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What is Anorexia Nervosa?
Anorexia Nervosa (AN) is an eating disorder that is categorized by extreme reduction in food intake. Individuals with this condition tend to avoid food, restrict food, or eat very small amounts of food. Some other common behaviors consist of obsessively weighing oneself [1]. People with AN have negative and distorted body image; even if they are severely underweight, they see themselves as overweight [1]. If untreated, AN can be fatal; people with AN have a high risk of dying from medical complications related to starvation and an increased risk of death by suicide [1]. Specifically, AN has a high prevalence among adolescent girls. Recommended treatment for this eating disorder includes hospital admissions, which are often prolonged and can negatively impact adolescent development, school and social life, and family dynamics [2]. Families of patients with AN report experiencing emotional distress, as well as, financial burdens [2].
It has been reported that, annually, the United States spends about $65 billon on eating disorders [3]. Despite this, the U.S. is facing a crisis in the care of AN. The biggest obstacles to effectively treating and providing long term support to individuals with AN are a lack of treatments that address the biology of AN, the loss of academic programs treating AN, the lack of standardize care, and the limiting insurance coverage and reimbursement. Understanding the biology of AN can help reduce prolonged hospitalizations and decrease relapse rates, which are currently approaching 50% after treatment [3]. In addition, from the healthcare and caregiver perspective, the loss of academic programs providing treatment for patients with AN serves as a big concern. Without these programs, health professionals in training will not have the necessary exposure to eating disorders' signs and symptoms to equip them with skills to identify and treat eating disorders. Another consequence that arises from the lack of academic programs is that caregivers have to turn to private programs and/or hospitalizations [3]. This, ultimately, limits access to care for families who are uninsured or underinsured. Together, these factors serve as barriers to successful and long-lasting treatment and contribute to patients' severe and long-term presentation of AN.
In 2015, a cost-analysis study was conducted that explored the economic impact of AN in adolescents- specifically, the hospital and caregiver costs for inpatient (IP) pediatric treatment from a Canadian perspective. The study included adolescents ages 12-18 who were admitted to the hospital for treatment of AN, and the results suggest that economic cost of IP pediatric hospital admission are estimated to be an average of $54,932 Canadian dollars per admission and mean length of 37.9 days [2]. When stacked against what is seen in the scientific literature, these results are close in comparison to the estimated inpatient treatment costs in the U.S. Hospital costs were shown to have a negative association with body mass index (BMI) at admission, meaning patients who were admitted with very low BMIs accrued higher medical costs, while caregiver costs were negatively associated with BMI and age [2]. The study suggests that the association between age and caregiver cost might be due, in part, to the fact that caregivers spend more time in the hospital if their child is younger and less time at work. Another issue might be the cost of child care for the siblings of patients with AN [2].
Along with monetary costs, AN also has quality of life burdens. One study found that AN had higher disability weights than chronic kidney disease or heart failure. On a scale of 0 (perfect health) to 1(death), AN has a disability weight of 0.224, whereas kidney diseases have a weight of (0.104), and heart failure has a weight of (0.179) [4]. Patients with AN have poorer mental and emotional health than the general public and an increased risk of comorbidities with their eating disorder, such as an increased risk of alcohol dependence syndrome and depressive disorders [4]. Social media also has a significant influence in promoting and glorifying eating disorders like AN, as well as, exacerbating eating disorder symptoms. Unfortunately, the Covid-19 pandemic intensified the use of social media amongst adolescents and teens and increased their exposure to pro-anorexia content [5]. Most recently, TikTok, a social media app created in 2016, has raised concerns about its influence of eating disorders among its adolescent audience and users. Despite TikTok restricting content and hashtags related to eating disorders, many users have found ways to bypass the community guidelines by intentionally misspelling certain hashtags. For example, TikTok banned the hashtag "thinspo," short for thin-inspiration, for being harmful, but users have found a loophole around this by misspelling the hashtag to "thinspao" [6]. Interestingly, a 2021 study found that anti-anorexia content on TikTok, which functions to raise awareness about AN, had a paradox effect and encouraged users to engage in self-harming behaviors that lead to AN [5].
AN is also shown to have a negative effect on childbearing and parenting. In one study, it was found that mothers who were 6 months postpartum with a history of eating disorders reported concerns about their child becoming overweight, and they were less likely, when compared to the control group, to be attentive to their baby’s hunger and satisfaction cues [4]. Maternal eating disorders have the potential to impact their child’s psychosocial and eating development [4].
It is important to understand both the economic and quality of life costs for Anorexia Nervosa to know how to effectively prevent and treat this eating disorder. In addition, it is important to consider the triggers of AN that have the potential to disrupt or undo treatment; most notably, social media is a very prevalent trigger, with even anti-pro anorexia content serving as a paradox. With restrictive and expensive treatment options, underserved and underinsured/uninsured individuals have less access to care, which increases the economic burden of the caregiver and the emotional burden of the family, as well as, decreases the quality of life of the patient. The lack of academic programs serving individuals with eating disorders negatively impacts future health professionals' ability to detect symptoms of AN early and to develop standards of care based on evidence-based treatments.
References:
1. Eating Disorders. National Institute of Mental Health (NIMH). Accessed May 18, 2022. https://www.nimh.nih.gov/health/topics/eating-disorders
2. Toulany A, Wong M, Katzman DK, et al. Cost analysis of inpatient treatment of anorexia nervosa in adolescents: hospital and caregiver perspectives. Can Med Assoc Open Access J. 2015;3(2):E192-E197. doi:10.9778/cmajo.20140086
3. Kaye WH, Bulik CM. Treatment of Patients With Anorexia Nervosa in the US—A Crisis in Care. JAMA Psychiatry. 2021;78(6):591-592. doi:10.1001/jamapsychiatry.2020.4796
4. Hoeken D, Hoek H. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden - PMC. Accessed May 21, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575017/
5. Logrieco G, Marchili MR, Roversi M, Villani A. The Paradox of Tik Tok Anti-Pro-Anorexia Videos: How Social Media Can Promote Non-Suicidal Self-Injury and Anorexia. Int J Environ Res Public Health. 2021;18(3):1041. doi:10.3390/ijerph18031041
6. Paul K. ‘It spreads like a disease’: how pro-eating-disorder videos reach teens on TikTok. The Guardian. https://www.theguardian.com/technology/2021/oct/16/tiktok-eating-disorder-thinspo-teens. Published October 16, 2021. Accessed June 14, 2022.
Contributors:
Author: Claire Mayani
Editors: Lauryn Agron and Terin Buckley
Health scientist: Claire Mayani