Interview

Dignity, Inclusivity and Long-term Recovery

Brad Smith MD, DFAPA, Chief Medical Officer, The Emily Program

What can you tell us about eating disorders and how they are diagnosed?

Eating disorders are serious, biologically influenced psychiatric illnesses that affect the brain and body, not a lifestyle choice. They include conditions such as anorexia nervosa, bulimia nervosa, binge-eating disorder, avoidant/restrictive food intake disorder (ARFID) and other common presentations that fit into the diagnosis of other specified feeding and eating disorders (OSFED) like orthorexia and atypical anorexia nervosa. The diagnosis is based on DSM-5-TR criteria utilizing a careful assessment of behaviors (food restriction, binge eating, purging, laxative/diuretic misuse, compulsive exercise), eating-related anxiety and avoidance, and the degree of impairment in physical health, mood, cognition and daily functioning. A key point is that eating disorders can occur at any weight and in any gender, age or cultural group, so clinicians should not rely on appearance alone to determine severity. Assessment includes weight trajectory and analysis, vitals (including orthostatic changes), labs (especially electrolytes), ECG, and screening for medical complications and co-occurring psychiatric conditions. In summary, eating disorders are diagnosable, treatable medical-psychiatric illnesses identified by patterns of eating-related behaviors and degree of medical and/or functional impairment—not by how someone looks. Eating disorders carry one of the highest mortality rates of any psychiatric illness, yet they are highly responsive to professional treatment despite common misperceptions to the contrary.  

How are they treated now and how has this changed over the years?

Evidence-based treatment today is multidisciplinary and matched to medical and psychiatric risk. Core components of treatment include psychotherapy, nutritional rehabilitation with a registered dietitian, ongoing medical monitoring and interventions, as well as psychiatric assessment and treatment — all delivered in a recommended level of care that is deemed safe and appropriate for the given condition. Levels of care remain an important concept in the treatment of individuals with eating disorders, as they represent matching the level of professional treatment support needed with the severity of the individual’s condition. Once stabilization is reached at one level of care, step-wise transition to lower levels of care allows gradual preparation and practice for the individual to maintain treatment gains with less and less professional support. Levels of care typically include: outpatient, intensive outpatient program (IOP), partial hospital program (PHP), residential and inpatient. For adolescents with anorexia nervosa (and many with bulimia nervosa), family-based treatment (FBT) is strongly supported and emphasizes training and empowering caregivers to interrupt the illness and restore nutrition. For many adolescents and adults, cognitive behavioral therapy (CBT) targets eating disorder behaviors and thoughts across diagnoses. When emotion dysregulation, suicidality, or self-harm is prominent, skills-based approaches such as dialectical behavioral therapy (DBT) can be essential. Medications are typically adjunctive — useful for very common comorbid psychiatric illness (i.e. major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder) and sometimes for bulimia nervosa or binge-eating disorder — while nutritional stabilization remains foundational. Over the years, care has moved toward earlier identification, trauma-informed practice, and more individualized pathways rather than one-size-fits-all programs. Modern eating disorder care is multidisciplinary team-based, evidence-driven, and tailored to severity, with psychotherapy and nutritional rehabilitation as the core interventions for fundamental change. Medical and psychiatric assessment and treatment interventions are especially important when the clinical condition has progressed to a need for a higher level of care, with particular emphasis on assessing and treating the acute consequences of the eating disorder and subsequently managing the comorbid conditions that are intertwined with the eating disorder.

What are the biggest barriers people with eating disorders face when seeking help?

Barriers often start with stigma and misunderstanding — many people fear judgment or believe they are “not sick enough,” especially if they do not fit stereotypes about who gets an eating disorder. Ambivalence is also common: the illness can feel protective or identity defining, and recovery can provoke substantial increase in anxiety about eating, weight change, or loss of perceived control. Clinically, shame and secrecy can delay disclosure, and families may misinterpret symptoms as “choices” rather than a serious illness. System barriers are significant: shortages of specialized clinicians, long waitlists, limited rural access and fragmented medical and psychiatric care. Insurance and cost issues can further delay or disrupt treatment, and practical burdens — time off work/school, transportation, childcare — can make consistent attendance in programming difficult. Weight stigma plays a major role as well; restrictive eating behaviors in people in larger bodies may be minimized or even reinforced, leading to later diagnosis and higher medical risk. People face both internal barriers (stigma, fear, ambivalence) and external barriers (access, insurance coverage, cost and bias) that commonly delay effective care.

What are some of the challenges related to insurance coverage for eating disorders?

Insurance challenges can be a major driver of delays and discontinuity in eating disorder treatment. Common obstacles include prior authorizations, limited in-network options and frequent medical necessity reviews that may not fully account for the psychiatric and behavioral risks of the illness. Because eating disorders have medical complications (e.g., bradycardia, electrolyte abnormalities) and also require psychotherapy and nutritional care, some insurance coverage decisions can become siloed: focusing on individual components rather than the holistic health of the patient. Step-up and step-down decisions can also be contentious: some insurers focus narrowly on weight or labs while underestimating rapid weight loss, suicidality, purging frequency, functional collapse or inability to maintain nutrition without structure. Even with parity laws, families may face significant administrative burden, appeals and out-of-pocket costs. Clinicians can help by documenting objective risk, functional impairment, failed lower levels of care and the rationale for the recommended level of care. Coverage barriers often seem misaligned with the medical and psychiatric risk profile of eating disorders.

Eating disorders can occur at any weight and in any gender, age or cultural group.

Over the years, The Emily Program has been a leader of the broader conversation around eating disorders, including spearheading advocacy efforts that contributed to the passage of the Anna Westin Act within the 21st Century Cures Act. Today, the organization is known for its warmth, passion and multidisciplinary approach — integrating medical, nutritional and psychological care — and for advancing a treatment philosophy centered on dignity, inclusivity and long-term recovery.

Eating disorders are often accompanied with one or more comorbid conditions. What can you tell us about this?

Comorbid conditions are extremely common and can both contribute to and be exacerbated by the eating disorder. Psychiatrically, we often see anxiety disorders, major depressive disorder, OCD, trauma-related disorders, ADHD, substance use disorders, and self-harm or suicidality — particularly in more severe presentations. Medically, malnutrition and compensatory eating disorder behaviors (i.e., purging, laxative abuse, diuretics, etc.) can affect nearly every organ system, leading to bradycardia and orthostasis, electrolyte disturbances, GI dysmotility, endocrine disruption, fertility changes and bone density loss. An important clinical nuance is that starvation and weight suppression themselves can generate psychiatric symptoms — irritability, cognitive slowing, heightened anxiety, obsessive thinking — so nutritional rehabilitation is not just “supportive,” it is treatment. We typically address the eating disorder and comorbidities in parallel, while prioritizing immediate medical safety and stabilizing nutrition so psychotherapy and medication can be more effective. In short, eating disorders frequently co-occur with other psychiatric and medical conditions, and effective care treats both while prioritizing medical stability and nutrition.

The impact of GLP-1 receptor antagonists on eating disorder pathology is understudied, but this has not slowed them from accounting for 7% of all U.S. prescriptions. What should we know about this?

First, a terminology clarification: commonly used medications in this category (e.g., semaglutide, liraglutide, tirzepatide) are GLP-1 receptor agonists. 

Their impact on eating disorder pathology and recovery is certainly understudied, so we need to approach them thoughtfully—especially for people with current or past eating disorders. By reducing hunger and increasing early satiety (and sometimes causing nausea or GI slowing), these agents can unintentionally reinforce dietary restriction urges and behaviors, intensify weight/shape preoccupation, or disrupt the structured nutrition plan that recovery requires. That concern is particularly relevant in anyone prone to restrictive eating as a component of their eating disorder. For those with a history of purging or laxative abuse, the fullness and GI slowing caused by these medications can reignite urges to resume those behaviors. For some individuals with binge-eating symptoms, early data and clinical experience suggest potential reductions in urges or episodes, but long-term outcomes (including relapse risk and effects on eating disorder cognitions) remain unclear. Best practice is careful screening, shared decision-making with goals beyond weight and close monitoring by an eating-disorder informed team. GLP-1 agonists are widely used, but in those with eating disorders, they require extremely careful screening and monitoring because they may complicate recovery or hasten a relapse.

What are some of the issues around eating disorders as they apply to individuals from diverse cultural or racial backgrounds?

Eating disorders occur across all racial, ethnic and cultural groups, but they are not recognized or treated equitably. Stereotypes about who “gets” an eating disorder contribute to under-screening and delayed diagnosis for people of color, men, older adults, LGBTQ+ individuals and people in larger bodies. Culture can also influence how symptoms are described: patients may emphasize GI distress, “health eating,” strength/fitness or a desire to feel “clean” rather than using weight/shape language so clinicians must ask behaviorally specific questions and remain culturally curious. Structural barriers matter: insurance coverage, language access, transportation, time off work and experiences of discrimination or mistrust can shape engagement and retention in care. Weight stigma and racism can intersect to normalize or even praise restrictive behaviors, increasing risk while decreasing access to help. High-quality treatment requires culturally responsive assessment, attention to identity and context and practical support that reduce barriers to sustained, evidence-based care. The core illness of an eating disorder is often the same, but inequities, stigma and cultural context strongly influence who gets a diagnosis and who gets effective treatment.

What do you see in the future for eating disorder treatment?

I expect several advances, alongside a continued emphasis on the fundamentals of recovery. Clinically, we will likely see broader access through virtual and hybrid models, improved coordination between primary care and specialty programs, and more measurement-based care so teams can identify stalled progress early and adjust treatment promptly. We are also learning more about how to tailor evidence-based therapies — such as CBT, DBT and FBT — to different developmental stages, comorbidity patterns and social contexts, which may improve engagement and reduce dropout. I also anticipate that eating disorder treatment centers and specialists will expand their ability to effectively treat the most common comorbid psychiatric and medical illnesses as one method of promoting holistic, rather than fragmented care for the individual. On the research front, there is active exploration of adjunctive interventions (e.g., digital tools, virtual reality–supported exposures, medication trials and neuromodulation) for carefully selected patients, but these will likely complement, not replace, nutrition rehabilitation and psychotherapy. First and foremost, I anticipate stronger efforts to address weight stigma, improve culturally responsive care, and reduce inequities that delay diagnosis and limit access to higher levels of care. The future is likely to bring more accessible and personalized care, more comprehensive care for an individual’s comorbid psychiatric and medical illnesses, more medication and medical intervention options, while keeping nutritional rehabilitation and psychotherapy at the core of effective treatment.

What are the most important things physicians should know about eating disorders?

Physicians should know, first, that eating disorders are common, potentially life-threatening, and treatable — and they occur at any weight, so appearance is not a reliable severity marker. Second, risk assessment matters: evaluate weight trajectory and rapid changes, orthostatic vitals, bradycardia, temperature, electrolytes (especially potassium, bicarbonate, phosphorus, magnesium), and consider ECG when indicated; significant medical instability can occur even with “normal” BMI. Third, ask directly and routinely about food restriction, binge eating, vomiting, laxative/diuretic misuse, diet pills, compulsive exercise, and ARFID-type avoidance; specific questions outperform vague ones. Fourth, intervene early: timely referral to an eating-disorder informed multidisciplinary team improves outcomes, and higher levels of care can be medically necessary and life-saving. Finally, language matters — avoid reinforcing diet culture or weight stigma, and emphasize recovery goals such as normalized nutrition, medical stability, improved cognition and restored functioning. Early identification, careful medical risk assessment, nonstigmatizing communication, and prompt referral to specialized care are the essentials physicians need to manage eating disorders well.

Brad Smith, MD, DFAPA, is the chief medical officer for The Emily Program. He is board-certified in adult and forensic psychiatry and is dedicated to advancing high-quality, patient-centered care for individuals with eating disorders.