A teenage girl counts calories with obsessive precision, exercises for hours each day, sees fat in the mirror where others see bones, and has become so consumed by control over her body that she has lost control over everything else. Her parents watch her disappear, knowing something is terribly wrong but not knowing how to reach her through the wall she has built. A young man binges in secret, eating until he is sick, then purges through exercise or vomiting, trapped in a cycle of shame that no one in his life knows about because eating disorders do not happen to people like him, or so he was always told. A woman in her forties has struggled with disordered eating her entire adult life, periods of restriction alternating with periods of chaos, never bad enough to be hospitalized, never well enough to be free. She wonders whether treatment would even work after all this time, whether her patterns are now too deeply ingrained to change. A family brings their son to the emergency room when he faints at school, and learns that his heart rate is dangerously low from malnutrition they did not see developing. They thought he was just eating healthy. Eating disorders are among the most dangerous mental illnesses, with the highest mortality rate of any psychiatric condition, yet they remain misunderstood, stigmatized, and inadequately treated. The gap between what is known about effective treatment and what is available leaves many without the help they need.
The Case for Specialized Eating Disorder Services
Advocates for specialized services argue that eating disorders require expertise that general mental health services cannot provide. From this view, specialized treatment is essential for recovery.
Eating disorders are medically serious. Malnutrition affects every organ system. Heart complications can be fatal. Medical monitoring during treatment is essential. General therapists without medical support cannot safely treat serious eating disorders.
Eating disorder treatment requires specific approaches. Family-based treatment for adolescents, cognitive behavioral therapy adapted for eating disorders, and other evidence-based approaches differ from general psychotherapy. Training and expertise matter for outcomes.
Eating disorders are ego-syntonic, meaning people often do not want to recover. The illness tells them they are fine, that others are the problem, that treatment is the enemy. Working with this ambivalence requires specific skills. Unmotivated patients are the norm, not the exception.
From this perspective, improving eating disorder care requires: specialized treatment programs with medical, nutritional, and psychological expertise; levels of care from outpatient through residential for different severity levels; evidence-based approaches delivered by trained clinicians; and recognition that eating disorders require specialist response.
The Case for Integrated Approaches
Others argue that over-specialization may limit access and that eating disorders can be treated within broader mental health frameworks. From this view, integration may serve more people.
Specialized eating disorder services are scarce and concentrated in urban areas. Many people cannot access specialized care due to geography, cost, or wait times. If treatment requires specialists, most people will not receive treatment.
Eating disorders often co-occur with other conditions including depression, anxiety, trauma, and substance use. Treating eating disorders in isolation from co-occurring conditions may not serve patients well. Integrated approaches that address the whole person may be more effective.
Primary care and general mental health providers can be trained to identify and treat eating disorders. Building capacity in existing systems may reach more people than building separate specialized systems.
From this perspective, improving eating disorder care requires: training for general mental health providers in eating disorder treatment; medical monitoring capabilities in community settings; integration of eating disorder treatment with treatment of co-occurring conditions; and recognition that specialist care should not be the only option.
The Family-Based Treatment Model
Family-based treatment puts parents in charge of refeeding for adolescents with anorexia, an approach with strong evidence but also controversy.
From one view, family-based treatment should be first-line treatment for adolescent anorexia. Evidence supports it as most effective approach. Parents are essential partners, not the problem. Training more families and clinicians in FBT would improve outcomes.
From another view, family-based treatment does not work for everyone. Some families cannot implement it. Some adolescents resist it in ways that harm family relationships. Individual approaches may be more appropriate for some. One size does not fit all.
Whether family-based treatment should be universally applied or selectively used shapes adolescent eating disorder care.
The Levels of Care Question
Eating disorder treatment exists on a continuum from outpatient to residential, but access to higher levels is limited.
From one perspective, appropriate levels of care must be available. Some people need residential treatment to interrupt patterns and restore weight. Limiting access to higher levels means people who need intensive care cannot get it.
From another perspective, higher levels of care are expensive and evidence for residential treatment specifically is limited. Investment in outpatient capacity might serve more people than investment in residential beds. The assumption that more intensive is better may not be supported by evidence.
What levels of care should be available and accessible shapes the treatment system.
The Coverage and Cost Crisis
Eating disorder treatment is often expensive and inadequately covered by insurance.
From one view, eating disorder treatment should be fully covered as medical necessity. The cost of untreated eating disorders in terms of medical complications, disability, and mortality exceeds treatment costs. Insurance coverage should match coverage for other serious medical conditions.
From another view, insurance systems must balance many demands. Unlimited coverage for expensive residential treatment may not be sustainable. Coverage decisions must consider cost-effectiveness alongside clinical need.
How eating disorder treatment is funded shapes access for those who need it.
The Men and Boys Question
Eating disorders in males are underrecognized and underserved.
From one perspective, eating disorder services have been designed primarily for females and may not serve males appropriately. Male presentations may differ. Stigma may be particularly intense for males. Services should actively reach and serve males with eating disorders.
From another perspective, females remain the majority of those with eating disorders. Limited resources should focus where most need exists. As male cases are identified, they can be integrated into existing services.
Whether services should specifically address male eating disorders shapes program design.
The Diverse Body Question
Eating disorders in people with larger bodies may be missed because they do not match stereotypes.
From one view, weight bias affects eating disorder recognition. Someone with atypical anorexia may have all the symptoms but be dismissed because they are not emaciated. People in larger bodies with eating disorders may even be praised for restrictive behaviors. Recognition must expand beyond stereotypes.
From another view, diagnostic criteria exist for good reasons. Not everyone who restricts eating has an eating disorder. Maintaining some diagnostic boundaries ensures treatment goes to those who truly have the conditions.
How eating disorders are recognized across body sizes shapes who receives diagnosis and treatment.
The Prevention Challenge
Preventing eating disorders is appealing but challenging.
From one perspective, prevention should be prioritized. School programs addressing body image, media literacy, and healthy relationships with food can reduce risk. Addressing diet culture more broadly would prevent eating disorders at population level.
From another perspective, eating disorder prevention programs have mixed evidence. Some may even increase risk by introducing ideas. Prevention of complex conditions with genetic components is difficult. Treatment for those who develop eating disorders may be more effective use of resources.
What prevention approaches deserve investment shapes resource allocation.
The Social Media Impact
Social media's role in eating disorders draws attention but remains debated.
From one view, social media platforms that promote thin ideals, host pro-eating-disorder content, and drive comparison harm vulnerable users. Platform regulation and content moderation could reduce harm.
From another view, social media is one factor among many. People developed eating disorders before social media existed. Focus on social media may distract from other contributors including genetics, trauma, and family factors.
Whether and how social media should be addressed in relation to eating disorders shapes policy response.
The Chronic Course Challenge
Some people with eating disorders do not recover despite treatment, raising difficult questions.
From one perspective, hope for recovery should be maintained. With the right treatment at the right time, recovery is possible. Giving up on anyone accepts preventable suffering and death.
From another perspective, harm reduction for those with chronic eating disorders may be appropriate. Reducing harm while accepting that full recovery may not occur can preserve quality of life. Not everyone recovers from every illness.
How chronic eating disorders are approached shapes care for those who struggle longest.
The Medical Versus Psychological Divide
Eating disorders involve both medical and psychological dimensions, but systems often separate these.
From one view, integrated medical-psychological care is essential. Treating the body without treating the mind, or vice versa, cannot produce recovery. Eating disorder treatment must bridge medical and mental health systems.
From another view, system integration is difficult to achieve. Ensuring adequate care in both medical and mental health systems may be more practical than integration.
How medical and psychological aspects are coordinated shapes treatment effectiveness.
The Canadian Context
Canada has specialized eating disorder programs in some provinces, but availability is uneven, wait times can be long, and many people cannot access appropriate levels of care. Provincial coverage varies, and many families face significant out-of-pocket costs. National standards and consistent access do not exist.
From one perspective, Canada should develop national eating disorder standards and ensure specialized services are accessible regardless of geography or ability to pay.
From another perspective, building capacity within existing mental health systems to treat eating disorders may be more achievable than building specialized systems everywhere.
How Canada addresses eating disorders shapes outcomes for those with these serious illnesses.
The Question
If eating disorders have the highest mortality rate of any mental illness, if effective treatments exist but are not accessible, if people die waiting for treatment that could save them, if we understand more about eating disorders than ever before but continue to fund treatment inadequately - why do we accept this gap between knowledge and action? When a young person with anorexia is told the wait for treatment is months while their body fails, is that acceptable care? When families bankrupt themselves to pay for treatment that should be covered as medical necessity, what does that reveal about how we value these lives? When we recognize eating disorders as serious mental illness in policy but fail to fund treatment as if they were serious in practice, what do our actions reveal? And when someone dies from an eating disorder that could have been treated, who bears responsibility for that death?