Review Reports - Mindfulness as a Protective Factor Against Orthorexia: The Mediating Role of Body Image Anxiety

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In the abstract, the way you list all types of analysis makes it ambiguous. Please make sure to clarify which analysis was applied for which association.
In line 73, do you mean translated to Greek if already established measures are used? Also, can you clearly identify your population? Is there a specific age group? Are there any exclusion criteria such as being diagnosed with another eating disorder at time of study?
Line 96: replace "valid" with "eligible"
Can you elaborate more on the recruitment strategy? How did you sample Greek people residing in Greece across social media platforms?
Although a measured variables section was included, the results listed for the demographic variables in the methods should be moved to the results section. There is repetition on demographics and cronbach's between methods and results. Keep in results.
A limitations section is missing from the discussion.
My major concern is the percentage of people with orthorexia in your sample. Since this is not one of the inclusion criteria, how can you account for such a small sample size and make assumptions accordingly?

Author Response

Reviewer 1:

In the abstract, the way you list all types of analysis makes it ambiguous. Please make sure to clarify which analysis was applied for which association.

Response: We thank the reviewer for this important comment. We agree that the original wording in the Abstract may have created ambiguity regarding which statistical analyses were applied to each association. To address this, we revised the Abstract to explicitly clarify the role of each analysis. Specifically, we now state that Spearman correlations were used to examine bivariate associations among mindfulness, body image anxiety, and orthorexia; multiple linear regression models were used to identify predictors of orthorexia and body image anxiety; multinomial logistic regression was applied to examine factors associated with lower mindfulness categories; and mediation analysis was conducted to test the mediating role of body image anxiety in the relationship between mindfulness and orthorexia.

In line 73, do you mean translated to Greek if already established measures are used? Also, can you clearly identify your population? Is there a specific age group? Are there any exclusion criteria such as being diagnosed with another eating disorder at time of study?

Response: We thank the reviewer for this important comment. We revised the Materials and Methods section to clarify that the questionnaire was administered in Greek and that validated Greek versions of the psychometric instruments were used. We also clarified that the target population consisted of Greek-speaking adults residing in Greece. Eligibility criteria were age 18–65 years, residence in Greece, and survey completion. No formal exclusion criteria were applied regarding current eating disorder or other psychiatric diagnoses.

Line 96: replace "valid" with "eligible"

Response: We thank the reviewer for this helpful comment. In accordance with the suggestion, we replaced the term “valid” with “eligible” in line 96 of the revised manuscript.

Can you elaborate more on the recruitment strategy? How did you sample Greek people residing in Greece across social media platforms?

Response: We thank the reviewer for this valuable comment. We revised the Methods section to clarify the recruitment strategy in greater detail. We now specify that recruitment was conducted through convenience and snowball sampling via the authors’ personal, academic, and professional networks on Facebook, Instagram, LinkedIn, and email, targeting Greek-speaking adults residing in Greece. We also note that participation was voluntary and the sample was non-probabilistic.

Although a measured variables section was included, the results listed for the demographic variables in the methods should be moved to the results section. There is repetition on demographics and cronbach's between methods and results. Keep in results.

Response: We thank the reviewer for this helpful comment. In response, we revised the manuscript to avoid repetition between the Methods and Results sections. Demographic findings and reliability coefficients were removed from the Methods section and retained only in the Results section.

A limitations section is missing from the discussion.

Response: We thank the reviewer We thank the reviewer for this important comment. In response, we added a dedicated “Study Limitations” paragraph in the Discussion section. This paragraph now acknowledges the main limitations of the study, including its cross-sectional design, the use of self-reported measures, the non-probabilistic online sampling approach, and the absence of information regarding current or past eating disorder diagnoses and other psychiatric conditions.

My major concern is the percentage of people with orthorexia in your sample. Since this is not one of the inclusion criteria, how can you account for such a small sample size and make assumptions accordingly?

Response: We thank the reviewer We thank the reviewer for this important comment. We clarify that orthorexia was not an inclusion criterion because the study was designed to assess orthorexia tendencies in a non-clinical community sample, rather than in a clinically diagnosed orthorexia population. The analyses relied on continuous scale scores, and we have revised the manuscript to clarify this point and to limit any overgeneralization of the findings. We also acknowledged this issue in the limitations section.

Reviewer 2 Report

Comments and Suggestions for Authors Thank you for the opportunity to read and review a topic that is gaining increasing scientific interest. The article is methodologically and statistically sound (personally, I would have abandoned correlation in favor of regression). The article's main strengths are its conciseness and logical flow. The article's weakness lies in its theoretical foundations. The literature on the subject is much broader than the authors present (for example, it lacks a distinction between neurotic and healthy orthorexia, thereby impoverishing its impact). There is a definite lack of more recent publications. Consequently, the Introduction and Discussion are very schematic and simplified.

Author Response

Reviewer 2:

Thank you for the opportunity to read and review a topic that is gaining increasing scientific interest. The article is methodologically and statistically sound (personally, I would have abandoned correlation in favor of regression). The article's main strengths are its conciseness and logical flow. The article's weakness lies in its theoretical foundations. The literature on the subject is much broader than the authors present (for example, it lacks a distinction between neurotic and healthy orthorexia, thereby impoverishing its impact). There is a definite lack of more recent publications. Consequently, the Introduction and Discussion are very schematic and simplified.

Response: We sincerely thank the reviewer for the careful evaluation of our manuscript and for the thoughtful and encouraging comments. We appreciate the positive assessment of the article’s methodological and statistical rigor, as well as its conciseness and logical flow. We also agree that the theoretical foundation of the manuscript required further development. Accordingly, we revised the Introduction and Discussion sections by expanding the theoretical background, incorporating more recent references, and including the distinction between healthy orthorexia and orthorexia nervosa in order to provide a more comprehensive interpretation of the topic.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript submitted to Behavioral Sciences. The manuscript addresses an important and timely topic by examining the associations among mindfulness, body image anxiety, and orthorexia tendencies in a Greek adult sample. The study is well‑motivated, and the authors employ established psychometric instruments and a reasonably large dataset. The manuscript is generally well structured, and the statistical analyses are clearly presented. However, several methodological and interpretive issues limit the strength of the conclusions.

Below are several recommendations that may help strengthen the manuscript:

Abstract:
1. Listing all statistical tests (reliability testing, descriptive statistics, Spearman correlations, multiple regression, ANOVA, multinomial logistic regression, mediation models) is excessive for an abstract. It reads like a methods section rather than a summary. Please condense this to a brief, integrated description of the analytic approach.
Materials and Methods:
1. The questionnaire was developed in Greek and included demographic items and validated psychometric scales (MAAS‑15, ORTO‑6, SPAS‑12, BMI, PAVS). It is unclear whether these instruments were administered in their original language or whether validated Greek translations were used. Please clarify the source and validation status of the Greek versions.
2. Convenience and snowball sampling are described, but the rationale for using these non‑probability methods is not provided. Given the topic, potential sampling bias should be acknowledged.
3. Data collection is stated as June–August 2025. If relevant history or local history effects (e.g., seasonal patterns, public health events, cultural timing) could influence eating behaviors or physical activity, this should be acknowledged as a potential limitation.
4. The manuscript states that the descriptive data “strengthen the generalizability” of the findings. However, even with a relatively large sample, heterogeneity in psychological characteristics does not enhance generalizability when non‑probability sampling is used. Variability is useful for examining associations, but it does not justify claims about representativeness. This statement should be revised to avoid overstating generalizability (see also lines 182–184).
Results
1. Line 139: “Tables 1” should be corrected to “Table 1”
2. Phrases such as “mindfulness plays a protective role,” “greater mindfulness is linked to lower levels of rigid, perfectionistic dietary control,” or “individuals who can remain aware and non‑judgmental appear less prone to compulsive ‘healthy eating’ behaviors” imply causal or protective effects that cannot be inferred from a cross‑sectional design. These associations should be described as correlations, not mechanisms.
3. The mediation results are interpreted in causal terms (“mindfulness protects against orthorexia,” “operates indirectly through reducing body image anxiety”). Cross‑sectional mediation cannot establish temporal ordering or causal pathways. The reduction in the mindfulness coefficient (from –1.497 to –0.817) reflects statistical attenuation consistent with partial mediation, but this should be framed as an indirect statistical association. The interpretation should avoid causal language and acknowledge the limitations of cross‑sectional mediation.
Discussion

The Discussion consistently interprets associations as if they reflect temporal or mechanistic processes (e.g., “mindfulness promotes adaptive eating behaviors,” “mindfulness fosters a non‑reactive awareness,” “mindfulness may exert protective effects,” “mindfulness weakens the pathway from body image anxiety to orthorexia”). A cross‑sectional design does not allow conclusions about directionality, temporal precedence, or causality. Cross‑sectional mediation can identify indirect statistical associations but cannot demonstrate that mindfulness reduces body image anxiety or that body image anxiety leads to orthorexia.

The section draws on ACT, self‑regulation models, and prior literature to propose mechanisms linking mindfulness, body image anxiety, and orthorexia. These frameworks are relevant, but the current data cannot confirm these processes. The authors should clarify that these interpretations represent possible theoretical explanations rather than mechanisms demonstrated by the study.

Statements such as “mindfulness promotes adaptive eating behaviors” or “individuals who cultivate mindfulness are less likely to rely on rigid dietary rules” imply behavioral outcomes that were not measured. The study assessed self‑reported mindfulness, body image anxiety, and orthorexia tendencies—not actual eating behaviors or regulatory processes. Interpretations should remain anchored to the constructs measured.

The Discussion would benefit from explicitly noting key limitations such as the cross‑sectional design, reliance on self‑report measures, potential history or seasonal effects, and non‑probability sampling. These factors are essential for contextualizing the mediation findings.

References

The reference list is not extensive, and only a few sources are from the last five years. I recommend updating and expanding the bibliography to include more recent and relevant studies, particularly given the rapidly evolving literature on mindfulness, body image, and orthorexia.

Author Response

Reviewer 3:

Below are several recommendations that may help strengthen the manuscript:

Abstract:

Listing all statistical tests (reliability testing, descriptive statistics, Spearman correlations, multiple regression, ANOVA, multinomial logistic regression, mediation models) is excessive for an abstract. It reads like a methods section rather than a summary. Please condense this to a brief, integrated description of the analytic approach.

Response: We thank the reviewer for this helpful comment. We agree that the previous wording in the Abstract included excessive methodological detail and resembled a methods description rather than a concise summary of the study. In response, we revised the Abstract to provide a more integrated and succinct description of the analytic approach, while retaining only the information necessary to understand the overall methodological framework of the study.

Materials and Methods:

The questionnaire was developed in Greek and included demographic items and validated psychometric scales (MAAS‑15, ORTO‑6, SPAS‑12, BMI, PAVS). It is unclear whether these instruments were administered in their original language or whether validated Greek translations were used. Please clarify the source and validation status of the Greek versions.

Response: We thank the reviewerr for this important comment. We revised the Materials and Methods section to clarify that the questionnaire was administered in Greek and included established psychometric instruments presented in Greek. We also specified the source of each instrument and clarified the available information regarding their use in Greek in order to avoid ambiguity.

Convenience and snowball sampling are described, but the rationale for using these non‑probability methods is not provided. Given the topic, potential sampling bias should be acknowledged.

Response: We thank the reviewer for this important comment. We agree that the use of convenience and snowball sampling may introduce sampling bias. In response, we revised the Materials and Methods section to clarify the rationale for using these non-probability sampling methods, given the online and exploratory nature of the study and the aim to recruit a broad community sample of Greek adults efficiently. We also expanded the limitations section to explicitly acknowledge the potential for selection bias and the limited representativeness of the sample.

Data collection is stated as June–August 2025. If relevant history or local history effects (e.g., seasonal patterns, public health events, cultural timing) could influence eating behaviors or physical activity, this should be acknowledged as a potential limitation.

Response: We thank the reviewer for this valuable comment. We agree that the timing of data collection may have influenced participants’ eating behaviors and physical activity patterns. In response, we revised the limitations section to acknowledge that data were collected during the summer period (June–August 2025), which may have introduced seasonal influences on lifestyle-related variables and should therefore be considered when interpreting the findings.

The manuscript states that the descriptive data “strengthen the generalizability” of the findings. However, even with a relatively large sample, heterogeneity in psychological characteristics does not enhance generalizability when non‑probability sampling is used. Variability is useful for examining associations, but it does not justify claims about representativeness. This statement should be revised to avoid overstating generalizability (see also lines 182–184).

Response: We thank the reviewer for this important comment. We agree that variability in the sample does not imply representativeness or enhanced generalizability, particularly in the context of non-probability sampling. In response, we revised the relevant wording to emphasize that the observed variability in the sample is useful for examining associations among the study variables, rather than for supporting claims of generalizability.

Results

Line 139: “Tables 1” should be corrected to “Table 1”

Response: We thank the reviewerr for this careful observation. The reference has been corrected from “Tables 1” to “Table 1” in the revised manuscript.

Phrases such as “mindfulness plays a protective role,” “greater mindfulness is linked to lower levels of rigid, perfectionistic dietary control,” or “individuals who can remain aware and non‑judgmental appear less prone to compulsive ‘healthy eating’ behaviors” imply causal or protective effects that cannot be inferred from a cross‑sectional design. These associations should be described as correlations, not mechanisms.

Response: We thank the reviewer for this important comment. We revised the relevant statements throughout the manuscript to avoid causal wording and to describe the findings in correlational terms that are more appropriate for a cross-sectional study design.

The mediation results are interpreted in causal terms (“mindfulness protects against orthorexia,” “operates indirectly through reducing body image anxiety”). Cross‑sectional mediation cannot establish temporal ordering or causal pathways. The reduction in the mindfulness coefficient (from –1.497 to –0.817) reflects statistical attenuation consistent with partial mediation, but this should be framed as an indirect statistical association. The interpretation should avoid causal language and acknowledge the limitations of cross‑sectional mediation.

Response: We thank the reviewer for this important comment. We revised the manuscript to avoid causal interpretation of the mediation findings and now describe them as a cross-sectional indirect statistical association consistent with partial mediation, rather than as evidence of a causal pathway.

Discussion

Response: We thank the reviewer for this important comment. We revised the Discussion to clarify that ACT, self-regulation models, and related interpretations are presented as possible theoretical explanations for the observed associations, rather than as mechanisms demonstrated by the study.

Response: We thank the reviewer for this important comment. We revised the relevant statements in the Discussion to ensure that the interpretation remains limited to the constructs directly measured in the study and does not imply unmeasured eating behaviours or regulatory mechanism.

Response: We thank the reviewer for this important comment. We revised the limitations section to more explicitly acknowledge the cross-sectional design, self-report methodology, seasonal/contextual influences, and non-probability sampling, and to clarify their relevance for the interpretation of the mediation findings.

References

Response: We thank the reviewer for this important recommendation. In response, we expanded and updated the bibliography by adding more recent and relevant references on mindfulness, body image, and orthorexia, and we incorporated these studies into the Introduction and Discussion sections to strengthen the manuscript’s theoretical and interpretive context.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript submitted to Behavioral Sciences. The manuscript is interesting and offers a clear exploration of how people with orthorexic tendencies understand their strict “healthy” eating habits, especially in relation to morality, identity, and feelings of self‑worth.

Below are several recommendations that may help strengthen the manuscript:

The Study Design section would be strengthened by briefly acknowledging why a constructionist approach is particularly suited to examining moral and identity‑related dimensions of eating practices.
Some sentences are long and could be streamlined for clarity and readability.
Consider reducing repetition of citations (e.g., Lim, 2025 appears twice in consecutive sentences).
The decision to rely on self‑identification as “strongly adhering to healthy eating” is understandable given the absence of diagnostic criteria, but the section would benefit from a clearer explanation of how the research team evaluated participants’ descriptions during initial contact and how the team ensured consistency across participants.
Purposeful snowball sampling is appropriate, but the description could be more explicit about how initial participants were selected, whether the sample achieved diversity in dietary practices or motivations, and how the researchers mitigated potential homogeneity introduced by snowball sampling.
The exclusion of individuals with current or past ED diagnoses is reasonable, but the rationale should be stated explicitly.

Author Response

Response: We thank the reviewer for this positive and encouraging comment. We appreciate the reviewer’s recognition of the relevance of the topic and the overall contribution of the manuscript. We have carefully considered the reviewer’s suggestions and revised the manuscript accordingly.

Below are several recommendations that may help strengthen the manuscript:

The Study Design section would be strengthened by briefly acknowledging why a constructionist approach is particularly suited to examining moral and identity‑related dimensions of eating practices.

Response: We thank the reviewer for the useful comment. However, the present study did not employ a qualitative or constructionist design. Instead, it used a cross-sectional quantitative survey approach to examine associations among mindfulness, body image anxiety, and orthorexia tendencies in a community sample. Therefore, a constructionist framework was not applicable to the aims or methodology of the current study. To improve clarity, we have further clarified the quantitative study design in the Methods section.

Some sentences are long and could be streamlined for clarity and readability.

Response: We thank the reviewer for the useful comment. We carefully revised the manuscript throughout to improve clarity and readability. Several long or overly complex sentences were shortened or rephrased, particularly in the Introduction, Methods, Results, and Discussion sections, in order to improve the overall flow of the text.

Consider reducing repetition of citations (e.g., Lim, 2025 appears twice in consecutive sentences).

Response: We thank the reviewer for the useful comment. We carefully re-checked the manuscript for repetitive citations in consecutive sentences and revised the text where appropriate to improve flow and readability.

The decision to rely on self‑identification as “strongly adhering to healthy eating” is understandable given the absence of diagnostic criteria, but the section would benefit from a clearer explanation of how the research team evaluated participants’ descriptions during initial contact and how the team ensured consistency across participants.

Response: We thank the reviewer for the useful comment. However, the present study did not rely on participants’ self-identification as “strongly adhering to healthy eating,” nor did it involve initial contact screening or qualitative evaluation of participants’ descriptions. Instead, the study used a cross-sectional online survey design in a community sample, and orthorexia tendencies were assessed quantitatively and dimensionally using the ORTO-6. To avoid any possible misunderstanding, we have clarified in the Methods section that participants were not selected on the basis of self-identification with healthy eating, but were recruited from the general adult population and assessed using standardized self-report instruments.

Purposeful snowball sampling is appropriate, but the description could be more explicit about how initial participants were selected, whether the sample achieved diversity in dietary practices or motivations, and how the researchers mitigated potential homogeneity introduced by snowball sampling.

Response: We thank the reviewer for the useful comment. In the present study, participants were recruited through convenience and snowball sampling rather than purposeful snowball sampling. Initial recruitment was conducted through the authors’ personal and professional networks on social media and email, after which participants could further share the survey link within their own networks. Because the study aimed to recruit a broad community sample rather than participants with specific dietary practices or motivations, no purposive selection criteria were applied in relation to eating behavior profiles. We have clarified this process in the Methods section and further acknowledged in the Limitations section that this sampling strategy may have increased sample homogeneity and limited representativeness.

The exclusion of individuals with current or past ED diagnoses is reasonable, but the rationale should be stated explicitly.

Response: We thank the reviewer for the useful comment. In the present study, no formal exclusion criteria were applied regarding current or past eating disorder diagnoses or other psychiatric conditions. Because the study was conducted in a non-clinical community sample, participants were not excluded on this basis. To avoid any possible misunderstanding, we have clarified this point in the Methods and Limitations sections.