Nutritional Inequities in Prisons: Investigating the Link Between Prison Food and Mental Health

Aditi Avinash
Nov 12, 2024
2 min read

The connection between food and mental health may not always seem apparent, but it is significant– particularly within incarcerated populations. Individuals in prison often face elevated rates of mental and behavioral health issues [1]. Research reveals a strong correlation between diet and mental health, showing that proper nutrition supports both physical and mental well-being. Balanced meals with proteins, protein, carbohydrates, and fats help produce neurotransmitters that assist in regulating mood and emotions. Without the necessary nutrients found in a healthy meal, one can be more prone to conditions such as “depression, anxiety, irritability, and cognitive impairment” [2].

This issue is especially relevant in prisons, where food quality is often poor, unhealthy, and even degrading for inmates. Junk food and spoilage are common, with three out of four formerly incarcerated individuals reporting rotten food on their trays [3]. For a population already experiencing poor mental health, these substandard food options may exacerbate existing issues.

It is important to note that about 95% of incarcerated people are released, so their mental health is not just a personal concern but rather a community concern [3]. Providing inmates with nutritious and proper meals aligns with an ethical obligation to treat all individuals with respect and dignity, and will improve outcomes for incarcerated people in the long run. Improving the nutritional quality of prison food could have far-reaching benefits, supporting inmates’ mental health both during and after incarceration. This shift would promote not only individual well-being but also a healthier, more resilient community as formerly incarcerated individuals reintegrate into society.

Reviewed By: Radhika Subramani

References:

[1] Mommaerts, K., Lopez, N. V., Camplain, C., Keene, C., Hale, A. M., & Camplain, R. (2023). Nutrition availability for those incarcerated in jail: Implications for mental health. International journal of prisoner health, 19(3), 350–362. https://doi.org/10.1108/IJPH-02-2022-0009

[2] Mass General Brigham McLean. “Diet and Mental Health: How Nutrition Shapes Your Well-Being.” Putting People First in Mental Health , 24 May 2024, www.mcleanhospital.org/essential/nutrition.

[3] Soble, L., Stroud, K., & Weinstein, M. (2020). Eating Behind Bars: Ending the Hidden Punishment of Food in Prison. Impact Justice. impactjustice.org/impact/food-in-prison/#report

Neffy: A Needle-Free Future For Allergy Emergency Care

David Axon
Nov 11, 2024
3 min read

For those with food allergies, every meal is a potential life-or-death situation. Yet throughout history, allergies were poorly understood and rarely treated. Reports from ancient China, Rome, Egypt, and Greece confirm that antibody-antigen interactions have existed for millenia, though the term “allergy” was only coined in 1906, by Clemens von Pirquet [1]. Despite their prevalence, scientists only came to understand the mechanisms behind allergies in the middle of the 20th century; in 1967, the crucial antibody immunoglobulin was identified. The modern standard of care, the EpiPen epinephrine auto-injector, was patented in 1977 and FDA approved in 1987 [1, 2]. Since then, the Epipen has revolutionized the treatment of severe anaphylactic shock and has saved countless lives. Nonetheless, epinephrine delivered via injection comes with challenges regarding needle use, administration complexity, and accessibility.

Neffy, a new nasal epinephrine delivery system, represents a promising advancement in allergy medicine administration by offering a needle-free option that could significantly impact emergency care for anaphylactic patients. By improving the public’s ability to administer epinephrine quickly and effectively, Neffy could positively affect anaphylaxis response times and survival rates. However, these benefits must be weighed against considerations of safety and equitable access.

With the current standard of care being injectable forms of epinephrine, people with allergies may be intimidated about using their delivery systems. In particular, many children face challenges with epinephrine auto-injectors due to needle phobias. Neffy provides a less threatening alternative: a nasal spray which might improve the willingness of patients and caregivers to administer life-saving treatment promptly. According to a survey of patients and caregivers, “72% would prefer using an epinephrine nasal spray instead of an auto-injector” [3]. Willingness to administer epinephrine has substantial effects on survival rates, as “delayed use of epinephrine during an anaphylactic reaction has been associated with deaths” [4]. Additionally, the nasal spray is both user-friendly and FDA approved, showing “greater or similar” efficacy to an auto-injector [3]. Finally, the cost provides an added benefit for those without insurance coverage—a package of 2 auto-injectors costs approximately $600-750, whereas 2 of the Neffy nasal sprays cost $498 [3,5]. Overall, a nasal delivery system may be a very attractive option to many people with severe allergies.

Despite these benefits, Neffy’s use raises ethical concerns, particularly regarding safety and efficacy. Since Neffy is a newer technology, it is crucial to evaluate whether it delivers epinephrine as effectively as injectables; the FDA approved it based on four studies (on healthy adults without anaphylaxis), but new evidence may come out to the contrary. Additional clinical trials should be done verifying Neffy’s effectiveness in patients actually experiencing anaphylactic shock, rather than just measuring epinephrine absorption. One of the biggest questions raised is whether one should prefer Neffy to a traditional auto-injector in an emergency. Many patients have used EpiPens for years and are comfortable with using them. For those who still carry an EpiPen but have decided to purchase Neffy, the dilemma of deciding between a trusted medication and Neffy may cause hesitation in a moment of distress. Even if patients carry both, they and their caregivers should have a clear plan in mind of which delivery system they plan to default to. One final concern lies with access equity: though the cost of Neffy and other innovative nasal therapies appear to be manageable, asymmetric distribution in the next few years might leave certain areas without access. Nevertheless, this is the case with many innovative treatments; with time, Neffy and other alternative nasal epinephrine delivery systems will hopefully become widely available.

With its nasal spray design, Neffy could increase accessibility and lower rates of medical errors by reducing the complexity of epinephrine administration. However, ensuring its efficacy remains crucial, as does conducting rigorous clinical trials to confirm its reliability. Future research and policy initiatives will play key roles in Neffy’s adoption. Should these concerns be addressed, Neffy has the potential to become a staple in life-saving allergy care, giving peace of mind to millions who worry about allergies daily.

Reviewed by Abby Winslow

Graphic by Haynes Lewis

References

The Cost of Thinness: Socio-Cultural Forces Behind Anorexia Nervosa

Margarita Krylova
Nov 5, 2024
7 min read

In societies that champion health and well-being, what drives so many young lives towards a relentless pursuit of thinness, even to the brink of death? Anorexia nervosa (AN) is a severe psychiatric disorder associated with “aberrant patterns of feeding behavior and weight regulation, and deviant attitudes and perceptions toward body weight and shape”.1 In industrialized countries, eating disorders are the third most common chronic disease in female adolescents. In Western countries, the rate of AN is 0.3%.2 AN sees a high prevalence among adolescent females, yet it is multifaceted in its causation, with complex intersections of biology, psychology, and socio-cultural dynamics. Notably, this disorder has the highest mortality rate of any psychiatric condition: approximately 5% of individuals diagnosed with anorexia die within the first four years of diagnosis. Morever, AN is associated with various causes of death: suicide, pulmonary disease, diabetes, liver and other digestive disease, to shock and organ failure.3 While studies indicate that genetic factors account for approximately 40-50% of the risk for developing AN, social components still play a key role by exposing individuals to distinct environments that can lead them to developing this devastating eating disorder.4

Although twin studies show that genetics contribute by establishing personal traits that may increase vulnerability to AN, the primary factor remains the social environment individuals are immersed in. Historically, socio-cultural factors—especially those tied to body image and ideals of thinness—have strongly influenced the development and persistence of anorexia nervosa, forming a complex situation that demands more than clinical treatment alone. Discussions on the socio-cultural origins of AN date back to 19785, but in the 50 years since few actionable solutions have been implemented to curb its prevalence. A cultural shift in societal standards of beauty and success is vital to disrupt the cycle that continues to trap at-risk individuals.

The societal conditioning towards thinness is alarmingly powerful. Although there is a "window of opportunity" for successful treatment during the first few years of the disorder, most young people seek help well after the eating disorder has taken root for early intervention to be effective, in part due to socio-cultural forces..6 The Tripartite Model of body dissatisfaction indicates that the sociocultural emphasis on thinness is reinforced by media, parents, and peers.4 Mass media campaigns propagate an “ideal of beauty” that endorses thinness for women, equating slenderness with success and appeal and influencing individuals, often beginning at a young age, to internalize these ideals. As Uchôa et al. reveal, a significant 45.3% of adolescents report being moderately influenced by the media. Unsurprisingly, girls are more affected, with 25.7% experiencing pronounced media influence compared to 19.6% of boys.2 These media-driven ideals exacerbate body dissatisfaction and pose an increased risk for eating disorders during a vulnerable developmental period.

The cultural contagion of disordered eating behaviors is also seen through peer dynamics. During adolescence, female friendship circles can cultivate an unhealthy focus on dieting and weight loss. Peer discussion and the ensuing social validation for losing weight often leads to a group-sanctioned pursuit of thinness, which solidifies the unhealthy idea that thinness equals beauty, within individuals. In such environments, anorexia nervosa can soon develop as adolescents strive to belong or stand out within these social hierarchies. The disorder, for some, can even become a source of identity, offering a sense of distinction and accomplishment where many peers might falter in their dieting efforts. By succeeding where others fail (at dieting, self-discipline and thinness), “the progression towards an eating disorder offers the appeal of a new adolescent identity and social distinction in the group”.6 The sense of success is further strengthened if one has genetic predisposition of having the following traits: perfectionism, the desire to correspond to a certain ideal image of oneself, instability of Ego, unstable identity violations, and reduced ability to form a picture of the future and themselves in the future.7 Personal vulnerabilities, amplified by genetic predispositions, can heighten susceptibility to the environmental triggers discissed.4

Further, these environmental triggers of anorexia nervosa are not confined to Western societies or Caucasian populations. In fact, binge eating and purging behavior are reported among Black women at least as frequently as among White women, yet AN is rarely found among Black women.8 However, differences in the prevalence or rates of occurrence of eating disorders among individuals or social groups do not mean that they are not at risk.9 Willemsen and Hoek present a case of a Black woman from Curaçao who developed AN after moving to the Netherlands. Initially, she conformed to Caribbean ideals that celebrated fuller figures, but upon exposure to Western beauty norms that idolize thinness, she changed her perception of self-worth. Mainly through television, she noticed that in the Netherlands being thin is considered attractive and that many Dutch women diet. As a result, she decided to pursue dieting and later was admitted with the AN diagnosis. This case illustrates that the patient’s ethnic background did not protect her from developing AN. It highlights the contribution of sociocultural influences, in the form of local norms regarding body size and shape, towards the development of AN. There is danger in taking too seriously the idea that some groups, particularly African-American women, are “protected” from eating problems. Assigning “immunity” to a specific group could result in the misdiagnosis and under-representation among people of different gender, racial, ethnic, sexuality and class backgrounds with eating disorders.9

Although some individuals with anorexia find a sense of community within their disorder, the stigma and isolation surrounding anorexia present substantial barriers to recovery.6 The friendships that persist at earlier stages of the disorder are frequently lost rapidly as the condition progresses, leaving the person socially isolated. Once anorexia becomes entrenched, patients often find themselves alienated from peers and friends. “Unlike other illness categories, anorexia nervosa was transformed from a clinical entity into a friend: it became Ana, a comforter – especially during the early ‘honeymoon phase’ of the disorder,” Allison et. al say. For some, anorexia nervosa forms a sense of distorted community, where “shared experiences in inpatient or day patient settings create a 'team activity' atmosphere with its covert rules”.6 The false of community that AN patients might find themselves engulfed in, delays seeking treatment or even makes treatment impossible, as the condition often becomes self-reinforcing, embedded within a sense of belonging and understanding that the disorder falsely provides.

In addition to media and peer influences, economic and political factors are also associated with control over women's bodies. The perpetuation of the thin ideal is as much an economic construct as a cultural one, perpetuated by industries that profit from women's insecurities about their bodies. These industries promise empowerment through self-improvement and control over one’s eating habits and weight — ideals that resonate with but limit women's autonomy by keeping them focused on unattainable body standards, diverting time, money, and energy away from pursuits that could foster true empowerment. This self-imposed societal pressure creates a cycle of control that aligns with patriarchal capitalism, leaving few avenues for women to escape unless systemic changes are made in how beauty and success are marketed.9

However, socio-cultural factors cannot be viewed independent of the individual psychological and genetic predispositions that heighten the risk of AN development. Research indicates that genetic influences account for over 40% of the variance in thin-ideal internalization.4 This genetic inclination combined with persistent socio-cultural messaging creates a fertile breeding ground for anorexia to thrive. While society may normalize thinness as beauty, not everyone will internalize this standard to the same pathological extent, illustrating an interesting battle between nature and nurture in the development of eating disorders. The differences in how individuals internalize beauty standards highlight the influence of diverse socio-cultural environments. In recent years, researchers have explored programs aimed at attempts to mitigate the development of AN.

A 2022 study conducted in the Netherlands found that positive body exposure, administered with the Positive Body Experience protocol, leads to “significant positive changes in attitudinal body image, eating pathology and depressive symptoms in female participants with eating disorders”, including anorexia nervosa “in a clinical setting”.10 However, what happens when the patients go back to their pre-clinical lives? Will the eating disorder return given the exposure to the same environments, social pressures, and media? Ultimately, resolving the pervasive issue of anorexia nervosa requires a holistic approach, addressing not only the individual psychological predispositions and AN patient’s environments but also the societal structures that engender these disorders.

The cost of thinness—embodied in the experiences of those struggling with anorexia nervosa—reveals a mixture of socio-cultural forces and individual genetic vulnerabilities. Acknowledging the complexity of these influences is an important step towards creating a more empathetic, informed, and equitable society where individuals are valued for their intrinsic worth rather than their adherence to unrealistic and harmful body ideals. The road to recovery and prevention is not short, nor is it without its challenges. Fundamental societal change necessitates systemic solutions that go beyond individual therapy but rather incorporate economic, political, and educational reform, reshaping the way beauty is perceived in our cultures. The ethical implications are clear. Healthcare providers must address both the biological and sociocultural dimensions of AN, while society at large must recognize its role in contributing to environmental conditions that can activate genetic vulnerabilities. Only by confronting the deeply ingrained socio-cultural forces and challenging the lucrative industries that benefit from persistent body dissatisfaction can we hope to alleviate the suffering of those grappling with AN and prevent future generations from falling into these unhealthy norms.

Reviewed by Anna Chen

Graphic by Eugene Cho

References

DMEJ

Duke Medical Ethics Journal