MISSOULA – When Assistant Professor Caitlin Martin-Wagar joined the University of Montana faculty in 2021, she knew she’d be a program of one.
Martin-Wagar’s specialty is the research and treatment of eating disorders. When it comes to her field, fellow practitioners are rare – particularly in rural states like Montana.
“There is huge gap in access to eating disorders care in rural communities,” she said. “I was excited to come here, and I want to be of help.”
There is no doubt much work needs to be done to improve outcomes for the estimated 30 million Americans who struggle with EDs in their lifetime – a situation that became even more dire during COVID-19, where one recent study found hospital admissions for those with eating disorders rose 48%.
“I wasn’t surprised about the significant uptick during the pandemic,” Martin-Wagar said. “Some of the sociocultural risk factors for eating disorders (for example, weight stigma) and normalized behaviors (like dieting) were already increasingly prevalent in society,” she said. “Add intense uncertainty, loneliness, fear, increased time online and loss of routine to the mix, and it was unsurprising so many individuals with eating disorders relapsed, and others developed eating disorders.”
She entered the field of eating disorder research through her work with dialectical behavior therapy, which is a type of treatment for people with emotional issues, suicidality and difficulty regulating emotions.
“There was an opening at an EDs facility provider, and I applied to work there providing DBT, cognitive behavioral therapy and family-based treatment after getting my master’s degree,” she explained. “Working with eating disorders felt exactly the place for me. I quickly noticed how inequities contributed to the development and maintenance of EDs.”
The Ohio native would go on to earn a Ph.D. in counseling psychology at the University of Akron and had just finished a postdoctoral associateship at Yale School of Medicine before joining UM’s Department of Psychology, housed in the College of Humanities and Sciences.
Recently, Martin-Wagar sat down with UM News to talk about EDs, dispelling myths and exploring reasons why EDs are often misdiagnosed. The good news, she said, is that eating disorders are treatable, especially if caught early, and people can go on to live meaningful, productive lives.
UM News: Are there common personality traits or personas of individuals that struggle with eating disorders?
Not really. Eating disorders occur in all types of people. However, we do know that certain factors, temperaments, traits and experiences can put someone at a higher risk for developing an eating disorder. For example, thin ideal internalization, expectations for thinness, perfectionism or negative impulsiveness can put someone at a higher risk for developing an eating disorder. Ultimately, complex biopsychosocial factors interact in a person to develop an eating disorder.
UM News: What misconceptions might we have about EDs that are important to clarify?
Where to begin? Eating disorders are highly misunderstood. To me, one of the most harmful misconceptions about EDs is that only young, thin, white, affluent girls have eating disorders. However, only six in 100 individuals with EDs are actually underweight! Unfortunately, those in larger bodies are about half as likely to be diagnosed with an eating disorder. Furthermore, eating disorders absolutely occur among all racial and ethnic groups, genders, age groups and socioeconomic backgrounds. In fact, being in a minoritized group, such as being a member of the LGBTQ+ community, puts someone at higher risk of developing an eating disorder.
Another misconception that is quite dangerous is the commonly held belief that those with EDs are making a choice to have an eating disorder. Eating disorders are highly impairing and deadly disorders that no one chooses to experience. Aside of opioid overdoses, eating disorders have the highest mortality rate of all mental illnesses.
Finally, a third misconception is that they are rare. It is estimated that EDs affect at least 30 million Americans at some point in their lifetimes. Though we don’t know the eating disorder prevalence on our own campus, a recent survey I provided to around 400 UM undergraduates found that about 9% endorsed having been previously or currently treated for an eating disorder. The number of individuals with eating disorders is likely even higher, with the vast majority being cases that are missed. Not to mention the millions of Americans who experience disordered eating but do not meet full criteria for an eating disorder diagnosis.
Our culture has a toxic relationship with food, eating and bodies, so it is somewhat normative to have some issues around eating and body image.
UM News: The Centers for Disease Control and Prevention and other health organizations reported increases in the number of teens, particularly girls, seeking medical care for EDs during COVID-19. What about the pandemic influenced this?
Eating disorders have increased substantially during the pandemic. With people feeling more uncertainty, less control over their environments and future, and disrupted routines and structures, the general public has experienced changes in their eating patterns. With this time being particularly stressful for most people, their vulnerability to mental health problems is quite high. This is even more so the case with adolescents, who are already at high risk for developing eating disorders during that developmental period.
Relapse for people with treated eating disorders has also risen during the pandemic. Despite the alarming prevalence and severity of eating disorders, waitlists and a lack of resources cause a gap in receiving vital care.
UM News: Eating disorders have long been associated with females, but they also occur in males. Are the factors that lead to EDs different for men and women?
Though eating disorders are more common in girls and women, the prevalence of eating disorders in boys and men is much higher than what folks expect. About one-third of those with eating disorders are men. A main difference in the presentations of eating disorders in men includes a greater focus on muscularity. Muscle-enhancing disordered behavior is more common in boys and men than in girls and women.
UM News: The media, and in particular social media, have been linked with an increase in the incidence of EDs among young people. How might our online culture be contributing to weight stigma?
Limiting promotion of social media accounts that encourage problematic body image and eating patterns would be helpful. However, I do think we are in for an uphill battle if weight stigma is not better acknowledged and addressed in our culture. In our society, we tend to obsess over weight, and people with higher weights face prejudice and discrimination. There are currently no federal laws in place that prohibit size or weight discrimination.
We also know that weight is not a direct indicator of health, and shaming people for their weight is cruel and can result in disordered eating, avoidance of health care, reduced exercise and poorer mental and physical health.
Even if we limit exposure to unhealthy messages on social media – and we should – how we all contribute to weight stigma will continue to negatively impact children and adolescents. Children as young as 3 exhibit anti-fat attitudes, and over 80% of 10-year-olds are afraid of being fat. Weight-based discrimination is one of the most common forms of discrimination, yet is socially acceptable and encouraged. As our society grapples with many forms of discrimination, we need to work hard to dismantle weight-based stigma and discrimination.
UM News: Your research has focused on EDs and mental/physical health outcomes related to sociocultural conditions. Talk a bit about what you have found in your research?
Yes, my research examined eating disorder interventions, mechanisms of change, access to care and weight stigma. An elephant in the room is that many folks with higher weight are being encouraged by loved ones and health care providers to engage in harmful eating disorder behaviors, with the hopes of decreasing body weight. Next, I am working on finding ways to more directly and intentionally decrease internalized weight stigma as part of eating disorder treatment.
Right now, current evidence-based eating disorder treatments are between 21-50% effective for adults, with slightly better results for adolescents doing family based treatments, so my work will aim to contribute to efforts to improve eating disorder treatment.
UM News: What steps can be taken to make access to mental health care more accessible in rural states like Montana?
Access to eating disorder care is not sufficient even in the most resourced states. Despite EDs routinely being seen in all health care settings – often at higher rates than those without eating disorders – providers typically view EDs as a “specialty” area.
In rural Montana, health care providers may be the only provider within hundreds of miles, and as such, tend to operate as health care generalists versus specialists. One of the many reasons I am so excited to be in Montana in this faculty role is that now more students will be trained in eating disorder research and clinical care. My hope is that some of those I train will fall in love with Montana and return here after residency to help address our shortage of eating disorder resources.
To make mental health care more accessible – especially eating disorder care – our state needs to allot more funding to mental health care. Despite the severe health implications and impairment with EDs, federal funding for EDs is extremely low compared to other mental health concerns.
I think telehealth can help improve treatment access, but it will not be a sufficient solution without more resources dedicated to training health care providers in assessing and treating eating disorders. We also need systemic changes to insurance and work to reduce weight-based stigma and eating disorder stigma. I also would love to see more school-based screening and interventions, because we know the best prognosis for EDs is if we intervene as soon after onset of symptoms as possible.
Finally, we need more eating disorder researchers and clinicians from underrepresented backgrounds to improve how we conceptualize and screen for EDs.
UM News: When we think about EDs and treatment, like other disciplines of health care, a question of privilege and equity arises. What can we glean from the socio-economic markers of those who have eating disorders and the resources to seek treatment and recover?
Only about 20% of individuals with EDs ever receive treatment. Access to treatment tends to be higher for those with good insurance and other financial resources. Then, treatment-related research at eating disorder clinics often has skewed demographics, furthering misconceptions in the field. One way to address this problem is for funding agencies to allot more money to eating disorder interventions studies, because these studies do not rely on folks having insurance or financial resources to participate in treatment.
Dave Kuntz, UM director of strategic communications, 406-243-5659, firstname.lastname@example.org.