Inspired by World Eating Disorders Action Day, RGA’s Leigh Allen and Dr. Peter Farvolden talk about the impact and treatment of eating disorders, including diagnosis changes, frequent comorbidities, and the outlook for treatment and recovery.
In May 2024, I had the opportunity to attend World Eating Disorders Action Day, a one-day summit held at the United Nations in New York. Hosted by the National Alliance for Eating Disorders (NAED) and the Kenneth Cole Mental Health Coalition, the event brought together activists and thought leaders to dispel eating disorder myths and inspire change around our awareness and treatment of eating disorders.
According to the NAED, over 29 million Americans will struggle with an eating disorder during their lives, and every 52 minutes, a life is lost due to eating disorders.
The primary focus of this year’s summit was exploring the challenges and hurdles that obstruct access to mental health treatment for eating disorders. Access barriers are significant for many; however, they are particularly daunting for men, people of color, LGBTQ+ individuals, and those with larger bodies. Panelists recounted instances of discrimination, gaslighting, and harm encountered both in seeking access to healthcare, appropriate diagnoses, and treatment. Society’s narrow stereotype of what an eating disorder sufferer "should" look like — thin, white, female — often leads to inadequate or absent care for many who do not fit this mold. Eating disorders affect individuals across all races, genders, orientations, and body sizes.
These challenges extend to the world of insurance. Speakers at the U.N. conference called for changes to the way insurers manage complex mental health conditions like eating disorders. It remains a common practice to carve out blanket exclusions for mental health conditions. Some insurers have successfully launched virtual care, counseling, and other telehealth options to help customers with mental health challenges. As detailed in RGA’s 2023 Global Mental Health Survey, a majority of insurance leaders reported that mental health is an organizational priority and a rising customer demand.
To check in on the latest medical and psychological advances around eating disorders, I contacted RGA’s Mental Health Consultant, Dr. Peter Farvolden. Here is our conversation, which touches on changes in the diagnostic criteria for some eating disorders (EDs), frequent comorbid conditions, and how insurers can better assess risk in individuals with EDs.
Peter Farvolden: Globally, over 3.3 million healthy life years are lost each year due to eating disorders. While other mental health conditions show a different trend, the years lived with disability (YLDs) for anorexia nervosa and bulimia nervosa are on the rise.
Despite advancements in treatment, the mortality rates associated with anorexia nervosa and bulimia nervosa remain alarmingly high. Individuals who undergo inpatient treatment for anorexia nervosa face a mortality risk over five times greater than the general population. Although the mortality risks for bulimia nervosa and outpatient-treated anorexia nervosa are lower, they are still roughly double compared to general population rates.
Individuals suffering from an eating disorder experience a diminished quality of life and incur healthcare costs that are 48% higher annually compared to the general population. If they have mental health comorbidities, their yearly earnings can be 48% lower than the general population. Additionally, women with eating disorders tend to have fewer children and face higher risks of negative pregnancy and neonatal outcomes.1
Peter Farvolden: Overall, the change was an improvement to the diagnosis and treatment of AN. Physicians and psychologists strongly debated about what body mass index (BMI) cut-offs to use. Some even claimed there is no evidence to support the DSM-5-TRBMI.2 Weight and BMI are still part of the diagnostic criteria, as are associated physical and medical problems. Most people with AN present for treatment as the result of a family member or friend being very concerned about their weight. Weight loss or being “underweight” is often the presenting problem, even though it may be less emphasized in the current diagnostic criteria. People who are not underweight are much less likely to present for treatment because their symptoms are not as overtly “visible.”
Most common eating disorders can be conceptualized as an obsessive-compulsive spectrum problem. Patients obsess about being “too fat” or becoming “too fat” and the behaviors range from avoidance (restriction) to compulsions (binging and purging). The clinical picture is complicated and clouded insofar as the effects of starvation are present.
Binge eating disorder, which is now formally classified in the DSM-5-TR, seems to most often present like an obsessive-compulsive problem – people with OCD typically have difficulty starting and stopping behaviors – with or without an addiction or ritual self-soothing component. People who binge use food to manage negative emotions. They’re also responding to a global food culture that markets high-calorie foods designed to be tempting as well as easy to prepare and eat. Nothing in our evolutionary history has prepared us to manage the intake of food engineered for the purpose of getting us to consume “more.” (See this recent RGA article about obesity and the behavioral drivers that encourage people to eat more.
Peter Farvolden: There was a very recent report on psychiatric comorbidity in feeding and eating disorders.3 That report found that psychiatric comorbidity is present in more than 70% of people with EDs, before or during the acute state of illness or in the long-term course. These comorbidities include personality disorders (>53%), anxiety disorders (>50%), mood disorders (>40%) and substance abuse disorders (>10%).
Major depressive disorder (MDD) is the most frequent comorbid psychiatric disorder with EDs.4 The lifetime prevalence of comorbid depression in EDs is 94%. For a person with AN, mortality is 18 times higher when depression is present.
Treating comorbid problems like anxiety and depression in patients with eating disorders requires a comprehensive integrated approach.
Psychologists tend to recognize common dynamics among those struggling with EDs. The first is that if someone is using food and binge eating to manage their negative emotions due to a mood or anxiety disorders, then the underlying mood or anxiety disorder needs to be treated. These treatments include teaching people other ways to manage their negative emotions. Psychotherapies such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy, and Dialectical Behavioral Therapy (DBT) can also be very helpful.
People with eating disorders typically have distorted/dysfunctional thinking related to food, weight, and body image that are very resistant to change. I agree with people like University of Oxford psychiatrist Christopher Fairburn who argue that effective treatment for eating disorders involves effectively challenging the distorted core beliefs that tend to persist even during periods of symptomatic recovery.
Peter Farvolden: According to a study published in 2021, patients with eating disorders (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified) diagnosed in hospital settings experience five to seven times higher mortality rates compared with the overall population.5 Another study published in 2021 found that anorexia nervosa and bulimia nervosa carry a five or more times increased mortality risk.6
A 2023 paper suggests there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for anorexia nervosa. The authors strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, be prioritised for people with eating disorders.7
→ The mortality risk for people followed up after inpatient treatment for anorexia nervosa is over five times higher than for age-matched and gender-matched people in the general population.
→ In people followed up after treatment for bulimia nervosa, or after outpatient treatment for anorexia nervosa, the mortality risk is around two times that in the general population.
→ Anorexia nervosa, bulimia nervosa, and binge eating disorder have substantial negative consequences for the number of years lived in good health (delayed recovery, and persistence of partial/full eating disorder pathology) and for quality of life.
Peter Farvolden: In addition to decreased stigma and increased recognition, there is a lot of promise for the informed use of integrated therapy techniques to improve outcomes for people with eating disorders. Individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder frequently exhibit persistent and distorted thought patterns concerning food, weight, and body image that are highly resistant to change.
Dr. Fairburn, the British psychiatrist I mentioned previously, suggests effective treatment for EDs involves using techniques from cognitive therapy to effectively challenging the distorted core beliefs that tend to persist even during periods of symptomatic recovery. There is increasing recognition among professionals that an important part of successful recovery is eradicating these beliefs over the long term. In addition to using CBT techniques to challenge the obsessions and compulsions associated with eating disorders, therapists can use techniques from ACT and DBT to help people learn to better manage their negative emotions.
Peter Farvolden: Because of the strong prevalence of comorbidities with EDs, insurers should certainly look for evidence of those frequent comorbidities like depression, personality disorders, or substance abuse disorders. It’s also important to study where the ED appeared in their life trajectory. Just like those diagnosed with anxiety or OCD, adolescents or young adults with these conditions can recover completely. If they manage their conditions and, if recommended, take medication, they could ultimately be a good insurance risk.
Peter Farvolden: That was a fascinating finding, yes. Insurers can more accurately assess risk around mental health conditions by utilizing medical specialist staff. Given the importance of mental health issues like ED and the growing demand for mental health coverage options, we see a significant opportunity for insurers to integrate more mental health specialists across various functional areas.
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