The pressure to be perfect can be overwhelming. A mother and daughter share their inspiring story of overcoming an eating disorder with treatment at the River Centre Clinic. Dr. Brithany Pawloski speaks to Chrys Peterson in a special for a story: “Deadly Secrets: A mother and daughter share their victory over eating disorders” on WTOL television.
http://www.wtol.com/story/16039249/deadly-secrets-a-mother-and-daughter-share-their-victory-over-eating-disorders
A recent New York Times article entitled “Eating Disorders a New Front in Insurance Fight” highlighted a new battleground in the insurance wars over mandated coverage for mental disorders. According to author Andrew Pollack, there has been an insurance company push-back against managed care mandates by not covering residential treatment for eating disorders or other mental or emotional conditions. The insurance position is that residential treatment is not only expensive but the results are unproven. Many insurers have written residential treatment out of policies and no longer “flex benefits” to allow less expensive residential treatment in place of inpatient care. The result has been an increasing number of denials for residential treatment. At the same time, inpatient treatment, although typically covered by insurance, generally only covers medical stabilization. It does not permit enough time for anorexia nervosa patients to gain sufficient weight to have a hope at recovery or for those with severe cases of bulimia nervosa to gain control of chaotic eating patterns. It has been our experience that the trend toward authorizing fewer treatment days has bled into coverage for Partial Hospitalization Treatment (7 hours a-day, 5-days-a-week). With some insurance companies, we find ourselves arguing daily about whether or not an 80 pound patient should step down to a lower level of care. This is horribly wasteful of the time we would like to be devoting to patient care and it is a source of incredible anxiety to the patient who cannot focus on treatment because of continual worry about whether or not benefits will be precipitously cut off. It is ironic that restricting benefits would be occurring at the time when parity was supposed to solve insurance inequities. The problems with the move to increasingly restrict insurance benefits have clear ramifications for those suffering from eating disorders.
It is very unlikely that a person can actually overcome anorexia nervosa as a result of a brief hospitalization. Weight restoration to an appropriate body weight is a consistent predictor of long-term recovery and this can only be achieved over a period of time and with a high level of nutritional support. Even the best inpatient programs do not achieve a rate of weight gain of more than 2-3 pounds a week. Therefore, if a person needs to gain 20 pounds to achieve a body weight that gives them a reasonable chance of recovery, this will take 7 to 10 weeks- period. The length of stay should be a simple matter of arithmetic and insurance companies should be primarily concerned about whether or not providers are achieving the benchmarks for care .
The “medical necessity” criteria are irrational since the focus should be on the disorder that created the serious medical symptoms. Can you imagine treating diabetes in the same manner? Only treat the diabetic hyperglycemic coma or the kidney damage, but neglect management of insulin and blood sugar levels over time. The medical necessity criteria fail to differentiate the medical severity of the illness (i.e. high death rates, high morbidity) from medical complications (i.e. electrolyte disturbances or orthostatic hypotension). Acute medical complications must be addressed but do not reflect the medical severity and treatment needs of the condition. Rather than simply normalizing electrolyte levels, it is necessary to address the chaotic eating patterns and purging behaviors that underlie these laboratory abnormalities, and this takes time. Managing any chronic condition takes an investment in long-term care and, if this is done responsibly, it saves the insurer money.
Killing the goose that laid the golden egg
Some of the current mess with insurance coverage rests squarely with providers. First, some residential treatment has been so outlandishly expensive that it has led to insurance push-back that has resulted in denials to program that are more economical. If a course of treatment costs $200,000, it becomes a red flag for an insurer. If the same outcome, using objective measures, could be achieved for $25,000, then it is no wonder that insurers are bucking at the exorbitant price tag and refusing to pay. Second, even though it is well known that achieving symptom control and discharging someone with an eating disorder at an appropriate body weight are the best predictors of long-term outcome, some residential programs do not focus on these benchmarks of care. What are the treatment outcomes for each center competing for insurance reimbursement and why are these objective data not readily available to insurance companies so that they can choose the most effective and economical treatments available?
So, where do we go from here? According the New York Times article, the case requiring insurers to cover residential treatment is under review by the United States Court of Appeals for the Ninth Circuit which ruled in August that insurers in California must pay for residential treatment for eating disorders. While this ruling applies only to California law, it is being closely watched all over the country since it may set a very important precedent for other states. In the meantime, it can be very difficult indeed for patients and their families to secure the residential treatment they need while all parties wait for the judicial ruling. One alternative is partial hospitalization since it has been shown that it can achieve excellent results in many cases eliminating the need for residential or inpatient care. However, for children under the age of 18 and who have to travel some distance to get the specialized treatment they need, partial hospitalization is not appropriate since the young person cannot be left in an independent care setting outside of treatment hours.
We have heard many heart-wrenching stories about insurance denials and sharing your own story may help others to cope with the hardships they are facing. If you have a story to tell about your experiences with insurance, please contribute to this blog. Also, to be fair, for those who have incredibly positive insurance experiences, please let us know about this as well. We deal with insurers every day who show competence, kindness and compassion in delivering the care that is needed for those suffering from eating disorders.
Next week is Eating Disorders Awareness Week- a laudable observance. The National Eating Disorder Association completed a survey in October of 2010 that shows an increase in public awareness of eating disorders. Though this is initially cause for celebration, the findings indicate that respondents’ knowledge about eating disorders has not increased. This lack of knowledge continues to plague not only the community at large but the medical, psychological, and health fields. Actually having knowledge about the precipitating and maintaining factors of eating disorders is crucial for clinicians as well as sufferers in order to move forward toward the best outcomes possible.
Awareness is enlightening but knowledge is power. It is vital that clinicians, as well as, the general population receives information that propels us beyond simple awareness that eating disorders exist. It is essential for widespread access to the knowledge base about treatment options, particularly what constitutes effective treatment. Knowledge regarding the detrimental aspect of dieting is essential for the prevention and treatment of eating disorders. Previous posts on this blog have explored this topic in detail and provide access to existing knowledge about the topic. Furthermore, those struggling with an eating disorder need to have information about their own attitudes, the cultural milieu and certain family risk factors that may have contributed to their risk for having an eating disorder.
To move beyond awareness of eating disorders takes meaningful self-examination as well as a desire to change. One reason that true knowledge about eating disorders has not increased is that it may create discomfort because of the implications for change. In depth knowledge of topics such as dieting, health, harmful ideals for beauty and exercise can cause extraordinary discomfort because the facts are inconsistent with continued pursuit of an unrealistic body weight. In other words, failure to accept one’s own healthy weight can lead to active resistance to the uncomfortable truths required to build a base of knowledge. The bottom line is that awareness and education are critical to overcoming an eating disorder; however, it is necessary to carefully examine potential sources of resistance to “uncomfortable truths” that may stand in the way of true knowledge.
Most seeking treatment at eating disorders centers are casualties of restrictive dieting and many have had a painful history of being teased, ridiculed and bullied for being overweight or obese. Studies have shown discrimination against the obese affects opportunities in housing, college admission, employment, job advancement, marriage and medical assistance. Fat discrimination may be one of the most often overlooked civil rights issues in America today because it is mistakenly believed that obesity is simply a consequence of poor self-control. Rather than continuing to offer obesity treatments that are ineffective in the long-term, there should be greater emphasis on exploring treatments designed to improve the self-esteem, self-acceptance, quality of life and health obese individuals without requiring prolonged or severe caloric restriction that greatly increases the risk of developing serious eating disorders.
It is very difficult for someone who spent years fighting their weight to suddenly accept the notion that significant weight loss is unrealistic. Giving up weight loss as a goal may be viewed as a surrender to self-loathing, and relinquishment of hope for a degree of self-acceptance that most thin people take for granted. In fact, the suggestion that weight-loss should be abandoned is often met a grieving reaction: denial, anger, bargaining, depression and, finally acceptance. Parting with the weight-loss myth is painful, but perhaps not as painful as lifelong pursuit of false hope and the delay of positive lifestyle changes that can improve health and well-being.
Contrary to the relentless declarations by the weight loss industry, for those who are heavier than average, improvements in health and self-image do not have to wait for a thinner physique. Several strategies can be helpful. First, weight charts are irrelevant in determining what you should weigh. They say a lot about the population but tell you little about the factors that have determined your own weight. Second, it is well established that modest exercise has a profound effect on health and longevity. Fitness plans that are geared for diminutive body sizes may be inappropriate for those who are obese and there are now exercise programs designed specifically for large women. Third, changes in eating patterns may improve health. Reducing the consumption of dietary fat, sodium and alcohol may have a positive effect on health without requiring weight-loss. Fourth, discrimination against obese individuals is rampant. When faced with weight-related ridicule or pressure by others (spouse, parents, friends and employers), it must be recognized that the solution to prejudice is not to change your shape, but rather, to demand fair treatment from others. It is time for greater emphasis on acceptance of fatness and concentration on the civil rights of the obese with efforts at public education to counter the social stigmatization associated with fatness. Socially disadvantaged minority groups have rarely prevailed by accepting their socially prescribed role and trying to erase their distinctive physical features. The eradication of prejudice and misinformation must begin by repudiation of destructive stereotypes and the inculcation of dignity and self-respect as with other minority group members.
A common objection to raising doubts about the universal mandate for weight reduction is that this may unleash an epidemic of obesity. Similarly, it could be argued that promoting “self-acceptance” among the obese might lead them to relax their dietary vigilance and gain weight. There is little evidence for these contentions. The literatures on the biology of weight regulation and the genetic basis for obesity suggest that the vast majority of individuals need not worry about becoming obese. Contrary to the relentless declarations by the weight loss industry, for those who are heavier than average, improvements in health and self-image do not have to wait for a thinner physique.
Obesity is viewed as a common condition in the United States. The US Department of Health and Human Services estimates that the prevalence of obesity for adults aged 20 years and older is about 34% and has doubled among adults between 1980 and 2004 (1). If there is good news in the estimates it is that the dramatic increase in obesity may have peaked since there has not been a significant change in the prevalence since 2003-2004.
The enormity of public alarm about obesity is reflected by the estimated $60 billion spent annually in the United States on weight loss products and services (2). While the diet industry still commands enormous profits and professionally led weight control programs are the standard treatment offered to those presenting with obesity, in the past 20 years there has been a growing wave of public discontentment with both commercial and professional programs over the past several years. There have been Congressional and FTC hearings charging the commercial dieting industry with misleading and fraudulent advertising; however, we are still flooded by false and deceptive claims for weight loss miracles. Just enter “diets” in your Google search bar and wade through the tsunami of ads that range from the pseudo credible to the bizarre.
There is seeming unity in the scientific community in condemning deceptive advertising; however, scientists remain sharply divided on the fundamental question of whether traditional behavioral and dietary treatments should be the standard offered to obese individuals. The traditional approach has been sharply challenged recently by reports suggesting that for the vast majority of people: 1) dieting is ineffective in producing lasting and clinically significant amounts of weight loss, 2) dieting is no match for the genetic and biological factors that resist permanent weight loss once obesity has occurred, 3) dieting may aggravate health risk factors associated with obesity, and 4) dieting can lead to serious side-effects such as binge-eating and depression. Traditionally, the only type of treatment offered to obese people has focused on reversing the obese state. It is either stated or implied that maintenance of significant weight loss is a realistic and that failure to maintain weight-loss does no harm. Both of these assumptions are inconsistent with much of what we know. There is evidence that binge-eating, wide fluctuations in body weight, negative mood changes and certain health problems may be a consequence of self-initiated and professionally led diet programs. We will have more to say later on this blog on these discussion points.
(1) http://www.cdc.gov/nchs/data/databriefs/db01.pdf
(2) Market Data Enterprises, http://www.marketdataenterprises.com/
It could be argued that the high percentage of women who are dieting may reflect that this behavior is relatively benign. The evidence does not support this view. Prospective studies indicate that body dissatisfaction and restrictive dieting are powerful predictors of the development of full-blown eating disorders as well as partial syndromes characterized by dangerous weight-controlling behaviors such as self-induced vomiting, fasting and laxative abuse. The magnitude of risk is considerable with 15-year-old girls classified as “dieters” having an eight times higher risk of developing an eating disorder compared to “non-dieters” and the risk is about 18 times higher for those classified as “severe” dieters.” The starting point for risk can be traced to maternal eating behavior. Prospective studies of mothers and their newborns indicate that maternal dieting and eating disorder symptoms are strong predictors of the development of early childhood eating disturbances.
There is a risk of oversimplifying the relationship between body dissatisfaction, dieting and eating disorders. Other variables such as media exposure to thin-ideal body stereotypes, internalization of the thin ideal, social comparison, self-esteem, family support and perfectionism have been shown to improve the prediction of body dissatisfaction and dieting. For example, perfectionistic women who perceive themselves as overweight engage in extreme dieting and bulimic symptoms more often if they have low self-esteem. They seem to doubt their ability to achieve their high standards. In contrast, perfectionistic women with high self-esteem seem to be protected from severe dieting and bulimic symptoms. Studies of Eating Attitudes Test (EAT-26) results from normal twin pairs has provided evidence for a substantial genetic contribution to body dissatisfaction and eating concerns.
Finally, understanding the role of dieting as a risk factor for eating disorders must reconcile the fact that trying to lose weight is endemic to young women in Western culture; however, it leads to the expression of eating disorders in only a small fraction of the population. However, this observation could also be applied to the association between cigarette smoking and cancer; it should not be used to minimize risks associated with dieting.
One of the strongest predictors of dieting in pre-adolescents, adolescents and adult women is body dissatisfaction. Body dissatisfaction and dieting behaviors have been fostered by a clash between unrealistic cultural imperatives to be thin and biological realities that preclude most women from ever achieving the shape standards portrayed in popular women’s magazines. In the past 50 years, the perceived cultural ideals of feminine beauty have become even thinner with the burgeoning dieting and weight loss industry successfully marketing the vision that ultra-thin shape ideals are attainable. This is evidenced by the industry’s annual revenues in North America, which are estimated between $35 and $50 billion. There is compelling evidence that women in Western culture increasingly have been socialized to view their body weight or shape as a marker for attractiveness, self-esteem, social desirability and competence. The impact of Westernization and globalization has propagated the gaunt standard of beauty to non-Western countries and has, coincidentally, led to the proliferation of dieting and dieting disorders. Studies have shown that as young women from other more weight-tolerant cultures (e.g., Egyptian, Japanese, and Chinese) are assimilated into “thinness-conscious” Western culture, weight concerns and dieting behaviors in the previously weight-tolerant cultures increase.
The term “dieting” can have different meanings. It can refer to attempts to limit certain types of foods for medical or health reasons (e.g. dairy products in lactose intolerance) with no intent of weight loss, or it can denote restricting amount eaten for the purpose of weight loss. Dieting can refer to behaviors designed to lose weight or, “cognitive restraint,” where the individual has a clear intent to lose weight, but this may not be evident in specific behaviors. Finally, dieting in an attempt to lose weight can be defined as “healthy,” such as moderate limitation of food intake, or “unhealthy,” such as fasting, vomiting, etc. The term “dieting” will be used for the purpose of this discussion to denote the intent to restrict food intake in order to reduce body weight without designating whether or not the behavior is “healthy” or whether or not it actually results in weight loss unless these factors are specifically relevant to the topic of discussion.
The impetus for dieting among women appears to have several key sources. First is the concern regarding the increasing prevalence of overweight and obesity and associated health risks observed in many countries. This source has led to public health campaigns to remedial or prevention efforts by recommending limiting caloric intake. The second motivation is the pursuit of improved health. A third, more pernicious, motive is the mounting pressure on women to be thin in order to meet cultural ideals for physical attractiveness. The mass media’s emphasis on ultra-thinness as a standard for beauty in Western culture has been linked to the high prevalence of body dissatisfaction and restrictive dieting among adolescent girls and women. It is well documented that individuals who are dissatisfied with their body weight are at a significantly higher risk of developing eating disorders. Along with the pervasiveness and risks of dieting, there is also evidence that weight-loss efforts may backfire by leading to mental and physical and health problems as well as higher weights over time. Ironically, rather than a solution to obesity, dieting may actually be one of the causes. Since restrictive dieting is the standard treatment recommendation for overweight and obese individuals, consideration of the potential risks of dieting is of utmost importance in any comprehensive discussion on the topic of obesity.
One of the most important advancements in the treatment of eating disorders has been the dissemination of evidence-based practice guidelines from the American Psychiatric Association (APA) in 2006, the National Institute for Clinical Excellence (NICE) in 2004, and the Evidence Based Practice Center in 2006. These clinical practice guidelines provide clinicians with specific treatment recommendations based on the best available empirical evidence. Where evidence is lacking, they provide recommendations based on the consensus view of experts in the field. Treatment centers should endeavor to follow these guidelines where possible. They should also be dedicated to improving clinical practice by evaluating therapeutic outcomes using well-established measures of change. Data should be collected prospectively using standardized measures that can be used as a benchmark for progress and to determine the outcomes and effectiveness of current practices. Patient evaluations of treatment are also part of routine assessment, and are used to assess the effective components of treatment, as well as to evaluate therapists for the purpose of remedying deficits and adding new skills.
