BY DEETTA K. VANCE, DNP, FNP-BC
Abstract
Eating disorders encompass a severe disturbance in eating behaviors, as well as emotional responses and thoughts resulting in unhealthy weight loss or gain. Most patients afflicted with eating disorders are diagnosed with a combination of anorexia, bulimia and binge-eating. In adolescents, bullying in schools, body image disturbance, genetic predisposition and other mental illnesses including anxiety, depression and obsessive-compulsive disorder leads to eating disorder development. Gaining access to care for early intervention and specialized care referral for disordered eating behaviors is essential in improving nutritional status, lowering the risk of suicide and other comorbidities developing such as cardiovascular disease, pulmonary disease and metabolic disorders. However, there are challenges that exist for accessing care for all adolescents, but specifically people of color and patients who have public insurance.
Advanced practice nurses (APNs) serve a unique role in healthcare in the way that gaps in care are often addressed through increasing provider availability. The pursuit of continuing education is a cornerstone and duty of the role of an APN. Being culturally aware of the impacts of socioeconomic status, race, ethnicity and insurance providers on these affected adolescents goes hand in hand with seeking to improve knowledge. Goals that accompany the pursuit of a post-master’s certificate in mental health include increasing access to care for all adolescents impacted by eating disorders, but especially those of color and with insurance that is not readily accepted by the scarce treatment facilities with any availability for treatment. As the prevalence of eating disorders and the correlating disparity has grown among various racial and ethnic groups, it is the charge of nurse practitioners to work to reduce this gap in care, increase awareness in fellow providers and train new nurse practitioners in the evaluation and management of eating disorders.
Disparities in Healthcare: Adolescents and Eating Disorders
Disordered eating is a psychiatric condition with one of the highest mortality rates impacting a growing number of adolescents in the United States. Disparities in outcomes exist among this population that correlates with access to care among all adolescents, but specifically people of color with public health insurance (Moreno et al., 2023). Defined, eating disorders are a severe disturbance in eating behaviors, as well as emotional responses and thoughts resulting in unhealthy weight loss or gain. Most patients afflicted with eating disorders are diagnosed with one of the following or combination of anorexia, bulimia and binge-eating. In adolescents, bullying in schools, body image disturbance, genetic predisposition, and other mental illnesses including anxiety, depression and obsessive-compulsive disorder increases the risk for eating disorder development (Chew & Temples, 2022). Gaining access to care for early intervention and specialized care referral for disordered eating behaviors is essential in improving nutritional status, lowering the risk of suicide and other comorbidities developing such as cardiovascular disease, pulmonary disease and metabolic disorders. According to Moreno et al. (2023), for adolescents of color and those who have public insurance, the increased incidence of lower socioeconomic status disproportionately increases the risks of a poor outcome for this vulnerable population.
Cultural Characteristics and Influences
Moreno et al. (2023) identified racial and ethnic characteristics as well as insurance type as significant in the prevalence of the disparities for treatment in adolescents with disordered eating. Among adolescents, racial and ethnic groups included were Asian, Latino, African American, or of another race that did not include Caucasian. Results indicated that adolescents of these racial and ethnic groups were less than two-thirds as likely to receive access to care for eating disorders compared to Caucasian adolescents. These adolescents also possessed public health insurance and often lived in an environment that led to food insecurity and adverse experiences such as violence or harassment.
Moreno et al. (2023) also explained that structural racism often serves as a barrier because of the underrepresentation of Latino and African American mental health care providers. Adolescents securing care with a provider of a concordant race reported increased satisfaction and outcomes of care, but because racial and ethnic diversity is limited among providers trained in disordered eating, structural racism further contributes to the disparity. In addition, apart from the lack of access to care for this group, cultural beliefs and sociocultural stigma associated with mental illness and mental health care serves as an additional barrier to these children receiving not only an appropriate screening, but a referral for recommended treatment (Moreno et al., 2023).
Impacts of Public Compared to Private Insurance on Disparity
As explained by Moreno et al. (2023), there is a substantial correlation between racial and ethnic groups and the use of public insurance for health care compared to those who have private insurance. With that comes several barriers to access that patients with private insurance may not face. There are a limited number of providers, both in primary care and specialized care that accept public insurance, resulting in delays in care or making obtaining appropriate care impossible. For those suffering from eating disorders, this delay in care could mean the difference between life and death at its worst, as eating disorders can lead to mortality when left untreated (Chew & Temples, 2022).
Unable to find outpatient care, adolescents are then left to seek care through emergency departments in hopes of a hospital admission, which according to Moreno et al. (2023), increases the likelihood that recommended care will be rendered. However, even if the adolescent is properly evaluated and admitted to the hospital, intensive outpatient care, as well as residential care following discharge is costly and difficult to access due to the few providers available who are specialty trained. The availability of programs accepting public insurance is insufficient for the number of children requiring services, further contributing to poor outcomes due to the existing disparity that is present within this population (Moreno et al., 2023).
Rural Living Compared with Urban Living Impacts on Disparity
Hahn et al. (2022) purported that there was little evidence available in the literature regarding the impacts of eating disorders on adolescents living in rural communities; however, risk factors are high. Rural community residents often face challenges associated with food security, lower socioeconomic status, body image and weight stigma and poor access to care compared with urban-dwelling residents. As a delay in care for disordered eating can profoundly impact outcomes, adolescents in rural communities may not seek care due to the intimacy of the communities. For instance, in contrast to patient perception of providers in urban areas, providers in rural communities are often viewed as neighbors, thus discouraging the adolescent from sharing sensitive information. Further, people of color living in a rural community face additional barriers compared to those living in urban areas due to cultural stigmas (Hahn et al., 2022).
Body image and weight stigma is a prevalent risk factor in rural communities that contributes to the increased development of eating disorders, thus widening the disparity. Many adolescents fear a larger body type would garner harassment and seek to keep weight down in avoidance of judgment from peers. Interestingly, Hahn et al. (2022) explained that the increased incidence of sexual abuse occurring during childhood in rural adolescents is significantly associated with self-induced vomiting to reach a desired weight, whereas urban adolescents tend to restrict food and consume diet pills. In addition, substance use and abuse with related mortality is higher in rural areas compared to urban areas due to untreated mental illness, including eating disorders and associated comorbidities (Hahn et al., 2022).
Advanced Practice Nursing Role in Decreasing Disparity
Advanced practice nurses (APNs) serve a unique role in health care in the way that gaps in care are often addressed through increasing provider availability (Advanced practice nursing, 2021). As stated by Moreno et al. (2023), instances of treatment for hospitalizations related to eating disorders are more often paid by Medicaid than by a private payer. APNs should consider that well-child visits and sick visits are still being completed by those with public insurance and of various racial and ethnic backgrounds allowing for the opportunity for recognition of a disordered eating problem. Taking steps to improve awareness of the warning signs of eating disorders across all cultures, as well as the screenings available, would help the APN improve early identification of disordered eating behaviors and facilitate timely intervention. Identifying eating disorders in an outpatient setting reduces the need for costly treatment sought through hospitals (Moreno et al., 2023).
The pursuit of continuing education is a cornerstone and duty of the role of an APN. APNs often identify issues in practice and can attain adjuvant education to help facilitate a solution. Being culturally aware of the impacts of socioeconomic status, race, ethnicity and insurance providers on these affected adolescents goes hand in hand with seeking to improve knowledge. Coursework is available to APNs to allow them to specialize in the treatment of eating disorders. According to Hufton (2022), an eating disorder nurse provides comprehensive care and support to patients affected by disordered eating through family-based therapy, physical health monitoring, and nutritional education, often in conjunction with a multi-disciplinary team of medical professionals. Through completion of a degree in mental health, qualifies an APN to become an eating disorder nurse at entry level. With continued work in this field, the APN can grow to a specialist level, thus increasing the vital support needed for this population and narrow the gap in care disparity (Hufton, 2022).
Implications for APN Practice
The issues presented by Moreno et al. (2023) provide significant awareness regarding the depths of the disparity impacting adolescents of color and those who possess public insurance, and most stand to inform current practice. Goals that accompany the pursuit of a post-master’s certificate in mental health include increasing access to care for all adolescents impacted by eating disorders, but especially those of color and with insurance that is not readily accepted by the scarce treatment facilities with any availability for treatment. Seeking an eating disorder specialization is also an essential contribution to future practice and support for this population. As the prevalence of eating disorders and the correlating disparity has grown among various racial and ethnic groups, it is the charge of nurse practitioners to work to reduce this gap in care, increase awareness in fellow providers, and train new nurse practitioners in the evaluation and management of eating disorders (Advanced Practice Nursing, 2021).
Conclusion
As research continues to bring awareness to the disparity that exists within racial and ethnic groups, as well as those with public insurance, it is essential that the APN take steps to inform personal practice. Seeking out opportunities to improve knowledge in providing culturally competent care, as well as engaging in research, legislative, and policy action to improve conditions for adolescents impacted by disordered eating is a crucial function of the APN. Ultimately, the responsibility to care for this vulnerable population falls to the health care provider, and due diligence is owed to work to decrease the adolescent disordered eating disparities and improve the state of current outcomes.
References
Advanced practice nursing alumna strives to eliminate health care disparities in rural Oklahoma. The University of Tulsa: Oxley College of Health Sciences. (2021, March 18). Retrieved February 18, 2023, from https://healthsciences.utulsa.edu/fnp-hannagan-rural-health-care/
Chew, K. K., & Temples, H. S. (2022). Adolescent eating disorders: Early identification and management in primary care. Journal of Pediatric Health Care, 36(6), 618–627. https://doi.org/10.1016/j.pedhc.2022.06.004
Hahn, S. L., Burnette, C. B., Borton, K. A., Mitchell Carpenter, L., Sonneville, K. R., & Bailey, B. (2022). Eating disorder risk in rural US adolescents: What do we know and where do we go? International Journal of Eating Disorders, 56(2), 366–371. https://doi.org/10.1002/eat.23843
Hufton, F. (2022). Could you become an eating disorder nurse? Mental Health Practice, 25(3), 14–15. https://doi.org/10.7748/mhp.25.3.14.s6
Moreno, R., Buckelew, S. M., Accurso, E. C., & Raymond-Flesch, M. (2023). Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: A retrospective cohort study. Journal of Eating Disorders, 11(1). https://doi.org/10.1186/s40337-022-00730-7
Deetta K. Vance, DNP, FNP-BC, completed her family nurse practitioner degree at Indiana State University and her doctor of nursing practice from the University of Alabama. She is an associate professor in the School of Nursing at Indiana State and has served the community in a variety of practice fields including palliative medicine, school-based care, urgent care and occupational health, as well as volunteering in the local community to provide physicals to underserved youth.
Image credit: ISTOCK.COM/TERO VESALAINEN
