Cross-cultural adaptation and psychometric properties of the Chinese version of the Orthorexia Nervosa Inventory (ONI)

doi:10.21203/rs.3.rs-4887861/v1

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Cross-cultural adaptation and psychometric properties of the Chinese version of the Orthorexia Nervosa Inventory (ONI)

https://doi.org/10.21203/rs.3.rs-4887861/v1

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Background

Orthorexia Nervosa (ON) is an emerging clinical eating disorder characterized by an obsessive and pathological focus on healthy eating. In recent years, the Orthorexia Nervosa Inventory (ONI) has gained recognition as a promising tool for assessing orthorexic tendencies and behaviors, addressing the limitations of existing ON-specific measures. This study aimed to evaluate the psychometric properties of the Chinese version of the ONI.

Methods

A total of 717 participants (Mage = 20.11 years, 78.66% female) completed the Orthorexia Nervosa Inventory (ONI) alongside the Chinese version of the Düsseldorf Orthorexia Scale (C-DOS). The ONI was translated into Chinese using the Brislin traditional translation model, following formal authorization from the original author. This translation process included literal translation, back translation, and cultural adaptation to ensure both linguistic and contextual fidelity. Item analysis was employed to assess item differentiation, while the Delphi method was used to evaluate content validity. Scale reliability was determined by measuring internal consistency. Furthermore, exploratory and confirmatory factor analyses were conducted to investigate and confirm the underlying factor structure and overall validity of the scale.

Results

The Chinese version of the Orthorexia Nervosa Inventory (ONI) comprises 24 items across three dimensions. The Cronbach’s alpha coefficient for the overall scale was 0.922, with individual dimensions having coefficients of 0.930, 0.925, and 0.855, respectively. The Spearman-Brown split-half reliability coefficient was 0.931, and McDonald's ω was also 0.931, indicating strong reliability. The KMO value was 0.949, well above the acceptable threshold of 0.600, confirming the data's suitability for factor analysis. Principal Component Analysis (PCA) with varimax orthogonal rotation retained items with loadings greater than 0.40 on a single factor. The resulting three-factor structure explained 62.439% of the total variance. All model fit indices fell within acceptable ranges, affirming the structural validity of the Chinese version. The results from both exploratory and confirmatory factor analyses further supported this conclusion.

Conclusion

This study successfully translated and culturally adapted the ONI into Chinese, followed by a comprehensive evaluation of its psychometric properties. The findings demonstrate that the Chinese version of the ONI possesses strong reliability and validity. In the context of varying cultural backgrounds and dietary habits, this scale serves as a valid tool for assessing and screening the Chinese ON population.

Orthorexia

Psychometric properties

Eating disorders

Factor analysis

Orthorexia is originated from Greek ortho created by Bratman S^[1]and means correct appetite^[2].Orthorexia Nervosa(ON)is an eating disorder which describes people engaging in extreme diet patterns for health, the main characteristics are the compulsive thinking and obsessive behavior for “healthy food”. During a 2022 consensus meeting attended by 47 eating disorders experts from 14 different countries, Orthorexia Nervosa (ON) was classified as a mental health disorder that is closely aligned with the DSM-5 category of 'Feeding and Eating Disorders' (F&ED)^[3].The excessive focus on food quality and pursuit of“purity of food”may lead to the development of certain forms of eating disorders with harmful and counter-productive result. Studies find that ON may lead to some adverse outcomes like malnutrition and/or social dysfunction ^[1].Dieters with ON may experience nutritional deficiency result from ignoring the diversity of food groups, long term dietary restriction develop symptoms similar to severe anorexia such as osteopenia, anemia, hyponatremia, metabolic acidosis, pancytopenia, testosterone deficiency, and bradycardia^[4–5].

At present, ON has no widely accepted official definition and is not listed in official ICD-11 or DSM-V^[2]. Though, there’re amount of diagnostic criteria for ON have been proposed^[3], most of them are criticized by researchers or have not been verified. As a result, there’s no standardized diagnostic criteria and treatment regime. The diagnostic criteria, classification, and underlying mechanisms of ON are still under discussion. At present, the possible treatment for ON is based on MTD model consisted of pharmacy, cognitive behavioral and nutritional intervention^[5–7]. In order to find reliable diagnostic criteria, researchers have developed many tools for ON measurement or diagnosis. For example, Orthorexia Self-Test (BOT) developed by Bratman and Knight^[8] is widely used to diagnose ON, however, it’s criticized for the invalid psychometric characteristics.;ORTO-15 was designed by Donini et al^[9] and translated into multiple language version ^[10–12]as a diagnostic tool for ON, while it was questioned for limitation like no clear validation of the tool, no standardization methods, and an excessive percentage of ON; Eating Habits Questionnaire(EHQ)developed by D.H Gravers^[13], though with high intergrity, there’s controversy for its factor structure. Other scales are not widely applied yet, the quality and the validity need verification. On the other hand, content most of scales focus on knowledge, behaviors or emotions, however, physical impairments caused by ON are ignored, which are very important for clinic.

ONI(Orthorexia Nervosa Inventory, ONI)is developed by Oberle CD et al.^[14]in 2020 which is a self-report questionnaire consisted of three dimensions: behaviors and preoccupation with healthy eating; physical and psychosocial impairments; and emotional distress, with a total of 24 items. The initial study reported the strong internal consistency level (total Cronbach a = 0.94, subscale Cronbach a > 0.86) and retest reliability (r > 0.86). What’s more, ONI is the first tool to assess physical impairment by ON, which had proved to be key factors of ON. ^[14]。

At present, the validity of the English version of ONI has been verified, but it has not been translated into Chinese version and applied to Chinese patients. Therefore, the purpose of this study is to translate the English version of ONI into Chinese and to examine the psychometric properties of the Chinese version of the ONI. By investigating its reliability, factor structure, and validity. Meanwhile In order to evaluate the criterion validity of the ONI, the Chinese version of the ten-item DOS (C-DOS) was employed.

Methods

Procedure

Data for this study were gathered through an online questionnaire administered between March and May 2024. Participants, after receiving a detailed explanation of the study's objectives and procedures, provided informed consent before voluntarily completing the survey. Importantly, no incentives were offered, ensuring genuine participation. The introductory page of the questionnaire provided a thorough overview of the study, explicitly informing respondents of their right to withdraw at any point by choosing not to submit their responses. Each survey session was designed to be brief, lasting approximately 10 minutes, with strict measures taken to guarantee complete anonymity; no personally identifiable information was collected. The study targeted adults who met specific criteria: participants were required to be of legal age (18 years or older), native speakers of Mandarin Chinese, and willing to provide informed consent. Those with visual or cognitive impairments that hindered their ability to complete the survey were excluded from the study.

Participants

To guarantee the dependability of the analysis outcomes, the sample size for Exploratory Factor Analysis (EFA) should include a minimum of 120 cases, while Confirmatory Factor Analysis (CFA) requires at least 200 cases. This recommendation follows the guideline that the sample size should be 5 to 10 times greater than the number of variables^[15]. And considering a sample loss rate of 20%^[16], the total sample size should be at least 384. In this study, 720 questionnaires were distributed, and 717 were successfully retrieved, yielding an effective response rate of 99.72%. Additional social demographic details are presented in Table 1.

Table 1

N = 717
Group	Factory	n	Percent %
medical college	educational background	625	87.17%
Non-medical college	educational background	92	12.83%

Measures

Demographics

The demographic information included age, sex, marital status, education level, residence and BMI. A total of 717 respondents were surveyed, 153 of them (21.34%) were male and 564 (78.66%) were female. Average scale score is 72.063 ± 14.677.

Orthorexia nervosa inventory (ONI)

The Orthorexia Nervosa Inventory (ONI)^[14] is a self-report instrument comprising 24 items, designed to assess three latent dimensions: behaviors and fixation on healthy eating, physical and psychosocial impairments, and emotional distress. Respondents rate each item on a 4-point scale, where 1 indicates 'not at all' and 4 indicates 'very '. Scale scores are derived by summing the items corresponding to each dimension, and an overall score is calculated by summing all item scores. The total score ranges from 24 to 96, with higher scores reflecting more pronounced orthorexia symptomatology.

Düsseldorf Orthorexia Scale (DOS)

In order to evaluate the criterion validity of the ONI, the China version of Düsseldorf Orthorexia Scale (DOS) was employed^[17].

The C-DOS demonstrated good internal consistency, with an ordinal alpha of 0.80, and solid test–retest reliability, with a coefficient of 0.77. The scale items are rated on a 4-point scale, ranging from 1 ("this does not apply to me") to 4 ("this applies to me"), yielding total scores ranging from 10 to 40. Higher scores indicate more severe orthorexia symptoms.

Cross-cultural adaptation of the Orthorexia Nervosa Inventory (ONI)

After obtaining permission from the original authors of the Orthorexia Nervosa Inventory (ONI) to translate and contextually modify the questionnaire, we carefully adhered to prescribed guidelines throughout the process. A comprehensive forward- and back-translation process was employed to ensure accuracy and cultural relevance. The translation and cross-cultural adaptation were rigorously executed in strict accordance with the Brislin translation model, culminating in the creation of a Chinese version of the ONI^[18–19]. The specific procedure involved several detailed steps:

Translation

The original English version of the scale was independently translated into Chinese by two bilingual researchers on our team, both of whom are native Chinese speakers. These initial translations, labeled T1 and T2, were carefully reviewed and compared by the research team. Through in-depth discussions, any discrepancies were resolved, leading to the integration of these versions into a preliminary draft, designated as T3.

Back Translation

To ensure the accuracy of the translation, T3 was independently back-translated into English by two bilingual native English speakers who were unfamiliar with the original scale. These back-translations, referred to as E1 and E2, were synthesized into a single English version, ET3. This version was then sent to the original authors of the scale for feedback. Based on their input and further deliberations within the research team, the first finalized Chinese version, labeled C1, was produced.

Cultural Adaptation

In October 2023, the Chinese version C1 underwent a rigorous cultural adaptation process utilizing the Delphi method. A panel of seven experts in eating disorders—each holding an associate senior professional title, a master’s degree or higher, and over 15 years of professional experience—was convened. These experts evaluated the context, cultural relevance, and linguistic expression of the C1 items based on their clinical experience and theoretical knowledge, while also referencing the original scale. Following their review, the research team made the necessary adjustments to the questionnaire based on the experts' feedback, resulting in the development of the revised Chinese version, C2.

Data analysis

For data entry and analysis, SPSS version 25.0 and AMOS version 23.0 were utilized. Descriptive statistics for continuous variables with a normal distribution are reported as mean values accompanied by standard deviations (SD), whereas categorical variables are presented as percentages. Item analysis was performed utilizing both the critical ratio method and the correlation coefficient method. Reliability was assessed through Cronbach’s alpha coefficient, split-half reliability. The validity of the questionnaire was evaluated using both content and construct validity assessments. Content validity was measured through the Item-Level Content Validity Index (I-CVI) and the Scale-Level Content Validity Index (S-CVI). Construct validity was examined using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

Item analysis

The critical ratio method and the correlation coefficient method were used to screen the items.

(1) For the critical ratio method, the 717 questionnaires were ordered from highest to lowest based on their total scores. A T-test was then conducted to determine whether the differences between the high group (the top 27%) and the low group (the bottom 27%) were statistically significant^[20]. When the critical ratio>3.000, the item was considered to have high discriminability^[20].

(2) Correlation Coefficient Method: The correlation coefficients between each of the 8 items and the total score of the translated scale were calculated. The retention of each item was determined based on its item-total correlation (r > 0.4) and the effect of removing the item on Cronbach’s alpha coefficient^[20].

Reliability analysis

Reliability serves as a key indicator of the accuracy and consistency of a measurement instrument in capturing the true characteristics of the variables being measured. It reflects the extent to which the measurement tool consistently produces stable and dependable results over repeated trials. In essence, high reliability indicates that the instrument reliably measures the intended variables with minimal error, ensuring that the observed results are a true representation of the measured object or variable. The greater the consistency in test outcomes, the lower the measurement error, and consequently, the higher the reliability of the instrument.^[21]. Cronbach’s alpha coefficient and split-half reliability were utilized to assess the reliability of the scale. Cronbach’s alpha was calculated for the translated scale, with a threshold of 0.70 set as the acceptable standard for evaluating the internal consistency of the scale^[22].

Validity analysis

Seven experts were selected to evaluate the content importance of each item in the ONI-C using a 4-point Likert scale, where 1 corresponded to 'irrelevant' and 4 to 'very relevant.' The item-level content validity index (I-CVI) and scale-level content validity index (S-CVI) were calculated based on the experts' ratings. The I-CVI represents the proportion of experts who rated an item as 3 or 4, while the S-CVI is the average of the I-CVI across all items. Typically, an I-CVI of ≥ 0.780 and an S-CVI of ≥ 0.900 are considered acceptable^[22]. The construct validity of the Chinese version of ONI was assessed using Confirmatory Factor Analyses (CFAs) with maximum likelihood estimation. Several goodness-of-fit indices were calculated to evaluate the model's fit, including the robust chi-square (χ²R), the robust chi-square to degrees of freedom ratio (χ2R/df), the Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI), the root-mean-square error of approximation (RMSEA) along with its 90% confidence interval (CI), and the standardized root-mean-square residual (SRMR). The following criteria were used to determine satisfactory model fit: χ²R/df ≤ 3, CFI and TLI ≥ 0.9, and RMSEA ≤ 0.08. Convergent validity was further evaluated by examining the average variance extracted (AVE) and composite reliability (CR) for each subscale, with AVE > 0.5 and CR > 0.7 indicating satisfactory convergent validity.

Scale translation and cross-cultural adaptation

In accordance with the linguistic and cultural nuances of China, the initial draft of the Chinese version was carefully reviewed and adjusted, taking into account semantics, idiomatic expressions, and cultural concepts. To ensure clarity and prevent conceptual misunderstandings among respondents of varying educational levels and backgrounds, annotations were added to certain professional terms within the scale.

Descriptive statistics

A total of 717 respondents were surveyed, 153 of them (21.34%) were male and 564 (78.66%) were female. Average scale score is 72.063 ± 14.677. Additional social demographic characteristics are presented in Table 1.

Item analysis

The purpose of item analysis is to determine whether the items in the questionnaire or scale are valid and appropriate. The principle is to first sum the analysis items and then divide them into high-scoring and low-scoring groups.(27% and73% quantiles are used as boundaries), then use t test to compare the discrepancy between high-scoring and low-scoring group, if the discrepancy exists, suggesting the design of scale items is appropriate, otherwise suggesting the scale items cannot distinguish the information, should be deleted. According to the table above, 24 items from Q1 to Q24 were analyzed. After summing up all of 24 items respectively, we divided them into high-scoring and low-scoring groups, then t test was used to compare the discrepancy. As table showed, 24 items all showed significance(p < 0.05) suggesting that items from Q1 to Q24 have good discrimination and should be reversed. In general, a total of 24 items all showed good discrimination and no items needed to be deleted.

Validity analysis

To assess the relevance of each item within the Chinese version, a panel of seven experts employed a 4-point scoring system, where scores ranged from 1 ('irrelevant') to 4 ('very relevant'). This evaluation yielded a Scale Content Validity Index (S-CVI) of 0.917, reflecting a high degree of overall content validity for the entire scale. Additionally, the Item Content Validity Index (I-CVI) for the items exhibited values ranging from 0.857 to 1.000, indicating that the majority of items were considered highly relevant by the experts. These findings underscore the robustness of the content validity in the Chinese version, as evidenced by the consistently high ratings across items.

criterion validity

C-DOS was used to analyze criterion validity of C-ONI and the total score of C-ONI and C-DOS was positively correlated. (r = 0.87, p<0.001)

Exploratory factor analysis

The KMO value is 0.949, > 0.6, satisfied with the requirement of factor analysis suggesting that the factor analysis can be used for data. Bartlett’s test of sphericity also showed the data is suit for factor analysis (p < 0.05).Principal component analysis was used to extract three factors with eigenvalue > 1, and factor loadings of each item are > 0.50 so there’s no items was deleted. Varimax rotation were used for orthogonal rotation of three factors, and the explained variance ratio of three factors are, 25.438%,23.496%,13.506%, and the accumulative explained variance ratio is 62.439% after rotation. The factor loading for each item is shown in Table 2.

Table 2

N = 289
Factor loadings of exploratory factor analysis for Chinese version of the ONI
Item
Item	Factory1	Factory2	Factory3
Q3	0.769	0.165	0.06
Q5	0.752	0.152	0.059
Q7	0.75	0.154	0.078
Q10	0.778	0.072	0.142
Q12	0.776	0.086	0.136
Q14	0.76	0.153	0.123
Q16	0.744	0.116	0.116
Q19	0.738	0.11	0.177
Q20	0.775	0.12	0.172
Q24	0.785	0.114	0.173
Q2	0.112	0.75	0.094
Q4	0.155	0.77	0.041
Q6	0.133	0.772	0.128
Q8	0.143	0.782	0.036
Q11	0.06	0.802	0.108
Q15	0.107	0.766	0.133
Q17	0.14	0.749	0.177
Q18	0.128	0.797	0.06
Q22	0.165	0.765	0.187
Q1	0.124	0.175	0.745
Q9	0.201	0.066	0.778
Q13	0.17	0.11	0.782
Q21	0.153	0.123	0.798
Q23	0.153	0.195	0.73

Confirmatory factor analysis

The model was constructed using Amos 23.0 software, and confirmatory factor analysis (CFA) was conducted on the survey data to derive the structural equation model, as illustrated in Fig. 1.

The goodness-of-fit indices for the models are presented in Table 3. In conclusion, the Chinese version of the ONI demonstrates good structural validity.

Table 3

Fit indices of the Chinese version of the ONI
Fit indices	Reference value	Result
X²/df	1–3	1.738
GFI	>0.9	0.924
AGFI	>0.9	0.908
CFI	>0.9	0.965
RMSEA	<0.08	0.042

Reliability analysis

The Cronbach’s alpha coefficient of the Chinese version was 0.922. Value of Spearman-Brown split-half reliability coefficient is 0.931. value of McDonald's ω is 0.931.

The present study aimed to investigate the psychometric properties of the ONI within a sample of Chinese respondents, providing valuable insights into its factorial structure, internal consistency, as well as its convergent and criterion validity.

Eating disorders manifest differently in different cultures and social preferences, and research has been conducted to support the idea that eating disorders manifest differently in Asian countries. More research is needed to investigate the cross-cultural validity of ON and how it manifests differently in different culture background^{[1–23−24]}. The development of C-ONI can help researchers investigate the different prevalence rates of ON across cultures and enhance the identification and screening of the disease.

The Chinese version of the scale has suitable reliability

This study assessed the reliability of the Chinese version of the ONI across three dimensions: internal consistency, split-half reliability.

The Chinese version of the scale has suitable validity

In this study, the validity of the scale was analyzed and assessed using both content validity and construct validity. Content validity measures how well the scale items align with the intended measurement objectives and requirements, while construct validity assesses the extent to which the scale's theoretical framework is reflected in the observed measurement outcomes^[25]. The I-CVI of the Chinese version ONI was between 0.857 to 1.000, and the S-CVI was 0.917, which was higher than the reference value of content validity and good content validity^[26]. Suitable for assessing the Chinese population.

To assess the construct validity of the Chinese scale, both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were employed. It is widely accepted that ideal structural validity should meet the following criteria: (1) the factors extracted through exploratory analysis should account for at least 40.00% of the total variance, and (2) each item should exhibit a high factor loading (> 0.400) on one factor, with low loadings on others. The results indicated that Principal Component Analysis (PCA) with varimax orthogonal rotation was conducted, and items with individual factor loadings greater than 0.40 were retained. Three common factors were ultimately extracted, collectively accounting for 70.781% of the total variance. All items in the component matrix exhibited loadings above 0.5 on their respective dimensions ^[27]. The results of CFA showed that χ2/df = 1.738, RMSEA = 0.924, RMR = 0.027, CFI = 0.965, GFI = 0.924, AGFI = 0.908. Convergent validity refers to the size of the factor loading coefficient of the corresponding variable reflected by each item, which is mostly calculated by AVE and CR. The standardization of each variable in this study is greater than 0.7, the AVE value is greater than 0.5, and the CR value is greater than 0.8. Therefore, the convergent validity test of the research data in this article is qualified.

Limitations

This study has several limitations. Firstly, retest reliability was not assessed, limiting our ability to draw conclusions about the stability of ONI scores over time. Additionally, we recruited a non-clinical sample, which may affect the generalizability of the findings. Future research should apply the ONI to clinical populations, with the aim of using receiver operating characteristic (ROC) analyses to distinguish between individuals at risk and those not at risk of ON, thereby determining the optimal cut-off score.

This study concentrated on translating and culturally adapting the Orthorexia Nervosa Inventory (ONI) into Chinese, followed by a thorough evaluation of its psychometric properties. The findings demonstrate that the Chinese version of the ONI exhibits strong reliability and validity. In the context of diverse cultural backgrounds and dietary habits, this scale provides a reliable tool for assessing and screening the Chinese ON population. Additionally, it lays the groundwork for future intervention studies targeting this group.

Funding

This study was supported by Philosophy and Social Science Research Project of Hubei Provincial Department of Education in 2022(22Y051).

Author Contribution

H.Q. and X.Z. wrote the main manuscript text and L.Y. prepared figures 1-3. C.P.deal with data collection. All authors reviewed the manuscript.

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No competing interests reported.

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Cross-cultural adaptation and psychometric properties of the Chinese version of the Orthorexia Nervosa Inventory (ONI)

Status:

Version 1

Abstract

Figures

Introduction

Methods

Procedure

Participants

Measures

Demographics

Orthorexia nervosa inventory (ONI)

Düsseldorf Orthorexia Scale (DOS)

Cross-cultural adaptation of the Orthorexia Nervosa Inventory (ONI)

Data analysis

Item analysis

Reliability analysis

Validity analysis

Results

Scale translation and cross-cultural adaptation

Descriptive statistics

Item analysis

Validity analysis

criterion validity

Exploratory factor analysis

Confirmatory factor analysis

Reliability analysis

Discussion

The Chinese version of the scale has suitable reliability

The Chinese version of the scale has suitable validity

Limitations

Conclusion

Declarations

Funding

Author Contribution

References

Additional Declarations

Status:

Version 1