Skip to main content

Association between religiosity and orthorexia nervosa with the mediating role of self-esteem among a sample of the Lebanese population – short communication



Orthorexia Nervosa is not yet classified as an eating disorder albeit it can be found in different populations. This condition can be characterized by a preoccupation with the quality of food, accompanied by obsessive thoughts regarding eating behaviors, leading to malnutrition. Previous associations have been reported between high levels of eating disorders and lower levels of self-esteem; where individuals have low self-esteem due to the pressured felt to fit the norms of society in beauty standards. The aim of the present study was to evaluate the relationship between religiosity and orthorexia nervosa via either trait or state self-esteem.


This study was conducted between September 2021 and February 2022 and included 428 participants from all Lebanese governorates. The Teruel Orthorexia Nervosa scale was used to measure orthorexia nervosa. The following scales state self-esteem and religiosity were used to measure self-esteem.


Sociodemographic characteristics (age, gender, marital status, household crowding index, body mass index and education) were entered in the mediation model as confounding variables. Higher religiosity was significantly associated with higher state self-esteem (Beta = 0.07), while higher state self-esteem was significantly associated with lower identification of those that exhibited ON tendencies or symptoms (Beta= -0.11).


A high state self-esteem was correlated with a lower level of orthorexia nervosa. Higher religiosity was shown to be associated with higher self-esteem, which in turn was associated with a decrease in the scores of orthorexia nervosa.


Self-esteem, described by the positive or negative value people attribute to themselves, is considered to be a basic need for humans [1, 2]. The construct of self-esteem, referred to as a trait, can be considered stable and global, includes the personal judgement of one’s value or worth [3]. Crouch & Straub (1983) have argued that a person’s trait self-esteem is developed and relatively unchangeable in adulthood, and hence this self-esteem trait is relatively stable [4]. The global aspect of self-esteem can be explained by the presence of both positive and negative feelings one might have towards themselves as measured by the Rosenberg Self-Esteem Scale (RSS) [5]. Global self-esteem, as explained by previous research, can include several domains such as: social, cognitive and physical self-esteems [6, 7]. Self-esteem is a flexible construct, it goes through fluctuations or small changes, where Heatherton and Polivy in 1991 distinguished it as a state of self-esteem [8]. Self-esteem state fluctuates depending on people approval by others [9] and consists of how individuals evaluate their self-worth. Unlike general or trait self-esteem which could be considered to be stable over time, Crouch and Straub suggested that a person’s trait self-esteem can be established by adulthood [4, 10]. On the other hand, Butler and colleagues referred to “self-esteem lability” to explain the changes in the state self-esteem in different contexts or situations [11].

For instance, the self-esteem state can refer to this change in self-esteem when someone is sick or unemployed [4]. This close relationship between trait self-esteem and state self-esteem is reduced when something might threaten the ego [8]. The reason for distinguishing between these two forms in the current study was to evaluate the difference between the trait self-esteem and the state self-esteem in the midst of the COVID-19 pandemic and the economic crisis happening in Lebanon. We hypothesized that the state self-esteem would be more significantly associated with Orthorexia Nervosa (ON). Moreover, previous research has found no significant association between trait self-esteem and ON while using the RSS which evaluated the self-esteem trait [5, 12, 13]. In-addition, there is absence in previous research that evaluated state self-esteem with ON or any form of self-esteem as a mediator between ON and religiosity.

Self-esteem can also be correlated with self-image, where a negative self-image of oneself was correlated with a negative self-esteem [14]. In fact, self-image is usually shaped by primary attachment styles or persons and it plays an important role in the interactions with others [15]. People with eating disorders scored more negative scores of self-images than controls [16, 17].

In 2019, a study showed that a higher score of eating disorder was associated with a lower self-esteem [18]. Previous literature showed that females with eating disorders were associated with a lower self-esteem where individuals may feel the pressure to fit society’s norms of beauty ideals [19, 20, 21]. A higher self-esteem was positively associated with a higher general wellbeing [22], whereas a low self-esteem was linked with more substance abuse/use as well as eating disorders [23].

Recent literature links mental health as well as other domains to religion [24, 25]. A cross-sectional study argued that religion has a great effect on human health and could provide people with a positive mental state [26]. In terms of self-esteem, previous research showed that higher levels of religiosity were associated with higher self-esteem score [27, 28]. Religious beliefs were positively associated with a higher self-esteem as well as better mental health [29].

Just like self-esteem, eating disorders were associated with spirituality, where strong religious beliefs were correlated with lower concerns about the body as well as disordered eating [30]. In a study conducted on Dutch health professionals, a 50-year-old female stated that the insecurities are emerging and one of the factors was that religion was gone and people were looking for a way to deal with the insecurities and fall back on, like ON or even Anorexia Nervosa [31]. To this date, there was no study that evaluated the association of religiosity with Orthorexia Nervosa. Religiosity can refer to several aspects associated with religious beliefs as well as involvements [32]. The beliefs would refer to a reverence for a deity and the involved would be engaging in activities or services related to this faith [33]. Previous authors have stated that religiosity also referred to as religiousness can be defined as the “strength of one’s connection to or conviction for their religion” [34]. Religion in this case is related to the practices, beliefs and behaviors associated with the idea of the “transcendent” that can be practiced individually or within a community [35].

ON, still not classified in the Diagnostic and Statistical Manual of Mental Health Disorder 5 (DSM-5), nor in the International Classification of Diseases, Eleventh Revision (ICD-11), can be explained as beliefs and behaviors that are obsessive and compulsive - respectively - in regards to eating behaviors [36]. The main concern of people with ON would be the healthy quality of the diet rather than the quantity, as in making sure of the presence of nutrients, preservatives or the use of pesticides, etc. [36,37,38]. This unhealthy obsession with healthy eating and strict dieting might lead to negative nutritional repercussions [36].

ON tendencies, according to Renee McGregor, are a self-development obsession rather than only striving for a perfect weight. The author describes the origin of ON tendencies to when people challenge themselves by pushing their limits in order to gain self-esteem [39]. In a previous research, bloggers identified with ON tendencies expressed that they felt the need to be in control and to reach perfection which maintained their disordered eating. This “punishing drive for perfection and control” as identified by the authors, pushed the participants to obsessively be in control of their diet and exercise by implementing strict rules [40]. Some participants shared that they became judgmental while using downward comparisons in regards of other people’s health life choices which brought them a sense of superiority. People with a low self-esteem might be particularly interested in social comparison which might increase their satisfaction [41, 42]. Moreover, self-esteem was previously shown to be a predictor for ON tendencies where higher scores on the ON scale were correlated with lower levels of self-esteem [43].

People with ON may also experience emotional distress as well as social and educational impairments on both physical and physiological levels [44, 45]. In addition, they may experience a high level of frustration when they are not satisfied with their food practices and a feeling of guilt when they do not follow their diet or transgress it [46]. ON was also associated with disordered eating attitudes [47], such as a severe restriction over food, unhealthy behaviors as well as diet habits to lose or maintain weight [48].

The association of ON and gender seemed to be controversial across several studies. Two studies found that ON tendencies were more prevalent in women than men [49, 50], whereas two other studies found the opposite [37, 51]. Few more studies found no significant correlations between the two [13, 52, 53]. A previous study found a significant association between ON and marital status in a Lebanese sample whereas another cross-cultural study conducted between Lebanon and Germany found no association between the two [54, 55]. Moreover, Bona and colleagues (2021) found that ON tendencies were more present in younger participants [43].No previous significant correlation was found between ON and other sociodemographic data such as education and household crowding index.

The following conceptual model (Fig. 1) represents the association between religiosity and ON with the mediating role of self-esteem. When an individual has a peaceful approach and has a higher level of religiosity, the less they want to validate their looks or rely on an uncomfortable wish to look healthy. The greater the religious awareness is, the lower the ON would be. Self-esteem can be associated with the negative feelings and the worries to appear in a healthy bod, and this association could be valid through the mediator role of spiritual awareness [43]. A higher level of intrinsic religion can play a protective factor against eating disorders [56]. As religious beliefs can help increase self-esteem [29], some evidence suggests that an enhanced self-esteem can play a protective factor against eating disorders [57]. With Lebanon being a religious country, religiosity was extensively studied in association of several mental health and psychology concepts such as suicidal risk, depression, addiction [58,59,60], the current study aimed to evaluate the association of religiosity with ON with a mediating role of self-esteem.

Fig. 1
figure 1

Conceptual framework of the association between religiosity and ON with the mediating role of self-esteem [29, 43, 56, 57]

Lebanon is considered to be a diverse country as per religions where we find Islam and Christianity as well as other religions ( accessed on 6 March, 2022). Most Lebanese would consider God as being full of power and the source of miracles, and religion plays a vital role in their life [61]. Previous research has shown the importance of religion in people’s life and illnesses where participants felt that their illness had a purpose. The authors of this previous study also recommended the integration of spiritual care to make sure patients have a better quality of life [62]. In a sample of 519 Lebanese individuals, the prevalence of ON tendencies (using the Dusseldorf Orthorexia Scale) was found to be present in 8.4% of the entire sample and 17.5% of the sample was at risk of developing ON [54]. In another study conducted on Lebanese individuals, the authors have highlighted the need for social awareness and behavioral interventions to treat ON [63]. The importance of this social awareness would be for people to be more vocal about eating disorders and especially about ON in order to be able to plan interventions and treatment plans accordingly.

With this being said and the scarce literature about ON in the Arab countries, the goal of the present study was to assess the association of higher religiosity with lower ON in a sample of the Lebanese population with the mediating role of self-esteem. We expected that self-esteem would mediate the association between religiosity and ON. Moreover, we used state self-esteem in this current study to study the fluctuation of self-esteem in the moment in which participants filled the questionnaire. This would give us a better idea on how they would feel at the time.


Study design

This study was carried out from September 2021 till February 2022 during quarantine restrictions imposed by COVID-19 pandemic. The data was collected online through a questionnaire designed on Google Forms where the questionnaire was shared online on several platforms (WhatsApp, LinkedIn, and Instagram) in order to reach the target number. The recruitment of this study was a general community sample that was collected from all over Lebanon using the snowball technique. A small description of the goal of the study and the criteria to participate (older than 18 and being a Lebanese citizen) were shared as well. Non-validated scales were translated from English to Arabic and then a back-translation was done to ensure a standardized translation. An Arabic-speaking psychologist first translated the scales from English to Arabic and sent it to an English-speaking psychologist who was not familiar with the scales who did the back-translation to English.

Minimal sample size calculation

A minimal sample of 410 was deemed necessary using the formula suggested by Fritz and MacKinnon [64] to estimate the sample size: \(n=\frac{L}{f2}+k+1\), where f=0.14 for small effect size, L=7.85 for an α error of 5% and power β = 80%, and k=8 variables to be entered in the model.


The questionnaire was designed in Arabic. The first part of the questionnaire targeted the sociodemographic data of the participants (age, sex, marital status and educational level). Body Mass Index (BMI) was calculated from self-reported height and weight. Household crowding index, reflecting the socioeconomic status, consists of the number of persons divided by the number of rooms in the house [65].

Teruel Orthorexia Scale (TOS)

The TOS is composed or 17 items that includes two aspects of orthorexia. The two aspects are Healthy Orthorexia and Orthorexia Nervosa and each one has respectively 9 and 8 items [66], (in this study, Cronbach’s alpha for ON = 0.86 and 0.88 for HeOr). The scale was validated in Lebanon [67] and was previously used among Lebanese samples with a good reliability score both subscales [68]. In this paper, the TOS ON subscale will be used.

State Self-Esteem Scale (SSES)

The SSES [8]( evaluated the fluctuations of self-esteem and consists of 20 items in which there are 13 reversed items. Items are rated from a scale of 1 to 5 (1 = Not At all, 5 = extremely), (in this study, Cronbach’s alpha = 0.91). Higher scores would indicate higher State Self-Esteem [8]. This scale was validated by Heatherton & Polivy (1991) in participants aged from 23 to 57 years.

Rosenberg Self-Esteem Scale (RSS)

The RSS [5] was used to evaluate trait self-esteem. It is composed of 10 items, in which 5 items are reversed. This scale is scored as a Likert scale, with a 4-point response from Strongly Disagree to Strongly Agree (in this study, Cronbach’s alpha = 0.66). This scale measured the global or trait self-esteem [69]. RSS was previously validated in research that included more than 15,000 adults’ participants across several countries [70].

Centrality of Religiosity Scales (CRS)

The CRS [71] assessed the importance and centrality of religiosity in individuals. It consists of 15 items, 12 of the items ranging from 1 = Never to 5 = Very much, and the 3 others consisted of rating of 8-points, from Several times a day to Never (in this study, Cronbach’s alpha = 0.94). Adequate psychometric qualities were reported by a validation among Brazilian adults [72].

Statistical analysis

There was no missing data since all questions were required in the Google form link. The TOS orthorexia nervosa score was considered normally distributed (skewness and kurtosis values between − 2 and + 2) [73] .The SPSS software v.22 was used to conduct the bivariate analysis. The Student t test was used to compare two means, whereas the Pearson correlation test was used to correlate two continuous scores. The PROCESS SPSS Macro version 3.4, model four [74] was used to calculate all pathways (Pathway A from the independent variable to the mediator, Pathway B from the mediator to the dependent variable and Pathway C from the independent to the dependent variable). Pathway AB calculated the indirect effect; the latter was deemed significant when the macro generated bias-corrected bootstrapped 95% confidence intervals (CI) did not pass by zero [74]. The covariates that were included in the mediation model were age, gender, education level, BMI, household crowding index.


Sociodemographic characteristics of the participants

A total of 428 participants was included in this study, with a mean age of 23.57 ± 7.38 years (min = 18; max = 57), 283 (66.1%) females, 383 (89.5%) single, and 406 (94.9%) with a university level of education. In addition, the mean BMI was 23.43 ± 4.41 kg/m2, whereas that of the household crowding index was 0.96 ± 0.47 persons/room (Table 1).

Table 1 Sociodemographic characteristics of the participants

Bivariate analysis

The bivariate analysis results are displayed in Table 2. Higher state self-esteem (r = − 0.27) was significantly associated with lower ON tendencies or symptoms, whereas higher body mass index (r = 0.15) was significantly associated with higher ON tendencies or symptoms. No significant difference was seen between males and females (12.88 vs. 12.55; p = 0.484), single and married participants (12.61 vs. 13.11; p = 0.491) and those with a secondary level of education or less vs. university level (12.36 vs. 12.68; p = 0.751) in terms of orthorexia nervosa.

Table 2 Correlation of continuous variables with orthorexia nervosa

Indirect effect of self-esteem

The results of the mediation analysis were adjusted over all sociodemographic characteristics. State self-esteem [95% BCa of the indirect effect: -0.01; -0.001], but not trait self-esteem [95% BCa of the indirect effect: -0.003; 0.001], had a significant indirect effect between religiosity and identification of those that exhibited ON tendencies or symptoms. Higher religiosity was significantly associated with higher state self-esteem (Beta = 0.07), while higher state self-esteem was significantly associated with lower identification of those that exhibited ON tendencies or symptoms (Beta= -0.10) (Fig. 2).

Fig. 2
figure 2

(a) Relation between religiosity and state self-esteem; (b) Relation between state self-esteem and orthorexia nervosa; (c) total effect of religiosity and orthorexia nervosa; (c’) direct effect of religiosity on orthorexia nervosa. Numbers are displayed as regression coefficients (standard error). *p < 0.05; ***p < 0.001


The aim of the current study was to investigate the association between religiosity and ON tendencies with the mediating role of self-esteem. Our results showed that higher state self-esteem was associated with lower ON, which aligns with previous results showing self-esteem as a predictor for ON [43]. Bona and colleagues (2021) tried to explain the relationship between self-esteem and ON by a fear coming from the pressures placed by society. It would be accepted on a social level to have strict and controlled diets because this would indicate having a healthy consciousness [75]. Moreover, a low score of self-esteem was also associated with eating disorders [76]. Previous studies have found no significant association between trait self-esteem scores and ON tendencies [12] and other studies have found that ON tendencies were positively associated with trait self-esteem [36]. This could be due to the assessment of trait self-esteem as in the current study where only state self-esteem was significantly negatively associated with ON tendencies. Some authors have found that having a high score of self-esteem reduced the tendency to healthy eating obsession making low self-esteem a susceptible predisposing factor for ON tendencies [77].

The results of our study found that state-self-esteem had a significant indirect effect between religiosity and ON. We predicted in our hypothesis a mediating role of self-esteem between religiosity and ON. Religiosity in this case refers to both religious beliefs and engagement in religious activities affiliated to one’s religion and can also be referred to as religiousness. Bona and colleagues, found that the higher the spiritual awareness was, the less likely the participants were found to have symptoms of orthorexia. People who have a high score on spirituality would generally not be concerned about other people’s opinions [78]. This would mean that with this spiritual approach, people’s self-esteem would not be low as they would not engage in restrictive diets or preoccupy themselves with healthy eating habits, which aligns with our theoretical framework and our initial hypothesis. Self-esteem could play a protective role against adverse situations and help reduce the impact of negative events [79, 80]. Almost 70% of reports, showed that religious individuals have higher levels of self-esteem [81] which can be interpreted by the fact that positive image of God and attending church duties, predicted higher levels of self-esteem among young people [82, 83]. This aligns with the results of this current study showing the association of religiosity with self-esteem. These results also align with previous research in which religious comfort and more religiosity were positively correlated with higher self-esteem [81, 84]. People might use self-esteem as a way to help themselves in adverse situations or dangers coming from the environment [85]. As no previous study evaluated the association of state self-esteem with religiosity, we assume that in the midst of the current situation in Lebanon, the fluctuation of people’s state self-esteem was significantly correlated with religiosity as people might be using religiosity as a way to cope with the daily stress. Another interpretation of the significant association of state self-esteem as mediator might be due to the many challenges faced by the Lebanese community on a daily basis. Alongside with the economic inflation in Lebanon, COVID-19, social insecurity, political instability as well as the increase in unemployment could be possibly associated with this fluctuation of state self-esteem. As trait self-esteem is considered to be a stable overtime it might not change immediately after challenging situations. Previous research has indeed found significant associations between the above-mentioned challenges in Lebanon with mental health aspects and mental health disorders [86,87,88,89]. This could, in some way, explain how state self-esteem – that can be changeable from one context to another – mediated the association of religiosity and ON.


Information bias is plausible since answers might not always be correct. A selection bias is possible because of the snowball technique used during the data collection; therefore, our results are not generalizable. More variables known to be associated with ON were not considered, predisposing us to a residual confounding bas.


Our study showed that state self-esteem had an indirect effect on religiosity and ON in our sample. Religiosity should be given more focus in the clinical practice, especially in Lebanon as it is considered as a religious country. This approach could be used by clinicians in their treatment plans in order to help some of their clients better.



Orthorexia nervosa


Teruel Orthorexia Scale


State Self-Esteem Scale


Rosenberg Self-Esteem Scale


Centrality of Religiosity Scale


  1. Baumeister RF, Campbell JD, Krueger JI, Vohs KD. Does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? Psychol Sci public interest. 2003;4(1):1–44.

    Article  PubMed  Google Scholar 

  2. Weiten W. Psychology Themes and Variations. Belmont. CA: Wadsworth, Thomson Learning 2004:127–136.

  3. Rosenberg M: Society and the adolescent self-image: Princeton university press; 2015.

  4. Crouch MA, Straub V. Enhancement of self-esteem in adults. Family and Community Health. 1983;6(2):65–78.

    Article  Google Scholar 

  5. Rosenberg M. Rosenberg self-esteem scale. J Relig Health. 1965.

    Article  Google Scholar 

  6. Harter S: Manual for the self-perception profile for children:(revision of the perceived competence scale for children): University of Denver; 1985.

  7. Shavelson RJ, Hubner JJ, Stanton GC. Self-concept: Validation of construct interpretations. Rev Educ Res. 1976;46(3):407–41.

    Article  Google Scholar 

  8. Heatherton TF, Polivy J. Development and validation of a scale for measuring state self-esteem. J Personal Soc Psychol. 1991;60(6):895.

    Article  Google Scholar 

  9. Thomaes S, Reijntjes A, Orobio de Castro B, Bushman BJ, Poorthuis A, Telch MJ. I like me if you like me: On the interpersonal modulation and regulation of preadolescents’ state self-esteem. Child Dev. 2010;81(3):811–25.

    Article  PubMed  Google Scholar 

  10. Neff KD, Vonk R. Self-compassion versus global self‐esteem: Two different ways of relating to oneself. J Pers. 2009;77(1):23–50.

    Article  PubMed  Google Scholar 

  11. Butler AC, Hokanson JE, Flynn HA. A comparison of self-esteem lability and low trait self-esteem as vulnerability factors for depression. J Personal Soc Psychol. 1994;66(1):166.

    Article  Google Scholar 

  12. Barnes MA, Caltabiano ML: The interrelationship between orthorexia nervosa, perfectionism, body image and attachment style. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 2017, 22(1):177–184.

  13. Oberle CD, Samaghabadi RO, Hughes EM. Orthorexia nervosa: Assessment and correlates with gender, BMI, and personality. Appetite. 2017;108:303–10.

    Article  PubMed  Google Scholar 

  14. Hulme N, Hirsch C, Stopa L. Images of the self and self-esteem: Do positive self-images improve self-esteem in social anxiety? Cogn Behav Ther. 2012;41(2):163–73.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Benjamin L. Every psychopathology is a gift of love. Psychother Res. 1993;3(1):1–24.

    Article  Google Scholar 

  16. Björck C, Clinton D, Sohlberg S, Hällström T, Norring C. Interpersonal profiles in eating disorders: Ratings of SASB self-image. Psychol Psychotherapy: Theory Res Pract. 2003;76(4):337–49.

    Article  Google Scholar 

  17. Mantilla EF, Bergsten K, Birgegård A. Self-image and eating disorder symptoms in normal and clinical adolescents. Eat Behav. 2014;15(1):125–31.

    Article  Google Scholar 

  18. Woodward K, McIlwain D, Mond J. Feelings about the self and body in eating disturbances: The role of internalized shame, self-esteem, externalized self-perceptions, and body shame. Self and Identity. 2019;18(2):159–82.

    Article  Google Scholar 

  19. Gross J, Rosen JC. Bulimia in adolescents: Prevalence and psychosocial correlates. Int J Eat Disord 7, 1; 1988.<51::AID-EAT2260070106>3.0.CO;2-Q.

  20. Shisslak CM, Pazda SL, Crago M. Body weight and bulimia as discriminators of psychological characteristics among anorexic, bulimic, and obese women. J Abnorm Psychol. 1990;99(4):380.

    Article  PubMed  Google Scholar 

  21. Gatward N. Anorexia nervosa: An evolutionary puzzle. Eur Eat Disorders Review: Prof J Eat Disorders Association. 2007;15(1):1–12.

    Article  Google Scholar 

  22. Orth U, Robins RW, Widaman KF. Life-span development of self-esteem and its effects on important life outcomes. J Personal Soc Psychol. 2012;102(6):1271.

    Article  Google Scholar 

  23. Leary MR, Schreindorfer LS, Haupt AL. The role of low self-esteem in emotional and behavioral problems: Why is low self-esteem dysfunctional? J Soc Clin Psychol. 1995;14(3):297. DOI:

    Article  Google Scholar 

  24. Hill PC, Pargament KI. Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. Am Psychol. 2003;58(1):64.

    Article  PubMed  Google Scholar 

  25. Thoresen CE, Harris AH, Oman D: Spirituality, religion, and health: Evidence, issues, and concerns. 2001.

  26. Curlin FA, Sellergren SA, Lantos JD, Chin MH. Physicians’ observations and interpretations of the influence of religion and spirituality on health. Arch Intern Med. 2007;167(7):649–54. doi:

    Article  PubMed  PubMed Central  Google Scholar 

  27. Carothers SS, Borkowski JG, Lefever JB, Whitman TL. Religiosity and the socioemotional adjustment of adolescent mothers and their children. J Fam Psychol. 2005;19(2):263.

    Article  PubMed  Google Scholar 

  28. Hammermeister J, Flint M, Havens J, Peterson M. Psychosocial and health-related characteristics of religious well-being. Psychol Rep. 2001;89(3):589–94.

    Article  PubMed  Google Scholar 

  29. Papazisis G, Nicolaou P, Tsiga E, Christoforou T, Sapountzi-Krepia D. Religious and spiritual beliefs, self‐esteem, anxiety, and depression among nursing students. Nurs Health Sci. 2014;16(2):232–8.

    Article  PubMed  Google Scholar 

  30. Akrawi D, Bartrop R, Potter U, Touyz S. Religiosity, spirituality in relation to disordered eating and body image concerns: A systematic review. J Eat Disord. 2015;3:29.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Syurina EV, Bood ZM, Ryman FV, Muftugil-Yalcin S. Cultural phenomena believed to be associated with orthorexia nervosa–opinion study in Dutch Health Professionals. Front Psychol. 2018;9:1419.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Bergan A, McConatha JT. Religiosity and life satisfaction. Activities Adaptation & Aging. 2001;24(3):23–34.

    Article  Google Scholar 

  33. Adeyemo D, Adeleye A. Emotional intelligence, religiosity and self-efficacy as predictors of psychological well-being among secondary school adolescents in Ogbomoso, Nigeria. Europe’s J Psychol. 2008;4(1):22–31.

    Article  Google Scholar 

  34. King JE, Williamson IO. Workplace religious expression, religiosity and job satisfaction: Clarifying a relationship. J Manage Spiritual Relig. 2005;2(2):173–98.

    Article  Google Scholar 

  35. Koenig HG. Religion, spirituality, and health: a review and update. Adv Mind Body Med. 2015;29(3):19–26.

    PubMed  Google Scholar 

  36. Bratman S, Knight D. Health food junkies: overcoming the obsession with healthful eating. Broadway Books; 2000.

  37. Donini LM, Marsili D, Graziani MP, Imbriale M, Cannella C: Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 2004, 9(2):151–157.

  38. Koven NS, Abry AW. The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatr Dis Treat. 2015;11:385. doi:

    Article  PubMed  PubMed Central  Google Scholar 

  39. McGregor R. Orthorexia: When healthy eating goes bad. Watkins Media Limited; 2017.

  40. Greville-Harris M, Smithson J, Karl A. What are people’s experiences of orthorexia nervosa? A qualitative study of online blogs. Eat Weight Disorders-Studies Anorexia Bulimia Obes. 2020;25(6):1693–702.

    Article  Google Scholar 

  41. Gibbons FX, Buunk BP. Individual differences in social comparison: development of a scale of social comparison orientation. J Personal Soc Psychol. 1999;76(1):129.

    Article  Google Scholar 

  42. Wayment HA, Taylor SE. Self-evaluation processes: Motives, information use, and self‐esteem. J Pers. 1995;63(4):729–57.

    Article  PubMed  Google Scholar 

  43. Bóna E, Erdész A, Túry F: Low self-esteem predicts orthorexia nervosa, mediated by spiritual attitudes among frequent exercisers. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 2021, 26(8):2481–2489.

  44. Dunn TM, Bratman S. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eat Behav. 2016;21:11–7.

    Article  PubMed  Google Scholar 

  45. Setnick J. The eating disorders clinical pocket guide: quick reference for healthcare providers. Snack Time Press; 2005.

  46. Mathieu J. What is orthorexia? J Am Diet Assoc. 2005;105(10):1510–2.

    Article  Google Scholar 

  47. Hallit S, Brytek-Matera A, Obeid S. Orthorexia nervosa and disordered eating attitudes among Lebanese adults: Assessing psychometric proprieties of the ORTO-R in a population-based sample. PLoS ONE. 2021;16(8):e0254948.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Hobart JA, Smucker DR. The female athlete triad. Am Family Phys. 2000;61(11):3357–64.

    Google Scholar 

  49. Arusoğlu G, Kabakçi E, Köksal G, Merdol TK. Orthorexia Nervosa and Adaptation of ORTO-11 into Turkish. Turkish journal of psychiatry 2008, 19(3).

  50. Keller M, Konradsen H. Orthorexia in young fitness participants. Klinisk Sygepleje. 2013;27:63–71.

    Article  Google Scholar 

  51. Fidan T, Ertekin V, Işikay S, Kırpınar I. Prevalence of orthorexia among medical students in Erzurum, Turkey. Compr Psychiatr. 2010;51(1):49–54.

    Article  Google Scholar 

  52. Bosi ATB, Camur D, Güler C. Prevalence of orthorexia nervosa in resident medical doctors in the faculty of medicine (Ankara, Turkey). Appetite. 2007;49(3):661–6.

    Article  Google Scholar 

  53. Herranz Valera J, Acuña Ruiz P, Romero Valdespino B, Visioli F: Prevalence of orthorexia nervosa among ashtanga yoga practitioners: a pilot study. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 2014, 19(4):469–472.

  54. Brytek-Matera A, Sacre H, Staniszewska A, Hallit S. The prevalence of orthorexia nervosa in polish and lebanese adults and its relationship with sociodemographic variables and bmi ranges: a cross-cultural perspective. Nutrients. 2020;12(12):3865.

    Article  PubMed Central  Google Scholar 

  55. Strahler J, Haddad C, Salameh P, Sacre H, Obeid S, Hallit S. Cross-cultural differences in orthorexic eating behaviors: Associations with personality traits. Nutrition. 2020;77:110811.

    Article  PubMed  Google Scholar 

  56. Castellini G, Zagaglioni A, Godini L, Monami F, Dini C, Faravelli C, Ricca V. Religion orientations and eating disorders. Rivista di psichiatria. 2014;49(3):140–4. doi

    Article  PubMed  Google Scholar 

  57. Neumark-Sztainer D, Levine MP, Paxton SJ, Smolak L, Piran N, Wertheim EH. Prevention of body dissatisfaction and disordered eating: What next? Eating disorders 2006, 14(4):265–285.

  58. Abou Kassm S, Hlais S, Khater C, Chehade I, Haddad R, Chahine J, Yazbeck M, Abi Warde R, Naja W. Depression and religiosity and their correlates in Lebanese breast cancer patients. Psychooncology. 2018;27(1):99–105.

    Article  PubMed  Google Scholar 

  59. Kassem M, Haddad C, Hallit S, Kazour F. Impact of spirituality and religiosity on suicidal risk among a sample of lebanese psychiatric in-patients. Int J psychiatry Clin Pract. 2021;25(4):336–43.

    Article  PubMed  Google Scholar 

  60. Kassem M, Rahme C, Hallit S, Obeid S: Is the presence of a psychiatric patient at home associated with higher addictions (alcohol, cigarette, and waterpipe dependence) in caregivers? The role of work fatigue, mental illness, spirituality, and religiosity. Perspectives in Psychiatric Care 2022, 58(1):383–394.

  61. Bejjani-Gebara J, Tashjian H, Abu-Saad Hujier H. End-of-life care for Muslims and Christians in Lebanon. Eur J Palliat Care. 2008;15(1):38–43.

    Google Scholar 

  62. Huijer HA-S, Bejjani R, Fares S. Quality of care, spirituality, relationships and finances in older adult palliative care patients in Lebanon. Ann Palliat Med. 2019;8:551–8.

    Article  Google Scholar 

  63. Haddad C, Obeid S, Akel M, Honein K, Akiki M, Azar J, Hallit S. Correlates of orthorexia nervosa among a representative sample of the Lebanese population. Eat Weight Disorders-Studies Anorexia Bulimia Obes. 2019;24(3):481–93.

    Article  Google Scholar 

  64. Fritz MS, MacKinnon DP. Required sample size to detect the mediated effect. Psychol Sci. 2007;18(3):233–9.

    Article  PubMed  Google Scholar 

  65. Melki I, Beydoun H, Khogali M, Tamim H, Yunis K. Household crowding index: a correlate of socioeconomic status and inter-pregnancy spacing in an urban setting. J Epidemiol Community Health. 2004;58(6):476–80.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Barrada JR, Roncero M. Estructura Bidimensional de la Ortorexia: Desarrollo y Validación Inicial de un Nuevo Instrumento. Anales de Psicología. 2018;34(2):282–90.

    Article  Google Scholar 

  67. Mhanna M, Azzi R, Hallit S, Obeid S, Soufia M. Validation of the Arabic version of the Teruel Orthorexia Scale (TOS) among Lebanese adolescents. Eating and Weight Disorders - Studies on Anorexia. Bulimia and Obesity. 2022;27(2):619–27.

    Article  Google Scholar 

  68. Awad E, Obeid S, Sacre H, Salameh P, Strahler J, Hallit S: Association between impulsivity and orthorexia nervosa: any moderating role of maladaptive personality traits? Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 2022, 27(2):483–493.

  69. Blascovich J, Tomaka J, Robinson J, Shaver P, Wrightsman L: Measures of self-esteem. Measures of personality and social psychological attitudes 1991, 1:115–160.

  70. Schmitt DP, Allik J. Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: exploring the universal and culture-specific features of global self-esteem. J Personal Soc Psychol. 2005;89(4):623.

    Article  Google Scholar 

  71. Huber S, Huber OW. The centrality of religiosity scale (CRS). Religions. 2012;3(3):710–24.

    Article  Google Scholar 

  72. Esperandio MRG, August H, Viacava JJC, Huber S, Fernandes ML. Brazilian validation of Centrality of Religiosity Scale (CRS-10BR and CRS-5BR). Religions. 2019;10(9):508.

    Article  Google Scholar 

  73. George D: SPSS for windows step by step: A simple study guide and reference, 17.0 update, 10/e: Pearson Education India; 2011.

  74. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford publications; 2017.

  75. Rangel C, Dukeshire S, MacDonald L. Diet and anxiety. An exploration into the Orthorexic Society. Appetite. 2012;58(1):124–32.

    Article  PubMed  Google Scholar 

  76. Sassaroli S, Gallucci M, Ruggiero GM. Low perception of control as a cognitive factor of eating disorders. Its independent effects on measures of eating disorders and its interactive effects with perfectionism and self-esteem. J Behav Ther Exp Psychiatry. 2008;39(4):467–88.

    Article  PubMed  Google Scholar 

  77. Yılmaz MN, Dundar C. The relationship between orthorexia nervosa, anxiety, and self-esteem: a cross-sectional study in Turkish faculty members. BMC Psychol. 2022;10(1):1–7.

    Article  Google Scholar 

  78. Margitics F. Handbook of new spiritual consciousness: theory and research. Incorporated: Nova Science Publishers; 2010.

    Google Scholar 

  79. Mann MM, Hosman CM, Schaalma HP, De Vries NK. Self-esteem in a broad-spectrum approach for mental health promotion. Health Educ Res. 2004;19(4):357–72.

    Article  PubMed  Google Scholar 

  80. Nartova-Bochaver S, Donat M, Rüprich C. Subjective well-being from a just-world perspective: A multi-dimensional approach in a student sample. Front Psychol. 2019;10:1739.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Koenig H, Koenig HG, King D, Carson VB. Handbook of religion and health. Oup Usa; 2012.

  82. Robbins M, Francis LJ, Williams E. Church attendance and self-esteem among adolescents. Psychologist in Wales 2007:4–5.

  83. Williams E, Francis LJ, Robbins M. Rejection of Christianity and selfesteem. North American Journal of Psychology 2006, 8(1).

  84. Szcześniak M, Timoszyk-Tomczak C. Religious struggle and life satisfaction among adult Christians: Self-esteem as a mediator. J Relig Health. 2020;59(6):2833–56.

    Article  PubMed  PubMed Central  Google Scholar 

  85. Pearlin LI, Schooler C. The structure of coping. Journal of health and social behavior 1978:2–21.

  86. El Othman R, Touma E, El Othman R, Haddad C, Hallit R, Obeid S, Salameh P, Hallit S. COVID-19 pandemic and mental health in Lebanon: a cross-sectional study. Int J Psychiatry Clin Pract. 2021;25(2):152–63.

    Article  PubMed  Google Scholar 

  87. Rahme C, Akel M, Obeid S, Hallit S: Cyberchondria severity and quality of life among Lebanese adults: the mediating role of fear of COVID-19, depression, anxiety, stress and obsessive–compulsive behavior—a structural equation model approach. BMC psychology 2021, 9(1):1–12.

  88. Rayan A, Fawaz M. Cultural misconceptions and public stigma against mental illness among Lebanese university students. Perspect Psychiatr Care. 2018;54(2):258–65.

    Article  PubMed  Google Scholar 

  89. Sfeir M, Akel M, Hallit S, Obeid S. Factors associated with general well-being among Lebanese adults: the role of emotional intelligence, fear of COVID, healthy lifestyle, coping strategies (avoidance and approach). Current Psychology 2022:1–10.

Download references


The authors would like to thank all who participated and helped spread the questionnaire around.


Not applicable.

Author information

Authors and Affiliations



MS, SO and SH participated in the design of the study as well as the questionnaire construction. DM collected the data; SH was involved in the statistical analysis. MS wrote the manuscript. DM reviewed the paper; all authors approved the final version of the manuscript.

Corresponding author

Correspondence to Michel Sfeir.

Ethics declarations

Ethics approval and consent to participate

The Psychiatric Hospital of the Cross’s ethical committee approved the study protocol (HPC-034-2021). Submitting the form online was considered equivalent to obtaining the informed consent. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of supporting data

Data is not available publicly; it is available upon a logical and valid request to the corresponding author.

Competing interests

The authors have nothing to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sfeir, M., Malaeb, D., Obeid, S. et al. Association between religiosity and orthorexia nervosa with the mediating role of self-esteem among a sample of the Lebanese population – short communication. J Eat Disord 10, 151 (2022).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI:


  • Orthorexia nervosa
  • Self-esteem
  • Religiosity
  • Lebanon