"When Are We Going to Hold Orthorexia to the Same Standard as Anorexia and Bulimia?" Exploring the Medicalization Process of Orthorexia Nervosa on Twitter.

This study contributes to understanding medicalization on social media, by using Conrad's concept of medicalization as a theoretical framework to explore the conversation about Orthorexia Nervosa (ON) on Twitter. The aim of this mixed-methods study was twofold: the quantitative component aimed to provide descriptive information on the type of tweets and users, as well as on the network structure of the ON-related conversation on Twitter, while the qualitative component aimed to explore how the medicalization of ON unfolds on Twitter by performing a thematic analysis of original tweets about ON. Quantitative descriptive findings show that the most popular hashtags associated with orthorexia include #rdchat, #psychology and #doctors, which hints to a link between discourses around ON and the medical profession. Among the most active, prominent and visible users are news accounts, a registered dietitian, a researcher, a professor and an editor. Qualitative thematic analysis shed light on the discursive process of medicalization. Some users bring about medicalization by approaching ON as a medical entity; in contrast, other users resist medicalization by describing ON as a social phenomenon. A discursive struggle emerges, where certain individuals feel confused around what constitutes ON. This leads to stigmatization of non-traditional diets like veganism, which in turn triggers complaints regarding over-medicalization. As the first Twitter investigation on ON, this study serves the purpose of providing insights into how an emerging disorder develops in society in a time of social media.

Barriers to and facilitators of diabetes self-management practices in Rupandehi, Nepal- multiple stakeholders' perspective.

BACKGROUND: Self-management of diabetes is associated with glycaemic control and adherence to medication and healthy lifestyle practices. There is lack of information on the barriers to and facilitators of diabetes self-management practices in low income country, Nepal. This study aimed to explore the barriers to and facilitators of Type 2 diabetes self-management practices taking multiple stakeholders' perspectives in Nepal. METHODS: Four focus group discussions and 16 semi-structured interviews with people with Type 2 diabetes, caregivers, health care providers and health managers were conducted from April to May 2018 in Rupandehi district of Western Nepal. They were audio-recorded, transcribed, and analysed using a thematic approach. RESULTS: Five main themes emerged that influenced diabetes self-management practices: individual factors, socio-cultural and economic factors, health system and policy factors, availability and accessibility of resources, and environmental factors. The important barriers were: lack of knowledge about diabetes self-management practices, cultural practices, insufficient counselling, lack of guidelines and protocols for counselling, and financial problems. The major facilitators were: motivation; support from family, peers, and doctors; and availability of resources in the community. CONCLUSION: Based on our findings, a multilevel approach is needed to address these barriers and facilitators. These findings will help guide strategies to develop programs that impart knowledge and skills to improve the diabetes self-management practices of people with Type 2 diabetes.

"And it snowballed from there": The development of orthorexia nervosa from the perspective of people who self-diagnose.

This study aims to include the perspective of those who share content about Orthorexia Nervosa (ON) on Instagram and self-diagnose with ON (SD-ON) to trace their development of ON, gain insights into risk factors, symptoms and recovery, and explore differences with those who do not SD-ON. This research used mixed methods, with a sequential explanatory design. The quantitative component (n = 185) aimed to identify biological, psychological, interpersonal, and contextual factors that play a role in each phase of ON development. The qualitative component (n = 10) aimed to probe how and why individuals who SD-ON feel that certain experiences have shaped their development of ON. Respondents defined ON an obsession with healthy eating and clean or pure foods, with unhealthy effects on physical, mental or social wellbeing. A minority of participants did not view ON as problematic, but as a "salvation" from chronic diseases. Three phases characterizing the development of ON were identified: onset, progression and help seeking. Regarding the onset, two routes were identified, both characterized by a snowball effect of interacting factors. Regarding the progression of ON, several symptoms were identified, with obsession with healthy eating being the most frequent one. The majority of participants were trying to lose weight during ON, but their rationale was health rather than appearance. Regarding the help-seeking phase, reasons for problem realization were identified. ON was not noticed by loved ones until major health problems occurred, this being a barrier for recovery. While most believed that recovery is possible, respondents agreed that ON is a condition that will always linger in the back of the mind. This study contributes to addressing the shortage of qualitative studies investigating ON from insiders' perspective.

"Keep Yourself Alive": From Healthy Eating to Progression to Orthorexia Nervosa A Mixed Methods Study among Young Women in the Netherlands.

This study aimed to understand the factors influencing people's choice to follow a diet considered healthy, and if and how these factors may contribute progress toward a higher (unhealthy) degree of preoccupation with healthy eating: orthorexia nervosa. This was achieved through mixed methods (interviews, n = 12; questionnaire, n = 82). The target group was young females in the Netherlands. Several biological, psychological, and social factors contribute to people's healthy eating. Having concerns about chronic conditions were found to be significantly associated with a higher degree of preoccupation with healthy eating, resulting implicated in the possible onset of orthorexia nervosa.

Genetic diversity of disease-associated loci in Turkish population.

Many consortia and international projects have investigated the human genetic variation of a large number of ethno-geographic groups. However, populations with peculiar genetic features, such as the Turkish population, are still absent in publically available datasets. To explore the genetic predisposition to health-related traits of the Turkish population, we analyzed 34 genes associated with different health-related traits (for example, lipid metabolism, cardio-vascular diseases, hormone metabolism, cellular detoxification, aging and energy metabolism). We observed relevant differences between the Turkish population and populations with non-European ancestries (that is, Africa and East Asia) in some of the investigated genes (that is, AGT, APOE, CYP1B1, GNB3, IL10, IL6, LIPC and PON1). As most complex traits are highly polygenic, we developed polygenic scores associated with different health-related traits to explore the genetic diversity of the Turkish population with respect to other human groups. This approach showed significant differences between the Turkish population and populations with non-European ancestries, as well as between Turkish and Northern European individuals. This last finding is in agreement with the genetic structure of European and Middle East populations, and may also agree with epidemiological evidences about the health disparities of Turkish communities in Northern European countries.

GSTM1, GSTP1, and GSTT1 genetic variability in Turkish and worldwide populations.

OBJECTIVE: Glutathione S-transferase (GST) variants have been widely investigated to better understand their role in several pathologic conditions. To our knowledge, no data about these genetic polymorphisms within the Turkish population are currently available. The aim of this study was to analyze GSTM1 positive/null, GSTT1 positive/null, GSTP1*I105V (rs1695), and GSTP1*A114V (rs1138272) variants in the general Turkish population, to provide information about its genetic diversity, and predisposition to GST-related diseases. METHODS: Genotyping was performed in 500 Turkish individuals using the Sequenom MassARRAY platform. A comparative analysis was executed using the data from the HapMap and Human Genome Diversity Projects (HGDP). Sequence variation was deeply explored using the Phase 1 data of the 1,000 Genomes Project. RESULTS: The variability of GSTM1, GSTT1, and GSTP1 polymorphisms in the Turkish population was similar to that observed in Central Asian, European, and Middle Eastern populations. The high linkage disequilibrium between GSTP1*I105V and GSTP1*A114V in these populations may have a confounding effect on GSTP1 genetic association studies. In analyzing GSTM1, GSTT1, and GSTP1 sequence variation, we observed other common functional variants that may be candidates for associated studies of diseases related to GST genes (e.g., cancer, cardiovascular disease, and allergy). CONCLUSIONS: This study provides novel data about GSTM1 positive/null, GSTT1 positive/null, GSTP1*I105V, and GSTP1*A114V variants in the Turkish population, and other functional variants that may affect GSTM1, GSTT1, and GSTP1 functions among worldwide populations. This information can assist in the design of future genetic association studies investigating oxidative stress-related diseases.

Translating results into action: the global impact of the World Breastfeeding Trends Initiative.

The World Breastfeeding Trends Initiative (WBTi) provides a participative framework to bridge the gaps in policies and programs on breastfeeding. This concurrent mixed-methods study investigated how and why carrying out WBTi evaluations in countries influences their breastfeeding policies and outcomes. We used data from WBTi's Global Repository to evaluate performance scores in 98 countries and conducted semi-structured in-depth interviews to investigate the impact of WBTi process, using the Managing for Development Results structure and actor-network theory. Countries that conducted WBTi multiple times seem to have better breastfeeding policies and practices than countries that have assessed only once. The central feature of the process and its subsequent impact is the dialectical interaction between the technical and political elements of the WBTi exercise. We believe that WBTi's framework is a promising monitoring and evaluation tool that could be used to engage dialogue in other public health areas.

Complex Interventions Deserve Complex Evaluations: A Transdisciplinary Approach to Evaluation of a Preventive Personalized Medicine Intervention.

Non-communicable diseases (NCDs) are the largest cause of disability and death globally. The human and financial costs of NCDs have raised questions of sustainability for many health systems. Personalized, preventive health interventions are an innovative way to address NCDs, but it is difficult to measure their effectiveness using standard evaluation methods. This article describes a novel approach to evaluation by coupling transdisciplinary methods with realist theory to design and pilot a health outcomes evaluation for a personalized medicine approach to NCD prevention in Istanbul, Turkey. Research and practice stakeholders contributed to study design, research questions, validation of results, and recommendations through interactive workshops, consistent dialogue, and reflection. They co-created a customized outcome measurement framework and recommendations that promote sustainability and continuous improvement of future evaluations. The participatory methods helped resolve the dichotomy between patient, practitioner, and researcher focus in the evaluation and improved stakeholders' data literacy. This research contributes to the body of evidence advocating for the use of non-standard methods such as transdisciplinary research to evaluate the effectiveness of complex interventions. The results of the pilot evaluation are also presented as a case study.

Incorporation of health economic evaluation into immunization policy-making in Canada: Barriers and facilitators.

INTRODUCTION: Despite the WHO recommendation that economic evidence be considered in national vaccine recommendations, this element of decision-making has been lacking or not done routinely in Canada. This study aimed to investigate barriers and facilitators to using economic evaluations in public health immunization programs decision-making across Canadian jurisdictions. METHODS: This mixed methods study consisted of a cross-sectional survey and semi-structured interviews of national, provincial and territorial public health level key informants, and of members of the national immunization research network in Canada. Barriers were categorized according to accessibility (e.g. access to human resources to conduct the evaluation) and acceptability (e.g. political resistance to using the evaluation). RESULTS: Of 63 survey participants, 12 were federal, provincial or territorial key informants (response rate 12/31, 39%) and 51 were members from the research network (response rate 51/214, 24%). Eleven stakeholders gave semi-structured interviews. All respondents support increased use of economic evaluation and of it becoming a routine part of immunization policy-making. However, 70% of the survey respondents identified limited resources (human and financial) to perform economic evaluations, and 39% reported lack of expertise to interpret economic evidence. Vaccine effectiveness and the burden of disease were seen as more important than cost-effectiveness by survey respondents and interviewees. Potential facilitators were for economic evaluations to either be conducted at the national level, or through a collaboration between provinces and territories with capacity to address shared needs so that evaluations occurred in a co-ordinated but distributed way. RECOMMENDATIONS: Barriers to incorporation of economic evaluation in immunization policy-making in Canada include lacking human and financial resources to conduct them and understanding of economic evidence. National, provincial and territorial public health actors reported that facilitators to incorporating economic evidence include developing increased capacity to conduct and use economic evaluations and establishing inter-jurisdictional systems to share the work of conducting economic evaluation and/or by national leadership.

Toward Integration of mHealth in Primary Care in the Netherlands: A Qualitative Analysis of Stakeholder Perspectives.

Background: There is a growing need to structurally change the way chronic illness care is organized as health systems struggle to meet the demand for chronic care. mHealth technologies can alter traditional approaches to health care provision by stimulating self-management of chronically ill patients. The aim of this study was to understand the complex environment related to the introduction of mHealth solutions into primary care for chronic disease management while considering health system functioning and stakeholder views. Methods: A transdisciplinary approach was used informed by the Interactive Learning and Action (ILA) methodology. Exploratory interviews (n = 5) were held with representatives of stakeholder groups to identify and position key stakeholders. Subsequently, professionals and chronically ill patients were consulted separately to elaborate on the barriers and facilitators in integration, using semi-structured interviews (n = 17) and a focus group (n = 6). Follow-up interviews (n = 5) were conducted to discuss initial findings of the stakeholder analysis. Results: Most stakeholders, in particular primary care practitioners and patients, seem to have a supporting or mixed attitude toward integration of mHealth. On the other hand, several powerful stakeholders, including primary care information system developers and medical specialists are likely to show resistance or a lack of initiative toward mHealth integration. Main barriers to mHealth integration were a lack of interoperability with existing information systems; difficulties in financing mHealth implementation; and limited readiness in general practices to change. Potential enablers of integration included co-design of mHealth solutions and incentives for pioneers. Conclusion: Stakeholders acknowledge the benefits of integrating mHealth in primary care. However, important barriers perceived by end-users prevent them to fully adopt and use mHealth. This study shows that the complexity of introducing mHealth into primary care calls for strategies encouraging collaboration between multiple stakeholders to enhance successful implementation.

Orthorexia Nervosa: Disorder or Not? Opinions of Dutch Health Professionals.

Introduction: Orthorexia nervosa (ON) is a condition that is characterized by a pathological obsession with eating foods one considers healthy and has recently been suggested as a new possible diagnosis. However, there is limited published research on health professionals' recognition, ideas and opinions regarding the diagnosis and classification of ON. Purpose: The aim of this mixed-methods study was to gain insight into the perspectives of clinically active health professionals on ON, and into their opinions on if and how the disorder should be classified. Results: Psychologists, psychiatrists, dietitians and physiotherapists in the Netherlands (n = 160) participated by responding to a self-administered questionnaire. Most health professionals (78%) reported that they thought that ON should have its own diagnosis. This opinion was more common in physical health professionals than in mental health professionals. A majority (74%) agreed that ON fits within the Diagnostic and Statistical Manual of Mental Disorders (DSM) category Eating and Feeding Disorders. Interviews with 15 mental health professionals were analyzed using code frequencies and continuous comparisons. Mental health professionals reported believing that ON is prevalent in the general population and that a separate diagnosis would have both advantages and disadvantages for health professionals and patients. Interview participants described the typical ON patient as being young, female, and highly educated; characteristics that overlap with typical anorexia nervosa and obsessive compulsive disorder cases. Conclusion: The results suggest that some health professionals from a heterogenous sample in the Netherlands think ON should have a separate diagnosis in the DSM, however, the study needs to be replicated to allow for further generalization. Methodological design of this study may be utilized in future research with similar aims. The findings can serve as a foundation for investigation of individuals' experiences of distress caused by ON, and further refinement of the diagnostic criteria.

Other side of the coin for personalised medicine and healthcare: content analysis of 'personalised' practices in the literature.

OBJECTIVES: Various terms and definitions are used to describe personalised approaches to medicine and healthcare, but in ambiguous and inconsistent ways. They mostly have been defined in a top-down manner. However, actual practices might take different paths. Here, we aimed to provide a 'practice-based' perspective on the debate by analysing the content of 'personalised' practices published in the literature. METHODS: The search in PubMed and EMBASE (April 2014) using the terms frequently used for personalised approaches resulted in 5333 records. 2 independent researchers used different strategies for screening, resulting in 157 articles describing 88 'personalised' practices that were implemented/presented on at least 1 individual/patient case. The content analysis was grounded on these data and did not have a priori analytical frameworks. RESULTS: 'Personalised medicine/healthcare' can be a commodity in the healthcare market, a way how health services are provided, or a keyword for emerging applications. It can help individuals/patients to gain control of their health, health professionals to provide better services, healthcare organisations to increase effectiveness and efficiency, or national health systems to increase performance. Country examples indicated that for integration of practices into health services, attitude towards innovations and health system and policy context is important. Categorisation based on the terms or the technologies used, if any, was not possible. CONCLUSIONS: This study is the first to provide a comprehensive content analysis of the 'personalised' practices in the literature. Unlike the top-down definitions, our findings highlighted not the technologies but real-life issues faced by the practices. 'Personalised medicine' and 'personalised healthcare' can be differentiated by using the former for specific tools available and the latter for health services with a holistic approach, implemented in certain contexts. To realise integration of 'personalised medicine/healthcare' into real life, science, technology, health policy and practice, and society domains must work together.

Nutritional habits, lifestyle, and genetic predisposition in cardiovascular and metabolic traits in Turkish population.

OBJECTIVES: Cardiovascular and metabolic traits (CMT) are influenced by complex interactive processes including diet, lifestyle, and genetic predisposition. The present study investigated the interactions of these risk factors in relation to CMTs in the Turkish population. METHODS: We applied bootstrap agglomerative hierarchical clustering and Bayesian network learning algorithms to identify the causative relationships among genes involved in different biological mechanisms (i.e., lipid metabolism, hormone metabolism, cellular detoxification, aging, and energy metabolism), lifestyle (i.e., physical activity, smoking behavior, and metropolitan residency), anthropometric traits (i.e., body mass index, body fat ratio, and waist-to-hip ratio), and dietary habits (i.e., daily intakes of macro- and micronutrients) in relation to CMTs (i.e., health conditions and blood parameters). RESULTS: We identified significant correlations between dietary habits (soybean and vitamin B12 intakes) and different cardiometabolic diseases that were confirmed by the Bayesian network-learning algorithm. Genetic factors contributed to these disease risks also through the pleiotropy of some genetic variants (i.e., F5 rs6025 and MTR rs180508). However, we also observed that certain genetic associations are indirect since they are due to the causative relationships among the CMTs (e.g., APOC3 rs5128 is associated with low-density lipoproteins cholesterol and, by extension, total cholesterol). CONCLUSIONS: Our study applied a novel approach to integrate various sources of information and dissect the complex interactive processes related to CMTs. Our data indicated that complex causative networks are present: causative relationships exist among CMTs and are affected by genetic factors (with pleiotropic and non-pleiotropic effects) and dietary habits.

International warfarin genotype-guided dosing algorithms in the Turkish population and their preventive effects on major and life-threatening hemorrhagic events.

AIM: To determine the accuracy of international warfarin pharmacogenetic algorithms developed on large multiethnic cohorts (comprising more than 1000 subjects) to predict therapeutic warfarin doses in Turkish patients. MATERIALS & METHODS: We investigated two Turkish warfarin-treated cohorts: patients with no history of hemorrhagic or thromboembolic event and patients with major and life-threatening hemorrhagic events. RESULTS: International pharmacogenetic algorithms showed good performances in predicting the therapeutic dose of patients with no history of bleedings, but they did not significantly detect the incorrect warfarin dose of patients with major and life-threatening hemorrhagic events. CONCLUSION: Although genetic information can predict the therapeutic warfarin dose, the accuracy of the international pharmacogenetic algorithms is not sufficient to be used for warfarin screening in Turkish patients.

A practice model for personalized healthcare with a public health genomics perspective.

Epidemiological and demographic transition has brought populations to an extended life expectancy in the 21st Century. The diseases of this century are complex, which stem mainly from the complex interactions of the human genome with lifestyle and environmental factors. These diseases are common, chronic and costly. Currently, the best-known prevention for complex diseases is adopting a healthy lifestyle. However, this is not achieved in many places in the world. Effective intervention models, including lifestyle changes for the prevention of these diseases, is urgently needed. In this report, we introduce a preventive healthcare model based on personalized healthcare. It is based on the application of public health genomics tools and concepts on an individual level, in order to stratify individuals according to risk groups, prevent diseases and detect them early.