Open Access Original

Article DOI: 10.7759/cureus.38451

Is Orthorexia Nervosa a Non-specific Eating

Disorder or a Disease in the Spectrum of
Review began 04/12/2023
Obsessive-Compulsive Disorder?
Review ended 04/29/2023
Published 05/02/2023 Nazan Dolapoglu 1 , Duygu Ozcan 1 , Rıza Gokcer Tulaci 2

© Copyright 2023
Dolapoglu et al. This is an open access 1. Department of Psychiatry, Balikesir University Faculty of Medicine, Balıkesir, TUR 2. Department of Psychiatry,
article distributed under the terms of the Balikesir University Faculty of Medicine, Balikesir, TUR
Creative Commons Attribution License CC-
BY 4.0., which permits unrestricted use,
Corresponding author: Nazan Dolapoglu, nazandolapoglu@gmail.com
distribution, and reproduction in any
medium, provided the original author and
source are credited.

Abstract
Background: In recent years, there has been a dramatic increase in awareness in society that healthy
nutrition has positive effects on health. However, obsession with these behaviors towards healthy foods
causes negative effects on health and quality of life.

Aim: The aim of this study was to elucidate the relationship between the incidence of orthorexia nervosa
(ON) in medical school students and the level of conscious awareness, obsessive-compulsive disorder, eating
attitudes and behaviors, health anxiety, and body image to clarify the unclear issues in the literature, such as
whether orthorexia nervosa is among the psychological disorders, "where" it will take place, and which
diagnoses it can be associated with.

Methods: Students between the 1st and 6th grades of medical school were invited to participate in this
research. The Sociodemographic Data Form, Maudsley Obsessive-Compulsive Question Index (MOCI),
Eating Attitude Test Short Form (EAT SF-26), Health Anxiety Inventory-Weekly Short Form (HAI-SF), ORTO-
11 scale, Body Perception Scale, and Conscious Awareness Scale have been applied to the students.

Results: In univariate analysis, the eating disorder scale, body image scale, and awareness scale total scores
all had an impact on orthorexia. Each increase in the eating disorder scale score increased the diagnosis of
orthorexia 1.07 times, while each increase in the body image scale score increased the diagnosis of
orthorexia 1.09 times. Additionally, each increase in the conscious awareness scale score decreased the
diagnosis of orthorexia by 0.92 times. When all variables were re-evaluated in the multivariate analysis, it
was seen that the total scores of the body image scale and conscious awareness scale affected the diagnosis
of orthorexia. There was a weak inverse relationship between the orthorexia scale score and only the health
anxiety inventory total score (p<0.05).

Conclusion: Regarding the outcomes of this research, one can say that orthorexia affected the eating
disorder scale, body image scale, and awareness scale total scores. While the increase in the eating disorder
and body image scale scores increased orthorexia, the increase in the conscious awareness scale score had a
decreasing effect.

Categories: Psychiatry, Nutrition

Keywords: conscious awareness scale, body perception scale, health anxiety, eating disorders, orthorexia nervosa

Introduction
In recent years, there has been a dramatic increase in awareness in society that healthy nutrition has
positive effects on health. However, obsession with these behaviors towards healthy foods causes negative
results in health and quality of life. This condition is called "orthorexia nervosa" (ON). ON is a new concept
among disease groups called eating disorders [1]. Unlike anorexia and bulimia, people with orthorexia may
experience feelings of guilt and a lack of motivation about not eating healthy. As the obsession with healthy
food becomes excessive, psychological and social complications arise as a result [2].

The obsessive and compulsive features of orthorexia nervosa become pathological over time and dominate
one's life. The effort to consume healthy and high-quality foods is the main cause of this disorder.
Concentration on biologically pure foods and the shops that sell them leads to a pathological obsession and
a special lifestyle. Efforts to comply with dietary rules lead to intense anxiety and feelings of guilt and
shame, which continue with more stringent dietary restrictions [3]. It is thought that there is a similarity
between these attitudes and obsessive-compulsive behaviors. However, the most important point where
orthorexia differs from obsessive-compulsive disorder is that the content of obsessions in orthorexia is
egosyntonic [4]. In other words, the orthorexic person finds his own attitudes, tendencies, behaviors, and
thoughts acceptable and accepts them as a normal reflection of his personality. Also, high levels of positive
correlations were found between eating disorders and ON symptoms [5]. On the other hand, concerns about

How to cite this article

Dolapoglu N, Ozcan D, Tulaci R (May 02, 2023) Is Orthorexia Nervosa a Non-specific Eating Disorder or a Disease in the Spectrum of Obsessive-
Compulsive Disorder?. Cureus 15(5): e38451. DOI 10.7759/cureus.38451
 weight gain in ON are thought to diverge from those in AN and BN. People with AN and BN eating disorders
focus on their quantity. However, orthorexic people are obsessed with the quality of the food they eat [6]. It
is still unclear whether ON is a type of eating disorder or a dimension of an eating pattern.

Cognitions and concerns about healthy eating, the right choice of food, or situations where proper nutrition
has become the most important part of their lives may lead to this attitude becoming pathological. People
are fed only certain foods, and this sometimes causes a deficiency of important nutrients. In addition, this
may change eating behavior by causing significant dietary restrictions, or ultimately, many things become
important about what people eat, how to eat, and how to prepare, thus affecting people in many areas (for
example, being socially separated from family members or friends who do not share similar views about
food).

The concept of orthorexia nervosa was first coined in 1997 by Steven Bratman. Bratman used the term
"orthorexia nervosa" to describe the pathology associated with healthy food consumption, as it means
"ortho" or "true" [7]. Bratman describes the concept of orthorexia in his book "Health Food Junkies" and
defines diets as a disease that people do to feel more attentive and clean. In the following years, orthorexia
nervosa entered the English language and affected the whole world [8]. Clinicians and scientists still carry
on the debate on whether orthorexia is a real and unique disorder and whether it is worth its own
categorization in the "Diagnostic and Statistical Manual of Mental Disorders (DSM-5)" together with eating
disorders (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified). On the one
hand, eating disorder experts in the United Kingdom argue that orthorexia is not currently identified with
an eating disorder because it does not begin with low self-esteem, but it may in time result in an eating
disorder as the diet becomes more refined and compulsive [9].

Although the exact figures are not known, there are different results regarding the prevalence. In a study
conducted in the United States, the prevalence of orthorexia nervosa was found to be 6.9-57.6% in the
general population, thus reaching up to 81.1% in special groups. In recent years, the incidence of orthorexia
has increased. The reason for this is the perception of beauty associated with thinness, the media's interest
in diet and the news about the ingredients of the products, and the fact that some products contain
additives, dyes, and carcinogenic substances. The higher-risk groups for orthorexia nervosa are women,
adolescents, people who practice sports (bodybuilding, athletics), medical physicians and medical students,
dieticians, as well as performance artists [10].

Clinical observations, theoretical views, and research findings suggest that health anxiety, body image, and
obsessive beliefs may be associated with orthorexia nervosa and disordered eating attitudes. However, when
these factors are taken together, it is not known which ones are important in explaining different eating
patterns. In this research, we aimed to elucidate the relationship between the incidence of orthorexia
nervosa in medical school students and the level of conscious awareness, obsessive-compulsive disorder,
eating attitudes and behaviors, health anxiety, and body image to clarify the unclear issues in the literature,
such as whether orthorexia nervosa is among the psychological disorders, "where" it will take place, and
which diagnoses it can be associated with. The hypothesis of our study is to clarify the unclear issues in the
literature, such as whether ON is among the psychological disorders, "where" it will take place, and which
diagnoses it can be associated with.

Materials And Methods

This is a cross-sectional and retrospective study. Two hundred students between the 1st and 6th grades of
the Balikesir University Medical Faculty have been invited to participate in this research. After all medical
faculty students were informed about the study, those who volunteered to participate were included in it. All
procedures followed were in accordance with the ethical standards of the responsible committee on human
experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Informed consent was obtained from all participants. The study has been approved by the ethics committee.

The sociodemographic data forms, Maudsley Obsessive-Compulsive Question Index (MOCI), Eating Attitude
Test Short Form (EAT SF-26), Health Anxiety Inventory-Weekly Short Form (HAI-SF), Body Perception Scale,
Conscious Awareness Scale, and ORTO-11 Scale, have been applied to the students. The ORTO-15 is a 15-
item self-administered questionnaire used in the diagnosis of ON. The responses designated as differential
criteria for orthorexia are graded by 1 point, while answers indicating a normal eating-behavior tendency
earn 4 points. The lowest possible score on the scale is 15 points, and the highest is 60 points. An overall
scale score below 40 points is considered indicative of orthorexia, while higher scores indicate normal eating
behavior [6]. The reliability and validity study of the Turkish version of the ORTO-15 was performed by
Arusoglu. It was adapted into Turkish as ORTO-11 for evaluation in Turkey.

As a result of the evaluation, the demographic data of students with and without high orthorexia nervosa
tendency have been compared, eating attitudes and behaviors, OCD symptoms, health anxiety level,
conscious awareness level, and body perception of students with high orthorexia nervosa tendency have
been analyzed, and the predictive power of the meaningful values has been interpreted. Students under the
age of 18, individuals with psychiatric disorders, and primary or acquired neurological diseases that may
affect cognitive abilities (stroke, dementia, head trauma, cranial operations) were excluded from the study.

2023 Dolapoglu et al. Cureus 15(5): e38451. DOI 10.7759/cureus.38451 2 of 8

 This study lasted two months, from March 1, 2022 to April 30, 2022.

Statistical analysis
Patient data collected within the scope of the study were analyzed with the IBM Statistical Package for the
Social Sciences (SPSS) for Windows 23.0 (IBM Corp., Armonk, NY) package program. Frequency and
percentage were given for categorical data and median, minimum, and maximum descriptive values for
continuous data. "Mann Whitney U-Test" was utilized for comparisons between groups, and "Chi-square or
Fisher's Exact Test" was used for the comparison of categorical variables. "Logistic regression analysis" was
used to determine the risk factors affecting the diagnosis of orthorexia, and "Spearman correlation analysis"
was used to evaluate the relationship between scale scores. The results were considered statistically
significant when the p-value was less than 0.05.

Results
Within the scope of the study, a total of 142 individuals, 76 (53.5%) with orthorexia and 66 (46.5%) in the
control group, were included in the study. While 52.8% (n=75) of the participants were female, 47.2% (n=67)
were male. The ages of the participants ranged from 18 to 31 years old, with an average age of 22 years old.
The distribution of demographic characteristics according to the status of being diagnosed with orthorexia
among the participants is denoted in Table 1. When the table was examined, a statistically significant
difference was found between the two groups in terms of age, the class they studied, and with whom they
lived (p<0.05).

Total (N=142) Orthorexia (n=76) Control (n=66)

p-value
n (%) or median (min-max) n (%) or median (min-max) n (%) or median (min-max)

Obsessive-compulsive disorder total 10 (0–31) 10.5 (1–29) 10 (0–31) 0.294

Control 2 (0–9) 2 (0–8) 2 (0–9) 0.327

Cleaning 3 (0–10) 3 (0–9) 3 (0–10) 0.569

Slowness 1 (0–6) 1 (0–6) 1 (0–5) 0.557

Doubt 2 (0–7) 3 (0–7) 2 (0–7) 0.301

Rumination 2 (0–9) 2.5 (0–9) 2 (0–9) 0.299

Eating disorder total 7 (0–39) 10 (0–39) 6 (0–23) 0.013

Dieting 2 (0–21) 4 (0–21) 1.5 (0–17) 0.007

Bulimia and eating obsession 1.5 (0–12) 2 (0–10) 1 (0–12) 0.032

Oral control behavior 3 (0–16) 2 (0–16) 3 (0–12) 0.661

Health anxiety inventory total 15 (3–42) 15.5 (4–36) 15 (3–42) 0.899

Hypersensitivity to bodily symptoms and anxiety 12 (2–32) 12 (4–27) 12 (2–32) 0.883

Negative consequences of the disease 3 (0–10) 3 (0–10) 3.5 (0–10) 0.372

Orthorexia total 25.5 (15–40) 23 (15–27) 30 (28–40) <0.001

Cognitive-rational domain 10 (5–16) 9 (5–12) 12 (8–16) <0.001

Orthorexia clinical field 9 (5–12) 8 (5–10) 10 (8–12) <0.001

Orthorexia emotional area 7 (3–12) 5.5 (3–9) 9 (6–12) <0.001

Body Perception Scale total 75 (5–150) 87.5 (40–150) 60 (5–88) <0.001

Conscious Awareness Scale total 68 (9–174) 56.5 (29–87) 89.5 (9–174) <0.001

TABLE 1: Distribution of participants' scale and scale subgroup scores

The distribution of total and sub-dimension scores of the scales according to the diagnosis groups of the
participants is elaborated in Table 2. When the table was examined, it was observed that there was a
statistically significant difference between the two groups in the total score of eating disorders and the sub-

2023 Dolapoglu et al. Cureus 15(5): e38451. DOI 10.7759/cureus.38451 3 of 8

 dimensions of dieting, bulimia, and eating obsession (p<0.05). It is noteworthy that the scores of the
orthorexia group were higher than the scores of the control group. Similarly, there was a statistically
significant difference between the two groups in the body image scale and awareness scale scores, while the
body image scale score in the orthorexia group and the awareness scale score in the control group were
found to be higher.

Univariant Multivariant

Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value

Obsessive-compulsive disorder 1.02 (0.97–1.08) 0.379 1.01 (0.92–1.12) 0.808

Eating disorder 1.07 (1.02–1.13) 0.010 1.08 (0.99–1.18) 0.097

Health anxiety inventory 0.99 (0.94–1.05) 0.819 1.00 (0.90–1.11) 0.954

Body Perception Scale 1.09 (1.06–1.12) <0.001 1.07 (1.04–1.11) <0.001

Conscious Awareness Scale 0.92 (0.90–0.95) <0.001 0.94 (0.91–0.97) <0.001

TABLE 2: Evaluation of risk factors affecting orthorexia

The distribution of risk factors affecting the diagnosis of orthorexia among the participants in the study is
shown in Table 3. When the table was examined, it was determined that orthorexia was affected by the
eating disorder scale, body image scale, and awareness scale total scores in univariate analysis. While the
increase in the eating disorder and body image scale scores increased orthorexia, it was seen that the
increase in the conscious awareness scale score had a decreasing effect. It was determined that each increase
in the eating disorder scale score increased the diagnosis of orthorexia 1.07 times, while each increase in the
body image scale score increased the diagnosis of orthorexia 1.09 times. It was observed that each increase
in the conscious awareness scale score decreased the diagnosis of orthorexia by 0.92 times. When all
variables were re-evaluated in the multivariate analysis, it was seen that the total scores of the body image
scale and conscious awareness scale affected the diagnosis of orthorexia.

Orthorexia Total Score

Correlation coefficient −0.122

Obsessive-compulsive disorder total p-value 0.292

N 76

Correlation coefficient −0.169

Eating disorder total p-value 0.144

N 76

Correlation coefficient −0.242

Health anxiety inventory total p-value 0.035

N 76

Correlation coefficient −0.052

Body Perception Scale total p-value 0.653

N 76

Correlation coefficient 0.152

Conscious Awareness Scale total p-value 0.190

N 76

TABLE 3: Evaluation of the relationship between scale scores of the orthorexia group

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 The distribution of the relationship between orthorexia total scores and other scale total scores for
individuals diagnosed with orthorexia is given in Table 4. When the table was examined, it was seen that
there was a weak inverse relationship between the orthorexia scale score and only the health anxiety
inventory total score (p<0.05).

Total (N=142) Orthorexia (n=76) Control (n=66)

p-value
n (%) or Median (Min-Max) n (%) or Median (Min-Max) n (%) or Median (Min-Max)

Gender 0.101

Woman 75 (52.8) 45 (59.2) 30 (45.5)

Male 67 (47.2) 31 (40.8) 36 (54.5)

Age, year 22 (18–31) 21 (18–31) 23 (20–27) <0.001

Class <0.001

1st grade 22 (15.5) 22 (28.9) 0 (0)

2nd grade 10 (7) 10 (13.2) 0 (0)

3rd grade 45 (31.7) 12 (15.8) 33 (50)

4th grade 9 (6.3) 9 (11.8) 0 (0)

5th grade 52 (36.6) 19 (25) 33 (50)

6th grade 4 (2.8) 4 (5.3) 0 (0)

Height, cm 170 (153–190) 170 (153–188) 171 (155–190) 0.450

Kilo, kg 65 (40–145) 62.5 (49–105) 65 (40–145) 0.443

BMI, kg/cm2 22.4 (16.2–42.8) 22.4 (17.5–33.2) 22.1 (16.2–42.8) 0.867

The weight you want to be 60 (43–100) 60 (48–90) 67 (43–100) 0.351

Place of residence 0.151

Bay 4 (2.8) 4 (5.3) 0 (0)

District 21 (14.8) 10 (13.2) 11 (16.7)

Province 117 (82.4) 62 (81.6) 55 (83.3)

Lives with 0.002

With my family 32 (22.5) 17 (22.4) 15 (22.7)

With my roommate 18 (12.7) 9 (11.8) 9 (13.6)

Home alone 56 (39.4) 21 (27.6) 35 (53)

In the state dormitory 15 (10.6) 12 (15.8) 3 (4.5)

In private dormitory 21 (14.8) 17 (22.4) 4 (6.1)

Mental disorders in the family 22 (15.5) 13 (17.1) 9 (13.6) 0.736

Smoking 21 (14.8) 7 (9.2) 14 (21.2) 0.076

Alcohol use 36 (25.5) 17 (22.7) 19 (28.8) 0.523

Mother education level 0.628

Illiterate 4 (2.8) 3 (3.9) 1 (1.5)

Literate​/primary school 46 (32.4) 27 (35.5) 19 (28.8)

Middle school-high school 49 (34.5) 24 (31.6) 25 (37.9)

College 43 (30.3) 22 (28.9) 21 (31.8)

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 Father's education level 0.710

Illiterate 1 (0.7) 1 (1.3) 0 (0)

Literate​/primary school 24 (16.9) 13 (17.1) 11 (16.7)

Middle school-high school 45 (31.7) 22 (28.9) 23 (34.8)

College 72 (50.7) 40 (52.6) 32 (48.5)

Any disease diagnosed by a doctor 24 (16.9) 16 (21.1) 8 (12.1) 0.233

Regular drug therapy 23 (16.2) 15 (19.7) 8 (12.1) 0.317

Regular dietary therapy 5 (3.5) 4 (5.3) 1 (1.5) 0.372

Vitamin support 0.306

Yes 17 (12) 12 (15.8) 5 (7.6)

Sometimes 51 (35.9) 27 (35.5) 24 (36.4)

Regular sport 55 (38.7) 33 (43.4) 22 (33.3) 0.218

TABLE 4: Distribution of participants' demographic findings

The correlation coefficient could be elaborated as being weak about being between 0.00 and 0.29, low about
being between 0.30 and 0.49, medium about being between 0.50 and 0.69, strong about being between 0.70
and 0.89, and very strong about being between 0.90 and 1.00.

Discussion
According to the results of our study, orthorexia was affected by the total scores of the eating disorder scale,
body image scale, and awareness scale in univariate analysis. Each increase in the eating disorder scale score
increased the diagnosis of orthorexia 1.07 times, while each increase in the body image scale score increased
the diagnosis of orthorexia 1.09 times. Additionally, each increase in the conscious awareness scale score
decreased the diagnosis of orthorexia by 0.92 times. When all variables were re-evaluated in the multivariate
analysis, it was seen that the total scores of the body image scale and conscious awareness scale affected the
diagnosis of orthorexia. There was a weak inverse relationship between the orthorexia scale score and only
the health anxiety inventory total score (p<0.05).

A healthy lifestyle and diet, which are one of the foundations of health attributes, can become an unhealthy,
life-threatening situation after a while. ON negatively affects the physical health of the person as well as
their interpersonal relationships, stress management, and mental health. The etiology, epidemiology, and
treatment approaches of this disorder are not fully known because studies on ON are not yet sufficient.

Zamora et al. stated that the obsessive-compulsive mechanisms and personality traits of patients with ON
were similar to those of patients with the restrictive anorexia nervosa type [11]. Arusoğlu et al. found that
deterioration in eating attitudes and obsessive-compulsive symptoms were associated with orthorexic
tendencies [12]. Women, adolescents, individuals doing sports, medical students, healthcare professionals,
and dietitians are considered to be the main risk groups for orthorexia nervosa [13]. Some researchers
suggest that health anxiety is related to orthorexia [14].

Considering the relationship between orthorexia nervosa and body image, it was found that preoccupations
with body appearance and anxiety about being overweight triggered orthorexia nervosa. It has been
suggested that excessive focus on appearance and fear of being overweight may be the hidden motivation
behind healthy diet preoccupation [15].

It is controversial whether orthorexia should be interpreted as a separate disorder or as a subset of

obsessive-compulsive disorder or anorexia nervosa. Among the common features of orthorexia and anorexia
nervosa, significant weight loss, increased anxiety, perfectionism, and an effort to keep control can be
counted. While anorexia nervosa and bulimia nervosa elaborate eating disorders in a quantitative context
(e.g., the amount of food consumed), orthorexia nervosa is seen in a qualitative context (the quality of food
consumed) [2]. In our study, each increase in the eating disorder scale score increased the diagnosis of
orthorexia 1.07 times, while each increase in the body image scale score increased the diagnosis of
orthorexia 1.09 times. It was observed that each increase in the conscious awareness scale score decreased
the diagnosis of orthorexia by 0.92 times.

In the association of orthorexia nervosa with obsessive-compulsive disorder, some obsessive tendencies are

2023 Dolapoglu et al. Cureus 15(5): e38451. DOI 10.7759/cureus.38451 6 of 8

 also observed in individuals. In addition, these individuals show intense anxiety about contamination,
ritualized eating and arranging food, and recurrent intrusive thoughts about food and health. The most
important difference between orthorexia and obsessive-compulsive disorder is that the content of the
obsessions in orthorexia is not alien to the ego but compatible with the ego. Some diagnostic criteria have
also been developed for ON previously [16,17]. In our study, we found a significant difference between the
two groups in the total score of eating disorders and the sub-dimensions of dieting and bulimic behaviors
like frequent binges, fear of losing control, extreme weight-control measures, and overt concern about body
weight.

Inconsistent results emerge when investigating sex differences in orthorexia nervosa. This may be due to the
differences in sampling and data collection tools. In addition, Oberle et al. mention the difficulty of
detecting gender differences due to the lack of experience working with clinically diagnosed individuals, as
ON is not yet included in the DSM-5 [18].

In some studies conducted in our country and around the world, it has been found that women may have
more orthorexic tendencies than men. Donini et al. stated that the orthorexic tendency was higher in males.
In addition to the different findings in the literature about ON, there are contradicting results in some
studies on whether there is a significant relationship between gender and ON [6].

Barnes and Caltabiano found that high scores obtained from the body image scale were predictors of ON [15].
In addition, Barthels et al. emphasized that individuals prone to orthorexia have very rigid thoughts not only
about healthy eating but also about a healthy body image [19]. Similarly, in our study, there was a
statistically significant difference between the two groups in the body image scale and awareness scale
scores, while the body image scale score in the orthorexia group and the awareness scale score in the control
group were found to be higher.

A positive relationship was also found between orthorexia and health anxiety. This means that as orthorexic
tendencies increase, health-related anxiety and worry also increase. It can be concluded that as the concern
about healthy, pure food and consuming it increases, the concerns about health also increase. Toth-Kiraly et
al. reached a similar conclusion in their study. According to this study, the more people worry about their
health and bodily functions, the more they focus on a strict diet and strict physical activity [20]. To the best
of our knowledge, this is the only study that evaluates many parameters together, such as eating attitudes,
body perception, obsessive-compulsive symptoms, health anxiety, and consciousness awareness.

Conclusions
Orthorexia nervosa involves obsessive thoughts about healthy eating and distress related to this obsession.
There is still dispute over whether ON should be considered on the obsessive-compulsive spectrum, the
eating disorder spectrum, or as its own disorder. Regarding the outcomes of this research, one can say that
the orthorexia-affected eating disorder scale, body image scale, and awareness scale total scores. While the
increase in the eating disorder and body image scale scores increased orthorexia, it was seen that the
increase in the conscious awareness scale score had a decreasing effect.

Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Balikesir University
Clinical Research Ethics Committee issued approval 2022/27. The study has been approved on February 23,
2022, by the ethics committee with protocol number 2022/27. Animal subjects: All authors have confirmed
that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the
ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have
declared that no financial support was received from any organization for the submitted work. Financial
relationships: All authors have declared that they have no financial relationships at present or within the
previous three years with any organizations that might have an interest in the submitted work. Other
relationships: All authors have declared that there are no other relationships or activities that could appear
to have influenced the submitted work.

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2023 Dolapoglu et al. Cureus 15(5): e38451. DOI 10.7759/cureus.38451 8 of 8