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Purpose: Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with “correct” eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included. Methods: 47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A–Definition, Clinical Aspects, Duration; B–Consequences; C–Onset; D–Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants. Results: 27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON. Conclusions: This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel. Level of evidence: Level V: opinions of expert committees

Background: While pellagra appears to be a rare entity currently, it may still develop. It is important to recognize how the disease manifests to ensure adequate and timely treatment. Case presentation: We present a case of pellagra secondary to anorexia nervosa in a 28-year-old woman. We observed the classical signs: erythema in the neck region, diarrhea, and neurologic symptoms. Diagnosis was made on a clinical basis, and the patient had a rapid recovery after undergoing therapy with nicotinamide and tryptophan. Conclusions: In our case, the patient did not exhibit any sign of being severely underweight with marked malnutrition such as the typical manifestation expected in pellagra. This case demonstrated that clinicians should have a high level of suspicion in making a diagnosis of pellagra, especially in patients with a history of eating disorders. Level of evidence: IV (case study).

Purpose: The purpose of this study was to evaluate changes in the nutritional status, body image concerns, and eating behaviors occurring in a patient who underwent deep brain stimulation (DBS) of the bed nucleus of the stria terminalis for treatment-refractory anorexia nervosa (AN). Methods: Bilateral DBS of the bed nucleus of the stria terminalis was performed in a 37-year-old woman affected by refractory AN. Pre- and post-surgical evaluations were conducted via an array of validated testing instruments, which took into account the weight variations, body image concerns, eating behavior, quality of life, and nutritional status. Results: Overall, eating behavior-, body image concern-, and nutritional status-related testing instruments demonstrated improvements starting from the first post-operative month. Normal body weight was restored after 4 months of stimulation. Discussion: Only a few cases of DBS for AN have been conducted to determine the efficacy of surgery based upon weight variation and psychometric scales for anxiety and affective disorders. In contrast, we have designed a comprehensive approach taking into account the most important aspects of this disease. This approach should be considered in future studies dealing with the neurosurgical treatment of AN.

Purpose: Oxidized LDL cholesterol (oxLDL) has been considered as a sensor of oxidative stress (OS) in childhood obesity. We integrated and related our oxLDL existing results previously assessed in overweight/obese children to lifestyle variables to investigate OS-related lifestyle variables. Methods: 178 Caucasian children/adolescents have been evaluated and according to BMI percentiles have been classified as normal weight (BMI < 75th); overweight (BMI 75–97th) and obese (BMI > 97th). Serum oxLDL levels have been measured. The dietary habits and physical activity have been also assessed. Results: No differences between normal weight and overweight/obese children were detected according to the total score of dietary habits section. Normal weight subjects reported a higher total physical activity score (p= 0.001) compared to overweight/ obese children. No correlation between oxLDL and total dietary habits and physical activity scores was noted. Increased oxLDL in subjects drinking < 1 L/day of water (p= 0.022) and in daily consumers of chocolate drinks at breakfast (p= 0.029) was observed, while a decreased oxLDL was reported in subjects consuming a breakfast based mainly on fruits (p= 0.004). Moreover, “high-fat diet” and “always eating a dessert at the end of the meal” were correlated with increased oxLDL with a trend towards significance. As regards physical activity, no correlations were observed. Conclusions: Diet and physical activity may not have an immediate impact on OS response in children with or without obesity. Unhealthy lifestyle, including increased fat, simple sugar intake, poor water intake, emerged as external exposome predictors of OS, that may be monitored to improve health status. Level of evidence: Level III, case-control analytic studies.

In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote health. The pursuit of an “extreme dietary purity” due to an exaggerated focus on food may lead to a disordered eating behavior called “orthorexia nervosa” (ON). ON raises a growing interest, but at present there is no universally shared definition of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related psychometric instruments and provides research propositions and framework for future analysis. The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last access on 07 August 2018), using “orthorexia”, “orthorexia nervosa” and “obsessive healthy eating” as search terms, and filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from English. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed. The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation. Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid, extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diagnostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c) psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia Self-Test developed by Bratman were the most used psychometric tools. The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psychometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both research and clinical activity until now. Level V, narrative review.

Individuals with autism spectrum disorders (ASD) are often characterized by food-selectivity, food-neophobia and a marked preference for mild flavor, semi-liquid foods with pale colors. Therefore, they adopt a monotonous dietary pattern, and they prefer ultra-processed food, leading to a high risk of developing malnutrition. In Italy, where 75,072 individuals are diagnosed with ASD, center-based services play a crucial role in their daily management. Despite the centrality of nutrition in maintaining a good state of health, even more for vulnerable subjects, no validated protocol at collective catering level has been developed yet. The manuscript presents customized dietary recommendations aimed at managing the meals for individuals with ASD at collective catering service, derived from a non-systematic literature review exploring food behaviors and nutritional needs in individuals with ASD. Simple practical tips for mealtimes, such as eating together, proper seating, lighting, smell control, presenting food in a simple manner and using the same type of tableware at each meal, to meet the needs of individuals with ASD, were described. The proposal could represent a starting point in developing official guidelines aimed at ASD individuals, in collective catering service.

The present study aimed to investigate the relationship between ORTO-15 score and obsessive-compulsive symptoms, disordered eating patterns and body uneasiness among female and male university students and to examine the predictive model of ORTO-15 in both groups. One hundred and twenty students participated in the present study (mean age 22.74 years, SD 7.31). The ORTO-15 test, the Maudsley Obsessive-Compulsive Questionnaire, the Eating Attitudes Test-26 and the Body Uneasiness Test were used for the present study. Our results revealed no gender differences in ORTO-15 score. Our results show, rather unexpectedly, that in female students lower scores, corresponding to greater severity, were related to less pathological body image discomfort and obsessive-compulsive signs, while in male students, lower ORTO-15 scores were related to less pathological eating patterns, as behaviors and symptoms. Further studies regarding the relationship between ON and anorexia nervosa, as well as obsessive-compulsive symptoms, are needed to better understand the causality. Level of EvidenceLevel V, descriptive study.

To evaluate the possible correlation between underreporting and anthropometric, psychological and socio-anagraphic characteristics in obese inpatients.Perspective longitudinal study.Forty-two obese inpatients enrolled to a multidisciplinary 3-week weight loss program in a psycho-nutritional rehabilitative structure located in Salice Terme, Northern Italy. They underwent anthropometric, dietary, clinical, and psycho diagnostic evaluation.Forty-two subjects were included in the study of which 29 (70 %) were females and 13 were males. Mean BMI and mean waist circumference were 42.7 ± 9.5 kg/m2and 125 ± 18 cm, respectively. The mean weight loss of 4.2 ± 2.2 kg in the whole sample was significantly greater in males compared to females. The waist circumference fell in equal measure in both of the sexes. Thirty patients were classified as underreporters according to Goldberg, two-thirds of which were females. In the course of the three recovery weeks, a third of the 30 subjects identified as underreporters at the beginning continued to underreport energy intake.In our study, the prevalence of underreporting was equal to over 70 % of the original sample. There was no significant difference between the weight losses achieved by the underreporter and non-underreporter groups. All the underreporters initially became partly non-underreporters during treatment. Those who gave up the practice of underreporting were patients who had a more elevated BMI, who were more susceptible to binge eating behavior and who experienced a strong uneasiness both physically and psychologically. They also had a strongly impaired quality of life.

OBJECTIVE:The Quality of Life (QoL) of overweight and obese subjects is a widely discussed topic. From numerous studies, it emerges that obese persons suffer significant damage as result of their overweight in terms of QoL with regard to their physical and psychosocial well-being, with greater incidence associated with the degree of obesity. Our study aims at evaluating the usefulness of specific psychometric tests on the “obese population” that may be effective for the overall evaluation of the patient and in identifying specific subgroups on the basis of psychometric characteristics relating to QoL and of motivation for treatment. METHODS:The study was carried out on a sample of 150 obese subjects who approached the Section of Human Nutrition of the University of Pavia requesting treatment for weight loss. The persons in the selected sample were subjected to a specialized examination during which, as well as collecting all the anamnestic information on each individual patient, they were also asked to fill out the obesity-specific ORWELL 97 (Obesity Related Well- Being) questionnaire and the DBI (Decisional Balance Inventory) questionnaire. RESULTS: An analysis of the results indicates that the female group is strongly characterized by a lower QoL, as well as by a clearly larger number of failed dieting attempts and by a strong motivation to undergo treatment. CONCLUSIONS:The evaluation of QoL and motivation for treatment in overweight and obese individuals appears to be an effective tool for better identification of the subjects and for planning the most appropriate diagnostic approach.

Objective: It is known that the psychopathology of eating disorders is associated with body image disturbances, but little is known concerning the body image of obese subjects. The aim of this study was to assess body uneasiness in overweight and obese women in relation to their age, degree of obesity, the percentage and distribution of body fat mass, and eating disordered behaviours. Method: The study population consisted of 99 overweight and obese women with a mean age of 34.3±10.1 years and a mean body mass index (BMI) of 31.3±5.4 kg/m2, who completed two self-report questionnaires: the Bulimic Investigation Test Edinburgh (BITE) to assess disordered eating behaviours and the Body Uneasiness Test (BUT) to assess body image uneasiness. Pearson correlations were used to determine the associations between the BUT scores and age, anthropometric measures (BMI, waist and hip circumferences, waist/hip ratio, percentage of body fat mass) and the BITE scores. The most significant determinants of the BUT scores were also determined using a multiple linear regression model. Results: Disordered eating behaviours were found in 7.1% of the patients. Neither BUT nor BITE scores correlated with age, but BITE scores correlated with BMI and hip circumference (p<0.05). The overall BUT score increased with increasing BITE scores and higher indices of all of the anthropometric measures (p<0.001) except for the percentage of body fat mass. Multiple linear regression analyses showed that, among the considered parameters, the only significant determinants of body uneasiness were disordered eating behaviours. Conclusions: Our results confirm that body uneasiness in an obese clinical population is closely associated with disordered eating behaviours, and suggest that it is not dependent on age, the degree of obesity, or the percentage or distribution of body fat mass.