Il digiuno e le diete estreme nel commercio sanitario ... · commercio sanitario: rischi sui...

Ildigiunoeledieteestremenelcommerciosanitario:rischisuidisturbi

dell’alimentazione

Dr.RiccardoDalleGrave

ResponsabileUnitàfunzionalediriabilitazionenutrizionaledellaCasadiCuraVillaGarda

ResponsabilescientificoAssociazioneItalianaDisturbidell’AlimentazioneedelPeso(AIDAP)

Introduzione• Negliultimianniimedia(libri,sitiweberiviste)hannopromossolapraticadeldigiunoedidieteestremeinvarieformecomepratica“salutare”perperderepeso,detossificarsi ridurreilrischiodimalattiaeaumentarel’aspettativadivita

• L’efficaciadiquestepratichenonèperòsupportadastudi“clinici”randomizzatiecontrollatiamediolungotermine

• Varistudihannoinoltredimostratochel’adozionediregoledieteticheestremeerigide,inalcunepersone,aumentailrischiodisviluppareidisturbidell’alimentazione

• Inoltrel’adozionediregoledieteticheestremeerigideèunpotentefattoredimantenimentodeidisturbidell’alimentazione

Scaletta

• Digiuno“terapeutico”neimedia• Effettideldigiunosulcomportamentoalimentare• Causedeidisturbidell’alimentazione• DietaferreaeHumanStarvation Study• Implicazionicliniche• Raccomandazioni

Ildigiuno“terapeutico”neimedia

• Ildigiunoèpropostoinmodomassicciodaimediaedaalcuniclinici,inassenzadistudirandomizzatiecontrollatiamedio-lungotermine,comepratica“salutare”per– perderepeso– detossificarsi– ridurreilrischiodimalattia– aumentarel’aspettativadivita

Sitiweb

Riviste

Scaletta

• Digiuno“terapeutico”neimedia• Effettideldigiunosulcomportamentoalimentare• Causedeidisturbidell’alimentazione• DietaferreaeHumanStarvation Study• Implicazionicliniche• Conclusioni

Effettideldigiunosulcomportamentoalimentare

Incrementodell’intake diciboedipatologiaalimentare• Duestudihannotrovatochenegliindividuicondisturbidell’alimentazionesiverificaunincrementosignificativodell’intake dicibodopo6e14oredidigiuno(Agras &Telch,1998;Telch &Agras,1996).Undatononosservatodaunaltrostudio(Hetherington etal,2000)

• Studisuisoggettisaninonhannoosservatounimpattonegativodiunbreveperiododidigiunosulcomportamentoalimentare(Johnstoneetal.,2002;Levitsky &DeRosimo,2010).

• Unostudiolongitudinaledi5annihatrovatocheildigiunoriportatoèunpredittore dellapatologiaalimentareedelleabbuffatericorrenti(Stice etal.2008)


Meccanismiproposti• Biologico.Ildigiunopuòcreareunadeplezioneditriptofano,unprecursoredellaserotonina,cheaumentalaprobabilitàdiabbuffataperripristinareilivelliditriptofano(Kaye,Gendall,&Strober,1998).

• Cognitivo.Larestrizionedieteticacognitivapuòpredisporreall’alimentazioneineccessoeagliepisodidiabbuffataquandoilciboèdisponibile(Polivy,1996).

• Attentivo.Ildigiunoinfluenzaibias attentivi neiconfrontidelciboriccodicalorierispettoaquellopoverodicalorie(Placanica,Faunce,&Soames Job,2002)


VariabilichepossonoinfluenzarelarispostaaldigiunoAdolescenzaesessofemminile

• Aumentanoilrischiodiabbuffateepatologiaalimentaredopoildigiuno(Stice etal,2008)

Immaginecorporeanegativa

• Aumentailrischiodisvilupparemodalitàalimentariproblematicherispettoaldigiunoadottatopermotivispiritualioreligiosi(Schaumberg &Anderson,2014).

Disinibizionecognitiva

• Isoggettisaniconelevatilivellididisinibizionecognitivabasalehannounamaggioretendenzaadavereepisodidiabbuffatadopoildigiuno(Schaumberg etal,2015)

Preoccupazioniperleconseguenzenegativedelmangiare

• Isoggetticonpreoccupazioniperlaconseguenzenegativedelmangiarehannounmaggiorrischiodisviluppareildisturboevitante/restrittivodell’assunzionedicibo(ARFID)quandoadottanopratichedieteticheestremeerigide(Rachel Bryant-Waughetal,2010)

Scaletta


Causedeidisturbidell’alimentazione

PuntigeneraliLecausenonsonoconosciute

Moltesfidemetodologiche

• IDAnonsonocomuni

• IDAsonodifficilidaindividuare

• Icampioniclinicinonsonorappresentativi• IDAsonodifficilidadiagnosticare,sonousatedelledefinizioniinconsistenti

• Nonvisonodeifenotipiovvidastudiare

– Peres.ANoANpersistente• Problemadellacomorbilità

–Moltoignorata,ancheseappareesistaunarelazionetraDAedepressione

• Lemodificazionisecolarisuggerisconoilcontributodiprocessisociali


Familiaritàindubbia

• Rischioaumentatodi10volteneifamiliaridiprimogrado

• TrasmissionecrociatatraiDAtradizionali

• Glistudisuigemellisuggerisconounimportantecontributogenetico

– Ifattorigeneticisembranocontribuireal40-60%dellapredisposizione


Studidiassociazionegenome-wide(GWAS)• Risultatinegativinelprimiduestudi(1000partecipanti)• Studiocon3495ANe10982controlli(Duncanetal,2017)

– Identificatounlocusgenome-widesignificativoperl’anoressianervosasulcromosoma12• (index variant rs4622308,p=4.3x10-9) nellaregione(chr12:56,372,585-56,482,185)cheinclude6geni.

– Correlazionipositiveconschizofrenia,neuroticismo,livellodiistruzioneeHDLcolesterolo

– Correlazioninegativeconalcunifenotipi(BMI,insulina,glucosioelipidi)• Unnuovostudioèincorso(obiettivoN =25000)


Fattoridirischio

• Studicasocontrollo

– Adolescenticonanoressianervosa(Rastam &Gilbert,1992)

– Oxfordrisck factor studies (Fairburn etal,1997,1998,1999)

– Anoressianervosa,bulimianervosa,BED(Hilbert etal,2014)

• Studidicoortelongitudinali

– Americachoort studies –adolescentiseguitiper8anni(Fieldetal,2008;Stice etal2011)

– Studidicoorteiniziatidurantelagravidanzaoallanascita(Micali etal,2014;Allenetal,2014)


Fattoridirischiopotenzialiidentificati

AN BN BED Psych

Esperienzeavversenell’infanzia ++ +++ ++ ++

Depressioneneigenitori + ++ + +

Abusodisostanze neigenitori - ++ - -

Fattoridivulnerabilitàalladieta + +++ + -

Menarcaprecoce - ++ - -

Perfezionismo +++ ++ - -

Bassaautostima +++ +++ + ++

Scaletta


Dietaferreaedisturbidell’alimentazione

• Ladietaprecedenellamaggiorpartedeicasil’insorgenzadeiDA• Ilsuoruolocomefattoredirischioèsupportatosiadastudiretrospettivicasocontrollosiadicoortelongitudinalisugliadolescenti

• QuestononsuggerisceperòcheladietacausiiDAdasola• Ladietasembraperòfavorirliinassociazioneconaltrifattoridirischio(genetici,fisiologici,psicologici,sociali)

• LadietaèunacondizionenecessariamanonsufficienteperlosviluppodeiDA

QualèilmeccanismoattraversocuiladietaaumentailrischiodisviluppareunDA?

Eccessiva valutazione delcontrollodell’alimentazione

Eccessivavalutazionedelpeso,dellaformadelcorpoedellorocontrollo

Dieta ferrea

Necessità dicontrollare vari aspettidella vita

A

Interiorizzazione dell’ideale dimagrezza

B

Vie d’ingresso nei disturbi dell’alimentazione

Dietaferrea

DescrizioneLepersoneconproblemialimentariadottanoregoledieteticheestremeerigideinmodopersistenteEstreme• Sonomoltonumerose• RichiedonounacontinuavigilanzaperpoteressereseguiteRigide• Devonoessereseguiteinmodorigido

Dietaferrea

Dietaferrea

Restrizionedieteticacognitiva(tentativodirestringere

l’alimentazione)

Restrizionedieteticacalorica(alimentazioneipocalorica

attuale)

Dietaferrea

DescrizioneRegoledietetichecomuni• Saltareipasti(quando)• Eliminaredeicibi(checosa)• Ridurrelequantità(quanto)• Nonmangiaremaiconglialtri• Mangiaresempremenodeglialtri• Nonassumeremaicibodicomposizionecaloricaincertaocucinatodaaltri• Nonmangiarequandononsièaffamationonsièconsumatoabbastanza• Mangiareilpiùtardipossibile• Nonandaremaialristoranteoinpizzeria

Dietaferrea

Descrizione(cont)• Ladietaferrea

1. Èdannosa2. Mantieneildisturbodell’alimentazione

Dietaferrea

Èdannosa• Èmotivodipreoccupazioniperilciboel’alimentazione• Interferisceconlaconcentrazione• Èemotivamentestressante(peres.preoccupazioniperl’alimentazione,

sceltadelcibo,etc.)• Èsocialmentedannosa(peres.difficoltàamangiarecibocucinatodagli

altri;difficoltàamangiarefuori)• Hamoltieffettiinterpersonalisecondari• Sedeterminaunacondizionedisottopesoproduceisintomida

malnutrizioneevidenziatidall’Human Starvation Study

Human Starvation Study

Descrizione• EseguitopressolaMinnesotaUniversity trail19novembre1944eil20dicembre1945(Keysetal.1950)

• Obiettivo:valutareglieffettifisiologiciepsicosocialidiunagraveeprolungatarestrizionecaloricael’efficaciadellariabilitazionenutrizionale

Human Starvation StudyPartecipanti

• Piùdi100uominisiproposerocomevolontariinalternativaalserviziomilitare

• I36cheavevanoilmigliorestatodisalutefisicoepsicologicofuronoselezionati

• Ipartecipantieranodirazzabianca,dietàtra22e33anni.25eranomembridell’Historic Peace Churches (Mennonites,ChurchoftheBrethren,andQuakers).

Human Starvation Study

Fasidellostudio• 3fasi

– 12settimanedicontrollo– 24settimanedisemidigiuno

• metàdellecalorieabitualmenteassunte(inmediada3.492kcala1.570kcal–perditadipesodicircail25%)

– 12settimanediriabilitazione

Idaticompletisonodisponibiliper32partecipanti

Effetti del semidigiuno

Attitudinineiconfrontidelcibo• Preoccupazioniperl’alimentazione

• Collezionidiricette,libridicucinaemenù

• Inusualiabitudinialimentari(rituali)

• Aumentatoconsumodicaffè,te,spezieegommeamericane

• Abbuffate

Modificazioniemotiveesociali• Depressione

• Variazionideltonodell’umore

• Ansia

• Irritabilità,ansia

• Episodipsicotici

• Isolamentosociale

• Diminuzionedell’interessesessuale

• Modificazionedellapersonalitàneitestpsicologici

Modificazionicognitive• Diminuitaconcentrazione

• Scarsacapacitàdigiudizio

• Pensieroinflessibile

• Rigidità

• Apatia

Modificazionifisiche• Disturbidelsonno

• Debolezza

• Sintomigastrointestinali

• Eccessivasensibilitàalrumoreeallaluce

• Sentirefreddo

• Sensodelgustoalterato

• Riduzionedelmetabolismobasale

HumanStarvation Study

Commentideipartecipanti• Nel2003–2004,18dei36partecipantieranoancoraviviefuronointervistatidairicercatoridellaTheJohnsHopkinsSchoolofMedicine,Baltimore,MD(Kalm andSemba 2005).

• Avevanopiùdi80annieognunoparlòinmodoappassionatodellostudiofornendounquadropiùrealedellaloroesperienza


Commentideipartecipanti• Dopounentusiasmoinizialesoffrironodiimportanticambiamentinellaloropersonalità

• Diventaronopiùirritabilieimpazientineiconfrontideglialtrieiniziaronoasoffriredeglieffettifisicidellarestrizionecalorica

• Svilupparonomaggioreintroversione,mancanzadienergia,stanchezza,perditadicapelli,riduzionedellacoordinazione

• Ilcibodivenneun’ossessione,emoltiperserol’interesseversol’altrosesso

• Nonostanteledifficoltàfuronodeterminatiacontinuarelostudiosuggerendocheimotividellaloropersistenzaincludevanoragionireligiose,disciplinaeforzadivolontà


Commentideipartecipanti• Peralcuniilperiodopiùdifficilefulariabilitazione(stanchezza,apatia,diminuzionedell’interessesessualepersistenti)

• Riportaronodinonessereingradodiritornarealleloroattivitàabitualiallafinedei3mesidiriabilitazione

• Iltempomedioperraggiungereunpienorecuperovariòdai2mesie2anni

nutrients

Article

The Starvation Symptom Inventory: Development

and Psychometric Properties

Simona Calugi1,

*, Mario Miniati2 ID , Chiara Milanese

3, Massimiliano Sartirana

1,

Marwan El Ghoch1

and Riccardo Dalle Grave1

1 Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo, 89, 37016 Garda (Verona),Italy; [email protected] (M.S.); [email protected] (M.E.G.);[email protected] (R.D.G.)

2 Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy;[email protected]

3 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37129 Verona,Italy; [email protected]

* Correspondence: [email protected]; Tel.: +39-045-810-3915; Fax: +39-045-810-2884

Received: 3 August 2017; Accepted: 30 August 2017; Published: 1 September 2017

Abstract: Background: Starvation symptoms are common in patients with anorexia nervosa, andaccording to the transdiagnostic cognitive behavioural theory for eating disorders, they contribute tomaintaining the eating disorder psychopathology. The aim of this study was therefore to describethe design and validation of the Starvation Symptoms Inventory (SSI); a self-report questionnairethat examines the symptoms of starvation in underweight patients with eating disorders. Methods:150 female patients with anorexia nervosa were recruited, as well as 341 healthy control subjects,30 not-underweight patients with an eating disorder, and 15 patients with bipolar depressive episodes.The 150 patients completed the Eating Disorder Examination Questionnaire and the Brief SymptomInventory. All participants rated their starvation symptoms on a continuous Likert-type scale (0–6),and reported the number of days in which they had experienced them in the previous 28 days.Results: Principal component analysis identified a single-factor, 15-item scale, which demonstratedgood internal consistency (↵ = 0.91) and test–retest reliability (r = 0.90). The SSI global score wassignificantly correlated with eating disorder and general psychopathology, demonstrating goodconvergent validity. SSI scores were significantly higher in the anorexia nervosa sample thanin the healthy control, not-underweight eating disorder and bipolar depressive episode samples.Conclusions: These findings suggest that the SSI is a valid self-report questionnaire that may provideimportant clinical information regarding symptoms of starvation in patients with anorexia nervosa.

Keywords: anorexia nervosa; starvation symptoms; dietary restraint; validity; reliability; factor analysis

1. Introduction

In the classic two-volume The Biology of Human Starvation, Keys and colleagues gave a detaileddescription of the symptoms of dietary restriction and underweight reported by 36 young malevolunteers who participated in the Minnesota Starvation Study [1]. The major “starvation symptoms”reported by volunteers included abnormal attitudes and behaviour towards food and eating(e.g., preoccupation with food and eating, ritualistic eating, cookbook and recipe collection), pooremotional and social functioning (e.g., mood liability, social withdrawal, reduction of sexual interest),impaired cognitive performance (e.g., poor concentration), and physiological changes (e.g., heightenedsatiety, gastrointestinal discomfort, cold intolerance).

The clinical observation that many symptoms reported by these volunteers were similar to thosefound in patients with anorexia nervosa improved the understanding and management of eating

Nutrients 2017, 9, 967; doi:10.3390/nu9090967 www.mdpi.com/journal/nutrients

Versione italianascaricabilenelsito:http://www.dallegrave.it/starvation-symptom-inventory-ssi/

Nutrients 2017, 9, 967 6 of 8

Table 2. Baseline characteristics and Starvation Symptoms Inventory (SSI) global score in patients withanorexia nervosa, not-underweight patients with an eating disorder, patients with bipolar depressiveepisodes and healthy controls.

Anorexia

Nervosa

(n = 150)

Not-Underweight

Eating Disorder

(n = 30)

Bipolar

Depressive

Episode (n = 15)

Healthy

Controls

(n = 341)

p-ValuePost-hoc

Comparison

Age (years) 25.2 (9.4) 28.3 (11.6) 32.2 (9.1) 30.0 (9.9) <0.001 a < c, d

Body weight(kg) 38.8 (5.8) 71.6 (26.8) 64.3 (11.2) 61.2 (9.8) <0.001 a < b, c, d

b > d

Body MassIndex (kg/m2) 14.7 (1.8) 26.6 (9.0) 24.1 (2.2) 22.0 (2.7) <0.001 a < b, c, d

b > d

SSI globalscore 55.1 (20.4) 46.9 (22.9) 26.3 (8.4) 10.4 (9.7) <0.001

a > b, c, db > c, d

c > d

a = patients with anorexia nervosa; b = patients with not-underweight eating disorder; c = patients with bipolardepressive episodes; d = healthy control sample.

4. Discussions

This study aimed to design and validate the SSI in a group of patients with anorexia nervosa,and to compare their scores with the healthy control, not-underweight eating disorder and bipolardepressive episode samples.

There were three main findings, the first regarding construct validity. Specifically, PCA in patientswith anorexia nervosa indicated that the one-factor solution was the best, accounting for more than43% of the variance. Similar results were obtained in the healthy control sample. Interestingly,the PCA enabled the identification of one item (namely, “Felt an increase in hunger”) with verylow factor loading; these were omitted from the final tool, which therefore comprised 15 items (seeSupplementary Table S2).

The second finding was that the final version of the SSI showed very good internal consistencyand test–retest reliability. This indicates that the items measure the same general construct, and thatthe tool is stable over time.

Our third finding concerned the convergent and divergent validity. In particular, the SSI globalscore was significantly associated with eating disorder and general psychopathology, and showedsignificantly higher scores in the anorexia nervosa sample, as compared with the healthy control,not-underweight eating disorder and bipolar depressive episode samples. This indicates that thestarvation symptoms investigated are related to the psychopathology, but are specific for underweightpatients. Moreover, the small but significant difference between patients with anorexia nervosa andnot-underweight eating disorders could indicate that some symptoms included in the SSI are notspecific to starvation, but are instead features of dietary restraint [5].

This study has a number of strengths, including the use of a large sample of treatment-seekingindividuals with anorexia nervosa. Moreover, the inclusion of a large healthy control sampleand a group of not-underweight patients with eating disorder psychopathology and patients withbipolar depressive episodes enabled examination of the psychometric and clinical validity of the tool.In particular, it allows us to exclude the possibility that some symptoms are related to eating disorderpsychopathology or depressive symptomatology rather than starvation.

However, the study also has limitations. The first concerns the inability to assess the concurrentvalidity with other existing tools, because no validated instruments to assess symptoms of starvationare available. Furthermore, the relatively limited clinical sample size prevented us from usingconfirmatory factor analysis or item-response theory analysis to examine the performance of itemsin greater detail. Moreover, the low number of patients in the not-underweight eating disorder andbipolar depressive episode samples could limit the representativeness of their respective populations.

nutrients

Article

The Starvation Symptom Inventory: Development

and Psychometric Properties

Simona Calugi1,

*, Mario Miniati2 ID , Chiara Milanese

3, Massimiliano Sartirana

1,

Marwan El Ghoch1

and Riccardo Dalle Grave1

1 Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo, 89, 37016 Garda (Verona),Italy; [email protected] (M.S.); [email protected] (M.E.G.);[email protected] (R.D.G.)

2 Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy;[email protected]

3 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37129 Verona,Italy; [email protected]

* Correspondence: [email protected]; Tel.: +39-045-810-3915; Fax: +39-045-810-2884

Received: 3 August 2017; Accepted: 30 August 2017; Published: 1 September 2017

Abstract: Background: Starvation symptoms are common in patients with anorexia nervosa, andaccording to the transdiagnostic cognitive behavioural theory for eating disorders, they contribute tomaintaining the eating disorder psychopathology. The aim of this study was therefore to describethe design and validation of the Starvation Symptoms Inventory (SSI); a self-report questionnairethat examines the symptoms of starvation in underweight patients with eating disorders. Methods:150 female patients with anorexia nervosa were recruited, as well as 341 healthy control subjects,30 not-underweight patients with an eating disorder, and 15 patients with bipolar depressive episodes.The 150 patients completed the Eating Disorder Examination Questionnaire and the Brief SymptomInventory. All participants rated their starvation symptoms on a continuous Likert-type scale (0–6),and reported the number of days in which they had experienced them in the previous 28 days.Results: Principal component analysis identified a single-factor, 15-item scale, which demonstratedgood internal consistency (↵ = 0.91) and test–retest reliability (r = 0.90). The SSI global score wassignificantly correlated with eating disorder and general psychopathology, demonstrating goodconvergent validity. SSI scores were significantly higher in the anorexia nervosa sample thanin the healthy control, not-underweight eating disorder and bipolar depressive episode samples.Conclusions: These findings suggest that the SSI is a valid self-report questionnaire that may provideimportant clinical information regarding symptoms of starvation in patients with anorexia nervosa.

Keywords: anorexia nervosa; starvation symptoms; dietary restraint; validity; reliability; factor analysis

1. Introduction

In the classic two-volume The Biology of Human Starvation, Keys and colleagues gave a detaileddescription of the symptoms of dietary restriction and underweight reported by 36 young malevolunteers who participated in the Minnesota Starvation Study [1]. The major “starvation symptoms”reported by volunteers included abnormal attitudes and behaviour towards food and eating(e.g., preoccupation with food and eating, ritualistic eating, cookbook and recipe collection), pooremotional and social functioning (e.g., mood liability, social withdrawal, reduction of sexual interest),impaired cognitive performance (e.g., poor concentration), and physiological changes (e.g., heightenedsatiety, gastrointestinal discomfort, cold intolerance).

The clinical observation that many symptoms reported by these volunteers were similar to thosefound in patients with anorexia nervosa improved the understanding and management of eating

Nutrients 2017, 9, 967; doi:10.3390/nu9090967 www.mdpi.com/journal/nutrients

Dieta ferreaMantieneildisturbodell’alimentazione

Dietaferrea

Abbuffate

Comportamentidicompenso

Bassopeso

Eccessivavalutazionedelpeso,dellaformadelcorpoedellorocontrollo

ab

Eventiedemozioniassociate

Scaletta


Implicazionicliniche

Visionetradizionale• Ènecessarialanormalizzazionedelpesoedell’alimentazionepereffettuareunavalutazioneaffidabiledellapersonalitàedelleproblematichepsicologichecoesistentineipazienticondisturbidell’alimentazione

• Ènecessarioilrecuperodelpesopereffettuareunapsicoterapiaefficace

Implicazionicliniche

Visionemoderna• Isintomidadigiuno,interagendoconlapsicopatologiaspecificadeiDA,aumentanolanecessitàdicontrollodell’alimentazione

Shafran etal.Behav ResTher.2003;41(8):887-94.

The interpretation of symptoms of starvation/severe dietary restraint in eating disorder patients

R. Dalle Grave*, D. Di Pauli*, M. Sartirana*, S. Calugi*, and R. Shafran*. Eating Weight Disord. 12: 108-113, 2007*

MeccanismidimantenimentospecificidelDAdeterminatidalsottopeso

Bassopeso

SintomidamalnutrizioneAmenorrea

DiminuzioneMBSensazionedipienezzaOssessionepercibo

IrritabilitàSbalzideltonodell’umore

IsolamentosocialeRidottointeressesexDeficitconcentrazione

Eccessivavalutazionedelpeso,dellaformadelcorpoe/odelcontrollodell’alimentazione

DietaferreaComportamentinondicompenso

Scaletta


Raccomandazioni

1. È necessarioimplementareinterventidiprevenzionemiratiperridurrel’incidenzadell’adozionedelladietaferrea negliindividuichesonopiùvulnerabiliasviluppareconseguenzenegativea. Adolescentidisessofemminileb. Individuiconimmaginecorporeanegativac. Individuiconelevatilivellididisinibizionecognitivad. Individuiconpreoccupazioniperleconseguenzenegativedel

mangiare

Raccomandazioni

2. Datalanaturaubiquitariadelleinformazioniscorrettesulladietaedellapubblicitàsullepratichedieteticheestremeènecessarioeducareiconsumatoriasviluppareattitudinicriticheneiconfrontidiquestimessaggieadadottareunostiledivitasalutarealternativoalladietaferrea

3. Lesocietàscientificheeiconsumatoridovrebberofarepressionesuipoliticiegliamministratoriaffinché sviluppinodeiregolamentispecificipergestirelefalseeingannevolipromessedell’industriadelladieta

Il digiuno e le diete estreme nel commercio sanitario ... · commercio sanitario: rischi sui...

Documents

Transcript of Il digiuno e le diete estreme nel commercio sanitario ... · commercio sanitario: rischi sui...