http://www.wtol.com/story/16039249/deadly-secrets-a-mother-and-daughter-share-their-victory-over-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.

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.

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.

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/

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.