February 22, 2022

Improving Eating Disorder Detection and Treatment

Mindy Klowden

Mindy Klowden

February 21- 27 is National Eating Disorders Awareness Week. This week we call much needed attention to eating disorders, some of the most complex and difficult to treat behavioral health conditions. Eating disorders are a group of mental illnesses that include anorexia nervosa, bulimia nervosa, binge-eating disorder, and orthorexia[i], and are characterized by disturbances in behaviors, thoughts, and feelings towards body weight and shape and/or food and eating. The adverse impacts of starvation, extreme dieting, weight loss, and purging behaviors include severe mental and physical trauma, and are sometimes fatal.

A 2020 Deloitte Access Economics Study estimated 28.8 million Americans will experience an eating disorder in their lives. The COVID-19 pandemic seems to have exacerbated eating disorders. A study published in the Journal of the American Medical Association (JAMA) found that the number of people who were hospitalized for eating disorders in the U.S. doubled during the pandemic. Researchers attributed the increased rates, which came as early as March 2020, to several conditions of the pandemic: grocery shopping was a more “fraught” experience, exercise may have become a focus of control, the closing of schools and colleges may have helped families identify unhealthy eating, and outpatient care may have been delayed.

Eating disorders have a high co-morbidity with other mental disorders, such as anxiety and depressive disorders. Further, a literature review revealed that approximately 30 percent of patients with eating disorders had a history of sexual abuse. As I discussed in my blog Pediatric Behavioral Health Will be Top of Mind in 2022, many key leaders are calling out a national crisis in mental health for children and adolescents. Given that the 95 percent of people with eating disorders are between the ages 12 and 25, it is critical that we increase detection and treatment of eating disorders.

Young athletes, such as runners, gymnasts, dancers, wrestlers, and swimmers may be particularly at risk of developing an eating disorder. These individuals tend to be competitive by nature, may engage in unhealthy behavior to achieve accolades from coaches, or meet weight restrictions.

There is a myriad of reasons this is challenging. Stigma is a pervasive barrier for individuals and families experiencing an eating disorder to seek help. There is still a commonly held view that an eating disorder is a lifestyle choice, and that recovery means simply changing a behavior. Men face heightened barriers to seeking and engaging in treatment as there is widely held misperception that only women are affected by eating disorders; however, in the U.S. alone, eating disorders will affect 10 million males at some point in their lives.  Males represent 25% of individuals with anorexia nervosa, and they are at a higher risk of dying, in part because they are often diagnosed later since many people assume males don’t have eating disorders[ii].

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Eating disorders are also prevalent among LGBTQ populations. For example, while gay males represent only five percent of all males, they represent 42 percent of males with eating disorders. Eating disorders affect people from all demographics of all ethnicities at similar rates. Yet, people of color – especially African Americans – are significantly less likely to receive help for their eating issues.

Eating disorders can be difficult to diagnose and treat in a health care delivery system that is all too often fragmented. Clinicians may lack specialized training to treat both the underlying mental health conditions and the physical impacts of those conditions, including the ability to reverse starvation and address potentially life-threatening cardiovascular and metabolic complications. Specialty behavioral health settings such as a community mental health center, or a private counseling practice, may not have access to an individual’s serial weight trajectory, a laboratory, or electrocardiogram (EKG) to run necessary diagnostic tests. Primary care practices often lack licensed mental health counselors and the training and capacity to offer trauma-informed care.

Health insurance carriers have also been historically fragmented, so eating disorders may get lost in the complexity of legacy systems where the carrier wants to clearly define a condition as either a mental health or a physical health condition rather than the multi-faceted health issue that it truly is.

Yet another challenge is people with eating disorders must be ready and willing to accept care. According to Dr. Donald Bechtold, VP of Healthcare and Integration and Medical Director of Jefferson Center for Mental Health, “not unlike people with severe addictive disorders, people with eating disorders will go to great lengths to mask their symptoms,” such as wearing baggy clothes, or presenting for a physical ailment without disclosing information about their eating disorder.

When residential treatment is necessary, it can be difficult to access and unaffordable. Insurers often won’t authorize residential treatment until the patient arrives at the facility for in-person evaluation and is deemed “medically necessary.” According to the Deloitte Access study, there are fewer than 1,500 residential beds across the U.S. for adults and many patients must travel out of state to get care. This is particularly complicated for people with Medicaid, which does not transfer across state lines.

Fortunately, behavioral health conditions are finally in the national spotlight as there has been a growing awareness of heightened community needs and the cost impacts of mental disorders. Now is the time to improve the detection and treatment of people with eating disorders. I suggest the following strategies.

  • Enhance training for behavioral health and other providers. Behavioral health clinicians, primary care providers, schools, athletic organizations, and other child-serving agencies should have access to support in learning how to identify and treat eating disorders. SAMHSA has invested in making free training available from National Center of Excellence for Eating Disorders, but additional resources and publicity of those resources is needed.
  • Focus on whole person care. Eating disorders require integrated behavioral health and medical treatment, as well as nutrition education and self-care practices. As providers, insurance carriers, and states work to increase integrated care, improving services for people with eating disorders should be a clear goal.
  • Parity enforcement. The 2022 MHPEA Report to Congress demonstrated significant gaps in enforcement of federal parity laws that require insurance coverage for behavioral health conditions to be no more restrictive than insurance coverage for other medical conditions. As the Biden administration wrestles with how to improve compliance, parity for treatment of eating disorders (particularly in-patient/residential treatment for eating disorders) should be addressed.
  • Fix the state line limitations in Medicaid. In states with limited capacity for residential treatment of eating disorders, state Medicaid agencies should work together to ensure coverage for persons with acute care needs.

If you or a loved one are struggling with an eating disorder, contact the national eating disorders helpline, or call or text (800) 931-2237.

Contact Third Horizon Strategies if your organization or company is seeking to improve services or navigate health care policy issues related to the treatment of eating disorders or other behavioral health conditions.

[i] While not currently a DSM diagnosis, orthorexia is a concerning eating disorder.

[ii] Mond, J.M., Mitchison, D., & Hay, P. (2014) “Prevalence and implications of eating disordered behavior in men” in Cohn, L., Lemberg, R. (2014) Current Findings on Males with Eating Disorders. Philadelphia, PA: Routledge

Mindy Klowden, MNM is a national consultant, leader, and strategist in behavioral health and integrated care. She is currently a senior director with THS, where she manages client relationships and deliverables, conducts research and policy analysis, and provides strategic consulting services to health systems, safety net providers, payers, and associations.