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

Anorexia and bulimia nervosa are characterized by unbalanced eating patterns that include inadequate dietary intake of various nutrients. Conservation mechanisms resulting from starvation and/or self-prescribed nutrient supplements can result in laboratory values that appear within normal limits. These artificially inflated values drop to dangerous levels in some patients once rehydration and refeeding begin. Electrolyte status must be closely monitored during this time to prevent complications. Other micronutrient deficiencies can be corrected with adequate dietary intake, but patients with eating disorders are unlikely to consume such an adequate diet immediately upon entering treatment, so they may benefit from supplementation. Depleted nutrient stores require longer supplementation than acute inadequacies in nutrient intake. This review compiles the findings reported to date regarding micronutrient deficiencies and supplementation for patients with anorexia and bulimia. Because of the widely varying eating practices from patient to patient and the current lack of data controlling for nutrient self-supplementation, nutrition assessment performed by a nutrition professional via food intake history may be more practical than laboratory tests and more accurate than current food intake for determining potential micronutrient deficiencies.

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Successful management of eating disorder (ED) symptoms includes Registered Dietitian Nutritionists (RDNs) with specialized expertise, nutrition counseling skills, and advanced training. We conducted an anonymous on-line survey of self-identified ED-specialized RDNs about their previous education and training, workload, job duties, and job satisfaction. Respondents were 182 RDNs who were U.S. members of the International Federation of Eating Disorder Dietitians. Qualitative methods identified salient themes from narrative responses to augment survey data. Most respondents expressed confidence in their ED-related competence, however these skills were gained from post-professional, self-funded activities, not from ED-specific education or training in either school or work settings. While two-thirds of RDNs surveyed held an advanced degree and more than half held specialty certification, an inverse relationship between provider expertise and patient acuity was observed. RDNs working at the highest levels of ED care with the most medically complex patients were less likely to hold graduate degrees or have prior clinical experience. Obstacles to job satisfaction included high patient caseloads, low compensation, lack of employer support, and high burnout. Facilitators of job satisfaction included professional and client communities, and the private practice setting. Considering the essential nature of nutrition rehabilitation in ED treatment and the high prevalence of dysfunctional eating behaviors in society at-large, these observations identify gaps in RDN preparedness and facility staffing practices that may affect treatment outcomes for individuals with known and undiagnosed ED’s. Enhancements in dietetics education and heightened attention to supervision for entry-level clinicians in ED-specific treatment programs are prime targets for actioSuccessful management of eating disorder (ED) symptoms includes Registered Dietitian Nutritionists (RDNs) with specialized expertise, nutrition counseling skills, and advanced training. We conducted an anonymous on-line survey of self-identified ED-specialized RDNs about their previous education and training, workload, job duties, and job satisfaction. Respondents were 182 RDNs who were U.S. members of the International Federation of Eating Disorder Dietitians. Qualitative methods identified salient themes from narrative responses to augment survey data. Most respondents expressed confidence in their ED-related competence, however these skills were gained from post-professional, self-funded activities, not from ED-specific education or training in either school or work settings. While two-thirds of RDNs surveyed held an advanced degree and more than half held specialty certification, an inverse relationship between provider expertise and patient acuity was observed. RDNs working at the highest levels of ED care with the most medically complex patients were less likely to hold graduate degrees or have prior clinical experience. Obstacles to job satisfaction included high patient caseloads, low compensation, lack of employer support, and high burnout. Facilitators of job satisfaction included professional and client communities, and the private practice setting. Considering the essential nature of nutrition rehabilitation in ED treatment and the high prevalence of dysfunctional eating behaviors in society at-large, these observations identify gaps in RDN preparedness and facility staffing practices that may affect treatment outcomes for individuals with known and undiagnosed ED’s. Enhancements in dietetics education and heightened attention to supervision for entry-level clinicians in ED-specific treatment programs are prime targets for actioSuccessful management of eating disorder (ED) symptoms includes Registered Dietitian Nutritionists (RDNs) with specialized expertise, nutrition counseling skills, and advanced training. We conducted an anonymous on-line survey of self-identified ED-specialized RDNs about their previous education and training, workload, job duties, and job satisfaction. Respondents were 182 RDNs who were U.S. members of the International Federation of Eating Disorder Dietitians. Qualitative methods identified salient themes from narrative responses to augment survey data. Most respondents expressed confidence in their ED-related competence, however these skills were gained from post-professional, self-funded activities, not from ED-specific education or training in either school or work settings. While two-thirds of RDNs surveyed held an advanced degree and more than half held specialty certification, an inverse relationship between provider expertise and patient acuity was observed. RDNs working at the highest levels of ED care with the most medically complex patients were less likely to hold graduate degrees or have prior clinical experience. Obstacles to job satisfaction included high patient caseloads, low compensation, lack of employer support, and high burnout. Facilitators of job satisfaction included professional and client communities, and the private practice setting. Considering the essential nature of nutrition rehabilitation in ED treatment and the high prevalence of dysfunctional eating behaviors in society at-large, these observations identify gaps in RDN preparedness and facility staffing practices that may affect treatment outcomes for individuals with known and undiagnosed ED’s. Enhancements in dietetics education and heightened attention to supervision for entry-level clinicians in ED-specific treatment programs are prime targets for actioSuccessful management of eating disorder (ED) symptoms includes Registered Dietitian Nutritionists (RDNs) with specialized expertise, nutrition counseling skills, and advanced training. We conducted an anonymous on-line survey of self-identified ED-specialized RDNs about their previous education and training, workload, job duties, and job satisfaction. Respondents were 182 RDNs who were U.S. members of the International Federation of Eating Disorder Dietitians. Qualitative methods identified salient themes from narrative responses to augment survey data. Most respondents expressed confidence in their ED-related competence, however these skills were gained from post-professional, self-funded activities, not from ED-specific education or training in either school or work settings. While two-thirds of RDNs surveyed held an advanced degree and more than half held specialty certification, an inverse relationship between provider expertise and patient acuity was observed. RDNs working at the highest levels of ED care with the most medically complex patients were less likely to hold graduate degrees or have prior clinical experience. Obstacles to job satisfaction included high patient caseloads, low compensation, lack of employer support, and high burnout. Facilitators of job satisfaction included professional and client communities, and the private practice setting. Considering the essential nature of nutrition rehabilitation in ED treatment and the high prevalence of dysfunctional eating behaviors in society at-large, these observations identify gaps in RDN preparedness and facility staffing practices that may affect treatment outcomes for individuals with known and undiagnosed ED’s. Enhancements in dietetics education and heightened attention to supervision for entry-level clinicians in ED-specific treatment programs are prime targets for actioSuccessful management of eating disorder (ED) symptoms includes Registered Dietitian Nutritionists (RDNs) with specialized expertise, nutrition counseling skills, and advanced training. We conducted an anonymous on-line survey of self-identified ED-specialized RDNs about their previous education and training, workload, job duties, and job satisfaction. Respondents were 182 RDNs who were U.S. members of the International Federation of Eating Disorder Dietitians. Qualitative methods identified salient themes from narrative responses to augment survey data. Most respondents expressed confidence in their ED-related competence, however these skills were gained from post-professional, self-funded activities, not from ED-specific education or training in either school or work settings. While two-thirds of RDNs surveyed held an advanced degree and more than half held specialty certification, an inverse relationship between provider expertise and patient acuity was observed. RDNs working at the highest levels of ED care with the most medically complex patients were less likely to hold graduate degrees or have prior clinical experience. Obstacles to job satisfaction included high patient caseloads, low compensation, lack of employer support, and high burnout. Facilitators of job satisfaction included professional and client communities, and the private practice setting. Considering the essential nature of nutrition rehabilitation in ED treatment and the high prevalence of dysfunctional eating behaviors in society at-large, these observations identify gaps in RDN preparedness and facility staffing practices that may affect treatment outcomes for individuals with known and undiagnosed ED’s. Enhancements in dietetics education and heightened attention to supervision for entry-level clinicians in ED-specific treatment programs are prime targets for actioSuccessful management of eating disorder (ED) symptoms includes Registered Dietitian Nutritionists (RDNs) with specialized expertise, nutrition counseling skills, and advanced training. We conducted an anonymous on-line survey of self-identified ED-specialized RDNs about their previous education and training, workload, job duties, and job satisfaction. Respondents were 182 RDNs who were U.S. members of the International Federation of Eating Disorder Dietitians. Qualitative methods identified salient themes from narrative responses to augment survey data. Most respondents expressed confidence in their ED-related competence, however these skills were gained from post-professional, self-funded activities, not from ED-specific education or training in either school or work settings. While two-thirds of RDNs surveyed held an advanced degree and more than half held specialty certification, an inverse relationship between provider expertise and patient acuity was observed. RDNs working at the highest levels of ED care with the most medically complex patients were less likely to hold graduate degrees or have prior clinical experience. Obstacles to job satisfaction included high patient caseloads, low compensation, lack of employer support, and high burnout. Facilitators of job satisfaction included professional and client communities, and the private practice setting. Considering the essential nature of nutrition rehabilitation in ED treatment and the high prevalence of dysfunctional eating behaviors in society at-large, these observations identify gaps in RDN preparedness and facility staffing practices that may affect treatment outcomes for individuals with known and undiagnosed ED’s. Enhancements in dietetics education and heightened attention to supervision for entry-level clinicians in ED-specific treatment programs are prime targets for action.

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