Eating disorders impact patients across race, ethnicity, gender, or income. However, patients with low income seem particularly vulnerable to barriers to evidence-based care, as they face obstacles that range from a lack of trained providers to the high cost of treatment.
Suzanne Bailey-Straebler, PhD, PMH-BC, Clinical Director of the Center for Eating Disorders Partial Hospital Program and Specialty Outpatient Clinic at NewYork-Presbyterian and Weill Cornell Medicine, recently worked with colleagues on a paper highlighting the prevalence and impact of socioeconomic disparities on people seeking treatment for eating disorders. Below, she shares how these barriers can delay or prevent care and offers practical strategies to improve access to treatment.
Most Common Barriers to Access
Individuals with low income are impacted by barriers to mental health care more than any other group. This disparity stems from a complex intersection of economic vulnerability with various other factors. One compounding issue is the significant overlap between individuals with low income being from historically marginalized ethnic or racial groups who are often misdiagnosed or underdiagnosed. Consequently, many of these individuals may be particularly hesitant to seek care, or may not realize they need care, for their eating disorder.
There also are not enough trained therapists to provide evidence-based care for eating disorders, and those who are trained rarely accept public insurance, which means the high cost of the treatment itself is a big barrier and deterrent. In addition, family-based therapy, a first line treatment for adolescents, requires that parents take the lead in refeeding their child. If a parent is not available in the evenings due to their work schedule or can’t afford to take time off from their job to come to treatment sessions, this therapy is out of reach for them. There are also further costs to consider in attending treatment, such as parking, gas, or public transportation. Even when sessions are conducted through telehealth, patients need access to Wi-Fi, which is an often-overlooked expense for patients.
How Food Insecurity Impacts Treatment
Food is a major components of our therapies. Patients, who need to regain weight, can require a tremendous number of calories to overcome their eating disorder, food insecurity can pose a challenge to that. For example, some adolescent patients may require about 4,500 calories a day to reverse malnutrition. This is incredibly costly for families. Donated food can be helpful, but it may not be the best food for weight regain, or it may be a food that someone is afraid to eat. This can disrupt the pattern of therapy because we cannot introduce foods in the way that we know is most effective. Further, patients who struggle with binge eating may find the monthly cycle of government assistance perpetuates their eating disorder symptoms. This occurs due to creating alternating periods of food abundance and scarcity, potentially worsening the illness.
Practical Strategies to Improve Access
To extend the reach of recommended therapies, we must consider the barriers our patients encounter and explore meaningful ways to help them overcome these obstacles. Strategies include:
- Improving diagnosis through challenging views on who can develop an eating disorder and using validated screening tools
- Training more therapists using more cost-effective training options like online programs
- Assuring that patients have access to nutritious foods – supporting them to sign up for government assistance and food banks
- Providing treatment in preferred languages and translate treatment materials
Most importantly, do not be afraid to have conversations about treatment barriers with patients. At first it may feel intimidating, or you may worry about offending a patient by asking about food insecurity or their ability to pay for Wi-Fi or transportation to a session. Be thoughtful in how you ask these questions, but make sure to ask them. Do it in a caring way and utilize measures that have already been validated by clinicians and people with lived experience. When we didn’t ask these questions, we didn’t know about our patients’ challenges. Now that we are asking, many more patients are able to talk comfortably about the difficulties that they face, and we are better able to help them reach their treatment goals.
Next Steps
In our clinic, we’re focused on addressing disparities among our clients and are reaching historically underserved populations by providing evidence-based therapies in patient and families’ preferred languages. We are preparing to start a group for parents that is delivered fully in Spanish, which has not been done before. We’re also continuing outreach in our local community, working to reduce shame and stigma, and helping individuals learn to identify when they need to ask for help.
