann, 2017). Importantly, however, not all expressions of orthorexic behavior are pathological. Barrada and Roncero (2018) highlighted the bidimensional nature of orthorexia, differentiating between its maladaptive variant, orthorexia nervosa, and a non-pathological form of interest in healthy nutrition, termed healthy orthorexia. While healthy orthorexia reflects a balanced and flexible interest in nutrition that is generally unrelated to psychological distress, orthorexia nervosa is characterized by rigidity, excessive preoccupation with food quality, and significant functional impairment (Horovitz and Argyrides, 2023; Zickgraf and Barrada, 2022). Emerging evidence suggests that these two dimensions show different patterns of association with psychological outcomes, with orthorexia nervosa being linked to mental health difficulties such as obsessive–compulsive symptoms, depression, and disordered eating behaviors, whereas healthy orthorexia tends to be unrelated or only weakly related to psychopathology (e.g., Awad et al., 2021; Strahler et al., 2022). This distinction is particularly important when examining cognitive and behavioral correlates, as the pathological features of orthorexia nervosa may reflect maladaptive cognitive patterns not observed in healthy orthorexia

It is now widely recognized that engaging in regular physical activity and following a balanced diet are fundamental for maintaining and promoting health (Warburton et al., 2006). However, for some individuals, the pursuit of an ideal state of health can become extreme and maladaptive, resulting in preoccupation, psychological distress, and disordered patterns of eating (Strahler et al., 2021). Within sport and exercise contexts, eating disorders are known to be more prevalent than in the general population, partly due to pressures to optimize performance, conform to esthetic ideals, and embody strict health standards (Bratland-Sanda and Sundgot-Borgen, 2013; Martinsen and Sundgot-Borgen, 2013). Orthorexia nervosa may be particularly relevant in exercising populations, as these individuals often face heightened pressures to maintain strict dietary regimens for performance or aesthetic purposes. Prior research indicates that orthorexia nervosa is positively associated with exercise participation and, more strongly, with exercise addiction (Rudolph, 2018; Strahler et al., 2021). Thus, individuals engaged in regular physical activity may represent a vulnerable group in which adaptive health behaviors risk evolving into maladaptive and compulsive eating patterns. Against this background, orthorexia nervosa, characterized by an obsessive focus on consuming foods perceived as healthy or pure, has been increasingly observed among individuals who regularly participate in exercise activities (Almeida et al., 2018; Segura-Garcia et al., 2012). This raises the question of how widespread orthorexia nervosa is in populations oriented toward physical fitness and athletic engagement. In this study, the term exercise refers broadly to any physical activity performed with the aim of improving or maintaining health and fitness. A recent meta-analysis found a small but significant correlation between orthorexia nervosa and exercise participation, as well as a stronger association between orthorexia nervosa and exercise addiction, indicating that while these constructs are distinct, they share meaningful connections (Strahler et al., 2021). Nevertheless, prevalence estimates of orthorexia nervosa in exercising populations remain inconsistent, with some studies reporting very low rates (e.g., Dunn et al., 2017; Hafstad et al., 2023) and others finding substantially higher levels (Rudolph, 2018). Such discrepancies underscore the need for further systematic investigation into the prevalence and correlates of orthorexia nervosa among individuals engaged in regular physical activity.

Orthorexia nervosa can be conceptualized within a self-regulation and executive control framework (Diamond, 2013; Dohle et al., 2018; Miyake and Friedman, 2012) in which health-oriented goals become governed by increasingly rigid, rule-based behavioral strategies (Strahler et al., 2020; Zagaria et al., 2022). From this perspective, executive functions provide the cognitive infrastructure that enables individuals to balance long-term health goals with contextual demands, integrate competing information, and flexibly revise behavioral rules when circumstances change (Diamond, 2013). When executive control is compromised, goal pursuit may shift toward inflexible reliance on simplified heuristics and repetitive routines, increasing vulnerability to compulsive, perfectionistic, and avoidance-based patterns (Chamberlain et al., 2021; Snyder et al., 2015a). In the context of orthorexia nervosa, difficulties in working memory may limit the ability to hold and manipulate multiple perspectives about nutrition, thereby strengthening perseverative focus on dietary purity rules and narrowing decision-making (Koven and Senbonmatsu, 2013). Similarly, reduced cognitive flexibility may impede set-shifting and adaptive updating of eating-related rules, promoting behavioral rigidity and resistance to contextual change (Grant and Chamberlain, 2023; Miles et al., 2022). This executive control account aligns with transdiagnostic models that link compulsive behavior to cognitive rigidity and reduced flexibility (Snyder et al., 2015a), and it offers a theoretically grounded rationale for expecting orthorexia nervosa, but not necessarily healthy orthorexia, to be associated with working memory difficulties and lower cognitive flexibility.

Executive functioning and orthorexia nervosa

Executive functions are higher-order cognitive processes that enable individuals to plan, monitor, and regulate their thoughts and behaviors in the service of long-term goals. These processes are commonly described as an umbrella construct encompassing distinct but interrelated domains such as working memory, cognitive flexibility, and inhibitory control (Diamond, 2013; Miyake et al., 2000). Adequate functioning in these areas is essential for adaptive decision-making, problem-solving, and emotional regulation, whereas deficits are consistently linked with a wide range of psychiatric disorders (Snyder, 2013). Because orthorexia nervosa shares symptomatic features with conditions such as anorexia nervosa and obsessive–compulsive disorder, both of which are strongly associated with impairments in executive functioning (Snyder et al., 2015b), investigating the role of executive processes in orthorexia nervosa is an important area of research.

Working memory

Working memory refers to the ability to temporarily store, update, and manipulate information to support complex cognitive activities, including reasoning, learning, and planning (Diamond, 2013). Deficits in working memory have been documented in individuals with anorexia nervosa and obsessive–compulsive disorder, where they contribute to rigid thinking styles, perseverative attention, and difficulties integrating new information (Thomas et al., 2022). In the case of orthorexia nervosa, preliminary findings suggest that similar difficulties may also be present. Koven and Senbonmatsu (2013), for example, found that the severity of orthorexia nervosa symptoms was associated with self-reported working memory difficulties, even when controlling for traits of anorexia nervosa and obsessive–compulsive disorder. Conceptually, impairments in working memory could exacerbate orthorexia nervosa by limiting an individual’s ability to hold multiple perspectives about food, nutrition, and health, which may in turn foster rigid adherence to dietary rules. In addition, working memory deficits may reduce the capacity to shift attention away from intrusive, food-related thoughts, reinforcing an obsessive preoccupation with dietary purity and quality.

Cognitive flexibility

Cognitive flexibility refers to the capacity to modify one’s thinking and behavior in response to changing circumstances or unexpected challenges (Dajani and Uddin, 2015; Logue and Gould, 2014). This capacity allows individuals to generate alternative perspectives, reframe stressful situations, and adopt new strategies when established ones prove ineffective. Cognitive flexibility is a central component of resilience, creativity, and adaptive coping (Genet et al., 2013; Lu et al., 2019). In contrast, impairments in cognitive flexibility are closely associated with rigid patterns of thought and behavior, and are consistently observed in depression, anxiety disorders, obsessive–compulsive disorder, and eating disorders (Grant and Chamberlain, 2023; Tchanturia et al., 2011). In anorexia nervosa and bulimia nervosa, for example, reduced cognitive flexibility manifests as strict dietary rituals, resistance to therapeutic change, and difficulty adapting eating behaviors (Miles et al., 2020, 2023). For orthorexia nervosa, empirical evidence is mixed. While self-report studies suggest that individuals with orthorexia nervosa experience cognitive rigidity, laboratory-based measures such as the Wisconsin Card Sorting Test and the Trail Making Test have not consistently demonstrated significant set-shifting impairments (Koven and Abry, 2015; Luck-Sikorski et al., 2019). One possible interpretation is that orthorexia nervosa involves a domain-specific form of rigidity: individuals may function adequately in general problem-solving contexts but show inflexibility in situations directly related to food and diet. This pattern would explain why self-reported flexibility difficulties emerge in everyday life, even when standardized cognitive tasks fail to detect impairments.

Inhibition

Inhibitory control refers to the ability to suppress automatic, dominant, or prepotent responses that are no longer adaptive or appropriate (Chambers et al., 2009; Miyake et al., 2000). Inhibitory control is a critical component of self-regulation, impulse control, and goal-directed behavior. Deficits in this capacity have been well documented in both anorexia nervosa and obsessive – compulsive disorder, where they are expressed in compulsive rituals, repetitive behaviors, and difficulties disengaging from maladaptive routines (Chamberlain et al., 2007; Li et al., 2024). In the case of orthorexia nervosa, the findings are less consistent. Experimental research using Stroop tasks, Go/No-Go tasks, and Flanker tasks has generally failed to reveal significant inhibitory deficits (Koven and Abry, 2015; Luck-Sikorski et al., 2019). However, self-report studies indicate that individuals with orthorexia nervosa often experience inhibition-related difficulties in daily life, particularly in regulating intrusive food-related thoughts and suppressing urges to follow rigid dietary rules (Koven and Senbonmatsu, 2013). This discrepancy between task-based and self-report evidence suggests that inhibitory control impairments in orthorexia nervosa may be subtle and context-specific, emerging most clearly in relation to food and health behaviors rather than across all domains of functioning.

Current study

Despite the growing recognition of orthorexia nervosa as a distinct form of disordered eating, empirical research examining its cognitive underpinnings remains scarce. While previous studies have documented executive functioning impairments in disorders with symptomatic overlap, such as anorexia nervosa and obsessive compulsive disorder, the extent to which orthorexia nervosa is similarly characterized by deficits in working memory, cognitive flexibility, and inhibitory control is less clear, largely due to the limited number of studies directly examining executive functioning in orthorexia nervosa and healthy orthorexia. Existing findings are inconsistent: laboratory-based measures often fail to identify significant executive functioning impairments, whereas self-report instruments suggest difficulties in everyday contexts. Moreover, there is limited evidence directly investigating these associations in non-clinical, physically active populations, despite exercise being a context in which orthorexia nervosa tendencies are particularly prevalent. In addition, recent literature (e.g., Barthels et al., 2019; Horovitz and Argyrides, 2023) has increasingly emphasized the conceptual distinction between healthy orthorexia, reflecting a non-pathological interest in healthy eating, and orthorexia nervosa, which is characterized by rigid, compulsive, and impairing dietary patterns. However, little is known about whether these two dimensions differ in their associations with executive functioning processes.

Aim of the study

The present study aimed to investigate the relationship between orthorexia nervosa symptoms and healthy orthorexia and executive functioning in a sample of physically active adults. Specifically, we examined whether orthorexia nervosa symptom severity and healthy orthorexia were associated with impairments in three core executive functioning domains: working memory, cognitive flexibility, and inhibitory control. By examining both healthy and pathological forms of orthorexic tendencies within the same framework, the study sought to address an important gap in the literature regarding whether executive functioning deficits are uniquely linked to maladaptive eating-related cognitions or also present in adaptive health-oriented eating patterns. By employing both validated measures of orthorexia nervosa and healthy orthorexia and executive functioning, this study sought to clarify the cognitive profile of different dimensions of orthorexic tendencies and contribute to a more nuanced understanding of how maladaptive health-related behaviors intersect with executive processes. Findings from this study may inform future prevention and intervention strategies by highlighting cognitive mechanisms that sustain orthorexic tendencies.

Methods

Participants and procedure

A total of 351 Turkish-speaking adult participants initially took part in the study. However, nine participants who reported having a chronic illness were excluded from the analyses, resulting in a final analytic sample of 342 participants. Participants’ ages ranged from 18 to 55 years (M = 23.40, SD = 5.62). Regarding gender, 174 participants (50.9%) were women and 168 (49.1%) were men. With respect to educational attainment, 91 participants (26.4%) had completed high school, 229 (66.4%) held a university degree, and 24 (7.0%) had completed graduate education. In terms of physical activity, the majority of participants (n = 342, 99.1%) reported engaging in regular exercise, whereas only three participants (0.9%) reported not engaging in exercise. The mean body mass index (BMI) of the sample was 23.26 (SD = 3.67). Participants’ body mass index (BMI) values were calculated according to the World Health Organization (WHO) criteria (WHO, 2000). Among the 342 participants, 34 individuals (9.9%) were classified as underweight (BMI < 18.5), 214 participants (62.6%) had a normal weight (BMI 18.5–24.9), 79 participants (23.1%) were overweight (BMI 25.0–29.9), and 15 participants (4.4%) were classified as obese (BMI ⩾ 30.0).

Data collection was conducted between March and June 2025 through both the paper-based and online formats. We used Google Forms for online data collection. A total of 103 responses were obtained online, while 251 forms were collected face-to-face. The paper-based data were gathered primarily from undergraduate and graduate students across various university departments of Mersin University, as well as from approximately 70 individuals recruited from 16 different fitness centers in Mersin, Türkiye. The remaining participants were predominantly university students. These settings were selected because they provided access to physically active young adults, a population in which health-focused eating behaviors and orthorexia-related tendencies are more likely to emerge. To assess potential mode effects, participants who completed the survey online and those who completed paper-based forms were compared on the main study variables, and no significant differences were found between the two groups.

Inclusion criteria for participation were (a) being over 18 years of age, (b) engaging in regular exercise at least twice per week, and (c) providing voluntary consent to take part in the study. Participants who exercised at least twice per week were selected to ensure that the sample represented individuals regularly engaged in physical activity, a context in which health-focused eating behaviors and orthorexia-related tendencies are more likely to emerge. Exclusion criteria included the (a) presence of any chronic illness and (b) involvement in professional sports. Participation in the study was entirely voluntary, and no incentives were provided to the participants. The study protocol received approval from the Social Sciences Ethics Committee of Mersin University (27.01.2025-10). All procedures adhered to the ethical standards of the responsible committee and to the Helsinki Declaration.

Measurements

The Adult Executive Functioning Inventory (ADEXI; Holst and Thorell, 2018) is a 14-item self-report instrument designed to assess two key dimensions of executive functioning: inhibition and working memory. Responses are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater executive functioning deficits. The scale consists of five items assessing inhibitory control (e.g., “I tend to act without considering the possible consequences”) and nine items assessing working memory difficulties (e.g., “When asked to do several things, I sometimes only remember the first or last”). Psychometric evaluations have demonstrated acceptable reliability, with Cronbach’s alpha values of 0.72 for inhibition and 0.88 for working memory. Turkish adaptation of the ADEXI was conducted by Alpay and Kızılöz (2023), who reported satisfactory internal consistency (α = 0.80 for the total scale, α = 0.83 for working memory, and α = 0.73 for inhibition). In the present study, Cronbach’s alpha internal consistency coefficients were calculated as 0.85 for the working memory and 0.76 for the inhibition.

The Cognitive Flexibility Inventory (CFI; Dennis and Vander Wal, 2010 ) is a 20-item self-report measure designed to assess individuals’ capacity to produce adaptive, balanced, and alternative thoughts when confronted with challenging or stressful situations. The instrument comprises two subscales: Alternatives, which measures the ability to perceive multiple explanations and solutions, and Control, which evaluates the perceived ability to regulate and manage difficult experiences. The scale was specifically developed to provide a clearer operationalization of the construct of cognitive flexibility, which had previously been ambiguously defined in the literature. Higher scores reflect greater levels of cognitive flexibility. The Turkish adaptation of the CFI was conducted by Gülüm and Dağ (2012). In their study, the internal consistency coefficient was reported as 0.90 for the total scale, demonstrating good reliability. In the present study, we used only the total score of the scale, and Cronbach’s alpha coefficient for the total score was calculated as 0.84, indicating good internal consistency.

The Teruel Orthorexia Scale (TOS; Barrada and Roncero, 2018) was developed to provide an assessment of orthorexic behaviors. The scale includes 17 items and measures two distinct dimensions. The first dimension, referred to as healthy orthorexia, captures a positive and adaptive interest in maintaining a healthy diet. The second dimension, called orthorexia nervosa, reflects obsessive and pathological attitudes toward healthy eating that negatively affect daily functioning. In the original validation study, internal consistency was reported as 0.85 for healthy orthorexia and 0.81 for orthorexia nervosa, indicating good reliability (Barrada and Roncero, 2018). Higher scores on the healthy orthorexia dimension represent an adaptive engagement with healthy nutrition, whereas higher scores on the orthorexia nervosa dimension indicate dysfunctional and compulsive eating-related patterns. The Turkish version of the Teruel Orthorexia Scale was adapted by Asarkaya and Arcan (2021). In their study, internal consistency coefficients were reported as 0.86 for healthy orthorexia and 0.81 for orthorexia nervosa, supporting the reliability of the Turkish adaptation. In the present study, Cronbach’s alpha coefficients were calculated as 0.83 for the healthy orthorexia dimension and 0.85 for the orthorexia nervosa dimension, indicating good internal consistency.

Statistical analysis

Prior to the main analyses, missing data were examined and were minimal (i.e., no case exceeded 10% missingness), suggesting a trivial level of missing data (Cohen et al., 2013). Missing values were replaced with the mean of the respective variable (Little and Rubin, 2019). Multivariate outliers were evaluated via Mahalanobis distance, with no extreme cases identified. The assumption of normality was assessed using skewness and kurtosis indices, all of which fell within the acceptable range of −2 to +2, confirming normal distribution of the variables (George and Mallery, 2018). The required sample size was estimated using G*Power 3.1 (Faul et al., 2009). A linear multiple regression: fixed model, R² increase was specified to test the incremental variance explained by the three executive function dimensions (working memory, inhibition, cognitive flexibility) beyond demographic controls. Assuming a medium effect size (f² = 0.15; Cohen, 1988), α = 0.05, and power (1 − β) = 0.80, the analysis indicated a minimum required sample of N = 100.

We first calculated descriptive statistics (means and standard deviations) for all study variables. We then conducted Pearson’s correlation analyses and hierarchical multiple regression analyses to examine associations among the variables and to identify predictors of both healthy orthorexia and orthorexia nervosa. We performed two separate regression analyses: in the first step of each analysis, we entered demographic variables to control for potential confounding effects, and in the second step, we added the dimensions of executive functioning. At each step, we reported standardized beta coefficients (β), explained variance (R²), and changes in explained variance (ΔR²). Data analysis was conducted using SPSS Statistics (Version 26).

Results

Bivariate correlations among study variables are presented in Table 1. Body mass index (BMI) was not significantly correlated with any other variable. Healthy orthorexia was positively correlated with orthorexia nervosa, r(341) = 0.54, p < 0.001, and with cognitive flexibility, r = 0.13, p = 0.017, while showing a negative correlation with inhibition deficits, r = −0.14, p = 0.012. Orthorexia nervosa was positively correlated with working memory difficulties, r = 0.28, p < 0.001, and negatively correlated with cognitive flexibility, r(350) = −0.29, p < 0.001. Regarding executive functions, inhibition was positively associated with working memory difficulties, r = 0.39, p < 0.001, and negatively with cognitive flexibility, r = −0.28, p < 0.001. Working memory deficits were strongly negatively correlated with cognitive flexibility, (r = −0.52, p < 0.001).

Table 1.

Means, standard deviations, and Pearson correlation coefficients of variables.

Variable	1	2	3	4	5	6	M	Sd
1. BMI	-	0.01	0.08	0.07	−0.06	0.01	23.26	3.67
2. Healthy orthorexia	-	-	0.54**	−0.14*	−0.06	0.13*	14.07	5.06
3. Orthorexia nervosa	-	-	-	0.05	0.28**	−0.29**	6.34	5.10
4. Inhibition	-	-	-	-	0.39**	−0.28**	14.33	4.69
5. Working memory	-	-	-	-	-	−0.52**	18.40	6.56
6. Cognitive flexibility	-	-	-	-	-	-	79.97	11.46

Note. BMI: Body mass index.

p < 0.05. **p < 0.01.

Regression analysis

Predictors of healthy orthorexia

A hierarchical multiple regression was conducted to examine whether executive function dimensions predicted healthy orthorexia beyond demographic factors (see Table 2). In step 1, demographic variables significantly predicted healthy orthorexia, F(4, 339) = 4.06, p = 0.003, accounting for 4.4% of the variance (R² = 0.044). Age was a significant positive predictor, B = 0.17, SE = 0.05, β = 0.19, p = 0.001. Gender, education, and physical activity were not significant.

Table 2.

Two-step multiple regression predicting healthy orthorexia.

Predictor	SE	β	t	p
Step 1
Age	0.17	0.19	3.46	0.001**
Gender	0.70	0.07	1.28	0.201
Education	0.21	0.05	0.92	0.360
Physical activity	–3.25	–0.07	–1.30	0.195
Step 2
Age	0.15	0.17	3.18	0.002**
Gender	0.67	0.07	1.24	0.215
Education	0.16	0.04	0.73	0.463
Physical activity	–2.71	–0.06	–1.09	0.279
Inhibition	–0.12	–0.11	–1.90	0.058
Working memory	0.05	0.06	0.97	0.334
Cognitive flexibility	0.05	0.11	1.71	0.088

Note. R² = 0.044 for Model 1; ΔR² = 0.018 for Model 2 (total R² = 0.062).

p < 0.01.

In step 2, executive functions were added. The model remained significant, F(7, 336) = 3.43, p = 0.001, explaining 6.2% of variance (R² = 0.062; ΔR² = 0.018). Age continued to predict healthy orthorexia, B = 0.15, SE = 0.05, β = 0.17, p = 0.002. Inhibition (β = –0.11, p = 0.058) and cognitive flexibility (β = 0.11, p = 0.088) showed marginal effects, while working memory was nonsignificant.

Predictors of orthorexia nervosa

A two-step hierarchical regression analysis was conducted to examine predictors of orthorexia nervosa (see Table 3). Step 1 with demographic variables was nonsignificant, F(4, 347) = 0.23, p = 0.921, explaining less than 1% of variance (R² = 0.003). In step 2, executive functions were added, yielding a significant improvement, F(7, 344) = 6.86, p < 0.001, accounting for 12.2% of variance (R² = 0.122; ΔR² = 0.119). Working memory difficulties were a positive predictor, B = 0.17, SE = 0.05, β = 0.21, p = 0.001, whereas cognitive flexibility was a negative predictor, B = –0.10, SE = 0.03, β = –0.22, p < 0.001. Inhibition was not significant.

Table 3.

Two-step multiple regression predicting orthorexia nervosa.

Predictor	SE	β	t	p
Step 1
Age	0.55	0.04	0.80	0.426
Gender	0.23	0.02	0.34	0.736
Education	2.58	0.01	0.15	0.884
Physical activity	0.05	0.02	0.44	0.664
Step 2
Age	0.05	0.05	0.91	0.364
Gender	0.53	0.08	1.46	0.146
Education	0.22	0.03	0.54	0.587
Physical activity	2.44	–.01	–.23	0.819
Inhibition	0.06	–.09	–1.61	0.109
Working memory	0.05	0.21	3.42	0.001**
Cognitive flexibility	0.03	–.22	–3.61	0.001**

Note. R² = 0.003 for Model 1; ΔR² = 0.119 for Model 2 (total R² = 0.122).

p < 0.01.

Discussion

The aim of the present study was to examine the effects of core dimensions of executive functioning (working memory, inhibition, and cognitive flexibility) on both healthy orthorexia and orthorexia nervosa in a sample of physically active adults.

In our study, no significant associations were found between participants’ body mass index and the executive functioning domains of working memory, inhibition, and cognitive flexibility. This finding contrasts with previous research that has reported links between body mass index and deficits in executive functioning, particularly in samples characterized by obesity or extreme underweight, such as anorexia nervosa (Fagundo et al., 2012; Verdejo-García et al., 2010). However, findings from studies conducted with healthy adult samples have been more mixed. For example, a large cross-sectional study reported that higher BMI was modestly associated with poorer executive functioning, with overweight and obese adults performing worse than normal-weight individuals on tasks such as verbal interference and problem-solving (Gunstad et al., 2007). One possible explanation is that the body mass index distribution in our sample was not sufficiently extreme to detect such effects, reducing the likelihood of significant associations. Another explanation is that the relationship between body mass index and executive functioning may be influenced by other variables, including impulsivity, emotional dysregulation, or comorbid psychiatric symptoms (Dohle et al., 2018; Favieri et al., 2019). Taken together, these findings suggest that impairments in working memory, inhibition, and cognitive flexibility among individuals with eating disorder symptoms may be more directly associated with the severity of psychological distress rather than body mass index itself.

Orthorexia nervosa and executive functions

Regression analyses revealed that working memory difficulties positively predicted orthorexia nervosa, whereas cognitive flexibility negatively predicted orthorexia nervosa. These findings align with previous self-report studies demonstrating associations between orthorexia nervosa symptoms and cognitive factors (Koven and Senbonmatsu, 2013; Noebel et al., 2022), but extend the literature by highlighting the distinct contributions of working memory and flexibility. The positive association with working memory difficulties suggests that orthorexia nervosa may be sustained by deficits in the ability to hold and manipulate information, potentially contributing to perseverative thinking about food rules and greater difficulty adapting eating patterns. Similarly, the negative relationship with cognitive flexibility supports the view that individuals with higher orthorexia nervosa symptoms tend to rigidly adhere to dietary routines and struggle to adjust behavior in changing contexts, consistent with findings from eating disorder and obsessive–compulsive disorder research (Grant and Chamberlain, 2023; Tchanturia et al., 2011). Interestingly, inhibition was not a significant predictor of orthorexia nervosa. This partially contrasts with evidence from anorexia nervosa and obsessive–compulsive disorder, where inhibition deficits are well documented (Chamberlain et al., 2007). A possible explanation is that inhibition difficulties in orthorexia nervosa may be more domain-specific (e.g., food-related thought suppression) and less evident in broader self-regulation domains, particularly when measured through self-report inventories.

Healthy orthorexia and executive functions

By contrast, healthy orthorexia, conceptualized as an adaptive orientation toward healthy eating, was not predicted by executive dysfunction. Age emerged as the most consistent predictor, with older participants scoring higher on healthy orthorexia. This finding is in line with previous research suggesting that adaptive health behaviors may become more salient with age, possibly reflecting increased health awareness or shifting life-stage priorities (Erkilic et al., 2024; Ferreira-Pêgo et al., 2020). Executive functioning variables demonstrated only marginal effects, indicating that healthy orthorexia is not strongly rooted in cognitive deficits but may instead reflect motivational or lifestyle-related factors.

Theoretical and clinical implications

These findings add to the growing differentiation between healthy orthorexia and orthorexia nervosa, reinforcing the notion that while both involve a preoccupation with healthy eating, only orthorexia nervosa is associated with maladaptive cognitive mechanisms. From a broader theoretical perspective, recent research has increasingly conceptualized executive dysfunction and cognitive rigidity as transdiagnostic mechanisms underlying compulsive and restrictive behaviors across psychiatric conditions, including eating disorders (Grant and Chamberlain, 2023; Li et al., 2024). Within this framework, rigid rule-based health behaviors may emerge when goal-directed control processes are compromised, leading individuals to rely on inflexible cognitive patterns and perseverative decision-making. This perspective further supports the interpretation that orthorexia nervosa may be maintained by similar executive control difficulties. Clinically, interventions for orthorexia nervosa may benefit from targeting cognitive rigidity and working memory processes. Cognitive remediation approaches, which have shown promise in eating disorders by enhancing flexibility and executive control (Miles et al., 2020), could be adapted to address the maladaptive cognitive style characteristic of orthorexia nervosa. In other eating disorder populations, particularly anorexia nervosa, cognitive remediation therapy has been used to improve set-shifting, reduce cognitive rigidity, and strengthen working memory through structured tasks and reflective exercises (Alserihi et al., 2024; Giombini et al., 2017; Thorsrud et al., 2024). Similar techniques could be adapted for individuals with orthorexia nervosa by focusing on increasing cognitive flexibility around food-related rules, encouraging tolerance for dietary variability, and challenging all-or-nothing thinking patterns related to “clean” or “pure” eating. Furthermore, prevention programs in physically active populations might emphasize promoting balanced eating behaviors while addressing cognitive styles that predispose individuals to rigid and compulsive dietary patterns. In this context, early intervention strategies that target inflexible thinking styles and perfectionistic tendencies may help reduce the risk of progression from health-oriented eating to more compulsive and impairing orthorexic behaviors.

Limitations and future directions

Several limitations should be noted. First, the cross-sectional design precludes causal inference, leaving it unclear whether executive dysfunction contributes to the onset of orthorexia nervosa or whether orthorexia symptoms exacerbate cognitive difficulties. Future research should therefore employ longitudinal and experimental designs to clarify these temporal and potentially bidirectional relationships. Second, executive functioning was assessed solely with self-report measures, which may not adequately capture performance-based deficits. Prior research has highlighted discrepancies between laboratory tasks and self-reported impairments (Koven and Abry, 2015; Luck-Sikorski et al., 2019), underscoring the need for multimethod approaches. Integrating behavioral tasks with neurocognitive assessments would provide a more comprehensive and ecologically valid profile of executive functioning in orthorexia nervosa. Third, the study sample consisted exclusively of physically active adults, which may limit generalizability to clinical or sedentary populations. Future studies should recruit more diverse samples to examine whether these associations hold across broader populations. Fourth, variation in exercise frequency and intensity among participants may contribute to individual differences in orthorexic tendencies. However, these factors were not systematically examined in the present study and should be considered in future research. Another limitation of the study is the reliance on self-report measures, which may be subject to recall bias and subjective interpretation. Finally, cultural context may shape both the expression and interpretation of orthorexia nervosa symptoms. Replication of the present findings in varied cultural settings would clarify whether the observed associations reflect universal versus culturally specific patterns.

Conclusion

In summary, the present study demonstrates that orthorexia nervosa symptoms are linked to deficits in working memory and cognitive flexibility, underscoring the crucial role of executive functioning in the persistence of maladaptive healthy-eating behaviors. In contrast, healthy orthorexia emerged as an adaptive orientation toward nutrition that appears largely independent of executive dysfunction. These findings contribute to the literature by providing empirical evidence that distinguishes orthorexia nervosa from healthy orthorexia and point to the clinical value of targeting cognitive processes. In line with previous research (Juarascio et al., 2015), our results highlight the potential importance of incorporating cognitive training and remediation strategies into the treatment of eating disorders, as such interventions may help address executive functioning difficulties and improve therapeutic outcomes. Future longitudinal studies with larger and more diverse samples, alongside standardized neuropsychological assessments, are warranted to further clarify the interplay between executive functioning and orthorexic behaviors and to guide the development of effective prevention and intervention programs.

Footnotes

ORCID iDs

Furkan Kerim Çakır

Kseniya Baydikova

Emre Han Alpay

Ethical considerations

This study was reviewed and approved by the Social Sciences Ethics Committee of Mersin University, Türkiye (IRB No: 27.02.2025-10). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval was required and obtained prior to data collection.

Consent to participate

Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and participants were informed about their right to withdraw from the study at any time without penalty.

Consent for publication

No identifiable data from individual participants are included in this article; therefore, consent for publication was not applicable.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Scientific and Technological Research Council of Türkiye (TÜBİTAK) under the 2209-A Research Projects Support Program for University Students, Grant No: 1919B012430499, 2024/1 term.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are openly available on the Open Science Framework (OSF) at the following link:

References

Almeida

Vieira Borba

Santos

(2018) Orthorexia nervosa in a sample of Portuguese fitness participants. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 23(4): 443–451.

Alpay

Kızılöz

(2023) Investigation of the validity and reliability of the Turkish form of the adult executive functioning inventory. Journal of Clinical Psychology Research 7(3): 369–383.

Alserihi

Hubayni

Alotaibi

, et al. (2024) Effect of cognitive remediation therapy in anorexia nervosa: A systematic review and meta-analysis. Frontiers in Psychiatry 15: 1484457.

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Publishing.

Asarkaya

Arcan

(2021) Teruel Ortoreksiya Ölçeği’nin (TOÖ) uyarlama, geçerlik ve güvenirlik çalışması. Klinik Psikoloji Dergisi 5(2): 113–127.

Awad

Salameh

Sacre

, et al. (2021) Association between impulsivity and orthorexia nervosa/healthy orthorexia: Any mediating effect of depression, anxiety, and stress? BMC Psychiatry 21(1): 604.

Barrada

Roncero

(2018) Bidimensional structure of the orthorexia: Development and initial validation of a new instrument. Anales de Psicología 34(2): 283–291.

Barthels

Barrada

Roncero

(2019) Orthorexia nervosa and healthy orthorexia as new eating styles. PLoS One 14(7): e0219609.

Bratland-Sanda

Sundgot-Borgen

(2013) Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal of Sport Science 13(5): 499–508.

10.

Bratman

(1997) The health food eating disorder. Yoga Journal 42: 50.

11.

Chamberlain

Fineberg

Menzies

, et al. (2007) Impaired cognitive flexibility and motor inhibition in unaffected first-degree relatives of patients with obsessive-compulsive disorder. American Journal of Psychiatry 164(2): 335–338.

12.

Chamberlain

Solly

Hook

, et al. (2021) Cognitive inflexibility in OCD and related disorders. In: Chamberlain

Fineberg

(eds) The Neurobiology and Treatment of OCD: Accelerating Progress. Cham, Switzerland: Springer International Publishing, pp.125–145.

13.

Chambers

Garavan

Bellgrove

(2009) Insights into the neural basis of response inhibition from cognitive and clinical neuroscience. Neuroscience and Biobehavioral Reviews 33(5): 631–646.

14.

Cohen

(1988) Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Erlbaum.

15.

Cohen

West

, et al. (2013) Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. Routledge.

16.

Dennis

Vander Wal

(2010) The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cognitive Therapy and Research 34(3): 241–253.

17.

Diamond

(2013) Executive functions. Annual Review of Psychology 64(1): 135–168.

18.

Dohle

Diel

Hofmann

(2018) Executive functions and the self-regulation of eating behavior: A review. Appetite 124: 4–9.

19.

Donini

Marsili

Graziani

, et al. (2005) Orthorexia nervosa: Validation of a diagnosis questionnaire. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 10(2): e28–e32.

20.

Dunn

Gibbs

Whitney

, et al. (2017) Prevalence of orthorexia nervosa is less than 1 %: Data from a US sample. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 22(1): 185–192.

21.

Erkilic

Bayraktar

Erkilic

, et al. (2024) Investigation of the relationship between orthorexic tendencies and some anthropometric measurements and variables in university students. Medicine Science 13(3): 674–680.

22.

Fagundo

de la Torre

Jiménez-Murcia

, et al. (2012) Executive functions profile in extreme eating/weight conditions: From anorexia nervosa to obesity. PLoS One 7(8): e43382.

23.

Faul

Erdfelder

Buchner

, et al. (2009) Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods 41(4): 1149–1160.

24.

Favieri

Forte

Casagrande

(2019) The executive functions in overweight and obesity: A systematic review of neuropsychological cross-sectional and longitudinal studies. Frontiers in Psychology 10: 2126.

25.

Ferreira-Pêgo

Rodrigues

Costa

, et al. (2020) Eating behavior: The influence of age, nutrition knowledge, and Mediterranean diet. Nutrition and Health 26(4): 303–309.

26.

Genet

Malooly

Siemer

(2013) Flexibility is not always adaptive: Affective flexibility and inflexibility predict rumination use in everyday life. Cognition & Emotion 27(4): 685–695.

27.

George

Mallery

(2018) Descriptive statistics. In IBM SPSS statistics, 25 step by step. Routledge, p126–134.

28.

Giombini

Moynihan

Turco

, et al. (2017) Evaluation of individual cognitive remediation therapy (CRT) for the treatment of young people with anorexia nervosa. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 22(4): 667–673.

29.

Grant

Chamberlain

(2023) Impaired cognitive flexibility across psychiatric disorders. CNS Spectrums 28(6): 688–692.

30.

Gülüm

Dağ

(2012) Tekrarlayıcı Düşünme Ölçeği ve Bilişsel Esneklik Envanterinin Türkçeye uyarlanması, geçerliliği ve güvenilirliği. Anadolu Psikiyatri Dergisi 13(3): 216–223.

31.

Gunstad

Paul

Cohen

, et al. (2007) Elevated body mass index is associated with executive dysfunction in otherwise healthy adults. Comprehensive Psychiatry 48(1): 57–61.

32.

Hafstad

Bauer

Harris

, et al. (2023) The prevalence of orthorexia in exercising populations: A systematic review and meta-analysis. Journal of Eating Disorders 11(1): 15.

33.

Holland

Tiggemann

(2017) “Strong beats skinny every time”: Disordered eating and compulsive exercise in women who post fitspiration on Instagram. International Journal of Eating Disorders 50(1): 76–79.

34.

Holst

Thorell

(2018) Adult executive functioning inventory (ADEXI): Validity, reliability, and relations to ADHD. International Journal of Methods in Psychiatric Research 27(1): e1567.

35.

Horovitz

Argyrides

(2023) Orthorexia and orthorexia nervosa: A comprehensive examination of prevalence, risk factors, diagnosis, and treatment. Nutrients 15(17): 3851.

36.

Juarascio

Manasse

Espel

, et al. (2015) Could training executive function improve treatment outcomes for eating disorders? Appetite 90: 187–193.

37.

Koven

Abry

(2015) The clinical basis of orthorexia nervosa: Emerging perspectives. Neuropsychiatric Disease and Treatment 11: 385–394.

38.

Koven

Senbonmatsu

(2013) A neuropsychological evaluation of orthorexia nervosa. Open Journal of Psychiatry 03(02): 214–222.

39.

Little

Rubin

(2019) Statistical Analysis With Missing Data. John Wiley & Sons.

40.

Tong

Wang

, et al. (2024) Task fMRI studies investigating inhibitory control in patients with obsessive-compulsive disorder and eating disorders: A comparative meta-analysis. World Journal of Biological Psychiatry 25(1): 26–42.

41.

Logue

Gould

(2014) The neural and genetic basis of executive function: Attention, cognitive flexibility, and response inhibition. Pharmacology Biochemistry and Behavior 123: 45–54.

42.

Luck-Sikorski

Jung

Schlosser

, et al. (2019) Is orthorexic behavior common in the general public? A large representative study in Germany. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 24(2): 267–273.

43.

Bartol

Venkataramani

, et al. (2019) Pitching novel ideas to the boss: The interactive effects of employees’ idea enactment and influence tactics on creativity assessment and implementation. Academy of Management Journal 62(2): 579–606.

44.

Martinsen

Sundgot-Borgen

(2013) Higher prevalence of eating disorders among adolescent elite athletes than controls. Medicine and Science in Sports and Exercise 45(6): 1188–1197.

45.

Messer

Liu

Linardon

(2023) Orthorexia nervosa symptoms prospectively predict symptoms of eating disorders and depression. Eating Behaviors 49: 101734.

46.

Miles

Gnatt

Phillipou

, et al. (2020) Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review. Clinical Psychology Review 81: 101905.

47.

Miles

Nedeljkovic

Phillipou

(2023) Investigating differences in cognitive flexibility, clinical perfectionism, and eating disorder-specific rumination across anorexia nervosa illness states. Eating Disorders 31(6): 610–631.

48.

Miles

Phillipou

Sumner

, et al. (2022) Cognitive flexibility and the risk of anorexia nervosa: An investigation using self-report and neurocognitive assessments. Journal of Psychiatric Research 151: 531–538.

49.

Miyake

Friedman

(2012) The nature and organization of individual differences in executive functions: Four general conclusions. Current Directions in Psychological Science 21(1): 8–14.

50.

Miyake

Friedman

Emerson

, et al. (2000) The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A latent variable analysis. Cognitive Psychology 41(1): 49–100.

51.

Noebel

Oberle

Marcell

(2022) Orthorexia nervosa and executive dysfunction: Symptomatology is related to difficulties with behavioral regulation. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 27(6): 2019–2026.

52.

Rudolph

(2018) The connection between exercise addiction and orthorexia nervosa in German fitness sports. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 23(5): 581–586.

53.

Segura-García

Papaianni

Capranica

, et al. (2012) Orthorexia nervosa: A frequent eating disordered behavior in athletes. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 17(4): e226–e233.

54.

Snyder

(2013) Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: A meta-analysis and review. Psychological Bulletin 139(1): 81–132.

55.

Snyder

Miyake

Hankin

(2015b) Advancing understanding of executive function impairments and psychopathology: Bridging the gap between clinical and cognitive approaches. Frontiers in Psychology 6: 328.

56.

Snyder

Kaiser

Warren

, et al. (2015a) Obsessive-compulsive disorder is associated with broad impairments in executive function: A meta-analysis. Clinical Psychological Science 3(2): 301–330.

57.

Strahler

Haddad

Salameh

, et al. (2020) Cross-cultural differences in orthorexic eating behaviors: Associations with personality traits. Nutrition 77: 110811.

58.

Strahler

Wachten

Mueller-Alcazar

(2021) Obsessive healthy eating and orthorexic eating tendencies in sport and exercise contexts: A systematic review and meta-analysis. Journal of Behavioral Addictions 10(3): 456–470.

59.

Strahler

Wachten

Neuhofer

, et al. (2022) Psychological correlates of excessive healthy and orthorexic eating: Emotion regulation, attachment, and anxious-depressive-stress symptomatology. Frontiers in Nutrition 9: 817047.

60.

Tchanturia

Harrison

Davies

, et al. (2011) Cognitive flexibility and clinical severity in eating disorders. PLoS One 6(6): e20462.

61.

Thomas

Birch

Jones

CRG

, et al. (2022) Neural correlates of executive functioning in anorexia nervosa and obsessive-compulsive disorder. Frontiers in Human Neuroscience 16: 841633.

62.

Thorsrud

Bang

Dahlgren

, et al. (2024) Cognitive remediation therapy for patients with eating disorders: A qualitative study. Journal of Eating Disorders 12(1): 142.

63.

Verdejo-García

Pérez-Expósito

Schmidt-Río-Valle

, et al. (2010) Selective alterations within executive functions in adolescents with excess weight. Obesity 18(8): 1572–1578.

64.

Warburton

Nicol

Bredin

(2006) Health benefits of physical activity: The evidence. Canadian Medical Association Journal 174(6): 801–809.

65.

World Health Organization (2000) Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. WHO Technical Report Series No. 894, Geneva: World Health Organization

66.

Zagaria

Vacca

Cerolini

, et al. (2022) Associations between orthorexia, disordered eating, and obsessive-compulsive symptoms: A systematic review and meta-analysis. International Journal of Eating Disorders 55(3): 295–312.

67.

Zickgraf

Barrada

(2022) Orthorexia nervosa vs. healthy orthorexia: Relationships with disordered eating, eating behavior, and healthy lifestyle choices. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity 27(4): 1313–1325.