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Individuals with eating disorders who have low income are frequently misdiagnosed and lack adequate access to appropriate therapy, according to researchers from Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons.

Their paper, published in the Cognitive Behaviour Therapist on Feb. 19, identified the barriers to care that come with having low income and offered guidelines on how therapists can make accommodations for these patients to improve diagnoses and access to treatment.  

According to the Academy of Eating Disorders, about 30 million Americans will have an eating disorder in their lifetime, which can cause medical complications and increase the risk of early death. Though people of all income levels and backgrounds can be affected, the cost of treatment—approximately $11,800 annually per patient—is out of reach for many.

“Patients with an eating disorder and low-income represent a vulnerable and overlooked group. Studies suggest that they may have more severe symptoms but are less likely to be correctly diagnosed,” said Dr. Suzanne Straebler, research associate in psychiatry at Weill Cornell Medicine and clinical director of the Center for Eating Disorders Outpatient Specialty Clinic at NewYork-Presbyterian/Weill Cornell Medical Center. “Even with an appropriate diagnosis, it is highly unlikely they will receive a recommended evidence-based treatment.”

The authors believe that educating healthcare providers is key to better identifying individuals with eating disorders and helping them overcome barriers to treatment and healing. For those with low income, these factors that often overlap may include having lower education levels; identifying as a sexual or gender minority; being part of a historically marginalized ethnic or racial group; and having limited English proficiency.

“We are trying to get more basic information out so that providers feel more comfortable and confident in identifying these cases and in making referrals for treatment,” said co-author Dr. Deborah R. Glasofer, associate professor of clinical medical psychology (in psychiatry) at Columbia University Vagelos College of Physicians and Surgeons and clinical psychologist at the New York State Psychiatric Institute’s Eating Disorder Research Unit.

Recognizing and Addressing Vulnerabilities

Patients with low income face enormous obstacles in overcoming an eating disorder. For a person who is food insecure, food banks or pantries may not have the types of food that a patient with an eating disorder needs. “Frequently, patients receive foods that they are unable to eat due to the food being a ‘feared’ or ‘avoided’ food. Or the amount is insufficient in terms of the nutrition and calories required to gain necessary weight,” said Dr. Straebler.

The authors suggest several ways to address shortcomings in the system. Therapists could help patients access government or local food resources and could engage with local food banks to educate them about eating disorders and maximize the chances of successful patient recovery.

Patients would also benefit from effective communication with treatment materials in different languages and access to interpreters during therapy. In addition, therapists need to have cultural humility—the willingness to learn about and understand different cultures. This would allow therapists to support not only patients but also include their families through the process.

Less obvious difficulties include not having adequate electricity to cook a meal or not having the technology or the private space to participate in telehealth appointments. Some solutions could include guiding patients to relevant governmental, community or charitable support resources.

“Our paper highlights the need for therapists to understand their role in helping normalize and regulate patterns of eating, regardless of an individual’s specific eating disorder or financial situation,” Dr. Glasofer said. Once healthcare professionals have the right information, they can make accommodations to help patients overcome the barriers that prevent them from healing.