Responding to the Call for Accessibility: Breaking Down Recent Findings on Telehealth Vs. In-Person Eating Disorder Treatment During COVID-19 In Plain Language
Written by Samantha Spoor B.S., Former Study Coordinator, Current PhD Student at University of Wyoming and Dr. Cheri A. Levinson, Ph.D.
The COVID-19 pandemic has posed unique challenges for those with eating disorders , particularly for those seeking support, and for providers who have had to adapt treatment delivery (e.g. virtual, hybrid; telehealth) to attend to barriers to treatment access associated with the pandemic. Most treatment centers responded to the pandemic by moving services either fully or partially online. However, we do not have a lot of science behind this transition. So we sought to change that.
Members of our team at the EAT Lab recently published an article in partnership with the Louisville Center for Eating Disorders (LCED1) Intensive Outpatient Program (IOP) evaluating outcomes for in-person versus telehealth treatment formats prior to and during the pandemic. In other words, we wanted to know, does telehealth intensive treatment (3 hours a day, 5 days a week) for eating disorders work? We expect that a lot of treatment moving forward will be delivered over telehealth, so it’s a very important question to answer!
Read the full article here.
To make these important telehealth vs. in-person IOP treatment findings from LCED accessible and understandable, this blog post replaces highly scientific language with a plain language summary of the findings below. We also provide additional comments about why these findings are important and what they show us about the ability of the eating disorder field to increase access to eating disorder treatment through the use of telehealth.
Background: COVID-19 led to BOTH 1) more eating disorder symptoms and diagnoses in the general public and 2) worsening eating disorder symptoms for those who had already had an eating disorder (Phillipou et al., 2020; Schlegl et al., 2020). Further, the pandemic also led to increased barriers to accessing treatment, such that in-person treatment delivery became harder to implement while following public health guidelines, and posed a potentially higher risk of contracting COVID-19 for patients with EDs. Lastly, not a whole lot is known about delivering intensive ED treatment (particularly IOP) virtually!
Purpose: We were interested in finding out whether moving the traditionally in-person IOP program to virtual in response to the COVID-19 pandemic would affect treatment outcomes. In other words, we were interested in the following questions: 1) Will eating disorder, depression, and anxiety symptoms decrease from admission to the IOP program to discharge, and 2) Will they decrease similarly regardless of if the treatment is in-person or fully online (telehealth)?
Participants (Who): Overall we had 93 participants with eating disorders go through the IOP program. About 60 patients received in-person (traditional) IOP treatment prior to COVID-19 and about 33 patients received virtual IOP treatment during COVID-19. These patients completed outcome measures of eating disorder symptoms, anxiety, and depression before and after treatment and agreed that we could use their data for research purposes. This sample of patients included individuals with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Otherwise Specified Feeding or Eating Disorder (OSFED), and Avoidant/Restrictive Food Intake Disorder (ARFID). In other words, patients with a wide variety of ED diagnoses participated in the research reported in this paper! Patients also reported a variety of other psychiatric diagnoses (in addition to ED diagnoses). Check out the article for figures and tables showing the breakdown of diagnoses!
Procedure (How): Treatment for those enrolled in the IOP program prior to the COVID-19 pandemic participated in treatment on average for 10 weeks. All treatment was in-person. For those who enrolled during COVID-19, the same exact treatment format was implemented, but the delivery was completely online and virtual.
Measures (What): For this study, we included measures of body mass index (BMI), and eating disorder, depression, and perfectionism symptoms as outcomes. You can read more about the specific scales we used in the full paper, but these were chosen because they are all important features of eating disorder treatment outcomes. For example, perfectionism has been shown to be intimately involved in eating disorders (Bardone-Cone et al., 2007).
Analytic Approach: We also ran statistics to determine if there were any major differences in our outcome measures at the start of treatment (reminder: BMI & eating disorder symptoms, depression, or perfectionism symptoms) between those who started treatment prior to COVID-19, or after COVID-19 (there were a few - see below). Repeated Measures ANOVAS (Click to learn more) were used to assess if there were significant differences in outcomes for those who received virtual (during COVID-19) or in-person (prior to COVID-19) IOP treatment. This means- we tested are there differences in how well the IOP treatment works that depends on format (in-person or telehealth)?
Results: The only significant differences between the virtual vs. in-person groups at the start of treatment were that the in-person group was more concerned than the virtual group was with two aspects of perfectionism that we measured: parental expectations and criticism. This result does not really mean much, but we always test for differences between groups when doing this type of research.
Here are the important findings:
BMI (weight): BMI increased overall and increased in both groups. See the Figure! The gray line are all the participants; the orange line are participants who did treatment via telehealth, and the blue is in-person. All the lines increase, which is what we want (for BMI specifically)! And, there were no differences between groups.
This is important because weight gain is a good sign that ED treatment is going well.
Eating Disorder Symptoms: Eating disorder symptoms went down overall and went down in both the in-person and telehealth groups. Again, there were no differences between groups. This means that both treatment formats make eating disorder symptoms better! See Figure below, remember, the gray line are all the participants; the orange line are participants who did treatment via telehealth, and the blue is in-person.
We won’t bore you with the additional figures, but you can find them in the full paper! We did find the same pattern for the rest of our outcomes: depression and perfectionism decreased similarly across treatment, regardless of whether patients received in-person or telehealth treatment. This is what we want to see!
Conclusions: Eating disorder symptoms decreased. BMI increased. Depression and perfectionism decreased. This is what we want! And importantly , all outcomes were comparable across both groups. This means that telehealth team-based eating disorder intensive outpatient programming (IOP)is not only possible, but also may be equally as effective as traditional in-person team-based IOP treatment for eating disorders. At least, that is what we found in our sample in Kentucky. We hope to see more of this research throughout the U.S. in the future!
There are a few limitations to consider regarding this research. Firstly, most of our sample was composed of white women, which, while representative of those who are most likely to access treatment, seriously limits the generalizability of our findings to truly representative and diverse populations of those with EDs. In other words, people of all races and genders can (and do) have eating disorders (Burke et al., 2020; Feldman & Meyer, 2007; Smolak & Striegel-Moore, 2001), and we have no way of knowing based on this study if our findings would apply to them, too. This is especially concerning given that those with marginalized identities, such as Black, Indiginous, and People of Color (BIPOC), and queer individuals, are frequently underserved in the eating disorder field. A few other important limitations include that we had a relatively small sample size (meaning having more people in the study would have increased our confidence in the findings), and that this wasn’t a randomized control trial (so we weren’t able to randomly select who got which type of treatment delivery, since we obviously did not predict the onset of the pandemic or offer any in-person treatment during COVID-19).
Limitations considered, there are still HUGE implications for increasing treatment access to those who otherwise might not be able to receive in-person eating disorder treatment. If we can do eating disorder IOP as well virtually as in-person, then there is no reason that those who a) cannot afford transportation to treatment, b) live in rural areas, or c) simply live too far away from specialized treatment to commute, should be denied the opportunity. In this way, COVID-19 may precipitate long-overdue efforts to increase ED treatment access for underserved communities.
Get Involved! Treatment Access Resource & Study: If you or someone you know has struggled to access high-quality eating disorder treatment for any reason at all, please consider checking out one of our EAT Lab partners, Project HEAL, for treatment access resources. Additionally, we are currently hosting a short, confidential online study (5-10 minutes long) in partnership with Project HEAL, to help the field understand the overlap and impact of various treatment access barriers for those with eating disorders. Please consider participating if you meet eligibility criteria outlined at the beginning of the survey and want to help.
If you have questions about the plain language study summary (or the original article, linked above), please reach out to us via the comment board below on this page, and we would be delighted to correspond with you (or clarify anything better). And, if you’d like to see more content on the blog like this, let us know!
1LCED is the only program in the state of Kentucky offering specialized IOP treatment for eating disorders. The center uses a multidisciplinary team-based approach to intensive eating disorder treatment, wherein psychologists, therapists, dieticians, and prescribers come together to treat each patient in an evidence-based and personalized manner.
Levinson, C.A., Spoor, S.P., Keshishian, A.C., & Pruitt, A. (in press). Pilot outcomes from a multidisciplinary telehealth vs in-person intensive outpatient program for eating disorders during vs before the Covid-19 Pandemic. International Journal of Eating Disorders.
Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical psychology review, 27(3), 384-405.
Burke, N. L., Schaefer, L. M., Hazzard, V. M., & Rodgers, R. F. (2020). Where identities converge: The importance of intersectionality in eating disorders research. International Journal of Eating Disorders, 53(10), 1605-1609.
Feldman, M. B., & Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay, and bisexual populations. International journal of eating disorders, 40(3), 218-226.
Phillipou, A., Meyer, D., Neill, E., Tan, E. J., Toh, W. L., Van Rheenen, T. E., & Rossell, S. L. (2020). Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project. International Journal of Eating Disorders, 53, 1158– 1165. https://doi.org/10.1002/eat.23317
Schlegl, A., Maier, J., Meule, A., & Voderholzer, U. (2020). Eating disorders in times of the COVID-19 pandemic results from an online survey of patients with anorexia nervosa. International Journal of Eating Disorders, 53, 1791– 1800. https://doi-org.echo.louisville.edu/10.1002/eat.23374
Smolak, L., & Striegel-Moore, R. H. (2001). Challenging the myth of the golden girl: Ethnicity and eating disorders. In R. H. Striegel-Moore & L. Smolak (Eds.), Eating disorders: Innovative directions in research and practice (pp. 111–132). American Psychological Association. https://doi.org/10.1037/10403-006
Written by Brenna M. Williams, M.S., Fourth Year Graduate Student
I have a confession to make. I love animation. I’m talking Disney, Pixar, Cartoon Network, Japanese anime. All of it. I have loved animation since I was a little kid, and today as a 25-year-old PhD student, I continue to browse for the latest popular animated television shows on Netflix and HBO Max. I couldn’t tell you exactly why I love animation so much, but as an adult, I think it has a lot to do with the characters. I relate to and admire many of the characters as they develop. However, it is a privilege to relate to these characters, and I am privileged to have grown up with characters that share many of my identities and reflect my appearance and my beliefs.
The world of animation is growing more and more diverse, with incredible animators from all backgrounds designing characters that reflect the variety of human beings in the world. This representation is important for children and adults alike. Positive representation (that is, portrayal of people in a positive and uplifting light) of individuals from marginalized communities, including people of color, women, LGBTQ+ individuals, and fat people can lead to increased self-esteem and decreased bias. Given how influential media is, positive representation in animation can have an impact on society. Shows like She-Ra and the Princesses of Power and Kipo and the Age of Wonderbeasts, with their diverse characters and cast, have already started making an impact. Given my specialty in eating disorders, I also think it’s important that animators design characters of all different body types. It’s also important that these characters’ bodies are portrayed positively, especially those in larger bodies. By showcasing characters of all body shapes and sizes, we can increase the representation of diverse bodies and challenge weight stigma and fatphobia.
Throughout my adventures through animated shows, I have found some shows and movies that represent individuals with a variety of body types in a positive light. In this blog post, I share three of my favorites.
Steven Universe (2013-2019; ~10+ years old)
Steven Universe is an animated television show that originally aired on Cartoon Network and is now available on Hulu or HBO Max. Steven Universe is a coming-of-age story about a young boy named Steven Universe who lives with the Crystal Gems in Beach City. The Crystal Gems are magical, humanoid aliens with special powers. This show explores themes of love, family, and relationships, and it features characters of all colors, genders, sexualities, and shapes and sizes. This series was created by Rebecca Sugar (she/they), who is both the first woman and non-binary person to independently create a series for Cartoon Network. The voice cast is also diverse, with women of color making up the majority of the main cast. Steven Universe is known for paving the way for many more recent LGBTQ+ series, and it focused on many LGBTQ+ themes prior to the SCOTUS ruling making same-sex marriage legal throughout the United States. Steven Universe was nominated for five Emmy Awards and is a beloved series by many. In 2019, a movie was also released, and a spin-off series, Steven Universe Future, was streamed from 2019-2020. I recently just started watching this series for the first time, and I am in love. Steven is a character unlike any other I have seen, and the mysteries of his family and the Crystal Gems has kept me watching for hours on end. This is definitely a series worth watching!
She-Ra and the Princesses of Power (2018-2020; ~8+ years old)
She-Ra and the Princesses of Power is a reboot of the 1985 series She-Ra: Princes of Power. Available on Netflix, She-Ra and the Princesses of Power follows Adora, a teenager who finds out she can transform into the legendary heroine She-Ra, and her friends as they work to build the Princess Alliance and defeat the evil Horde. This series showcases characters of all shapes, sizes, colors, sexualities, and genders. Importantly, it includes a diverse cast as well. She-Ra and the Princesses of Power explores a variety of themes, including family, justice, and relationships and is best known for its exploration of LGBTQ+ themes. This one of my absolute favorites because of its character building and sense of humor. I shared this with my boyfriend and my roommate (who both loved it), and I recommend it to pretty much anyone who lets me.
Bee and PuppyCat (2013-Present; ~13+ years old)
Bee and PuppyCat is an animated web series that follows Bee, an unemployed young woman, and PuppyCat, a mysterious creature that appears to be a cat-dog hybrid, as they work various temporary jobs together. The art style of this show is beautiful, and it has been compared to the work of Hayao Miyazaki. The characters are designed in a way that represents a variety of body types, and I especially love how Bee looks like an average woman in her 20s. The first season is available on YouTube, and season 2 is scheduled to stream on Netflix in 2022. There is still a great deal to learn about the characters and their backstories, but this storyline has become one of my favorites. I especially love PuppyCat, who is voiced by Oliver, a Vocaloid. I’m looking forward to watching the second season on Netflix, but in the meantime, I’ll keep watching the first season on repeat.
I love animation. I love the art and the characters, and I especially love when the character design and development is focused on diversity. There are so many incredible series and movies out there that include main characters who represent many different backgrounds. I am looking forward to seeing more of these characters, and I hope that animators will continue to design characters that positively represent individuals of all body sizes.
By Claire Cusack, M.A., Lab Manager, Incoming 1st year graduate student
Ew. Gross. Ick. Yuck.
People describe an array of things as gross, repulsive, or disgusting.
But what is disgust, and what does it have to do with eating disorders?
At its base, disgust means “bad taste.” Disgust is a tool that may keep us alive by helping us to reject, spit out, and avoid food and substances may cause us disease and death (1). Disgust is a basic emotion characterized by a facial reaction (for instance, scrunching the nose), physiological sensation (e.g., nausea), and a visceral feeling of revulsion. As you’d expect, or have perhaps experienced, it is typically followed by avoidant behavior, such as moving backward, covering your nose, spitting something out, or closing your eyes. With this understanding, disgust may help us. For example, if you spit out poisoned food because it tastes bad, it may save your life!
How does disgust run amok?
Though disgust may serve as a protective function for our bodies, things can go awry in eating disorders (2,3) That is, your brain sends a false alarm that there is a threat, when in actuality there is none. Similar to anxiety, you may interpret a food as disgusting and overestimate the harm caused by it (4). Over time, your brain may pair a certain food with the feelings of disgust, and you may avoid foods that are not harmful but necessary for your survival. This pathway is difficult to change for a couple reasons:
1) Your brain’s resources are dedicated to prioritizing “safety,” and
2) Avoidance feels good (5).
What sets off the false alarm?
This likely varies person to person, but there are some common triggers that may signal disgust. First, disgust is culturally bound (6) and tied to related ideas of morality (4). As a society, we decide what is “disgusting,” and when we engage in behaviors that elicit disgust, we then attach a good or bad value judgment to it. While fat is important for our survival, we may falsely learn that fat is bad or disgusting. So we may learn to believe that certain food or certain body sizes and shapes are good or bad due to us learning that fatness is disgusting (incorrectly; 7).
Another player in setting off the disgust alarm are physical sensations (8-10). These could include feelings of bloating, tightness in stomach, nausea, or other unpleasant bodily sensations or experiences. These bodily sensations can be confused as feelings (11). Importantly, making sense of these sensations relies on our ability to detect and appraise sensations (12). For instance, for our survival, we first need to recognize a feeling and then evaluate it (e.g., harmful or safe). Below, we see how two different people can process the same event (eating cake) differently in terms of thoughts (it was fun vs. I shouldn’t have), emotions (connected vs. guilt), and physical sensations (e.g., feeling bloated).
It can be challenging to integrate physical feelings, emotions, and thoughts. It’s especially difficult when you don’t trust your body (13). It makes sense to evaluate food as disgusting if you don’t believe your body will take care of you. However, food is only one aspect of disgust and eating disorders. Individuals with eating disorders find an array of things disgusting, such as food, weight gain, their body, but disgust can generalize beyond eating disorder content (14). The line between body and self can become blurred (15). In other words, individuals with eating disorders may also feel disgusted by who they are (8, 16). It’s so tempting to accept these thoughts and feelings at face value, but not all thoughts are true, in fact most are not. The bottom line: your body is not disgusting, and neither are you.
Ways to work through false alarm disgust:
1.) Identify what’s disgusting. Work with your therapist to identify and rank what is disgusting from least to most disgusting (17).You may work together to plan exposures to work through feelings of disgust.
2.) Learn your values. What are your values? Family, friends, school or work, spiritual growth, social justice, kindness, or maybe something else? You can write these down. Now, when you look at the disgusting list, do you believe the things on the disgust list above are disgusting or does your eating disorder? With this awareness, you may be able to make decisions that could still feel gross, but actually align with your values (18).
3.) Create opportunities for new learning. This suggestion builds on #1 and #2. If physical sensations such as drinking water, following your meal plan, eating foods that feel heavy in your stomach, or something else feels disgusting to you, and if they are a false alarm disgust, then press through and approach them. One way to approach false alarms is through interoceptive exposures. An interoceptive exposure is where you intentionally engage in activity that causes you to feel a particular sensation in your body. These exposures may help distress associated with your eating disorder (8,9,19). Let’s say feeling full disgusts you because you think that the sensation of fullness means you are gaining weight. You could drink water and sit with the bodily and emotional sensations that arise (or work with your therapist to do this).
Mirror exposures may be useful for working through the body parts you find disgusting (20). This involves looking at the parts of your body that bring up feelings of disgust for you. These exposures can be practiced in therapy sessions and between therapy sessions. The goal is not to feel less disgusting but learn that you can handle this feeling.
“You can be still and still moving. Content even in your discontent.”
– Ram Dass
4.) Notice when the disgust alarm is false. Mindfulness exercises and meditation to increase awareness and accuracy of body signal interpretation (21, 22). For example, breathing exercises, progressive muscle relaxation, or 5-4-3-2-1 (5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can taste, and 1 thing you can smell) can bring you to the present moment. Then, you may be better able to answer questions like, “Is this actually disgusting? Am I safe? Should I avoid this? Does that match my values?”
5.) You are more than your body. You may feel disgust in or about your body or body areas. This does not mean you are disgusting, because feelings are not always accurate. The feeling of disgust may be a false alarm, but it is felt as very real. Two truths can exist at once. A feeling (and/or a thought) is not a fact, so challenge these feelings/thoughts by asking yourself questions rather than accepting feelings as absolute truths. Is there evidence to suggest you are not disgusting? For example, did you help a friend? Or maybe you were kind to a coworker or peer?
6.) Fight fatphobia. Create new culture that values and celebrates all body sizes and shapes, including yours. Ask yourself, “Where did I learn this was disgusting?” If you’re interested in fighting fatphobia and learning more about diet culture, let us know by emailing firstname.lastname@example.org – We have a new treatment study coming soon focused on this very issue!
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By Brenna M. Williams