The Unhealthiness of Healthy Eating

Being healthy has always been trendy. Diets and exercise regimens have been popular for decades. With the prevalent use of social media, a person can find an online community from which they can find inspiration for their personal lifestyle goals. The culture of dieting is pervasive, common, and perhaps most importantly, dangerously acceptable. Think about the last time you heard someone say they wanted to lose “x” amount of pounds, or the last time someone mentioned they were trying a new pattern of eating for their health. It has become quite common in every day conversation, from “today is my cheat day” to “no thanks, I’m on a diet.” Intentionally choosing to eat vegetables over hot dogs every day is not inherently bad. In fact, we should encourage patients to make conscious efforts in eating delicious, nutritious foods. But what happens when we take it too far?

In the past few years, orthorexia nervosa, a pathologically disordered healthy eating disorder, has gained quite the spotlight in media coverage. It is not recognized by the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5), and not very well documented or understood. Orthorexia nervosa is not body dysmorphia nor is it necessarily always driven by pure desire for thinness. It is an eating disorder that evolves from only eating what the individual perceives is to promote good health, whether that be mainstream acceptable healthy foods, or dangerously restrictive diets. Dr. Steven Bratman, a physician who practices alternative medicine, first described orthorexia nervosa in an article in the 1997 Yoga Journal. It would not be until 2004 when orthorexia was described in the peer-reviewed journal of Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesity. Since then, there have been multiple propositions for diagnostic criteria, although none that is formally or officially used.

 

In the primary care setting, patients are often encouraged to lose weight, told that they are overweight, and advised to change their eating patterns. More often than not, patients are praised when they inform their clinician about their behavioral changes in eating a perceivable healthy diet. In a case study of a 28 year old woman who presented with severe malnutrition and BMI of 10.7, the patient was 14 years old when told by a nutritionist to cut fats from her to diet to control her acne refractory to treatments. When the patient was 16 years old, she began to eat extremely restrictive diet, having no desire to be thin nor poor body image, she began only eating uncooked vegetables and socially isolated herself as these radical changes were not conducive to social environments. She simply held to the belief that certain foods were toxic and needed to be avoided. While weight changes may result from orthorexic behaviors or may be peripherally desired, thinness is not the main reason.

 

Simply desiring to eat healthily in itself is not orthorexia. According to the literature review, “one widely accepted practice to determine pathological behavior or clinical significance is whether the behavior is interpersonally distressing or causes impairment in important areas of functioning: occupational, social, or educational. While some patients may present themselves all too readily for further evaluation (belief that they should only have 3 tablespoons of brown rice and spinach daily), some patients may evolve to develop orthorexia nervosa from an innocent desire to simply be healthy. Care should be taken by clinicians when conversing with their patients about their eating habits.

 

Below are the diagnostic criteria proposed in a literature review by Thomas Dunn and Dr. Steven Bratman himself.





Chelsea Salas  DUCOM 2020

PrEP Awareness Among People of Color

                           
During my recent community health rotation, I was curious about understanding and identifying the factors behind why certain high-risk communities were hesitant to start PrEP. Some factors that I thought of included lack of knowledge about PrEP, decreased access to healthcare, and not trusting physicians. I came across an article (Ojikutu et al.) that addressed those factors and more. The article looked at socio-demographic characteristics and barriers to PrEP use among black individuals across the United States. There were 855 participants, of which 38.2% were identified as high risk based on the stratification criteria, and 54.5 % were female. What took me by surprise was that among all participants, only 14.5% were actually aware of PrEP.


The study found that only 35.1% of high-risk patients were willing to use PrEP. Furthermore, the most common reason for lack of willingness to use PrEP was low risk perception where 65.1% of the patients in the high-risk category believed that they were not at increased risk for getting HIV. Other common reasons included not believing that PrEP would actually work, and potential side effects of the medication.


Black individuals are disproportionately affected by HIV and as a result, increasing their awareness about their risk along with the benefits of primary prevention through methods like PrEP should be explained to them more thoroughly. While improving access may be more of a long-term goal in situations like this, trying new methods such as increasing pharmacy access and online purchasing may benefit these communities. Recently, California enacted legislation stating that high risk individuals who tested negative for HIV should be informed about PrEP during post-test counseling. Having these post-test counseling sessions nationwide will be crucial to increasing patients’ knowledge about PrEP and increasing their awareness of being high risk.


Another study (Roth et al) pointed out that as of 2016, Pennsylvania was ranked ninth in the number of new HIV diagnoses, with most cases occurring in Philadelphia, where there are a variety of cultural backgrounds leading to significant racial and ethnic disparities. Of the newly diagnosed cases, 56.2% was among women and 86.4% occurred Black and Latin people.  What they found was that the overall PrEP awareness was very low at 4.9% and lower among those who had seen a physician in the last 12 months than those who had not!  This was extremely discouraging because it indicates that people of color and women actively seeking care are still not being actively informed about PrEP and its benefits, especially the those who are at high risk for getting HIV due to their risky behaviors. The only variable that was associated with increased PrEP awareness was participation in an HIV prevention intervention (specifically with HIV prevention physicians). 

All providers need to be cognizant of asking about their sexual practices and other activities that could potentially put patients at risk for contracting HIV. Physicians need to be comfortable asking these intimate questions because that’s how patients will understand how they’re putting themselves at risk, and it’s the most efficient way to educate patients about PrEP.  The disconnect between physicians and people of color is something that is creating a huge barrier to patients getting the care that they need so it is up to physicians to come up with a consistent method to ensure that every patient who may be at high risk is informed of primary prevention options, like PrEP.

Lakshana Senthilkumar  DUCOM 2020

 

Ojikutu, B. O., Bogart, L. M., Higgins-Biddle, M., Dale, S. K., Allen, W., Dominique, T., & Mayer, K. H. (2018). Facilitators and barriers to pre-exposure prophylaxis (PrEP) use among black individuals in the United States: results from the National Survey on HIV in the Black Community (NSHBC). AIDS and Behavior, 22(11), 3576-3587.

Roth, A. M., Tran, N. K., Piecara, B. L., Shinefeld, J., & Brady, K. A. (2019). Pre-Exposure Prophylaxis (PrEP) Awareness Is Low Among Heterosexual People of Color Who Might Benefit From PrEP in Philadelphia. Journal of primary care & community health, 10, 2150132719847383.