Friday, January 4, 2019

Orthorexia: The extreme quest for a healthy diet

One of the best parts of being a geriatrician (a specialist caring for older adults) is to meet individuals who are aging successfully, taking care of themselves, and taking their health seriously. Well-informed individuals usually like to know if their chronic health conditions are well controlled or not.

With improved public education, it is now common knowledge that uncontrolled diabetes leads to damage to the major organs of the body, such as the heart, kidneys, eyes, nerves, blood vessels, and brain. So, it is important to ask how tightly blood glucose (also called blood sugar) should be controlled to decrease the risk of harm to these organs.
Blood sugar: too high, too low, or just right?

To answer this question, first let’s discuss how diabetes is different than other chronic health conditions. For example, a doctor can tell you that your cholesterol levels need to be below a certain number to lower the risk of heart disease. Diabetes is different. Diabetes is a unique condition in which both high and low glucose levels are harmful to the body.

Diabetes control is measured as A1c, which reflects average blood sugar levels over the past two to three months. High glucose levels (A1c levels greater than 7% or 7.5%) over a long period can cause damage to the major organs of the body. However, medications and insulin that are used to lower glucose levels can overshoot and lead to glucose levels that are too low. Low glucose levels (known as hypoglycemia) can result in symptoms such as rapid heartbeat, excessive sweating, feeling dizzy, difficulty thinking, falling, or even passing out.

So, both high and low glucose levels are harmful. Thus, diabetes management requires balancing the risk of high and low glucose levels, and requires constant assessment to see which of these glucose levels is more likely to harm an individual patient.
Different blood sugar goals over a lifetime

The next consideration in answering the question about tight glucose control is to understand why younger and older adults need different goals. In younger individuals, longer life expectancy means a higher risk of developing complications over many decades of life. Younger adults typically recover from hypoglycemic episodes without severe consequences.

On the other hand, people in their 80s or 90s may not have several decades of life expectancy, and so the concern about developing long-term complications due to high glucose levels is decreased. However, hypoglycemia in these individuals may lead to immediate consequences such as falls, fractures, loss of independence, and subsequently a decline in quality of life. In addition, tighter control of diabetes frequently requires complicated treatment regimens, such as multiple insulin injections at different times of the day or a variety of glucose lowering pills. This further increases the risk of hypoglycemia, as well as stress, to both older patients and their caregivers at home.
Identifying the “why” of blood sugar control

Thus, when considering goals for blood glucose in older adults, it is important to ask why we are managing diabetes. As the reason to tightly control diabetes is to prevent complications in the future, tighter control of diabetes could be a goal in an older adults who are in good health and have few risk factors for hypoglycemia. Hypoglycemia risk factors include previous history of severe hypoglycemia that required hospital or emergency department visits, memory problems, physical frailty, vision problems, and severe medical conditions such as heart, lung, or kidney diseases.

In older individuals with multiple risk factors for hypoglycemia, the goal should not be tight control. Instead, the goal should be the best control that can be achieved without putting the individual at risk for hypoglycemia.

Lastly, it is important to remember that health status is not always stable as we get older, and the need or the ability to keep tight glucose control may change over time in older adults. Goals for all chronic disease, not just blood sugar control, need to be individualized to adapt to the changing circumstances associated with aging.
The pursuit for the healthiest diet continues. Just as I was finishing writing this blog post, a new study came out suggesting that both low-carb and high-carb diets may shorten lifespan. In the 1980s and ‘90s, we were following the low-fat trend. These days, the ketogenic diet and the very-low-carb diet are all the rage. And if you think there is controversy about the right amount of carbohydrates, fats, and proteins you should eat, the conversation can get downright ugly if we start talking about specific items like gluten. Research continues to look for insight into the best diet for humans. But the relentless focus on diet and health may lead some people to obsessively seek a perfect “utopian” diet, a condition called orthorexia.
The difference between healthy eating and orthorexia

Orthorexia, although not yet recognized as a disease, is the obsessive fixation on healthy food and healthy eating. People with orthorexia are often on a stringent diet and may have anxiety about how much they eat, how certain foods are prepared, and where those foods came from. This behavior has hints of obsessive-compulsive disorder and anorexia nervosa. Some people feel very guilty if they do not follow the rigid plans they originally designed to have a healthy diet. Their lives are too focused on healthy eating, and they hardly ever have dinner with friends. They prefer starvation to eating “impure” foods. The result is social isolation and hours spent preoccupied and anxious about what to eat. It is important to note that people who choose to eat a specific diet for religious or environmental reasons, or to protect animal welfare and agricultural sustainability, are not considered to have orthorexia.
Cultural shifts about healthy eating

Growing up in the ‘80s, I hardly knew anyone who had dietary restrictions. Today it is very common to know people who strictly avoid certain foods. There are several theories to explain this new phenomenon: exposure to more toxins and chemical products in our foods; the advent of genetically modified organisms; the modern, more hygienic way of living (which is also blamed for the rise of allergies, asthma, and autoimmune diseases). But others think it may be partially related to the increased recognition and awareness of healthier habits and the significant influence of social media, blogs, health magazines, and clinicians who pontificate ideas of what is right and wrong in the nutritional world. All these factors, added to the avalanche of contradictory studies published almost daily about what we should eat, create the perfect storm for those who may have anxiety about health and avoiding illness.
When the quest for a healthy diet leans toward orthorexia

For those who have documented medical reasons to do so (for example, food allergies or celiac disease), a restricted diet is essential and sometimes lifesaving. But if you do not have much reason to support a restricted diet, and a rigid eating pattern negatively impacts your life and relationships with friends and family, consider looking for medical help, ideally a mental health clinician with whom you can talk about your concerns and underlying fears. Relaxation training, behavior modification strategies, and medications may also help with obsessive and compulsive thoughts. Try to avoid reading blogs and books from people who have radical opinions regarding specific food items. The information era has brought great advancement in publicizing tips about a healthy lifestyle, but the broadcast of extreme views may not be so healthy. Of course, eating a lot of sugar, flour, and red meat every day, all day, will not help you live a long and healthy life, but it doesn’t mean you can never touch them.

Most of the population will never need to avoid specific foods. If you suspect you might have a problem with a specific food item, before you make a final decision about eliminating it, first consult with your doctor. The aspiration to eat a healthy diet is not a problem in itself, but when these thoughts are excessive it may undermine the original goal. Food is one of the great pleasures in life; it is connection, it is culture, it is something to cherish. We should avoid going overboard toward notoriously unhealthy items, but we should be able to eat the most comprehensive diet possible. For most of us, eating nutritionally dense whole foods, mostly vegetarian and non-processed, rarely causes problems.

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