Cross-Cultural Adaptation and Psychometric Validation of the Turkish Düsseldorf Orthorexia Scale in Adolescents

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Validated tools to assess ON in adolescent psychiatry settings are scarce. This study evaluated the validity and reliability of the Turkish version of the Düsseldorf Orthorexia Scale (TR-DOS) in an adolescent clinical sample. Methods Adolescents aged 12–18 presenting to a child and adolescent psychiatry outpatient clinic completed the TR-DOS, Orthorexia Nervosa Inventory, Eating Attitudes Test-26, and Revised Child Anxiety and Depression Scale – Child Version. Psychiatric diagnoses were established through clinician-administered DSM-5 interviews. Construct validity was examined with confirmatory factor analysis. Internal consistency was assessed using Cronbach’s α and McDonald’s ω. Convergent validity was evaluated via correlations with related measures. Receiver operating characteristic analysis was used to determine an optimal cut-off. Results The sample comprised 209 adolescents (61.2% female; mean age = 15.7 years). Model fit indices supported a one-factor solution (χ²/df = 2.00; CFI = 0.961; TLI = 0.944; RMSEA = 0.0688; SRMR = 0.0443). Internal consistency was high (α = 0.868; ω = 0.871). TR-DOS scores correlated positively with orthorexic symptomatology and disordered eating (r = 0.595 and r = 0.374, both p < .001). A cut-off score of 26 yielded an AUC of 0.968, with 91.2% sensitivity and 100% specificity. Only obsessive–compulsive disorder was significantly associated with higher TR-DOS scores. Conclusion The TR-DOS is a valid, reliable, and practical tool for assessing orthorexic tendencies in Turkish adolescents and may facilitate early identification and clinical decision-making. Level of evidence Level V, descriptive study Orthorexia nervosa Adolescent mental health Psychometric validation Düsseldorf Orthorexia Scale Eating behavior disorders Figures Figure 1 INTRODUCTION Adolescence represents a critical period in which biologic, hormonal, cognitive, and psychological alterations occur rapidly and the need for energy and food required by development increases [ 1 ]. In this process, sensitivity to body image, fears for becoming overweight, and social influences may render adolescents vulnerable to irregular eating attitudes and unduly controlled behaviors about healthy eating [ 2 ]. Therefore, nutritional problems are more common in this period and eating habits acquired at these ages may persist throughout life [ 3 ]. Interest in healthy eating has increased in recent years [ 4 ]. However, this growing interest may give rise in some individuals to rigid rules, obsessive thoughts, and considerable functional losses over time. This condition, first referred to by Bratman in 1997 as orthorexia nervosa (ON), can be distinguished from traditional eating disorders by focus on nutritional quality and purity, rather than quantity [ 5 , 6 ]. This process that begins with the intention of healthy eating may be transformed over time to an obsessive passion that can adversely affect the daily life, social relations, and psychological well-being of individuals [ 7 ]. Orthorexia nervosa has been primarily studied in adults, with few studies and validated diagnostic scales in adolescents. Among limited number of studies in Türkiye, one study, which employed the Orthorexia Nervosa Inventory (ONI), reported a prevalence of 0.5% in high school students, being 0.3% among boys, and 0.6% among girls [ 8 ]. Nevertheless, an international consensus regarding the diagnostic classification and assessment of ON has not yet been established [ 6 , 9 , 10 ]. In studies based on ORTO-15, one of the most commonly used tools in the assessment of orthorexic tendencies, differences in cut-off points and methodological approaches have led to highly variable prevalence rates being reported in adolescent samples. For instance, in a study conducted among Polish adolescents, the prevalence of ON varied between 24.7% and 77.8% depending on the cut-off points used for ORTO-15 [ 9 ]. Similarly, across different countries and samples, prevalence rates identified with ORTO-15 have been reported to range widely—from as low as 6% to as high as 88% [ 11 ]. These debates on measurement have clearly revealed the need for approaches with high diagnostic specificity, incorporating functional impairment and supported by robust psychometric properties. In this context, the Düsseldorf Orthorexia Scale (DOS) was developed to provide a more reliable assessment of ON [ 12 ]. The DOS is a 10-item scale that measures the severity of orthorexic behaviors, and validation studies conducted in different cultures have demonstrated high internal consistency and a strong factor structure [ 13 – 16 ]. Moreover, the validity and reliability of the scale have also been investigated in adolescent populations; for instance, in Lebanon, among adolescents aged 15–18, the DOS demonstrated high internal consistency and a unidimensional construct validity, while in the United States, face validity was found to be satisfactory in adolescents aged 14–17 [ 17 , 18 ]. The study aims to investigate the Turkish validity and reliability of the DOS in a clinical adolescent population, in order to address the methodological gap related to ON. With these findings, the study aims to contribute to a deeper understanding of the relationship between orthorexic tendencies and psychiatric diagnoses, as well as to the diagnostic applications of ON in child and adolescent mental health. METHODS Participants and procedure This study was conducted among adolescents aged 12–18 who presented to a child and adolescent psychiatry outpatient clinic in Istanbul, the most populous city in Türkiye [ 19 ]. Written permission was obtained from the developer of the DOS, before data collection, the study was approved by the Institutional Review Board of Çam and Sakura City Hospital (Decision No: 2024-KAEK-11), and it was conducted in accordance with the Declaration of Helsinki. All participants in the clinical sample were assessed through face-to-face psychiatric interviews conducted by a clinician using DSM-5 criteria; current psychiatric diagnoses were determined according to DSM-5 diagnostic standards and documented in the medical records. The inclusion criteria were being between 12 and 18 years of age, providing voluntary participation consent from both the parent and the adolescent, and completing all scales in full. The exclusion criteria were being outside the specified age range, having an intellectual disability, a psychotic disorder, or a history of serious neurological illness, being illiterate, and not consenting to participate in the study. Cross-cultural adaptation process This phase was carried out in accordance with the standard principles for the linguistic and cultural adaptation of international assessment instruments. The translation was performed by five child and adolescent psychiatrists who are native speakers of Turkish and fluent in English. First, the original form of the scale was translated into Turkish by two child psychiatrists independently of each other. By comparing the translations obtained, semantic integrity was preserved, and a unified draft was created by ensuring conceptual equivalence. Afterwards, this draft was back-translated into English by two language experts who were unaware of the original form of the scale. The back-translations were reviewed by the developer of the scale to assess whether conceptual and semantic consistency had been preserved, and they were deemed appropriate. In the subsequent phase, a pilot administration was conducted with a group of 20 adolescents to determine the comprehensibility and cultural appropriateness of the scale. In line with the feedback received from the participants, minor linguistic adjustments were made and the Turkish version of the scale was finalized. Finally, the resulting Turkish version of the DOS was administered to the study sample to be used in the validity and reliability analyses. Measures Sosyodemographic Data Form This form was prepared by the researchers in order to collect information regarding the participants’ demographic, medical, psychiatric, and eating habits. The questions were created using the literature on ON and other eating disorders. The form includes questions addressing demographic variables such as age, gender, grade level, height, weight, family structure, parents’ educational and occupational status, family income level, and number of siblings, as well as psychiatric diagnosis and medication use, history of chronic medical conditions, diet type, number of daily meals, water and nutritional supplement intake, and smoking and alcohol consumption. Düsseldorf Orthorexia Scale (DOS) The DOS scale, developed by Barthels and colleagues (2015), was designed to assess individuals’ rigid and obsessive tendencies regarding healthy eating. The scale is a 4-point Likert-type self-assessment tool consisting of 10 items.The severity of orthorexic behaviors and thoughts increases as the total score obtained from the scale increases [ 12 ]. Studies associated with the Turkish adaptation of the DOS have shown that the scale demonstrates high internal consistency(Cronbach’s alpha = 0.87 and 0.85) and good construct validity in both clinical samples and university students [ 16 , 20 ]. The confirmatory factor analysis supported the single-factor structure, and the test-retest reliability was found to be high (r = 0.99). The positive correlations between the DOS and the ONI and EAT-26 support the convergent validity of the scale. These findings indicate that the Turkish version of the DOS is a valid and reliable instrument across different populations. Revised Child Anxiety and Depression Scales – Child Version (RCADS-CV) This scale was developed by Chorpita and colleagues to evaluate anxiety disorders and depressive symptoms based on DSM-IV criteria [ 21 ]. The scale consists of a total of 47 items and has a 4-point Likert-type structure. The Turkish validity and reliability study was conducted by Görmez et al.(2017) [ 22 ]. The scale consists of six subscales: Generalized Anxiety Disorder, Social Phobia, Separation Anxiety Disorder, Panic Disorder, Obsessive–Compulsive Disorder, and Major Depressive Disorder. Eating Attitude Test-26 (EAT-26) The instrument is a self-report measure developed by Garner and Garfinkel to assess eating attitudes and behaviors related to Anorexia Nervosa [ 23 ]. The scale consists of 26 items, and the total score obtained from the scale ranges between 0 and 53. The recommended cut-off score for the scale is 20; scores of 20 and above indicate abnormal eating attitudes, whereas scores below 20 indicate normal eating attitudes. In the Turkish validity and reliability study conducted by Ergüney-Okumuş and Sertel-Berk (2019), the internal consistency coefficient of the scale was reported as 0.84, and the test–retest reliability coefficient was reported as 0.78 [ 24 ]. Orthorexia Nervosa Inventory (ONI) This scale, developed by Oberle et al. (2021), was designed to assess ON symptoms [ 25 ]. It consists of 24 items with a 4-point Likert-type response format. In the original scale development study, the internal consistency coefficient (Cronbach’s α) was reported as 0.94. The scale includes three subscales: behavioral tendencies, impairment in physical and psychosocial functioning, and emotional distress. An increase in the total and subscale scores indicates higher levels of orthorexic symptoms. Scores of 72 and above are considered indicative of the presence of ON or a high risk for ON. The Turkish validity and reliability studies were conducted in adolescent and adult samples. Cronbach’s α was found to be 0.92 in the Turkish adolescent group, while it was 0.91 in the adult group [ 26 , 27 ]. Statistical analyses The data obtained from the research was statistically examined using SPSS version 23.0 (The Statistical Package for Social Sciences) and the Lavaan package in R (version 4.3.3) for Confirmatory factor analysis (CFA). The normality of the distribution of continuous variables was assessed using skewness and kurtosis tests. Continuous variables were presented as mean and standard deviations (mean ± SD), while categorical variables were reported as numbers and percentages (N, %). The construct validity of the DOS was analyed using CFA with maximum likelihood estimation. Model fit was evaluated using multiple indices, including the chi-square to degrees of freedom ratio (χ²/df), Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Internal consistency reliability of the DOS was assessed using Cronbach’s α and McDonald’s ω. To assess convergent validity, Pearson’s correlation coefficients were calculated between DOS scores and related constructs, including the ONI, EAT-26 and RCADS-CV scores. Finally, Receiver Operating Characteristic (ROC) curve analysis was performed to determine the optimal cutoff value for the DOS. Sensitivity, specificity and the area under the curve (AUC) with 95% confidence intervals were presented. RESULTS The sociodemographic, clinical, and dietary characteristics of the participants are presented in Table 1. The mean age of the participants was 15.7±1.72 years, and 61.2% of the participants were female. 77.0% of participants came from nuclear families. 16.7% of participants had a chronic medical condition. A family history of psychiatric disorders was reported in 70 participants (33.5%). 10.5% reported following a specific diet. Daily meal patterns showed that 80 participants (38.3%) consumed 1–2 meals per day, 118 participants (56.5%) consumed 3–4 meals, and 11 participants (5.3%) consumed 5 or more meals. 28.2 % of participants reported eating alone. Dietary supplement use was reported in 43 participants 20.6(%). 32 participants were smokers (15.3%). In the additional analyses regarding comorbidities, only the presence of OCD was found to be significantly associated with DOS scores (p = 0.013), and a medium effect size was calculated (Cohen’s d = 0.59). A confirmatory factor analysis (CFA) was conducted to examine the fit of the proposed model, and the fit indices are presented in Table 2. The results showed an acceptable to good fit: χ²/df = 2.00, CFI = 0.961, TLI = 0.944, RMSEA = 0.0688, and SRMR = 0.0443. Table 3 presents the reliability statistics for the DOS. The mean item score was 1.78±0.641. Internal consistency of DOS was robust, with a Cronbach’s α of 0.868 and McDonald’s ω of 0.871. As part of the confirmatory factor analysis, standardized factor loadings were obtained and are reported in Table 4. The findings supported a three-factor structure, with item loadings ranging between .41 and .92. Table 5 summarizes the correlation results of the DOS total scores with each variable. The DOS total scores were positively correlated with ONI (r = 0.595, p < .001) and EAT-26 (r = 0.374, p < .001), but not significantly associated with BMI (r = 0.099, p = .159) or RCADS-CV total anxiety (r = 0.075, p = .282) Figure 1 shows the ROC curve analysis for the DOS. The results indicated an optimal cutoff score of 26, yielding a sensitivity of 91.2% and a specificity of 100.0%. The area under the curve (AUC) was 96.8% (95% CI = 93.0–100.0), demonstrating good discriminatory power. Figure 1. ROC Curve Analysis of DOS DISCUSSION To the best of our knowledge, this study is the first to assess the validity and reliability of the Turkish version of the DOS in a clinical adolescent sample. The findings indicate that the scale is a psychometrically robust instrument for assessing orthorexic tendencies in this age group. Internal Consistency and Reliability The analyses have shown that the Turkish version of the DOS has high internal consistency (Cronbach’s α = 0.868, McDonald’s ω = 0.871) and that the scale’s factor structure retains its cultural validity in the adolescent sample. Similarly, in the Arabic reliability and validity study of the DOS conducted among Lebanese adolescents, it was reported that the scale’s single-factor structure was preserved and that it had high internal consistency (Cronbach’s α = 0.85) [ 17 ]. The original scale developed by Barthels et al. (2015) demonstrated an internal consistency of 0.84 (Cronbach’s alpha), and validity–reliability studies conducted in various countries have also reported Cronbach’s alpha values ranging from 0.84 to 0.88 [ 12 – 15 , 28 ]. In studies conducted in Türkiye, the internal consistency of the TR-DOS was found to be 0.87 in an adult clinical sample and 0.85 among university students [ 16 , 20 ]. These findings support that the scale is a valid and reliable measurement tool across different age groups and cultural contexts. Construct and Criterion-Related Validity In our study, significant positive correlations were found between the total DOS score and the EAT-26 and ONI scores. These findings indicate that the DOS demonstrates convergent validity with disordered eating attitudes and orthorexic symptoms, consistent with similar studies in the literatüre [ 20 , 29 , 30 ]. Previous research conducted in different cultures and samples has also shown that the relationship between orthorexic tendencies and eating attitudes falls within the low to moderate range [ 16 , 17 ]. Our findings support that the DOS sensitively captures the dimensions of reduced flexibility in eating attitudes and cognitive preoccupation with diet in a clinical adolescent sample, and that it exhibits expected associations with related constructs. Sociodemographic and Clinical Findings In our study, no significant relationship was observed between BMI and orthorexic tendencies. This finding is consistent with the literature emphasizing that ON focuses not on weight but on obsessive attitudes regarding the healthiness of foods, and that behavioral patterns may develop that do not necessarily reflect on body weight [ 31 , 32 ]. This result supports theoretical perspectives suggesting that ON differs from traditional eating disorders that center on weight and body image. The findings also indicated that there was no significant difference in orthorexic tendencies between genders. This result is partially consistent with the inconsistent findings in the literature; indeed, several systematic reviews and meta-analyses highlight that ON symptoms are generally independent of gender [ 33 – 35 ]. For instance, reviews focusing on healthcare professionals and university students have reported that gender differences are typically absent, with such inconsistencies being attributed to variations in measurement tools and sample characteristics (such as age and cultural factors) [ 34 , 35 ]. Our findings support the notion that ON exhibits a more balanced gender distribution compared to traditional eating disorders, thereby underscoring its distinct etiological profile. In this context, perspectives suggesting that ON may represent a pattern of eating behavior shaped more by individual psychological tendencies rather than gender-based factors are gaining support [ 36 , 37 ]. Indeed, these findings are reinforced by systematic reviews and meta-analyses, which indicate that ON shows consistent and strong associations with psychological characteristics such as perfectionism, OCD, and anxiety, whereas its associations with demographic and bodily indicators (e.g., age, BMI, gender) remain weak or inconsistent [ 33 , 36 – 39 ]. This underscores, once again, that the evaluation of ON should prioritize individual cognitive–emotional determinants rather than gender-based assumptions. In contrast to the weak associations observed with sociodemographic variables, the analytical examination conducted according to comorbidity in our study revealed that orthorexic symptoms were specifically confined to the presence of comorbid OCD. This pattern is consistent with studies reporting that increases in OCD symptom severity are associated with elevated ON tendencies [ 40 , 41 ]. The conceptual proximity between ON and the obsessive–compulsive spectrum is frequently described through obsessive beliefs regarding ‘food purity’ and contamination, as well as ritualized, rule-bound behaviors related to food preparation and consumption [ 42 , 43 ]. Taken together, our findings demonstrate that orthorexic symptoms are significantly higher in the presence of OCD, aligning with the ON-OCD connection reported in the literature; however, longitudinal and multivariate studies are needed to clarify the causal direction and continuity of this relationship. Strength and limitations This study has several limitations. First, due to its cross-sectional design, the findings do not allow for the determination of causal relationships or the examination of changes over time. Additionally, as the data were collected from a single center and a clinical sample, the generalizability of the results to different socioeconomic and cultural groups may be limited. Future research incorporating longitudinal designs and larger, more heterogeneous samples may strengthen the validity and reliability of the findings. Conclusions In conclusion, the findings demonstrate that the TR-DOS is a reliable and valid measurement tool in a clinical adolescent sample. These results suggest that the scale can be integrated into clinical practice for the assessment of orthorexic tendencies and can serve as a standardized outcome measure in future epidemiological and clinical research. Moreover, the study contributes to a better understanding of the pathological dimensions that may emerge under the discourse of “healthy eating” in adolescents—such as rule-governed behavior, cognitive rigidity, and loss of flexibility—thereby providing a solid foundation for the development of early screening methods, risk stratification strategies, and targeted intervention approaches. What is already known on this subject? Orthorexia nervosa (ON) has gained growing clinical and research attention due to increasing societal pressure toward healthy eating and rising concerns about restrictive dietary patterns among adolescents. Although adolescence is a developmentally vulnerable period for disordered eating, the assessment of ON in this population remains challenging. The Düsseldorf Orthorexia Scale (DOS) is one of the most widely used instruments for evaluating orthorexic tendencies and has demonstrated strong psychometric properties in several adult and youth samples across different cultures. However, despite its growing international use, evidence regarding the validity and reliability of the DOS in adolescent clinical populations—particularly within non-Western contexts—remains limited. In Türkiye, no prior study has examined the psychometric properties of the DOS specifically in clinically referred adolescents, leaving a significant gap in the availability of culturally adapted and psychometrically robust tools for identifying ON in routine child and adolescent psychiatric practice. What this study adds? In this study, the Düsseldorf Orthorexia Scale (DOS) was linguistically and culturally adapted into Turkish for use in a clinically referred adolescent population. Its psychometric properties—including construct, convergent, and criterion validity, as well as internal consistency—were rigorously evaluated using comprehensive statistical methods such as confirmatory factor analysis and ROC analysis. The Turkish version (TR-DOS) demonstrated a strong factorial structure, high internal consistency, and meaningful associations with established measures of orthorexic and disordered eating symptoms. Importantly, this research provides the first evidence supporting the validity and reliability of the DOS in a Turkish clinical adolescent sample, addressing a significant gap in the literature. By establishing an empirically robust tool for assessing orthorexic tendencies, this study offers an important resource for clinical practice and future epidemiological and diagnostic research on ON in youth. Declarations Ethics Statement All procedures were carried out in accordance with the World Medical Association Declaration of Helsinki. Written and verbal consent was obtained from all participants following the provision of written information regarding the purpose and methodology of the study to participants who volunteered to participate. Funding The present study received no financial assistance in the form of funding or grants. CRediT authorship contribution statement Omca Guney: Project administration, Conceptualization, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Supervision, Writing – review & editing. Selman Yildirim: Project administration, Conceptualization, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Supervision, Writing – review & editing. Ibrahim Halil Akbas: Project administration, Conceptualization, Data curation, Formal analysis,Investigation, Methodology, Validation, Visualization, Writing – original draft, Supervision, Writing – review & editing. Duygu Kınay Ermis: Data curation, Investigation, Validation,Writing – original draft. Nurdan Kasar: Data curation, Investigation, Validation, Writing – original draft. Declaration of competing interest The authors confirm that there are no conflicts of financial interest or personal relationships that could have influenced the findings presented in this study. Acknowledgments We would like to express our sincere gratitude to all those who contributed to the completion of this study. Special thanks go to our colleagues and mentors for their valuable guidance and support. We are especially grateful to the participants whose involvement made this research possible. Data Availability Statement The data sets generated and analyzed are available from the corresponding author upon reasonable request from a qualified investigator. References Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health . 2018;2(3):223–228. 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J Clin Med . 2022;11(20):6134. Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 02 Apr, 2026 Read the published version in Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity → Version 1 posted Editorial decision: Revision requested 27 Feb, 2026 Reviews received at journal 19 Dec, 2025 Reviewers agreed at journal 17 Dec, 2025 Reviewers invited by journal 17 Dec, 2025 Editor assigned by journal 22 Nov, 2025 Submission checks completed at journal 22 Nov, 2025 First submitted to journal 18 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8148135","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561910842,"identity":"a10003f8-bc13-41d7-9fd1-711931c5073a","order_by":0,"name":"Omca Guney","email":"","orcid":"","institution":"University of Health Sciences, Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Omca","middleName":"","lastName":"Guney","suffix":""},{"id":561910843,"identity":"4b9c2b14-f62a-4df9-9224-da0f84232476","order_by":1,"name":"Selman Yildirim","email":"","orcid":"","institution":"Blekinge Hospital","correspondingAuthor":false,"prefix":"","firstName":"Selman","middleName":"","lastName":"Yildirim","suffix":""},{"id":561910845,"identity":"67211d46-cea2-41dc-8156-fbf7e4c409d7","order_by":2,"name":"Ibrahim Halil Akbas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDACHh4gYXCAgUGCsYEhoQLIYWZuIEHLgzMgLYzEaGEAaWFgYHzYBuIQ0MLfc/bgxx8Fd/L5Zze3bkicVxvN3w7U8qNiG04tEmf7kqV5DJ5ZzrhzsO1G4rbjuTMOMzYw9py5jdua8zwG0gwGhw0YbiSCtBzLbQBqYWZsw61F/jyP8c8fQC3yYC1zjuXOJ6TF4GyPmQQPUIsBWEtDTe4GQloMz5xLswb6xcAQpCXh2IHcjUAtB/H5Re5M7uGbP/7cMZC7kf7s5o+autx55w8ffPCjAo/30cBhMHmAaPVAUEeK4lEwCkbBKBghAAAu02cmegBTUAAAAABJRU5ErkJggg==","orcid":"","institution":"Şanlıurfa Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ibrahim","middleName":"Halil","lastName":"Akbas","suffix":""},{"id":561910846,"identity":"605b3513-872a-4db3-b7aa-3ac81a7e1fc3","order_by":3,"name":"Duygu Kinay Ermis","email":"","orcid":"","institution":"University of Health Sciences, Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Duygu","middleName":"Kinay","lastName":"Ermis","suffix":""},{"id":561910849,"identity":"b0695832-c883-4a81-9908-2597a5c30347","order_by":4,"name":"Nurdan Kasar","email":"","orcid":"","institution":"University of Health Sciences, Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nurdan","middleName":"","lastName":"Kasar","suffix":""},{"id":561910850,"identity":"749276e0-9d03-4631-9c5d-c4f3f17c6386","order_by":5,"name":"IBRAHIM HALIL AKBAS","email":"","orcid":"","institution":"Şanlıurfa Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"IBRAHIM","middleName":"HALIL","lastName":"AKBAS","suffix":""}],"badges":[],"createdAt":"2025-11-18 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1","display":"","copyAsset":false,"role":"figure","size":171089,"visible":true,"origin":"","legend":"\u003cp\u003eROC Curve Analysis of DOS\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8148135/v1/f1b7bd2f285b69799ca6a0c4.png"},{"id":106343590,"identity":"3b01c147-4549-4c16-972d-610bb20e59d1","added_by":"auto","created_at":"2026-04-07 16:06:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1116441,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8148135/v1/958876ab-06c9-4004-9294-a355a981310a.pdf"},{"id":98778851,"identity":"a1ea234d-13a0-4bd3-a83c-6061b36101ef","added_by":"auto","created_at":"2025-12-22 12:29:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22421,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8148135/v1/a7741ed420d0cb02f7db8e0b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-Cultural Adaptation and Psychometric Validation of the Turkish Düsseldorf Orthorexia Scale in Adolescents","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAdolescence represents a critical period in which biologic, hormonal, cognitive, and psychological alterations occur rapidly and the need for energy and food required by development increases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In this process, sensitivity to body image, fears for becoming overweight, and social influences may render adolescents vulnerable to irregular eating attitudes and unduly controlled behaviors about healthy eating [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, nutritional problems are more common in this period and eating habits acquired at these ages may persist throughout life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterest in healthy eating has increased in recent years [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, this growing interest may give rise in some individuals to rigid rules, obsessive thoughts, and considerable functional losses over time. This condition, first referred to by Bratman in 1997 as orthorexia nervosa (ON), can be distinguished from traditional eating disorders by focus on nutritional quality and purity, rather than quantity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This process that begins with the intention of healthy eating may be transformed over time to an obsessive passion that can adversely affect the daily life, social relations, and psychological well-being of individuals [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Orthorexia nervosa has been primarily studied in adults, with few studies and validated diagnostic scales in adolescents. Among limited number of studies in T\u0026uuml;rkiye, one study, which employed the Orthorexia Nervosa Inventory (ONI), reported a prevalence of 0.5% in high school students, being 0.3% among boys, and 0.6% among girls [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, an international consensus regarding the diagnostic classification and assessment of ON has not yet been established [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In studies based on ORTO-15, one of the most commonly used tools in the assessment of orthorexic tendencies, differences in cut-off points and methodological approaches have led to highly variable prevalence rates being reported in adolescent samples. For instance, in a study conducted among Polish adolescents, the prevalence of ON varied between 24.7% and 77.8% depending on the cut-off points used for ORTO-15 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Similarly, across different countries and samples, prevalence rates identified with ORTO-15 have been reported to range widely\u0026mdash;from as low as 6% to as high as 88% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These debates on measurement have clearly revealed the need for approaches with high diagnostic specificity, incorporating functional impairment and supported by robust psychometric properties. In this context, the D\u0026uuml;sseldorf Orthorexia Scale (DOS) was developed to provide a more reliable assessment of ON [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The DOS is a 10-item scale that measures the severity of orthorexic behaviors, and validation studies conducted in different cultures have demonstrated high internal consistency and a strong factor structure [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Moreover, the validity and reliability of the scale have also been investigated in adolescent populations; for instance, in Lebanon, among adolescents aged 15\u0026ndash;18, the DOS demonstrated high internal consistency and a unidimensional construct validity, while in the United States, face validity was found to be satisfactory in adolescents aged 14\u0026ndash;17 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The study aims to investigate the Turkish validity and reliability of the DOS in a clinical adolescent population, in order to address the methodological gap related to ON. With these findings, the study aims to contribute to a deeper understanding of the relationship between orthorexic tendencies and psychiatric diagnoses, as well as to the diagnostic applications of ON in child and adolescent mental health.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedure\u003c/h2\u003e \u003cp\u003eThis study was conducted among adolescents aged 12\u0026ndash;18 who presented to a child and adolescent psychiatry outpatient clinic in Istanbul, the most populous city in T\u0026uuml;rkiye [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Written permission was obtained from the developer of the DOS, before data collection, the study was approved by the Institutional Review Board of \u0026Ccedil;am and Sakura City Hospital (Decision No: 2024-KAEK-11), and it was conducted in accordance with the Declaration of Helsinki. All participants in the clinical sample were assessed through face-to-face psychiatric interviews conducted by a clinician using DSM-5 criteria; current psychiatric diagnoses were determined according to DSM-5 diagnostic standards and documented in the medical records. The inclusion criteria were being between 12 and 18 years of age, providing voluntary participation consent from both the parent and the adolescent, and completing all scales in full. The exclusion criteria were being outside the specified age range, having an intellectual disability, a psychotic disorder, or a history of serious neurological illness, being illiterate, and not consenting to participate in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCross-cultural adaptation process\u003c/h3\u003e\n\u003cp\u003eThis phase was carried out in accordance with the standard principles for the linguistic and cultural adaptation of international assessment instruments. The translation was performed by five child and adolescent psychiatrists who are native speakers of Turkish and fluent in English. First, the original form of the scale was translated into Turkish by two child psychiatrists independently of each other. By comparing the translations obtained, semantic integrity was preserved, and a unified draft was created by ensuring conceptual equivalence. Afterwards, this draft was back-translated into English by two language experts who were unaware of the original form of the scale. The back-translations were reviewed by the developer of the scale to assess whether conceptual and semantic consistency had been preserved, and they were deemed appropriate. In the subsequent phase, a pilot administration was conducted with a group of 20 adolescents to determine the comprehensibility and cultural appropriateness of the scale. In line with the feedback received from the participants, minor linguistic adjustments were made and the Turkish version of the scale was finalized. Finally, the resulting Turkish version of the DOS was administered to the study sample to be used in the validity and reliability analyses.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSosyodemographic Data Form\u003c/h2\u003e \u003cp\u003eThis form was prepared by the researchers in order to collect information regarding the participants\u0026rsquo; demographic, medical, psychiatric, and eating habits. The questions were created using the literature on ON and other eating disorders.\u003c/p\u003e \u003cp\u003eThe form includes questions addressing demographic variables such as age, gender, grade level, height, weight, family structure, parents\u0026rsquo; educational and occupational status, family income level, and number of siblings, as well as psychiatric diagnosis and medication use, history of chronic medical conditions, diet type, number of daily meals, water and nutritional supplement intake, and smoking and alcohol consumption.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDüsseldorf Orthorexia Scale (DOS)\u003c/h3\u003e\n\u003cp\u003eThe DOS scale, developed by Barthels and colleagues (2015), was designed to assess individuals\u0026rsquo; rigid and obsessive tendencies regarding healthy eating. The scale is a 4-point Likert-type self-assessment tool consisting of 10 items.The severity of orthorexic behaviors and thoughts increases as the total score obtained from the scale increases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies associated with the Turkish adaptation of the DOS have shown that the scale demonstrates high internal consistency(Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.87 and 0.85) and good construct validity in both clinical samples and university students [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The confirmatory factor analysis supported the single-factor structure, and the test-retest reliability was found to be high (r\u0026thinsp;=\u0026thinsp;0.99). The positive correlations between the DOS and the ONI and EAT-26 support the convergent validity of the scale. These findings indicate that the Turkish version of the DOS is a valid and reliable instrument across different populations.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRevised Child Anxiety and Depression Scales \u0026ndash; Child Version (RCADS-CV)\u003c/h2\u003e \u003cp\u003eThis scale was developed by Chorpita and colleagues to evaluate anxiety disorders and depressive symptoms based on DSM-IV criteria [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The scale consists of a total of 47 items and has a 4-point Likert-type structure. The Turkish validity and reliability study was conducted by G\u0026ouml;rmez et al.(2017) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The scale consists of six subscales: Generalized Anxiety Disorder, Social Phobia, Separation Anxiety Disorder, Panic Disorder, Obsessive\u0026ndash;Compulsive Disorder, and Major Depressive Disorder.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEating Attitude Test-26 (EAT-26)\u003c/h3\u003e\n\u003cp\u003eThe instrument is a self-report measure developed by Garner and Garfinkel to assess eating attitudes and behaviors related to Anorexia Nervosa [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The scale consists of 26 items, and the total score obtained from the scale ranges between 0 and 53. The recommended cut-off score for the scale is 20; scores of 20 and above indicate abnormal eating attitudes, whereas scores below 20 indicate normal eating attitudes. In the Turkish validity and reliability study conducted by Erg\u0026uuml;ney-Okumuş and Sertel-Berk (2019), the internal consistency coefficient of the scale was reported as 0.84, and the test\u0026ndash;retest reliability coefficient was reported as 0.78 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eOrthorexia Nervosa Inventory (ONI)\u003c/h3\u003e\n\u003cp\u003eThis scale, developed by Oberle et al. (2021), was designed to assess ON symptoms [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It consists of 24 items with a 4-point Likert-type response format. In the original scale development study, the internal consistency coefficient (Cronbach\u0026rsquo;s α) was reported as 0.94.\u003c/p\u003e \u003cp\u003eThe scale includes three subscales: behavioral tendencies, impairment in physical and psychosocial functioning, and emotional distress. An increase in the total and subscale scores indicates higher levels of orthorexic symptoms. Scores of 72 and above are considered indicative of the presence of ON or a high risk for ON.\u003c/p\u003e \u003cp\u003eThe Turkish validity and reliability studies were conducted in adolescent and adult samples. Cronbach\u0026rsquo;s α was found to be 0.92 in the Turkish adolescent group, while it was 0.91 in the adult group [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eThe data obtained from the research was statistically examined using SPSS version 23.0 (The Statistical Package for Social Sciences) and the Lavaan package in R (version 4.3.3) for Confirmatory factor analysis (CFA). The normality of the distribution of continuous variables was assessed using skewness and kurtosis tests. Continuous variables were presented as mean and standard deviations (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), while categorical variables were reported as numbers and percentages (N, %). The construct validity of the DOS was analyed using CFA with maximum likelihood estimation. Model fit was evaluated using multiple indices, including the chi-square to degrees of freedom ratio (χ\u0026sup2;/df), Comparative Fit Index (CFI), Tucker\u0026ndash;Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Internal consistency reliability of the DOS was assessed using Cronbach\u0026rsquo;s α and McDonald\u0026rsquo;s ω. To assess convergent validity, Pearson\u0026rsquo;s correlation coefficients were calculated between\u003c/p\u003e \u003cp\u003eDOS scores and related constructs, including the ONI, EAT-26 and RCADS-CV scores. Finally, Receiver Operating Characteristic (ROC) curve analysis was performed to determine the optimal cutoff value for the DOS. Sensitivity, specificity and the area under the curve (AUC) with 95% confidence intervals were presented.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe sociodemographic, clinical, and dietary characteristics of the participants are presented in Table 1. The mean age of the participants was 15.7\u0026plusmn;1.72 years, and 61.2% of the participants were female. 77.0% of participants came from nuclear families. 16.7% of participants had a chronic medical condition. \u0026nbsp;A family history of psychiatric disorders was reported in 70 participants (33.5%). \u0026nbsp; 10.5% reported following a specific diet. Daily meal patterns showed that 80 participants (38.3%) consumed 1\u0026ndash;2 meals per day, 118 participants (56.5%) consumed 3\u0026ndash;4 meals, and 11 participants (5.3%) consumed 5 or more meals. 28.2 % of participants reported eating alone. Dietary supplement use was reported in 43 participants 20.6(%). 32 participants were smokers (15.3%).\u003c/p\u003e\n\u003cp\u003eIn the additional analyses regarding comorbidities, only the presence of OCD was found to be significantly associated with DOS scores (p = 0.013), and a medium effect size was calculated (Cohen\u0026rsquo;s d = 0.59).\u003c/p\u003e\n\u003cp\u003eA confirmatory factor analysis (CFA) was conducted to examine the fit of the proposed model, and the fit indices are presented in Table 2. The results showed an acceptable to good fit: \u0026chi;\u0026sup2;/df = 2.00, CFI = 0.961, TLI = 0.944, RMSEA = 0.0688, and SRMR = 0.0443.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 presents the reliability statistics for the DOS. The mean item score was 1.78\u0026plusmn;0.641. Internal consistency of DOS was robust, with a Cronbach\u0026rsquo;s \u0026alpha; of 0.868 and McDonald\u0026rsquo;s \u0026omega; of 0.871.\u003c/p\u003e\n\u003cp\u003eAs part of the confirmatory factor analysis, standardized factor loadings were obtained and are reported in Table 4. The findings supported a three-factor structure, with item loadings ranging between .41 and .92.\u003c/p\u003e\n\u003cp\u003eTable 5 summarizes the correlation results of the DOS total scores with each variable. The DOS total scores were positively correlated with ONI (r = 0.595, p \u0026lt; .001) and EAT-26 (r = 0.374, p \u0026lt; .001), but not significantly associated with BMI (r = 0.099, p = .159) or RCADS-CV total anxiety (r = 0.075, p = .282)\u003c/p\u003e\n\u003cp\u003eFigure 1 shows the ROC curve analysis for the DOS. The results indicated an optimal cutoff score of 26, yielding a sensitivity of 91.2% and a specificity of 100.0%. The area under the curve (AUC) was 96.8% (95% CI = 93.0\u0026ndash;100.0), demonstrating good discriminatory power.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFigure 1.\u0026nbsp;\u003c/strong\u003eROC Curve Analysis of DOS\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo the best of our knowledge, this study is the first to assess the validity and reliability of the Turkish version of the DOS in a clinical adolescent sample. The findings indicate that the scale is a psychometrically robust instrument for assessing orthorexic tendencies in this age group.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInternal Consistency and Reliability\u003c/h2\u003e \u003cp\u003eThe analyses have shown that the Turkish version of the DOS has high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.868, McDonald\u0026rsquo;s ω\u0026thinsp;=\u0026thinsp;0.871) and that the scale\u0026rsquo;s factor structure retains its cultural validity in the adolescent sample. Similarly, in the Arabic reliability and validity study of the DOS conducted among Lebanese adolescents, it was reported that the scale\u0026rsquo;s single-factor structure was preserved and that it had high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.85) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe original scale developed by Barthels et al. (2015) demonstrated an internal consistency of 0.84 (Cronbach\u0026rsquo;s alpha), and validity\u0026ndash;reliability studies conducted in various countries have also reported Cronbach\u0026rsquo;s alpha values ranging from 0.84 to 0.88 [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In studies conducted in T\u0026uuml;rkiye, the internal consistency of the TR-DOS was found to be 0.87 in an adult clinical sample and 0.85 among university students [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These findings support that the scale is a valid and reliable measurement tool across different age groups and cultural contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eConstruct and Criterion-Related Validity\u003c/h2\u003e \u003cp\u003eIn our study, significant positive correlations were found between the total DOS score and the EAT-26 and ONI scores. These findings indicate that the DOS demonstrates convergent validity with disordered eating attitudes and orthorexic symptoms, consistent with similar studies in the literat\u0026uuml;re [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Previous research conducted in different cultures and samples has also shown that the relationship between orthorexic tendencies and eating attitudes falls within the low to moderate range [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our findings support that the DOS sensitively captures the dimensions of reduced flexibility in eating attitudes and cognitive preoccupation with diet in a clinical adolescent sample, and that it exhibits expected associations with related constructs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and Clinical Findings\u003c/h2\u003e \u003cp\u003eIn our study, no significant relationship was observed between BMI and orthorexic tendencies. This finding is consistent with the literature emphasizing that ON focuses not on weight but on obsessive attitudes regarding the healthiness of foods, and that behavioral patterns may develop that do not necessarily reflect on body weight [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This result supports theoretical perspectives suggesting that ON differs from traditional eating disorders that center on weight and body image.\u003c/p\u003e \u003cp\u003eThe findings also indicated that there was no significant difference in orthorexic tendencies between genders. This result is partially consistent with the inconsistent findings in the literature; indeed, several systematic reviews and meta-analyses highlight that ON symptoms are generally independent of gender [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. For instance, reviews focusing on healthcare professionals and university students have reported that gender differences are typically absent, with such inconsistencies being attributed to variations in measurement tools and sample characteristics (such as age and cultural factors) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Our findings support the notion that ON exhibits a more balanced gender distribution compared to traditional eating disorders, thereby underscoring its distinct etiological profile.\u003c/p\u003e \u003cp\u003eIn this context, perspectives suggesting that ON may represent a pattern of eating behavior shaped more by individual psychological tendencies rather than gender-based factors are gaining support [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Indeed, these findings are reinforced by systematic reviews and meta-analyses, which indicate that ON shows consistent and strong associations with psychological characteristics such as perfectionism, OCD, and anxiety, whereas its associations with demographic and bodily indicators (e.g., age, BMI, gender) remain weak or inconsistent [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This underscores, once again, that the evaluation of ON should prioritize individual cognitive\u0026ndash;emotional determinants rather than gender-based assumptions.\u003c/p\u003e \u003cp\u003eIn contrast to the weak associations observed with sociodemographic variables, the analytical examination conducted according to comorbidity in our study revealed that orthorexic symptoms were specifically confined to the presence of comorbid OCD. This pattern is consistent with studies reporting that increases in OCD symptom severity are associated with elevated ON tendencies [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The conceptual proximity between ON and the obsessive\u0026ndash;compulsive spectrum is frequently described through obsessive beliefs regarding \u0026lsquo;food purity\u0026rsquo; and contamination, as well as ritualized, rule-bound behaviors related to food preparation and consumption [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Taken together, our findings demonstrate that orthorexic symptoms are significantly higher in the presence of OCD, aligning with the ON-OCD connection reported in the literature; however, longitudinal and multivariate studies are needed to clarify the causal direction and continuity of this relationship.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, due to its cross-sectional design, the findings do not allow for the determination of causal relationships or the examination of changes over time. Additionally, as the data were collected from a single center and a clinical sample, the generalizability of the results to different socioeconomic and cultural groups may be limited. Future research incorporating longitudinal designs and larger, more heterogeneous samples may strengthen the validity and reliability of the findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, the findings demonstrate that the TR-DOS is a reliable and valid measurement tool in a clinical adolescent sample. These results suggest that the scale can be integrated into clinical practice for the assessment of orthorexic tendencies and can serve as a standardized outcome measure in future epidemiological and clinical research. Moreover, the study contributes to a better understanding of the pathological dimensions that may emerge under the discourse of “healthy eating” in adolescents—such as rule-governed behavior, cognitive rigidity, and loss of flexibility—thereby providing a solid foundation for the development of early screening methods, risk stratification strategies, and targeted intervention approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is already known on this subject?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOrthorexia nervosa (ON) has gained growing clinical and research attention due to increasing societal pressure toward healthy eating and rising concerns about restrictive dietary patterns among adolescents. Although adolescence is a developmentally vulnerable period for disordered eating, the assessment of ON in this population remains challenging. The Düsseldorf Orthorexia Scale (DOS) is one of the most widely used instruments for evaluating orthorexic tendencies and has demonstrated strong psychometric properties in several adult and youth samples across different cultures. However, despite its growing international use, evidence regarding the validity and reliability of the DOS in adolescent clinical populations—particularly within non-Western contexts—remains limited. In Türkiye, no prior study has examined the psychometric properties of the DOS specifically in clinically referred adolescents, leaving a significant gap in the availability of culturally adapted and psychometrically robust tools for identifying ON in routine child and adolescent psychiatric practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, the Düsseldorf Orthorexia Scale (DOS) was linguistically and culturally adapted into Turkish for use in a clinically referred adolescent population. Its psychometric properties—including construct, convergent, and criterion validity, as well as internal consistency—were rigorously evaluated using comprehensive statistical methods such as confirmatory factor analysis and ROC analysis. The Turkish version (TR-DOS) demonstrated a strong factorial structure, high internal consistency, and meaningful associations with established measures of orthorexic and disordered eating symptoms. Importantly, this research provides the first evidence supporting the validity and reliability of the DOS in a Turkish clinical adolescent sample, addressing a significant gap in the literature. By establishing an empirically robust tool for assessing orthorexic tendencies, this study offers an important resource for clinical practice and future epidemiological and diagnostic research on ON in youth.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were carried out in accordance with the World Medical Association Declaration of Helsinki. Written and verbal consent was obtained from all participants \u0026nbsp;following the provision of written information regarding the purpose and methodology of the study to participants \u0026nbsp;who volunteered to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study received no financial assistance in the form of funding or grants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOmca Guney:\u0026nbsp;\u003c/strong\u003eProject administration,\u0026nbsp;Conceptualization, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Supervision, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelman Yildirim:\u0026nbsp;\u003c/strong\u003eProject administration,\u0026nbsp;Conceptualization, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Supervision, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIbrahim Halil Akbas:\u0026nbsp;\u003c/strong\u003eProject administration,\u0026nbsp;Conceptualization, Data curation, Formal analysis,Investigation, Methodology, Validation, Visualization, Writing – original draft, Supervision, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDuygu Kınay Ermis:\u003c/strong\u003e Data curation, Investigation, Validation,Writing – original draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNurdan Kasar:\u003c/strong\u003e Data curation, Investigation, Validation, Writing – original draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that there are no conflicts of financial interest or personal relationships that could have influenced the findings presented in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to all those who contributed to the completion of this study. Special thanks go to our colleagues and mentors for their valuable guidance and support. We are especially grateful to the participants whose involvement made this research possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets generated and analyzed are available from the corresponding author upon reasonable request from a qualified investigator.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. \u003cstrong\u003eLancet Child Adolesc Health\u003c/strong\u003e. 2018;2(3):223\u0026ndash;228.\u003c/li\u003e\n \u003cli\u003eVoelker DK, Reel JJ, Greenleaf C. Weight status and body image perceptions in adolescents: current perspectives. \u003cstrong\u003eAdolesc Health Med Ther\u003c/strong\u003e. 2015:149\u0026ndash;158.\u003c/li\u003e\n \u003cli\u003eChristian P, Smith ER. 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ON in health workers \u0026amp; students. \u003cstrong\u003eInt J Environ Res Public Health\u003c/strong\u003e. 2024;21(8):1103.\u003c/li\u003e\n \u003cli\u003eMcComb SE, Mills JS. Psychosocial risk factors in ON. \u003cstrong\u003eAppetite\u003c/strong\u003e. 2019;140:50\u0026ndash;75.\u003c/li\u003e\n \u003cli\u003eNg QX, Lee DYX, Yau CE, et al. ON: a systematic review of reviews. \u003cstrong\u003ePsychopathology\u003c/strong\u003e. 2024;57(4):345\u0026ndash;358.\u003c/li\u003e\n \u003cli\u003eStrahler J, Wachten H, Neuhofer S, et al. Psychological correlates of orthorexic eating. \u003cstrong\u003eFront Nutr\u003c/strong\u003e. 2022;9:817047.\u003c/li\u003e\n \u003cli\u003ePratt VB, Hill AP, Madigan DJ. Perfectionism \u0026amp; ON. \u003cstrong\u003eEat Weight Disord\u003c/strong\u003e. 2024;29(1):67.\u003c/li\u003e\n \u003cli\u003eVaccari G, Cutino A, Luisi F, et al. ON as a feature of OCD. \u003cstrong\u003eEat Weight Disord\u003c/strong\u003e. 2021;26(8):2531\u0026ndash;2544.\u003c/li\u003e\n \u003cli\u003eHallit S, Azzi V, Malaeb D, Obeid S. ON\u0026ndash;OCD overlap. \u003cstrong\u003eBMC Psychiatry\u003c/strong\u003e. 2022;22(1):470.\u003c/li\u003e\n \u003cli\u003eDuradoni M, Gursesli MC, Fiorenza M, et al. ON \u0026amp; OCD relationship. \u003cstrong\u003eEur J Investig Health Psychol Educ\u003c/strong\u003e. 2023;13(5):861\u0026ndash;869.\u003c/li\u003e\n \u003cli\u003ePontillo M, Zanna V, Demaria F, et al. ON, EDs \u0026amp; OCD review. \u003cstrong\u003eJ Clin Med\u003c/strong\u003e. 2022;11(20):6134.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"eating-and-weight-disorders-studies-on-anorexia-bulimia-and-obesity","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"eawd","sideBox":"Learn more about [Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity](https://www.springer.com/journal/40519)","snPcode":"40519","submissionUrl":"https://submission.nature.com/new-submission/40519/3","title":"Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Orthorexia nervosa, Adolescent mental health, Psychometric validation, Düsseldorf Orthorexia Scale, Eating behavior disorders","lastPublishedDoi":"10.21203/rs.3.rs-8148135/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8148135/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOrthorexia nervosa (ON) is an excessive preoccupation with healthy eating that can lead to rigidity, impairment, and distress. Validated tools to assess ON in adolescent psychiatry settings are scarce. This study evaluated the validity and reliability of the Turkish version of the D\u0026uuml;sseldorf Orthorexia Scale (TR-DOS) in an adolescent clinical sample.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAdolescents aged 12\u0026ndash;18 presenting to a child and adolescent psychiatry outpatient clinic completed the TR-DOS, Orthorexia Nervosa Inventory, Eating Attitudes Test-26, and Revised Child Anxiety and Depression Scale \u0026ndash; Child Version. Psychiatric diagnoses were established through clinician-administered DSM-5 interviews. Construct validity was examined with confirmatory factor analysis. Internal consistency was assessed using Cronbach\u0026rsquo;s α and McDonald\u0026rsquo;s ω. Convergent validity was evaluated via correlations with related measures. Receiver operating characteristic analysis was used to determine an optimal cut-off.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe sample comprised 209 adolescents (61.2% female; mean age\u0026thinsp;=\u0026thinsp;15.7 years). Model fit indices supported a one-factor solution (χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;2.00; CFI\u0026thinsp;=\u0026thinsp;0.961; TLI\u0026thinsp;=\u0026thinsp;0.944; RMSEA\u0026thinsp;=\u0026thinsp;0.0688; SRMR\u0026thinsp;=\u0026thinsp;0.0443). Internal consistency was high (α\u0026thinsp;=\u0026thinsp;0.868; ω\u0026thinsp;=\u0026thinsp;0.871). TR-DOS scores correlated positively with orthorexic symptomatology and disordered eating (r\u0026thinsp;=\u0026thinsp;0.595 and r\u0026thinsp;=\u0026thinsp;0.374, both p\u0026thinsp;\u0026lt;\u0026thinsp;.001). A cut-off score of 26 yielded an AUC of 0.968, with 91.2% sensitivity and 100% specificity. Only obsessive\u0026ndash;compulsive disorder was significantly associated with higher TR-DOS scores.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe TR-DOS is a valid, reliable, and practical tool for assessing orthorexic tendencies in Turkish adolescents and may facilitate early identification and clinical decision-making.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLevel of evidence\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLevel V, descriptive study\u003c/p\u003e","manuscriptTitle":"Cross-Cultural Adaptation and Psychometric Validation of the Turkish Düsseldorf Orthorexia Scale in Adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 10:07:32","doi":"10.21203/rs.3.rs-8148135/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-27T14:12:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-19T12:04:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185752247574898231756835891449178171378","date":"2025-12-17T16:41:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-17T12:08:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-22T15:39:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-22T09:36:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity","date":"2025-11-18T17:46:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"eating-and-weight-disorders-studies-on-anorexia-bulimia-and-obesity","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"eawd","sideBox":"Learn more about [Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity](https://www.springer.com/journal/40519)","snPcode":"40519","submissionUrl":"https://submission.nature.com/new-submission/40519/3","title":"Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7cc03fb4-adca-49a6-9d00-cdb09345492f","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:03:12+00:00","versionOfRecord":{"articleIdentity":"rs-8148135","link":"https://doi.org/10.1007/s40519-026-01847-3","journal":{"identity":"eating-and-weight-disorders-studies-on-anorexia-bulimia-and-obesity","isVorOnly":false,"title":"Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity"},"publishedOn":"2026-04-02 15:58:41","publishedOnDateReadable":"April 2nd, 2026"},"versionCreatedAt":"2025-12-22 10:07:32","video":"","vorDoi":"10.1007/s40519-026-01847-3","vorDoiUrl":"https://doi.org/10.1007/s40519-026-01847-3","workflowStages":[]},"version":"v1","identity":"rs-8148135","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8148135","identity":"rs-8148135","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}