Helping families and youth treat eating disorders

March 08, 2023

Podcast Transcript:

The conversation transcript has been edited for clarity and length.

Ben Furr (BF): Welcome to the HealthChangers podcast presented by Regence, where we share real-life stories and expertise from leaders who are working to make health care simpler, personalized and more affordable. I’m your host, Ben Furr.

The rate of young people with eating disorders increased significantly during the pandemic. Eating disorders can affect anyone and are often accompanied by mental health conditions such as anxiety and depression, in addition to potentially causing lifelong physical issues.

Today on HealthChangers, we’ll learn more about eating disorders, as well as some innovative ways of treating them.

Joining us today is Dr. Mike Franz, Regence’s senior medical director for behavioral health, and Dr. Erin Parks, chief clinical officer and co-founder of Equip Health, which provides virtual family-based treatment of eating disorders and co-existing mental health conditions for patients age 6 to 24.

BF: Dr. Parks, Dr. Franz, welcome to HealthChangers.

Erin Parks (EP): Good to be here.

Mike Franz (MF): Great to be here.

BF: We know eating disorders most frequently start during childhood, adolescence or young adulthood. This is also a time when many young people are frequently on social media quite a bit and the internet. I'm curious about the connection between social media use and body image concerns. Dr. Parks, do you want to kick us off?

EP: I would love to. I'll try to be concise, but there's so much to say about this. Eating disorders is an umbrella term. There are seven different types of eating disorders that fall under that umbrella, and they all really start at some point before the age of 18. ARFID (Avoidant Restrictive Food Intake Disorder) is the newest one. You'll see that kind of start in toddlerhood. Then anorexia often starts right around puberty, which tends to be not long after people are starting to get on social media. You definitely see a contribution there.

We think there's some sort of hormonal trigger, but then you throw in this kind of overexposure to the societal-thin ideal—this idea that we should be thinking all the time about how we look. And then usually right alongside those social posts are posts about how to eat perfectly, how to eat more kale, and how to have cauliflower pizza, and you know, basically oxygen over carbs at all times.

Our kids (I mean, they truly are kids with developing brains) are being bombarded by this information. I think that social media would always be harmful, but it's even more harmful in the context of the fact that most three-year-olds—80% of three-year-olds—will identify body image concerns and will assume that thin people are better than fat people. It is so inherent in our culture, the fatphobia, that we know it by the age of three. If you finally get access to social media by 13, that is after 10 years of being told that the thin ideal is what we should be striving for. It’s kind of like that big pow at the end of 10 years or a whole decade of indoctrination into this culture.

BF: That's incredible … by age three. How do we know in terms of when we cross the line between someone being body-conscious versus having an actual eating disorder or developing one?

Most people in our culture will engage in disordered eating, which isn't the same as having an eating disorder.

EP: I love that question because almost everybody in our culture is body conscious. Most people in our culture will engage in disordered eating, which isn't the same as having an eating disorder. I usually remind people to think about it like alcohol. Most people will drink alcohol. There are a lot of people who may struggle with their alcohol, right? They're a sloppy drunk, they're a bad drunk, or it’s a maybe-they-should-cut-back type of thing.

But it's a whole other thing for someone to be diagnosed with a substance use disorder. I tell people to think less about the behaviors and more about the impact they're having on your functioning. This is especially true of teens because out of every teen who sees me, a hundred percent don't want to see me, right? They kind of want to hold on to their eating disorder. They're mad that their parents brought them to me.

And so, I'll say, let's just forget about eating food for a second. Close your eyes. On a scale of one to 10, with 10 being all the time when you're awake and one being almost never, how often are you thinking about food? And usually they'll tell me, eight … nine. And then I'll ask, how often do you want to be thinking about food? And that's when I'll usually hear a number around two or three, sometimes a five if it's a budding foodie. But that delta, that difference between how often they are thinking about food and what they want it, that is the disorder.

... that difference between how often they are thinking about food and what they want it, that is the disorder.

And I usually then say to them, what would you think about instead? And their mind is blown. They're like, whoa. And then I do that exact same game again with the body. How often are you thinking about your body? How often do you want to? And I say, our time together with this disorder is about reclaiming your brain. Let's think about food and body, the amount that you want to, not the amount that the eating disorder is making you.

BF: I like that a lot. Tapping into what the individual wants and what they're aspiring toward. I think that's really great. Dr. Franz?

MF: That's just an incredible story about what happens even with a three-year-old. I agree. I get asked all the time about social media, just in regards to general behavioral health conditions with young people, children and adolescents. I think broadly it relates to depression and anxiety and youth. I always identify the advent of the smartphone as one inflection in time where we saw an uptick. Not a causation, but perhaps a correlation around 2007 or so. And then maybe the early 2010s when we saw social media platforms like Instagram, Snapchat, TikTok and other things began to emerge, we saw another inflection point. Again, it’s correlation.

Then with COVID, we've had this epidemic on top of a pandemic that I think a lot of us have talked about. I know we've seen some increased eating disorders, at least at the health plan level in our claims and our utilization concurrent with COVID. And I suspect that, in addition to all the stress of COVID, maybe more time was spent on social media during that time as well.

But I'm curious, Dr. Parks, what are your thoughts on that whole trajectory, and also the COVID time set? And are you seeing, and do you have any updated statistics, on increased prevalence of eating disorders in young people during COVID?

EP: That is a great question. Yes, eating disorders soared during the pandemic. 70% increases. We saw inpatient units having four times the demand in a given day or week. And I have lots of thoughts as to why. I'm right there with you. Researchers talk about kids who spend more time with screens. They might be behind in developing their language skills or their reading skills. What they found is, it's not like the screen caused them to be bad at language or reading, but it was a substitute for how they would have otherwise spent their time. I think the same thing is true with social media. To an extent, I also think it causes some harm directly, not just as a time substitute.

Now I'm a kid of the 80s and 90s. I flipped through magazines that were just as airbrushed as Instagram. The difference is that in 30 minutes of reading a magazine, I would see maybe a hundred images. Now, today’s kids in 30 minutes can see a thousand images on social media. And just think about how that’s always the most recent thing you saw – a perfect image. We have the accessibility to it. It's not just when I'm in the doctor's office and I finally get to see People magazine. I remember going to the dentist and thinking, “Yes! People magazine, the thing that my mom didn't keep at home.” And I looked through it. Now you can look at these images in the morning before school. You can look during lunch at school. You can look after school. You look at it before you go to bed.

The amount of perfect or unattainable images that you see has exponentially increased.

Also, the time points throughout your day have increased. And then on top of it, it's taking away from your social interactions with actual human beings who look like human beings instead of filtered faces. So, yes, there's been a surge in eating disorders, and everything is to blame.

MF: This notion that there is a social-cultural context that interplays with the development of eating disorders; it’s always intrigued me because I’ve heard various points of view over the past couple of decades about eating disorder prevalence in other societies and other cultures. My latest reading of the literature is that it does matter, and it is pertinent whether you are raised in a more developed world where there’s more access to those types of media versus not. Of course, the world is getting smaller in that regard, where almost every culture is able to access media in a way that’s far more than they used to. Do you see a social-cultural context by country or part of the world where there's different prevalence versus say the United States?

EP: Yeah, so in the United States, you're right that it's all the same. We see that the disorder rates are the same by ethnicity, race, middle America, the coasts—all the same. I think when it comes to other countries, some of the oldest cases of anorexia were around religious piety. The idea was that if fasting for God, which is common in lots of religions, for one day is good, well then clearly fasting for two days must be better. And if I fast for three days, I'm even more pious. We saw some of the earliest documented cases of anorexia and striving for perfection around being the most religious and, thus, fasting. Now we have something else that people are striving for, which is to have the most thin body or the most chiseled body. We see eating disorders actually at the same rates in men as we do women.

We see eating disorders actually at the same rates in men as we do women.

It's whatever the ideal is. I think in other cultures, where maybe if they don't have the same social media access, we might not see the same prevalence rates of eating disorders. But they've always been there because there might be something else that’s causing you to adjust your food intake. I think the last thing I'll add, which is really new research coming out of Carolyn Becker's lab, is looking at increased eating disorders when there's food insecurity. So, we used to think eating disorders were a rich person's issue. We now know that, not only does it affect all socioeconomic levels, but if you experience food insecurity, you have higher rates of eating disorders, oftentimes bulimia. What we're seeing in some other countries is not necessarily the overall prevalence, but the prevalence of different types.

BF: We've talked a bunch about the mental strain of eating disorders. I wonder if you could touch on the effects on a person's physical health, both in the short term and the long term as well.

EP: Yes. So eating is many things, right? We talk about how eating is culture, eating is socializing. But eating is still also the fuel for our body, our entire body. When we mess with eating, and that can be by both restricting calories, but also restricting the range of foods we eat, the frequency or making ourselves vomit. Lots of teas like weight-loss teas are sold on Instagram, which are really just laxatives. These are all things that affect different aspects of our bodies.

The most harmful and common things we see are gastrointestinal. I would say easily more than 50% of the kids who we treat are having gastrointestinal complaints. If a child comes to us before the age of 12, they've usually spent about a year-and-a-half with GI getting workups before they've made it to us. It really messes with your whole intestinal system, your gastrointestinal system, when you are messing with food intake, which is logical.

The other most common thing we see is cardiac. A lot of our kids have pretty low heart rates, and we see this well into adulthood. College athletes have eating disorders at a rate far higher than the rest of the population. And this is where it always gets tricky because a lot of well-meaning physicians will say, oh, you have a resting heart rate is 44. You're such a great athlete. Well, even a great athlete, even Michael Phelps, doesn't have a resting heart rate of 44, right? That's pretty dangerous.

The good news is that we have found with full weight restoration, almost everything gets better. The one exception really is bone health. I have met 12-year-olds with the bones of an 80-year-old and that’s something you really can't get back. It’s one of the reasons to catch it early.

If an eating disorder is caught within the first three years once the symptoms start, your chance for a full recovery is quite high. But additionally, your chance for a full physical recovery is high.

If an eating disorder is caught within the first three years once the symptoms start, your chance for a full recovery is quite high.

Lastly, I think something to bring up is reproductive health. There was a woman who had been in our support group and her child had an eating disorder. She said, “I really wish my physician would've just told me to gain 10 pounds and perhaps then wouldn't have struggled with infertility so much.” It makes sense that it affects all of the body. I think the flip side is also true—just because someone is pregnant, running a marathon, or getting all As in school, it doesn't mean they have an eating disorder. Our body wants to survive. It's amazing the things our bodies will do, even when under tremendous stress, even in the middle of an eating disorder.

MF: One of the things I've seen in some of the kids who I've treated is that they have comorbid eating disorders. I haven't specialized in it, but I often work with kids who have the condition and some additional cognitive impairment, especially during the more acute or early recovery stage of their eating disorder. I've learned from eating disorder experts like yourself that it actually can get in the way of treatment at times. Certainly, with academic functioning, but also just your thoughts. There are other organ systems that are obviously very important. We think about those, but the effect on the brain and lack of nutrition, what are your thoughts on that and how that impacts kids?

EP: There are some good neuroimaging studies showing both brain shrinkage for people who are struggling with anorexia, with restricting calories, and also a lack of creating new neural pathways. Which I think is what we really see in these cognitive symptoms. People who are in the middle of their eating disorder have a very hard time learning. In some ways, it makes sense. They're not learning that we need to eat, or that we need to recover from our eating disorder. They're not learning skills to help them recover. Some of them continue to excel at school, but it's typically schooling that is very black-and-white with rote memorization, and they struggle a lot more when it comes to things you’ve got to work on and turn around.

And then this also goes to the temperament traits that we see in the brain of people with eating disorders. If I could take just like a little turn here and talk about one of my favorite set of studies. We put people in fMRI (functional magnetic resonance imaging) scanners, right? We're doing functional imaging to see how their brain responds looking at the risk and reward circuitry. One thing I'd like to compare this to is kind of like a bunny rabbit. Imagine a bunny running around with its reward circuitry firing and wanting a carrot. But if all of a sudden they see a fox,-bam, that reward circuitry needs to become silent. So, the consequence circuitry, which is a parallel pathway in the insula, starts firing and gets them back to their bunny hole. But patients with anorexia are the bunnies that never leave the bunny hole because the consequence of being eaten by the fox is so much greater than the reward of finding a carrot.

And if you ask any parent whose kid has had anorexia, they'll say the same things – I offered to find my kid a car if they would just gain five pounds. I will gain five pounds, you know, between Thanksgiving Thursday and Thanksgiving Sunday. Why can't they do that for a car? I would've killed for that.

But it's because rewards just aren't salient for people with anorexia. In a study, we put patients in a scanner and had them play a bunch of gambling tasks. And some of these people had active anorexia and some had long since recovered. What we found is that the amygdala, the emotional circuitry in the central part of our brain, fires and gets so excited for someone who's never had an eating disorder. If they win money, because we give them $20, they put it in their pocket and we say, “Win as much as you can.” A lot of people won like a $100.

For the people who have an eating disorder, they only got excited if they didn't lose the $20. The consequence of losing $20 was so much greater than the reward of winning $100.

I think that all kind of goes together with what’s happening cognitively. Certainly, starving the brain isn't good for our thinking. We all experience that if we have to miss lunch and continue working. But there's also the long-term effects of getting in the way of learning. Learning is about taking risks and experiencing consequences and rewards.

BF: Are there connections between someone who has an eating disorder and other common mental health issues such as depression, bipolar disorder, etc.?

EP: That's a great question. Yes, at this point I have either treated or been indirectly responsible for probably 2,000 different patients. And I still don't know if I've met anybody who only had an eating disorder.

One of the reasons probably goes to the Minnesota male starvation study. Another one of my favorite studies, not just because I'm from Minnesota. They took a bunch of conscientious objectors to World War II in the early 1940s. They were Mennonites and the study said, “Hey, you don't have to go in the draft, but participate in the study.” They moved into these dorms, underneath the University of Minnesota football field actually. They tracked them--everything they ate, all the exercise they did. And they systematically starved these men. What they had hoped to figure out was the best way to re-feed someone following a period of starvatio, because they knew that this often happens in wartime.

Instead, they had to end this study early because as these men started losing weight – and keep in mind most of these men were eating a lot more than many of our patients are eating – once they became underweight for their body type, their anxiety increased, their depression increased. One guy cut off a couple of his fingers, and the men began obsessively cutting recipes from newspapers. Their spouses or partners would visit them and comment about how their husband is a whole different person. And so, what we learned is that just the act of being underweight induces these personality changes, and anxiety and depression. With a lot of people, when you get them back to a healthy weight, the anxiety and depression decreased to an extent. But oftentimes it's kind of like a nice overlapping Venn diagram, where they kind of already had the anxiety and depression and the eating disorder increased those symptoms.

BF: Dr. Franz, do we find that with our region's members as well as your practice?

MF: We definitely find comorbidities, yes. I would agree with Dr. Parks. I've never met a patient who had an eating disorder and didn't also have another psychiatric condition. And that's true. That's actually the nature with a lot of psychiatric disorders, especially anxiety disorders, and there's a lot of anxiety associated with eating disorders. You know, I also see kind of an obsessive-compulsive personality trait with a lot of the folks who have eating disorders. And in our utilization data among our membership, many of these folks struggle with depression and anxiety in addition to eating disorders and are treated for those as well.

Equip’s model keeps kids and young adults who have a primary caregiver in the home in the natural setting.

A lot of the folks who come to my attention at the health plan level are those who have been in and out of residential eating disorders quite often, unfortunately for decades and often with very little improvement in overall outcomes. It can be a chronic illness, it can be episodic. But one of the things that I've really appreciated about Equip’s model, and why we brought them on as part of our provider network, is that because of those poor outcomes, we need to do something different. Equip’s model keeps kids and young adults who have a primary caregiver in the home in the natural setting. And just doing that, I think, is less traumatizing and can allow kids and families to be near their natural supports; to continue to go to school, engage in work, and not remove them for treatment sometimes hundreds of miles away, several states away.

And that can also relate back to the comorbidity issue and care needed with other conditions like depression and anxiety. It’s pretty disruptive to take a 12- or 14-year-old kiddo and place them in a treatment center far removed from everyone else. So Equip’s approach is really helpful to treat these folks holistically and address those other comorbid issues in a way that's not going to exacerbate them.

EP: I love what you said about the trauma of going away. I don't know if you all remember middle school, but I certainly wouldn't go back. I’m watching my son go through it right now. You leave middle school, and you go someplace else where they don't have the drama of middle school, and maybe they even have horses, the ocean and yoga. Of course you like it, but what you really like is that you make friends. I don't know anyone who's gone to treatment and hasn't made friends. And there's a trauma associated with spending 8, 10, 12 hours a day talking with five kids your age about the same struggles. You get really, really close and then, boom, you're leaving them and you're going back to this middle school where everyone's whispering about where you’ve been. So of course, you want to return to the residential treatment.

That is a traumatic experience that they went through. There's definitely a percentage of kids and adults where residential treatment is needed. But I do think we have a bit of a chicken and egg problem, where 50% of people who go to residential are going to have to go back. Then if you've gone a second time, then it's 60% who will relapse. If you've gone three times, it's 70%. And so, at what point are we not building a life worth living?

And I had the privilege of working in a higher level of care for a while, 10 hours a day with PHP (Partial Hospital Programming). And one of the patients said to me once, “Erin, do you hear what you're telling me? You want me to think about food in my body less, but you want me to spend 10 hours a day here talking about food in my body? So how exactly am I supposed to do this?” And I say, “Yeah, I want you making friends at soccer. I want you making friends with your after-school theater club. I don't want you spending all of your time with me talking about food in your body.” So, I'm excited about being able to support people to get better at home because that's the whole reason you're getting better – so you can enjoy your home and your life that is there, too.

BF: We've touched on this a little bit, but I'm wondering if we could take a step back and just talk through what are some of the barriers to accessing care, given just how common eating disorders are and the need both with Regence members and in general. I'm curious what those barriers are.

EP: I think one of the biggest barriers starts at the training level, right? I think health plan payers get a bad rap when I think the system that produces us providers is partially to blame. We don't learn about eating disorders. I went through way too many years of school. I think I got one one-hour lecture and all I learned about eating disorders was, “Oh, you don't really want to treat it, stay away from it.” And that's it. Was that the same for you, Dr. Franz? Did you get much eating disorder training?

MF: You know, we didn't get enough. And for psychiatry, it's one that I'm pleased to say we are much more integrated with our other medical specialist colleagues. But it was one that I was actually attracted to in training because it blurred the lines between psychiatric and medical. It's truly a psychiatric condition, but it has medical complications pretty much unlike any other psychiatric condition we have. So, in that regard, I welcomed it and it gave me a chance to truly integrate behavioral health with the rest of medicine. But I got to say I still would agree, it's an extraordinarily complex issue to treat. It does take a team, and again, Equip uses a team model. So, I'm a big fan of that. When I do have patients who have eating disorders, I make sure I bring a team of experts to do treatment beyond just myself because I know that's so important.

But having said that, just on this access issue, I would say, oh my gosh, yeah, it's really hard to find on-the-ground treatment providers. I'll use my own home area of Central Oregon where I live. Up until we brought Equip in, we tended to cobble together a nutritionist, a PCP (primary care provider) and a therapist, all from different organizations trying to work and coordinate care through those barriers of being in their own setting. And not holistically bring a treatment team that works as a single unit and has maybe the psychiatric expertise as well as the medical expertise.

When you have a virtual provider that's literally able to beam into the home and the home community and provide that entire team, it's revolutionary in what it does to increase access to those services.

I'm sure Dr. Parks is going to talk about two of their team members are engaged in peer and family support so the traditional health worker role. I mean, this is what's really needed. And you just can't find that to refer to in a brick-and-mortar setting in much of the country, certainly in rural and frontier, western United States. When you have a virtual provider that's literally able to beam into the home and the home community and provide that entire team, it's revolutionary in what it does to increase access to those services.

EP: I think a reason a lot of therapists and psychiatrists say they don't treat eating disorders is because you do need a team approach and it's so hard to put together a team.

BF: And so, in terms of the value of virtual therapy, I know one of Equip’s big focus areas is family-based therapy. Can you talk a little bit more about that in terms of approach?

I strongly believe that virtual is not just taking a session you would've had in a room and just putting it on a computer.

EP: Yes, we were fortunate in that we were virtual before the pandemic. We really built Equip in a virtual-first way. I strongly believe that virtual is not just taking a session you would've had in a room and just putting it on a computer. There are so many advantages to being virtual. One of the advantages you just mentioned is it's easier to bring the whole family. I am someone who relies heavily on my mom, my brother and my sister-in-law in addition to my spouse. If I needed to go to family therapy to help one of my sons through an eating disorder, I would want all of them to come, too. But the chance that they could all get off work, deal with traffic, find a parking spot at one o'clock on a Tuesday and come to an appointment is slim-to-none. I would just be taking the kids solo, or my husband would be taking our kids solo.

That's just practical. We would see this all the time when I was at a brick-and-mortar hospital. That the other parent or the other people wanted to be involved but the logistics were impossible. By being fully virtual, we often have at least two adults involved. It's not uncommon to have two parents involved whether they live together or they don't, but also grandparents, aunts, siblings.

It’s so nice having siblings. The siblings are the ones who are not trying to make everyone like them. So, you ask the teen and their parents, “So how did meals go this weekend?” And the teen says fine. And the parents think, “Oh, it all went well.” And then the nine-year-old says, “No, it didn't, you threw a plate out at the restaurant.” It's wonderful and fantastic. Now it's out there and we can all talk about it.

One of the joys of virtual is that you can truly bring the whole family, and everyone heals together because everyone is being harmed by the eating disorder. Certainly the person who has it, but the whole family. We can all heal together.

One of the joys of virtual is that you can truly bring the whole family, and everyone heals together because everyone is being harmed by the eating disorder.

My other favorite thing though about being virtual is that patients don't need to sit here in a chair and talk to me. I can ask them to show me their room. Go show me your pantry. Go show me your fridge. Let me have dinner with you. Let me eat a snack with you. We have a lot of meals with our families because it's easy to say that things are going well with food when food is down the hall or downstairs. It's another to watch people eat a meal.

BF: It's a whole new world and it seems like it makes it more real-time and impactful in ways that brick-and-mortar cannot achieve. I thought we could wrap up by talking about eating disorders more broadly when people are aging later in life. I’m curious about what triggers that in their lives or how those develop.

EP: While most people will develop an eating disorder in childhood or adolescence, bulimia and binge eating disorder tend to have an onset between ages 15 and 25. The majority of patients will not get diagnosed or treatment until later in life. We think about 20% are maybe getting diagnosed right now. While the other 80% aren't magically recovering from their eating disorder – they are just high-functioning.

We see this with other disorders as well. We know very depressed people who are functioning well. You know, people struggling with substances continue to function. What often happens is at some point in life, it just becomes too much. Sometimes it's after a major event. It could be losing a job or getting a job. It could be having a baby. And so, we see the stress in their life increase. And finally, their eating disorder behaviors, which like most mental health behaviors serve a purpose. Nobody self-harms for fun. Nobody drinks when they don't want to be drinking for fun. It's just that it helps them. It helps them to restrict. They feel better when they don't eat. Most of us, if we don't eat, we get hangry. We get hungry-grumpy, at least in my household. But for people with an eating disorder, oftentimes being hungry calms them down. Or vomiting. For most of us, we hate vomiting. However, for people struggling with bulimia, they'll tell you that vomiting actually makes them feel a lot better. It brings their emotions down. It's a way of self-harm or numbing. And so, people will take these behaviors with them because they're serving a purpose, and then at some point in their life, it's now starting to cause harm.

And that's when we'll finally get a call. I think one of the unique things about being virtual is how many adult men in their 30s, 40s or 50s have been reaching out to us. They say, “Hey, I've been struggling with an eating disorder my entire life. I've never had treatment because I can't leave my job. I go to websites to get help and it's all covered in butterflies and flowers. So, it just screams that this is for 15-to-25-year-old girls. It'd be pretty weird if 45-year-old me, male me, shows up and comes to a group.” I think there are also just a lot of people who, it's not that the eating disorder appeared in adulthood, it's just no treatment options did. We're excited to be able to help them, too.

MF: Serendipitously, earlier this week the American Psychiatric Association in the Journal of American Journal Psychiatry came out with their eating disorder practice parameters updated for the first time in over a decade. It was just released.

On the family-based treatment, they call it out as high-level evidence, as we now know that it really is, for anorexia specifically, the go-to treatment. And it's one of the things that really caught my attention as we were vetting virtual providers in general, but also eating disorder providers specifically. And that really sold me, if you will, on Equip. They have this fidelity to the model of treatment and thus far have had their scope of treatment for kids, adolescents and young adults with a primary caregiver in the home, which is really what's required to do for effective family-based treatment.

I just wanted to call that out. That this is really the best evidence treatment for anorexia specifically, but it can be helpful for a variety of eating disorders. This resource is available to folks, too. It’s publicly available. You don't have to be a clinician to go look at it. I think you might find it helpful and interesting.

...from 2018 to 2019 fiscal years the total economic cost of eating disorders in the United States was $64.7 billion.

And again, I would be remiss if I didn't, as a representative of a health plan, call out the financial implication of eating disorders. The practice parameters call out that from 2018 to 2019 fiscal years the total economic cost of eating disorders in the United States was $64.7 billion. That's $64.7 billion with an additional $326.5 billion attributable to reductions in well-being associated with eating disorders. There's the human cost of this, which is tremendous. But there's also a financial cost of eating disorders that is also important for us to address and to use effective, high-value treatment and treatment providers like Equip. We're just excited to be able to bring them on board so that our members can get these needs met.

EP: Well, I am so glad to be on board and your members are quite fortunate. We surveyed parents of kids with eating disorders and the average parent was over a hundred thousand dollars in debt from helping their child get care because their health plans weren't coming up with options for how they could have accessible care. They were stuck paying out-of-pocket for things.

...we cannot go through hard things alone.

I want to say something about FBT (family-based treatment) really quickly. I think people hear family-based treatment and they think, “That might be great for other families, but not for us. My teenager doesn't want me involved.” Just know that a hundred percent of people don't want you involved. Like a hundred percent of teenagers don't want their parents involved. That is normal, that's developmentally appropriate. But also, even about 65% of parents think, “I don't want to do it. Don't make me do it. They already kind of hate me. Do I really want to do family therapy with them and be telling them to eat? I'm worried about my kid’s health, which is also affecting their education. The only thing I have left is my relationship with my kid. Please don't take that away by making me be in a family therapy session with them. It's only going to make things worse.”

...people have stronger relationships between parent and kid who've gone through family therapy.

I like to share with people that, of course, this is your reaction. That is a normal reaction to have. And two things. One, we cannot go through hard things alone, whether it's depression or a divorce or a loss of job or an eating disorder. We need support. Family-based therapy is about bringing in healthy people to structure the home, to offer support and help make it easier to recover. The second is that in the end, people have stronger relationships between parent and kid who've gone through family therapy. It is yucky in the beginning. Like I shouldn't sugarcoat it. Those first four to eight weeks are tough. Your kid will be mad at you, and then your kid will thank you. And we've got some beautiful stories of kids thanking their parents, and also of parents thanking their health plans. It's incredible that you're doing this for your members, and we are so excited to be partnering with you on it.

BF: Well, thank you. I can't imagine a better way to wrap up. Dr. Franz, any final thoughts?

MF: I appreciate your time, Dr. Parks, and thanks, Ben, for facilitating today.

BF: Thank you both.

And that wraps up this episode of HealthChangers. Episodes are available on your favorite podcast platforms like Apple Podcasts, Stitcher and Spotify. Just search for HealthChangers. Thanks for listening.