Is there an association of prenatal exposure to benzodiazepines or benzodiazepine-like hypnotics with immediate birth outcomes?This cohort study including 82 038 pregnancies found that benzodiazepine or benzodiazepine-like hypnotic use during pregnancy was associated with a mean decrease in birth weight of 79 g, a mean decrease in gestational age of 2.1 days, and a 1.41-fold higher risk of preterm birth.While the magnitudes of these findings are not of obvious clinical relevance, benzodiazepines and benzodiazepine-like hypnotic should only be used in pregnancy after a thorough evaluation of the benefits and risks for the mother and child. This cohort study examines the association of benzodiazepine or benzodiazepine-like hypnotic (z-hypnotics) exposure with immediate birth outcomes among pregnant women in Norway. Understanding the safety profile of medications used in pregnancy is crucial for clinical decision-making. Few studies exist on the associations of exposure to benzodiazepines and benzodiazepine-like hypnotic drugs (z-hypnotics) in pregnancy with pregnancy outcomes.To determine whether exposure to benzodiazepines or z-hypnotics in pregnancy is associated with greater risk of negative immediate pregnancy outcomes compared with nonexposure.This questionnaire-based cohort study used data from the Norwegian Mother, Father and Child cohort study (MoBa), which also includes data from the Medical Birth Registry of Norway. Pregnant women were recruited from all over Norway from 1999 and 2008. The first child was born in October 1999 and the last in July 2009. This analysis included women who completed 3 questionnaires, twice during pregnancy and once 6 months after delivery. Data analyses were conducted from September to November 2019.Self-reported exposure to benzodiazepines or z-hypnotics during pregnancy, characterized in terms of any exposure, timing , and duration of exposure.The main outcomes were gestational age at delivery, risk of preterm delivery, birth weight, birth weight relative to gestational age and sex, risk of being small for gestational age, head circumference, Apgar score less than 7 at 5 minutes, and risk of neonatal respiratory distress. Continuous outcomes are reported using effect estimates as mean differences, and binary outcomes are reported using risk ratios.z score), or any of the other immediate birth outcomes.The MoBa study included 114 234 mother-child dyads. This analysis of MoBa data includes 82 038 singleton pregnancies among 69 434 unique women. Mean (SD) maternal age was 30.2 (4.5) years, and 37 641 pregnancies (45.9%) were in primiparous women. Exposure to benzodiazepines or z-hypnotics was reported in 679 pregnancies (0.8%). After adjusting for all measured baseline and postbaseline confounders, benzodiazepine or z-hypnotic use during pregnancy was associated with lower birth weight , lower gestational age at birth , and higher risk of preterm birth . We found no significant association of exposure to benzodiazepines or z-hypnotics with the child’s birth weight relative to gestational age and sex (z score for birth weight relative to gestational age and sex suggests that association of exposure to benzodiazepines or z-hypnotics with birth weight could be explained by earlier delivery rather than impaired intrauterine growth.These findings suggest that the magnitude of the association of exposure to benzodiazepines or z-hypnotics with gestational age is not necessarily clinically significant. The absence of an association of exposure to benzodiazepines or z-hypnotics with  However, these medications have been associated with increased risk of preterm birth, low Apgar score, neonatal intensive care unit admission, and respiratory distress syndrome in the infant.12 Currently, recommendations for use of benzodiazepines in pregnancy are similar to those for women who are not pregnant, meaning that short-term use can be considered for women with severe anxiety disorders or sleep disturbance after an individual risk-benefit evaluation.13When used during pregnancy, these medications cross the placental and blood-brain barrier, where they can bind to γ-amino butyric acid receptors in the developing fetal central nervous system, potentially affecting fetal growth and development.14 to examine the association of prenatal exposure to benzodiazepines and z-hypnotics with immediate birth outcomes, including birth weight, gestational age at delivery, z score for weight relative to gestational age and sex, head circumference, Apgar score less than 7 at 5 minutes, risk of preterm delivery, and risk of neonatal respiratory distress. While benzodiazepines and z-hypnotics are not first-line treatment for either anxiety or insomnia, determining the outcomes associated with use in pregnancy may be useful for counseling women who enter pregnancy with dependence or who require treatment for clinically significant reasons when other interventions are not working alone.We used data from a large population-based cohort study linked with data from a medical birth registrySTROBE) reporting guideline.This study was approved by the Regional Committees for Medical and Health Research Ethics, Region South East, Norway. All participants provided written informed consent. Our findings are reported according to the Strengthening the Reporting of Observational Studies in Epidemiology .14 Pregnant women were recruited from all over Norway from 1999 and 2008. The first child was born in October 1999 and the last in July 2009. The women consented to participation in 40.6% of the pregnancies. The cohort now includes 114 500 children, 95 200 mothers, and 75 200 fathers. This study is based on version 9 of the quality-assured data files released for research in 2016. The MBRN is based on mandatory notification of all births or abortions occurring at 12 weeks of gestation or later. It is a nationwide registry that prospectively has collected information on pregnancy, delivery, and the health of the neonate on all births in Norway since 1967.15 Follow-up of MoBa participants is conducted by questionnaires at regular intervals and is ongoing. The first MoBa questionnaire 1 (Q1) is completed during week 17 of pregnancy, questionnaire 3 (Q3) is completed during week 30, and questionnaire 4 (Q4) is completed 6 months after birth. Questionnaire 2 is a food frequency questionnaire developed to measure the mother’s diet in pregnancy and completed around week 22 of pregnancy. It was not included in this study.This study is based on the Norwegian Mother, Father and Child cohort study (MoBa), a prospective population-based pregnancy cohort study conducted by the Norwegian Institute of Public Health,The establishment of MoBa and initial data collection was based on a license from the Norwegian Data protection agency and approval from the Regional Committee for Medical Research Ethics. The MoBa cohort is currently regulated by the Norwegian Health Registry Act. All mothers and fathers gave informed consent for their questionnaires to be linked with registry data and used for research purposes at the time they enrolled in MoBa.Of 114 234 pregnancies with records in MoBa and MBRN, 82 038 were included in our primary analyses. Inclusion and exclusion criteria are presented in the Benzodiazepines included drugs within the Anatomical Therapeutic Chemical Classification System code N05BA , N05CD , and N03AE01 . Z-hypnotics included zopiclone and zolpidem . Owing to similar mechanisms of actions, benzodiazepines and z-hypnotics were studied as 1 group and separate classes.Data on self-reported use of benzodiazepines or z-hypnotics was retrieved from MoBa questionnaires Q1, Q3, and Q4. In the MoBa questionnaires Q1 and Q3, women were asked a range of disease-oriented questions, including whether they have had depression or anxiety or other mental disorders before and/or during pregnancy or sleeping problems during early pregnancy (Q1 only). For each condition, mothers provide information on whether medications were used in 4-week intervals during pregnancy . In the analysis that assessed overall associations of the medications, we classified exposure in terms of whether use of any of these medications was reported in any interval during pregnancy. To examine the relevance of timing, we further categorized exposure according to whether medication use was reported in early pregnancy , midpregnancy , or late pregnancy . These categories correspond roughly to the MoBa questionnaires on which the relevant items were included but with some overlap, as items for weeks 13 to 16 were included on Q1 and Q3. To explore possible cumulative dose-response association, we classified exposure according to the number of 4-week intervals during which use was reported . In secondary analyses, we restricted the exposure definition to benzodiazepines , to benzodiazepine-anxiolytics only , or to z-hypnotics only .z score), head circumference (centimeters), Apgar score at 5 minutes, and respiratory distress. These variables are recorded in electronic medical records by midwives at birth and sent to the MBRN. Gestational age at delivery was estimated based on second trimester ultrasonographic results. Information on last menstrual period was used if an ultrasonographic investigation had not been conducted. For analyses of binary outcomes, preterm birth was defined as delivery at less than 37 completed weeks of pregnancy, low Apgar score was defined as score less than 7 at 5 minutes, and small for gestational age was defined as z score less than −1.28, which corresponds to the tenth percentile in weight relative to gestational age and sex. All outcomes were prespecified.Outcome data was retrieved from MBRN, including gestational age (days), birth weight (grams), birth weight relative to gestational age and sex  criteria for lifetime major depression.18Confounders were selected in accordance with the modified disjunctive cause criterion.19 at gestational week 17 and at week 30, and standardized z scores were computed at each time point.Time-varying covariates, all from MoBa, included maternal symptoms of depression and anxiety during pregnancy, comedication use during pregnancy , and fever during pregnancy. Maternal symptoms of depression and anxiety during pregnancy were assessed with a validated short version of the Hopkins Symptom Checklist21 The full procedure for handling missing data relied on an assumption that the data were missing at random and is described in eAppendix 1 in the We accounted for missing data using a combination of multiple imputation and inverse probability of censoring weights.P values were 2-sided, and statistical significance was set at .05. We described the distribution of baseline characteristics and the absolute risks and distributions of outcomes in women exposed and unexposed to benzodiazepines or z-hypnotics in pregnancy. For every outcome, we conducted all analyses separately for all 3 definitions of the exposure . We conducted a crude analysis to obtain unadjusted estimates with 95% CIs. In the first adjusted analysis, we controlled only for baseline covariates using standard multivariable regression models. In the second adjusted analysis, we additionally accounted for time-varying covariates using stabilized inverse probability of treatment weights.23 Linear outcome models were used for continuous outcomes, and log-binomial models were used for binary outcomes. No interaction terms were included in the models. In adjusted analyses, we used sandwich variance estimators that are robust to clustering.24 Estimation of the inverse probability of treatment weights and the details of the outcome model are described in eAppendix 2 in the We used R statistical software version 3.4.4  for all statistical analysis. We also conducted all analyses in the disease sample. In the benzodiazepine sample, we conducted a simplified analysis comparing only women who reported any use of benzodiazepines or z-hypnotics in pregnancy vs women who reported no use in pregnancy. To check for effect modification, we conducted analyses stratified on the sex of the offspring. To explore the robustness of our findings to between-unit clustering, we further conducted analyses in a data set that was restricted to women who participated in MoBa for the first time. We also conducted analyses in which the exposure definition was limited to benzodiazepines, to benzodiazepine anxiolytics only, and to z-hypnotics. Data analyses were conducted from September to November 2019.The study population included 82 038 singleton pregnancies in women who completed all 3 MoBa study questionnaires. The mean (SD) maternal age was 30.2 (4.5) years, 37 641 women (45.9%) were primiparous, and 41 987 infants (51.2%) were boys. Missing data for 82 038 women who completed all questionnaires included prepregnancy body mass index (1992 women [2.4%]), maternal education (345 women ), alcohol intake (6739 women [8.2%]), income (2614 women [3.2%]), planned pregnancy (119 women [0.1%]), lifetime history of major depression (2012 women [2.5%]), and depressive or anxiety symptoms during pregnancy .Among 82 038 women, 679 were exposed to benzodiazepines or z-hypnotics during pregnancy. Women who were exposed to benzodiazepines or z-hypnotics compared with women who were not exposed were older , less likely to be married or cohabiting (614 women [90.4%] vs 78 483 women [96.5%]), more likely to be primiparous (356 women [52.4%] vs 37 285 women [45.8%]), more likely to smoke (112 women [16.5%] vs 6061 women [7.4%]), more likely to report low or moderate alcohol intake during pregnancy (28 women [4.1%] vs 2050 women [2.5%]), more likely to report illicit drug use (33 women [4.9%] vs 468 women [0.6%]), less likely to have a planned pregnancy (189 women [27.8%] vs 66 691 women [82.0%]), more likely to have depression (211 women [31.1%] vs 5328 women [6.5%]), and more likely to have had at least 1 painful or very painful adverse life event (387 women [57.0%] vs 28 377 women [34.9%]). An overview of the distribution of baseline covariates in the exposed and in the unexposed groups is shown as All unadjusted and adjusted estimates are shown in z scores)  or the binary variable small for gestational age .The mean (SD) birth weight in children with benzodiazepine or z-hypnotic exposure was 3506 (592) g compared with 3613 (538) g in children without exposure. The crude absolute risk of being small for gestational age was 6.6% in the exposed group and in 5.0% in the unexposed group. The fully adjusted estimate suggests that exposure to benzodiazepines or z-hypnotics was associated with lower birth weight . This strongest association was found in midpregnancy  and late pregnancy  rather than early pregnancy . The adjusted analysis found no significant evidence of an association with birth weight relative to gestational age and sex . Additionally, there was no statistically significant difference in Apgar score less than 7 at 5 minutes  or risk of respiratory distress .eTable 1 and eTable 2 in the In the analysis that restricted the exposure definition to benzodiazepines, to z-hypnotics, or to benzodiazepine-anxiolytics only (eTable 5 in the z score) or any other immediate birth outcome.This cohort study found that among children born to mothers participating in the MoBa cohort study, exposure to benzodiazepines or z-hypnotics during pregnancy was associated with slightly lower gestational age at delivery, slightly lower birth weight, and a slightly to moderately higher risk of preterm delivery. The timing analysis suggests that these results were primarily driven by exposure in the second and third trimester. We found no association with the child’s birth weight relative to gestational age and sex (One plausible interpretation of this pattern may be that benzodiazepine or z-hypnotic exposure (particularly late in pregnancy) results in earlier birth, and that this explains the lower birth weight in infants who were exposed to benzodiazepines or z-hypnotics in utero. In other words, the results are consistent with a hypothesis that these medications are not associated with impaired intrauterine grown but are associated with birth weight, primarily due to an association with pregnancy duration.11 that reported a nearly 50% increase in the odds of preterm delivery after use of benzodiazepines in early pregnancy, and a more than 150% increase in odds after use in late pregnancy. This association is much weaker than that reported by Calderon-Margalit et al,12 who reported a nearly 7-fold increase in odds of preterm delivery after use of benzodiazepines at any time during pregnancy. Earlier studies by Ornoy et al10 and Ogawa et al9 have not reported any adverse associations with birth weight.Our results for the association of benzodiazepines or z-hypnotics exposure with preterm delivery are consistent with a study by Wikner and colleaguesIn-utero exposure to benzodiazepines or z-hypnotics was much less common in our study than what has been observed in other countries but relatively similar to what has been observed in prescription databases in Norway. Norwegian prescription practices and cultural factors may explain the differences in use.25 to the causal hypothesis as one possible explanation for the findings to discuss those limitations of our study that relate specifically to the question of causality.This study has some limitations. Observational studies are, by their nature, limited in their ability to establish causation with certainty. Consequently, our results are not necessarily reflective of a causal relationship. However, in the following discussion, it will be necessary to occasionally refer explicitly26 In this context, it may be worth noting that the association was primarily seen in the second and third trimester. If symptoms of anxiety do not vary significantly during the course of pregnancy, and if the findings were explained by confounding by unmeasured aspects of anxiety, one would expect to see just as strong an association in the first trimester.Residual confounding cannot be fully ruled out as an explanation for these findings. While we controlled for a binary covariate for baseline anxiety and a time-dependent Hopkins Symptoms Checklist that includes a component for anxiety during pregnancy, these constructs may not be able to fully capture and control the confounding effects of anxiety, which is the primary indication for benzodiazepines and z-hypnotics and which is also known to reduce gestational duration.When the analysis is restricted to the benzodiazepine sample, which included only women who used benzodiazepines or z-hypnotics before pregnancy, the data no longer provide any clear indication of an association with continued use. The benzodiazepine sample was subject to less confounding by indication than the full study sample . Therefore, it is not entirely implausible that the attenuated results from the benzodiazepine sample represent a more accurate estimate of the true association. However, the benzodiazepine sample was very small and potentially underpowered, which could prevent detection of a true association.While we hypothesize that the estimated association of benzodiazepines or z-hypnotics with birth weight was primarily driven by the effect of exposure on gestational duration, we were not able to test this hypothesis formally in a mediation analysis. Such an analysis was not planned or prespecified and would also have been challenging given potential for strong confounding of the mediator-outcome association. If mediator-outcome confounding can be addressed adequately, such mediation analysis may be a target for future work.The analysis for cumulative duration of exposure did not show evidence of a dose-response trend. However, this type of analysis may not capture the true dose-response association, as we only had access to data on number of exposure intervals during which use of medications were reported. The cumulative exposure within each exposure window may differ substantially between women.27 The self-selected participants in MoBa have been shown to differ from women in MBRN who did not enroll in MoBa in terms of several baseline characteristics, including age and social status. While this may be a threat to generalizability and external validity, earlier analysis using data from MBRN has shown that for several exposures and for several immediate birth outcomes, the measures of association did not differ between women enrolled in MoBa and women not enrolled in MoBa.28Our study is based on self-reported exposure; therefore, underreporting of medication use is a potential limitation. However, self-reported exposure in MoBa has been shown to correlate well with drug prescription data.This cohort study found that children born to mothers who were exposed to benzodiazepines or z-hypnotics in pregnancy had slightly lower birth weight, were born at approximately 2 days younger gestational age, and had slightly higher to moderately higher risk of preterm birth compared with children without exposure. These patterns were only slightly attenuated when controlling for baseline and time-dependent covariates and were primarily associated with exposure in middle and late pregnancy. The lower birth weight in children exposed to benzodiazepines or z-hypnotics was not necessarily due to impaired intrauterine growth and could potentially be explained by earlier delivery. While the magnitudes of the associations were not necessarily clinically significant, benzodiazepines and z-hypnotics are not first-line treatment for either anxiety or insomnia and should only be used in pregnancy after a thorough evaluation of the benefits and risks for the mother and child.


This cross-sectional research aims to study the effect of yoga practice on the illness perception, and wellbeing of healthy adults during 4–10 weeks of lockdown due to COVID19 outbreak. A total of 668 adults  participated in the online survey. The participants were grouped as; yoga practitioners, other spiritual practitioners, and non-practitioners based on their responses to daily practices that they follow. Yoga practitioners were further examined based on the duration of practice as; long-term, mid-term and beginners. Multivariate analysis indicates that yoga practitioners had significantly lower depression, anxiety, & stress (DASS), and higher general wellbeing (SWGB) as well as higher peace of mind (POMS) than the other two groups. The results further revealed that the yoga practitioners significantly differed in the perception of personal control, illness concern and emotional impact of COVID19. However, there was no significant difference found for the measure of resilience (BRS) in this study. Yoga practitioners also significantly differed in the cognitive reappraisal strategy for regulating their emotions than the other two groups. Interestingly, it was found that beginners -those who had started practicing yoga only during the lockdown period reported no significant difference for general wellbeing and peace of mind when compared to the mid- term practitioner. Evidence supports that yoga was found as an effective self- management strategy to cope with stress, anxiety and depression, and maintain wellbeing during COVID19 lockdown. A report by the World Economic Forum estimates that about 2.6 billion people around the world have been in some kind of lockdown that may lead to second form of stress-related disorder epidemic in the second half of 2020 . SimilarVarious factors have been suggested to be contributing to the worsening of mental health. One of the major factors reported causing stress, anxiety and depression is fear of getting infected with the virus/disease COVID19) . Previou . PrevioEven though there are some studies supporting that yoga can be used as complementary and alternate therapy for mental health, there is need for empirical research studies to provide evidence for yoga as effective strategy for self-management of stress-related problems during COVID19. Further, to the best of our knowledge the empirical investigation for the effects of yoga and other spiritual practices on illness perception and wellbeing related problems experienced by people during COVID19 has not been examined so far. The present research uses a cross-sectional study design to examine the effect of the practice of yoga and other spiritual practices on illness perception, and wellbeing of adults. In this study, wellbeing has been assessed through measures of depression, stress, anxiety, resilience, peace of mind and the strategies employed to regulate the emotional upheavals. This approach has been reported in earlier studies that have examined wellbeing in terms of anxiety, stress, and depression –13, emot‘Chitta vritti nirodha’ literally translating as controlling or calming of the mind. Most commonly, a typical yoga schedule follows a combination of asanas (postures), pranayama (breath control), pratyahara , Dharana (concentration), dhyana (meditation) and Samadhi (absorption). While asanas are reported to help in improving the physical strength and flexibility, it is argued to also help in building concentration Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Comments to Authors:Ref: PONE-D-20-30379The article entitled ‘Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study’ by Sahni et al., is an interesting study on the impact of yoga practices on the psychological management of youths in a pandemic related broader societal lockdown that minimizes social interaction. By nature, humans are social animals and have evolved various social institutions to satisfy their psychological well being and thereby overall mental health of its individual members. The lockdown like condition goes against this concept and isolate the individuals, albeit in many cases with their families, in solitary habitation leading to severe mental stress and venting avenues. Thus, in this background, the present manuscript dwells on a pertinent subject.The introduction is lengthy and can be drastically shortened to remain focused on the problem being studied and the relevant literature in the field. It should be curtailed by half the size (from 4 pages to 2 pages). The 2nd page and half of the third page (line 64 to 94) of the introduction can be removed, and the remaining text may be realigned by moving the line 120 to 125 right after line 63 to maintain the flow.Abstract says 64.8 % males, while methods says 64.7%. Although the difference is miniscule, the accuracy of data presentation is compromised.In assessing Brief Illness Perception did authors have options of neutrality in the Questionnaire. E.g. in 179-182, ‘The emotional representation of COVID19 was assessed by 2 items incorporating negative reactions such as fear, anger, and distress .’ did the participants have option ‘it did not affect them emotionally?’. Because many participants may not have been affected or felt the given emotion, but would have to choose one of the provided stress response!At places the references are cited as number in big parentheses [2], at other cited as authors names followed by Year in small parentheses . It should be corrected. At yet other the cited authors have not been given numbers e.g. Gross and John (2003).Once multivariate analysis of variance (MANOVA) has been abbreviated, MANOVA should be subsequently used.In the results section data presentation is apt. However, if some of the data could be presented in the chart form that would make it more comprehensible for the readers.In the discussion section, analysis was lacking in some part. E.g. sentences like ‘..demonstrate that females reported higher illness concern and were emotionally more impacted than males by the COVID19 lockdown’ could be substantiated with analysis of the likely causes of more emotional impact. Was the trend same for rural vs urban, young vs old, working vs housewife? And how much did Yoga contributed to cope up with this?Can the authors comment on whether the forced practice vs voluntary practice having positive effects especially in youths and did the author have data on how many of the practitioners started the yoga voluntarily and how many forced to do by others in the family.Was the participant being in a family a factor in overall wellbeing vs. a person residing alone during the lockdown?The manuscript is written well but at some places the excessive use of ‘the’ and other minor errors in sentence formation can be edited carefully.Reviewer #2: In the present study Sahni et al have analyzed the results of cross-sectional study of yoga practice as an effective strategy for self-management of stress-related problems and well-being. Many statistical methods have been used to present the results pertaining to illness perception, and wellbeing of healthy adults across age, gender, place of work and residence.The study and study timeline of 4-10 weeks of lockdown due to COVID19 outbreak is appropriate and timely. However, explanation is required in the manuscript to support the statistical analysis especially with respect to:1.) Daily practice of Yoga with respect to frequency and duration specifically how many days a week and how long  for all three groups2.) Higher stress among female during COVID19 lockdown as compared to men**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  1 Dec 2020The authors thank the editors and reviewers for recognizing the relevance of the study in the current pandemic times and for their encouraging words. The authors also appreciate the efforts of the reviewers and editors for thorough review of the manuscript which is evident from the valuable and constructive feedback that is provided for enriching the manuscript.Please find below the pointwise response to the reviewers comments:The article entitled ‘Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study’ by Sahni et al., is an interesting study on the impact of yoga practices on the psychological management of youths in a pandemic related broader societal lockdown that minimizes social interaction. The authors thank the editors and reviewers for recognizing the relevance of the study in the current pandemic times and for their encouraging words. response: The authors also appreciate the efforts of the reviewers and editors for thorough review of the manuscript which is evident from the valuable and constructive feedback that is provided for enriching the manuscript. By nature, humans are social animals and have evolved various social institutions to satisfy their psychological well being and thereby overall mental health of its individual members. The lockdown like condition goes against this concept and isolate the individuals, albeit in many cases with their families, in solitary habitation leading to severe mental stress and venting avenues. Thus, in this background, the present manuscript dwells on a pertinent subject. The authors completely agrees that the disruptions of the social interactions may be argued to have a detrimental effect on psychological wellbeing. Further the change in social situation posed by pandemic may have led to severe mental stress in many individuals.1) The introduction is lengthy and can be drastically shortened to remain focused on the problem being studied and the relevant literature in the field. It should be curtailed by half the size (from 4 pages to 2 pages). The introduction has been reduced after incorporating the changes as suggested in point no. 2.2) The 2nd page and half of the third page (line 64 to 94) of the introduction can be removed, and the remaining text may be realigned by moving the line 120 to 125 right after line 63 to maintain the flow. Thanks for the valuable suggestion. The changes as recommended have been made to the revised manuscript.3) Abstract says 64.8 % males, while methods says 64.7%. Although the difference is miniscule, the accuracy of data presentation is compromised. The correction has been made in the revised manuscript.4) In assessing Brief Illness Perception did authors have options of neutrality in the Questionnaire. E.g. in 179-182, ‘The emotional representation of COVID19 was assessed by 2 items incorporating negative reactions such as fear, anger, and distress .’ did the participants have option ‘it did not affect them emotionally?’. Because many participants may not have been affected or felt the given emotion, but would have to choose one of the provided stress response! The participants were asked to respond to the question,’ How much does thinking about this illness affect you emotionally? e.g. does it make you angry, scared, upset or depressed?’ on the scale presented as linear scale as, ‘ 0  to 10 ’. The participants had the option to choose ‘0’ which meant that ‘it did not affect them emotionally’.5) At places the references are cited as number in big parentheses [2], at other cited as authors names followed by Year in small parentheses . It should be corrected. The citations have been made as numbers in the big parentheses in the revised manuscript as per the PLOS ONE guidelines for referencing.6) At yet other the cited authors have not been given numbers e.g. Gross and John (2003). The corrections in the citations have been made in the revised manuscript.7) Once multivariate analysis of variance (MANOVA) has been abbreviated, MANOVA should be subsequently used. Multivariate analysis of variance has been abbreviated as MANOVA in all subsequent use in the revised manuscript.8) In the results section data presentation is apt. However, if some of the data could be presented in the chart form that would make it more comprehensible for the readers. The authors had a deep discussion on this proposed form of data representation. The figures 1-6 and table 3 and table 5 provides a quick glimpse of the key outcomes of the study. However, it was felt that many layers of the analysis as described in the manuscript would be compromised if the data representation were to be further reduced. 9) In the discussion section, analysis was lacking in some part. E.g. sentences like ‘..demonstrate that females reported higher illness concern and were emotionally more impacted than males by the COVID19 lockdown’ could be substantiated with analysis of the likely causes of more emotional impact. In the present study the likely causes of stress were analyzed through an additional item on the three most important causal factors (in rank order) of stress during lockdown (‘Please list in rank-order the THREE most important factors that you believe are reasons for stress due to lockdown’). The responses were analyzed through a percentage analysis of the most frequently reported reasons for stress. Additionally, in the revised manuscript (line 387-390) we have also included the gender wise analysis of the reported reasons for stress. The authors also feel that a gender specific study could be undertaken in future to further substantiate the causes of emotional impact due to COVID 19 lockdown.10) Was the trend same for rural vs urban, young vs old, working vs housewife? And how much did Yoga contributed to cope up with this? Yes, the trend for place of residence, age and working status was analyzed, as described in section; Results>demographic Variables. MANOVA results indicated no statistically significant main effect of working status and qualification on the COVID19 perception, wellbeing measures  or emotion regulation strategies (ERQ). There was a significant effect of place of residence on illness consequence of COVID19 F  =5.61, p<0.05, partial eta squared=-.01, with urban participants reporting higher concern for consequences of COVID19  than semi-urban  or rural . Age had a significant effect on depression (DASS-D) F  = 9.34, p<0.005, partial eta squared=-.01 and Peace of Mind (POMS) F  =13.02, p<0.001, partial eta squared=-.02, with participants from age group 18-25 years reporting higher depression (DASS-D) than age group 26-35 years , age group 36-45 years  and age group 46 and above .11) Can the authors comment on whether the forced practice vs voluntary practice having positive effects especially in youths and did the author have data on how many of the practitioners started the yoga voluntarily and how many forced to do by others in the family. The study of forced practice vs voluntary practice is an interesting research question, especially for youth. However, this study did not collect data on whether the respondents practiced yoga of their own will or were forced as a part or compulsory course or family/peer pressure. This stimulating research question that can be addressed by a future research.12) Was the participant being in a family a factor in overall wellbeing vs. a person residing alone during the lockdown? The authors agree that stress during lockdown would differ for a person staying alone and in a family setup. The stress due to being alone or in a family setup was not one of the factors taken in to account. The focus of the study was to understand the effects of yoga practice on stress during lockdown. The authors also feel that the study of wellbeing due to living alone or in a family is a very relevant and important research that should be taken up in future. 13) The manuscript is written well but at some places the excessive use of ‘the’ and other minor errors in sentence formation can be edited carefully. The revised manuscript has again been reviewed carefully to omit any minor errors. Reviewer #2: In the present study Sahni et al have analyzed the results of cross-sectional study of yoga practice as an effective strategy for self-management of stress-related problems and well-being. Many statistical methods have been used to present the results pertaining to illness perception, and wellbeing of healthy adults across age, gender, place of work and residence. The study and study timeline of 4-10 weeks of lockdown due to COVID19 outbreak is appropriate and timely. The authors are thankful to the reviewers to have recognized the in depth statistical analysis conducted for the study.The authors are also grateful to the editor and reviewers for acknowledging the relevance of the manuscript for the current pandemic situation. 15) However, explanation is required in the manuscript to support the statistical analysis especially with respect to:Daily practice of Yoga with respect to frequency and duration specifically how many days a week and how long  for all three groups In the study sample, 59.6% (n=384) reported that they practice yoga and were categorized as yoga practitioners. Further, among the yoga practitioners, 35% (n=134) were beginners (those who had started yoga practice during COVID19 lockdown period), 39.7% (n=152) were mid- term (1≤year of practice≤4), and 25.32 % (n=97) were Long term (≥ 5 years of practice) practitioners. “Within the beginners, 39.9 % reported practicing yoga for all days in the week, 23.9 % for 5-6 days, 23.2 % for 3-4 days and 13 % for 1-2 days in a week. For mid-term practitioners 32.4% reported practicing yoga for all days in the week, 30.4 % for 5-6 days, 29.7 % for 3-4 days and 7.4 % for 1-2 days in a week. For long term practitioners, 58.8 % reported practicing yoga for all days in the week, 19.6 % for 5-6 days, 11.3 % for 3-4 days and 10.3 % for 1-2 days in a week.The data for frequency in terms of hours of practice per day was asked as an open choice question,’ How many minutes in a day do you practice yoga? Beginners reported on an average spending 31.2 mins, mid-term practitioner average of 39.10mins, and long term practitioners reported spending average of 51.2 mins, on their daily yoga practice.”This above quoted text has been added to the revised manuscript.16) Higher stress among female during COVID19 lockdown as compared to men The explanation for the higher stress among female during COVID19 lockdown as compared to men has been added in the revised manuscript as described in point no. 9 of this document.Additional remarks have also been added to discussion section.Attachmentresponse to reviewers comments.docxSubmitted filename: Click here for additional data file. 26 Dec 2020Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional studyPONE-D-20-30379R1Dear Dr. Sahni,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Gagan DeepAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #1: All comments have been addressedReviewer #2: All comments have been addressed**********2. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********4. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********5. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: (No Response)**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The authors have responded satisfactorily to all the comments by this reviewer and have revised the manuscript accordingly. The manuscript may be accepted for publication.Reviewer #2: (No Response)**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article (If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.Yes: Umesh C S YadavReviewer #1: Reviewer #2: No 19 Jan 2021PONE-D-20-30379R1 Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study Dear Dr. Sahni:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Gagan Deep Academic EditorPLOS ONE


Although the amount of research about orthorexia nervosa (ON) has grown in the last two decades, to date, research on ON remains inconsistent. More is known about some behavioral characteristics of ON and its prevalence but nothing is known about the profile analysis behind this pathological eating behavior maintenance. Therefore, the objective of the present study was to determine the profiles of the participants in terms of eating behaviors, eating disorder psychopathology, obsessive-compulsive disorder symptoms and physical activity as well as check their association with ON. The sample was composed of 229 Polish female and male adults. Our findings showed three clusters and four-related factors . In our sample, a higher percentage of adults belonging to cluster 1 had no ON, whereas a higher percentage of adults belonging to cluster 3 had ON. Our results emphasize the possibility to target pathological eating behaviors and obsessive-compulsive disorder (OCD) symptoms in ON in psychological intervention. Healthism places an emphasis on personal responsibility for health which is to be attained primarily through the modification of lifestyles . WherefoOne of the disordered eating patterns is orthorexia nervosa (ON). It is characterized by obsessive thoughts and compulsive behaviors concerning healthy eating that includes rigidly following a restrictive “healthy” diet  for achieving optimal health (and/or to avoid illness) ,5. ThereAlthough ON is not classified as a formal diagnostic category (neither in DSM-5 nor in ICD-11), there is initial evidence that ON shares overlapping features with eating disorders, especially anorexia nervosa (AN): eating preoccupation, dietary restriction, intense anxiety regarding certain food and their avoidance, need for control, obsessive-compulsive personality traits  ,9. The mAccording to available data, ON and obsessive-compulsive disorder (OCD) exhibit similar thinking patterns  and behavioral patterns  that disturb the social functioning of the individual through the need to adhere to their strictly defined dietary patterns, which significantly impairs life quality . DespiteRecent research reveals that increased ON symptomatology corresponds to a high level of physical activity . SeveralThe majority of prior research has focused on epidemiological studies in non-clinical samples ,24,25,26Although the amount of research about ON has grown in the last two decades, to date, the literature on ON is dominated by descriptive and anecdotal data, frequently with inconsistent results . More isPerson-centered approaches  are used to detect the dynamics of emergent sub-populations in a sample  based on a set of chosen variables and it is appropriate for examining research questions and hypotheses aimed at categorizing subjects into common subpopulations based on substantive variables and understanding the relations of these subpopulations with predictors, correlates, or outcomes . ClusterThe objective of the present study was to determine the profiles of the Polish adults in terms of eating behaviors, eating disorder psychopathology, obsessive-compulsive disorder symptoms and physical activity and check their association with ON. We focused on mapping the pattern of eating behaviors, eating disorders, physical activity and obsessive-compulsive disorder in ON using a cluster analysis (to investigate which mentioned variables could contribute to a lack of ON versus a risk of ON vs. having ON). We aimed at investigating (1) what emergent groups (clusters) can be identified through the ON and (2) which variable values have a significant influence on participants concerning their ON categories. The expected result of this study was forming the three clusters within ON and associated variables .A total of 230 participants  were recruited through convenience sampling through several universities, companies and health centers in Poland. Of the 313 individuals who received the questionnaires, 254 (81.15%) returned them. Finally, from those, 230 questionnaires (73.48%) were recognized as completed to provide reliable data.The survey was administered via the Internet. Participants received notice about the research with the announcement including the online link to the study. Interested individuals were invited to visit a website that directed them to the consent form, information form , and questionnaires. All participants offered their informed consent before starting the survey and responded voluntarily to the survey. There was no financial compensation for participating in the study.The present study has been approved by the SWPS University of Social Sciences and Humanities Human Research Ethics Committee (No. WKEB59/05/2019). All procedures performed in our study were in accordance with the 1964 Helsinki declaration  and its later amendments or comparable ethical standards.The minimal sample size was calculated based on a previous study  that shop = 0.001) [The Düsseldorf Orthorexia Scale is a 10-item unidimensional questionnaire assessing and screening ON. A score of 30 or higher indicates the presence of ON. A score between 25 and 29 demonstrates a risk of developing ON, while a total score of less than 25 identifies the absence of ON [= 0.001) . In the = 0.001) .The TFEQ-R18  is an 18The EDI  is a 64-https://sites.google.com/site/theipaq/questionnaire_links; [The short form of the IPAQ (7-items)  assessese_links; ). We useThe OCI-R  is an 18In addition, the participants were asked questions regarding socio-demographic characteristics  and dietary patterns .Statistical analyses were carried out using the Statistical Package for Social Sciences 25.0 . Patterns among specific samples can be concluded from the factor and cluster analyses. An exploratory factor analysis was conducted as the first step to classify patterns of the multiple factors associated with ON; the extraction was done using a promax rotation since the factors were correlated. Sample adequacy was guaranteed using the Kaiser–Meyer–Olkin (KMO) index and Bartlett’s Chi-square test of sphericity. Factors with an Eigenvalue >1 were retained. Items with factor loading >0.4 were considered as belonging to a factor. A cluster analysis, using the K-mean method, was conducted next using the results obtained in the exploratory factor analysis, in order to classify participants according to their patterns (into three clusters). The Chi-square test was used to compare DOS categories with categorical variables, whereas the ANOVA test was used to compare three or more means. Three multinomial regressions were conducted taking the ON categories as the dependent variable; in the first one, each scale was entered as a separate independent variable; in the second one, the factors obtained from the factor analysis were entered as independent variables, whereas in the third one, the clusters obtained from the cluster analysis were entered as independent variables.p < 0.2 were considered as independent variables in order to eliminate confounding variables as much as possible. All models were adjusted over sociodemographic variables taken as covariates. p < 0.05 was considered significant.The DOS total score did not follow a normal distribution as verified by the Shapiro–Wilk test; therefore, non-parametric tests were used. The Mann–Whitney and Kruskal–Wallis tests were used to check for an association between two and three or more means respectively, whereas the Spearman correlation test was used to check for an association between continuous variables. A forward linear regression analysis, taking the DOS total score as the dependent variable, was conducted; all variables that showed a 2 ± 5.31) in the range of normal weight (from 18.5 to 24.9 kg/m2). One hundred thirty-eight participants (60.0%) indicated an omnivore diet and 92 (40.0%) reported to adhere to a vegetarian diet.The sample was composed of 175 Polish women (76.1%) and 55 men (23.9%) with ages ranging between 18 and 60 years (mean 26.52 ± 7.65 years). The entire group of participants had a mean body mass index (BMI) value  participants exhibited traits of ON, 13 (5.7%) participants were at risk of ON and 210 (91.3%) participants presented “normal” eating behavior (no risk of developing ON). Descriptive statistics are presented in p < 0.001. According to the promax rotated matrix, the components are summarized in The factor analysis for the scales’ scores was run over the whole sample. All items could be extracted and converged over a four-factor solution that had an Eigenvalue over 1, explaining a total of 63.40% of the variance ; KMO = 0.854; Bartlett’s test of sphericity A cluster analysis was used to identify profiles of individuals within our sample. We found three clusters . ClusterIn order to investigate factors associated with the three ON categories among adults  a bivariate analysis was used . The resThe results of the bivariate analysis of factors associated with the DOS total score showed that a higher mean DOS score was found in participants belonging to cluster 3 compared to the other two clusters. Furthermore, higher DOS scores were significantly associated with higher cognitive restraint, uncontrolled eating, emotional eating, drive for thinness, bulimia, interoceptive awareness, ordering, mental neutralizing, washing, obsessing, checking and total OCI-R score .Multinomial logistic regression was used to assess factors (independent variables) associated with a nominal/categorical dependent variable (in our case DOS categories). The results of the multinomial logistic regression, acknowledged as being at risk of ON vs. absence of ON as the dependent variable and each score as an independent variable, showed that higher cognitive restraint (aOR = 1.12), higher drive for thinness (aOR = 1.17) and more hoarding (aOR = 1.30) were significantly associated with higher odds of being at risk of ON, whereas higher ineffectiveness (aOR = 0.74) was significantly associated with lower odds of being at risk of ON , Model 1None of those variables were significantly associated with the presence of ON compared to its absence , Model 2The results of the multinomial logistic regression, acknowledged as being at risk of ON vs. absence of ON as the dependent variable and the four factors obtained in the factor analysis as independent variables, showed that higher Factor 1 scores (more obsessive-compulsive disorder features) (aOR = 1.88), and higher Factor 4 scores (more perfectionism and behaviors associated with weight maintenance or weight loss) (aOR = 2.05) were significantly associated with higher odds of being at risk of ON , Model 1None of those factors was significantly associated with the presence of ON compared to its absence , Model 2The results of the multinomial logistic regression, acknowledged as being at risk of ON vs. absence of ON as the dependent variable and the clusters as independent variables, showed that belonging to cluster 2 vs. cluster 1 (aOR = 4.31) was significantly associated with higher odds of being at risk of ON , Model 1None of those clusters were significantly associated with the presence of ON compared to its absence , Model 2The results of a forward linear regression, taking the DOS total score as the dependent variable, showed that a higher drive for thinness (β = 0.22), higher cognitive restraint (β = 0.45) and higher mental neutralizing (β = 0.39) were significantly associated with higher orthorexia nervosa (higher DOS scores) .Person-specific analysis, conducted in the present study, resulted with three clusters showing groups of adults according to their ON related-behaviors. We hypothesized that within our Polish adult sample, the cluster analysis would reveal three groups of adults with distinct patterns of comorbid behaviors. In our analysis, the largest cluster  was characterized by low OCD features , low inappropriate eating and body-related behaviors , low psychological and affective ED traits  and low perfectionism and behaviors associated with weight maintenance or weight loss . Individuals in cluster 2 (24.02% of the sample) were characterized by high OCD features, moderate inappropriate eating and body-related behaviors, moderate psychological and affective ED traits and moderate perfectionism and behaviors associated with weight maintenance or weight loss. Last, the smallest cluster  was characterized by moderate OCD features, high inappropriate eating and body-related behaviors, high psychological and affective ED traits and high perfectionism and behaviors associated with weight maintenance or weight loss.Our results demonstrated that adults who belonged to cluster 1 showed “normal” eating behavior and had no risk of ON, whereas adults who belonged to cluster 3 had ON. Belonging to cluster 2 (vs. cluster 1) was significantly associated with higher odds of being at risk of ON among adults who participated in the present study. This could indicate that higher OCD features, moderate inappropriate eating and body-related behaviors, moderate EDs symptoms and moderate low perfectionism and behaviors associated with weight maintenance or weight loss are associated with being at risk of developing ON. While, moderate OCD and high inappropriate eating and body-related behaviors, high ED symptoms and high perfectionism and behaviors associated with weight maintenance or weight loss are related to having ON. These findings are consistent with the results of the studies pointing out that ON is more linked to ED than to OCD . The recIn our sample, a higher level of OCD features (factor 1) and higher perfectionism and behaviors associated with weight maintenance or weight loss (factor 4) were associated with higher odds of being at risk of ON. Previous studies have shown a positive association between ON and OCD ,19,49, pOur study showed that a higher conscious restriction of food intake in order to control body weight or to promote weight loss, higher excessive concern with dieting as well as a preoccupation with weight and entrenchment in an extreme pursuit of thinness and higher total OCI-R scores were found in adults at risk of ON. Whereas higher feelings of general inadequacy, insecurity, worthlessness and the feeling of not being in control of participants’ life were significantly associated with lower odds of being at risk of ON. The recent review on psychosocial ON factors  has founOur findings showed that more hoarding was found in adults at risk of ON. Deficits in cognitive processes, maladaptive beliefs and maladaptive behavioral patterns are considered to underlie pathological hoarding . IndividStudies have demonstrated that hoarding develops as a result of conditional emotional responses to various thoughts and beliefs . It has A number of limitations should be borne in mind. With a small sample size in cluster 3 (having ON) the findings cannot be extrapolated to all individuals with ON. Moreover, the number of participants who meet the criteria for ON or for being at risk of ON is small and represents less than 10% of the total sample. These results are in line with other studies showing that ON prevalence (used the DOS) among a general population sample ranges from 2.3%  to 8.4% As with any research, the characteristics of our clusters are limited to our data and setting. There may be other individual characteristics which we did not include . The next limitation of our study is associated with a disproportionately high ratio of female adults. The cross-sectional study design is unable to identify directions of causality. A selection bias also is present because of the convenience sampling technique followed.Our results suggest that being at risk of ON is more classified on the OCD spectrum, whereas ON is more classified on the ED spectrum. Since the motivation for specific food choices and eating behaviors differ in ON and ED distinguishing both of these disorders is necessary from a therapeutic perspective . The proIn the present study, we used a cluster analysis to identify distinct subgroups of Polish adults with and without ON and specific co-occurring behaviors. To the best of our knowledge, the present study was the first to investigate the profile analysis of different types of varying  eating patterns (related or not related with ON).A cluster analysis can be used to identify separate groups of individuals with specific combinations of comorbid behaviors. This method can be used to develop targeted psychological interventions designed to improve health and eating outcomes. Future research could focus on collecting data from larger sample  for the purpose of assessing the profile analysis of ON. Identifying individuals with ON based on their actual pattern of behaviors has the potential to be used in the psychological intervention focusing on improving their health and eating behaviors.