Toledo Center for Eating Disorders Outcome Data
At its conception, Toledo Center was committed to ensuring effective treatment for eating disorders. Once the program became established, we worked to test the outcomes by using comprehensive study over the span of twelve years.
The Toledo Center is committed to consistent:
- Clinical service delivery enhancement
- Utilization of outcome data to increase treatment effectiveness
- Clinical training and use of evidence-based clinical practice
Where it is possible, well-established standardized measures of change are used to assess therapeutic outcomes.
Our innovative treatment design:
- Is accessible to all clients and families
- Is over nineteen years of a well-established therapy model for treating eating disorders that integrates individual, group, and family therapy 1,2,3
- Is linked to evidence-based treatment principles and is facilitated by an internally developed electronic medical record.
We believe positive outcomes are an essential decision point to those seeking treatment. Very few eating disorder treatment centers systematically collect outcome data or publish it in a way that would allow comparison across facilities. We want our clients and families to have this information to help make the right decision about treatment.
What data and programs were used in the outcome study?
From 1996 through 2014, the Toledo Center has seen 1,474 first admissions in its two main treatment programs:
- Adult Partial Hospitalization Program (PHP)
- Adolescent Residential Program (ARP)
Although the PHP has been in operation for more than 20 years, the Adolescent Residential Program (ARP) was not started until 2002. To use comparable data from both our PHP and our ARP programs, the data reported here are from the time period from 2002-2014. During this period, a total of 1,103 first admissions were seen in either the PHP or the ARP after excluding 9 patients who presented with a pattern of weight loss or feeding disorder not typical of the main eating disorders as specified in the latest Diagnostic and Statistical Manual (DSM-5). Toledo Center developed an Intensive Outpatient Program (IOP) for binge-eating disorder in 2014 and data on this new program will not be presented in the following description of outcomes.
What diagnosis were included in the outcome study?
It is important to understand the diagnostic groups compared in our reported outcomes. In 2013, the American Psychiatric Association (APA) published the Fifth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), which made significant changes to the older diagnostic classification system for eating disorders. A detailed presentation of these changes is beyond this outcome report; however, the major changes to the DSM-5 involved:
- Adding severity codes for anorexia nervosa (AN) based on BMI;
- Lowering the binge-eating threshold for bulimia nervosa (BN) to one time per week (from two);
- Eliminating the Eating Disorder Not Otherwise Specified (EDNOS) classification;
- Making Binge Eating Disorder (BED) a full-fledged diagnostic entity; and,
- Adding a major diagnostic category “Other Specified Feeding or Eating Disorder (OSFED)
The OSFED diagnosis consists of a heterogeneous group of patients who meet some but not all, of the criteria for the main eating disorder diagnoses. More than half of the OSFED group in the Toledo Center sample reported self-induced vomiting without binge eating. All first admissions in the Toledo Center database were classified into five DSM-5 eating disorder diagnostic groups:
- Anorexia Nervosa, Restricting Type (AN-R, N=314),
- Anorexia Nervosa Binge/ Purge Type (AN-B, N=221),
- Bulimia Nervosa (BN, N=370), Binge Eating Disorder (BED, N=46) and
- Other Eating Disorders (including Other Specified Feeding and Eating Disorder or OSFED, N=152).
The proportion of patients in each of these diagnostic groups is presented in Figure 1.
The proportion of BED patients in the Toledo Center sample is relatively small; however, national surveys have indicated that this is the most common eating disorder in the United States affecting 3.5% of adult women, 2% of adult men and up to 1.6% of adolescents. The proportion of patients admitted to the Toledo Center with the BED diagnoses has increased dramatically in the past two years (Figure[Have this ether be a link to the figure or maybe be able to be opened within the page.] 2) providing the rationale for our developing an IOP specifically aimed to meet the needs of BED patients.
Where woman and men along with teen girls and teen boys involved in the outcome study?
Eating disorders are more common in women than men and the proportion of both genders represented by our first admissions is consistent with earlier reports in the literature. Of our first admissions, 50 (4.5%) were male. The average age for first admissions is 22.1 years (SD=8.6) and 60% of admissions are between the ages of 17 and 27. Approximately 90% of those admitted are younger than 35 years of age. Table[Link to the table][Have this ether be a link to the figure or maybe be able to be opened within the page.] 1 compares the different diagnostic groups on pretreatment demographic and clinical features.
Separating the groups into the adult PHP and adolescent ARP samples (Figure[Have this ether be a link to the figure or maybe be able to be opened within the page.] 3), shows the marked disparity in age between the two program groups. The PHP admissions are in their mid to late 20s for all diagnostic groups compared to the adolescents who are more than 10 years younger than the adults. The practical implication of this age disparity is that the developmental and family themes are different in the two programs. This requires therapists in each program to be familiar with approaches that fit best with the younger and the older patient groups.
How does the length of stay impact recovery?
Duration of the eating disorder is an important variable since it has been positively associated with poor outcome.4,5 The longer patients remain ill, the more difficult the treatment process and the more ominous the outcome. The average duration of illness for the entire patient sample is 7.1 years (SD=7.3) for patients seen since 2002 which is similar to other specialized eating disorder treatment facilities.6 Of importance, there has been a significant increase in the duration of illness over the past 13 years with the average age from 2009 increasing by about 1½ years.
Data on the long-term effectiveness of treatment is difficult to interpret because many factors unrelated to the initial treatment (e.g. admission to another treatment facility, inadequate insurance coverage) can play a role after a person is discharged from the index treatment. However, it is possible to measure the general effectiveness of treatment by looking at changes from the beginning to the end of treatment since certain discharge variables have repeatedly been shown to affect both short-term and long-term outcomes. Some of the most well-established variables shown to predict outcomes include patient retention levels, achieving an appropriate body weight in the case of anorexia nervosa, post-treatment binge eating and vomiting, disturbed eating attitudes, and overall psychological functioning using reliable and standardized measures.
Patient Retention Rates
Clearly, treatment is not effective if patients do not engage in the treatment process; therefore, the patient retention rate is one important indicator of potential treatment effectiveness. There are several reasons people leave treatment in the first week after admission including the inability to obtain ongoing insurance coverage, not being ready for the challenges of needed treatment or needing a higher level of care. However, these premature discharges are relatively rare with patients admitted to the RCC. Only about 1 in 20 patients drop out of treatment in the first week. Among adolescent patients, the retention rate is higher with approximately 97% staying at least one week. We would encourage all programs to publish retention rates to allow consumers to determine the likelihood of engagement in the treatment process.
By far the best predictor of long-term outcome in anorexia nervosa is being discharged at appropriate or healthy body weight. This has been shown to be true in dozens of studies in the past 20 years. 4,5,6 Of course, this fact is problematic since most patients with anorexia nervosa are extremely frightened of a discharge weight that would give them the best chance of sustained recovery. However, within the supportive environment of treatment with an effective nutritional rehabilitation plan, most anorexia nervosa patients can gain healthy weight.
Determining an ideal body weight for an individual is a complex process and is based on age, weight history, duration of illness, and the ability to tolerate change. Therefore, there are serious limits to the interpretation of “average” discharge weights. Moreover, although treatment outcome depends on many factors two of them are particularly important. The first is the quality of treatment. Poor or misguided treatment rarely produces positive outcomes. The second factor that influences the outcome is the degree to which the patient is willing to stay engaged in treatment and tolerate weight gain despite the discomfort inherent in achieving meaningful changes.
The anorexia nervosa patients admitted from 2002 through 2014 (n=535) were classified into categories of “Not Improved” (n=58, 10.8%), “Somewhat Improved” (n=68, 12.6%), “Much Improved” (n=166, 31.0%) and “Optimal” (n=243, 45.4%) based on the amount of weight gained in treatment (<5 lb., 5-9.9 lbs., 10.0-19.9 lbs. and 20 lbs. or more respectively) and the average discharge BMIs for these groups were 17.2, 18.1, 19.4 and 20.4 respectively. More than 76% of patients admitted to Toledo Center were discharged as “Much Improved” or “Optimal” in terms of body weight.
However, most impressive is the finding illustrated in Figure[Link to table] 4 showing the weight outcomes for patients (n=463, 87% of the total) who can stay engaged in treatment for at least 20 days (1 month for the 5 day-a-week Adult PHP and just under 3 weeks for the Adolescent Residential Program). This Figure shows that only 2.4% of those who stayed in treatment for 20 days or more were “Not Improved.” More than 87% were discharged as “Much Improved” or “Optimal” outcome in terms of weight gained in treatment. It is notable that these impressive findings are obtained by a nutritional rehabilitation program that does not use nasogastric tube feeding (which is unnecessary, is associated with medical complications and can be seen as punitive) and with very minimal dependence on nutritional supplements. We use real food and teach patients how they can safely and dependably gain weight and then reduce calories to maintenance levels, in most cases, before they leave treatment.
Although it can be agreed that body weight at discharge is very important, we want to emphasize that treatment is not simply about weight or weight gain. We are aware that some programs primarily focus on weight gain and neglect the vitally important emotional and psychological factors are at the heart of the eating disorder. We are dedicated to treating the whole person and the emphasis is on addressing key psychological and interpersonal issues. One of the outcome measures we employ is the Eating Disorder Inventory (EDI-3) which is one of the most widely cited self-report measures of psychological traits or constructs shown to be clinically relevant in individuals suffering from eating disorders.7 The EDI-3 is completed by patients at the beginning and the end of treatment. This measure is comprised of 12 primary scales plus five composite scales derived by adding the standardized score of two or more scales together. Three of the primary scales are “eating disorder risk” scales since research has shown that high scores on these scales place the individual at an increased risk for having or developing an eating disorder.
EDI-3 Eating Disorder Risk Scales
- Drive for Thinness (DT)
- Bulimia (B)
- Body Dissatisfaction (BD)
There are nine primary psychological scales that assess constructs having conceptual relevance to the development and maintenance of eating disorders.
EDI-3 Psychological Scales
- Low Self-Esteem (LSE)
- Personal Alienation (PA)
- Interpersonal Insecurity (II)
- Interpersonal Alienation (IA)
- Interoceptive Deficits (ID)
- Emotional Dysregulation (ED)
- Perfectionism (P)
- Asceticism (A)
- Maturity Fears (MF)
A detailed description of the EDI-3 scale constructs can be found here.[Maintain link] Figure[Link to figure] 5 shows the pre and post-treatment scores for the 12 main EDI-3 scales for patients who completed the test at the beginning and the end of treatment from 2002-2014. The pre to post-treatment changes all showed significant improvement using paired samples t-tests (p<.001).
At the beginning and end of treatment, patients complete the Eating Attitudes Test (EAT-26) which is probably the most widely used standardized self-report measure of symptoms and concerns characteristic of eating disorders.8,9 Figure 6 above shows the pre and post-treatment EAT-26 scores for first admissions who had complete data (n=776) indicating significant changes following treatment (paired T-test, p<.001). The post-treatment EAT-26 scores are within the range typically seen in normal college students.9
Symptom Control: Binge Eating and Self-Induced Vomiting
Bingeing and vomiting frequency are major target symptoms in treatment and their amelioration is an important performance indicator at the end of treatment because control of these symptoms is a predictor of long-term positive outcome.10,11 Bingeing and vomiting were assessed both by self-report and clinical interview for all patients. When there was a disagreement between these two measurement methods, the most symptomatic report was used for this analysis. Figures 7 and 8 show the mean pre- and post-treatment binge eating and vomiting frequencies for the four diagnostic groups indicating a substantial decline in these target symptoms with treatment.
The percentage of patients abstinent from binge eating at the end of treatment for AN-B, BN and BED groups was 92%, 84%, and 98% respectively. The percentage abstinent from vomiting at the end of treatment for AN-B, BN, and Other ED groups was 83%, 80%, and 85% respectively. The percentage reduction in binge eating and vomiting across all groups was 94% and 93% respectively.
In sum, the Toledo Center is a modern treatment facility designed to provide comprehensive and highly specialized treatment for individuals with eating disorders. It has provided high-quality treatment to adolescents and adults for almost 20 years and has systematically collected treatment and outcome data to demonstrate effectiveness and affordability. It has developed an innovative Partial Hospitalization Program that includes, at no extra charge, an on-site independent living residence for adults that bridges the gap between typical partial hospitalization level of care and inpatient treatment, allowing program participants to be treated safely and economically. Independent Living allows the PHP to be available to those who live too far away to commute to treatment but is recommended even for those who live locally since therapeutic social milieu seems to be very important to achieving positive outcomes. The Toledo Center also provides specialized Residential Treatment Program for Adolescents with eating disorders.
In the future, we look forward to aligning our outcome tools towards either the EDI-3 or EAT-26 so we can now benchmark ourselves within the eating disorder provider community.
- Garner, D.M., Garfinkel, P.E. and Bemis, K.M. (1982) A multidimensional psychotherapy for anorexia nervosa. International Journal of Eating Disorders, 1, 3-46.
- Garner, D.M., Vitousek, K. & Pike, K. (1997). Cognitive-Behavioral Therapy for Anorexia Nervosa. Handbook for Treatment of Eating Disorders. (94-144). D.M. Garner & P.E. Garfinkel (Eds). New York, NY: Guilford Press.
- Garner, D.M. & Keiper, C.D. (2010). Anorexia and bulimia. In J. Thomas & M. Hersen (eds.) Handbook of Clinical Psychology Competencies, New York: Springer Science + Business Media.
- Le Grange, D., E. E. Fitzsimmons-Craft, et al. (2014). “Predictors and moderators of outcome for severe and enduring anorexia nervosa.” Behaviour Research and Therapy 56: 91-98.
- Steinhausen, H. C. (2009). “Outcome of eating disorders.” Child Adolesc Psychiatr Clin N Am 18(1): 225-242.
- Steinhausen, H. C., R. Seidel, et al. (2000). “Evaluation of treatment and intermediate and long-term outcome of adolescent eating disorders.” Psychological Medicine 30(5): 1089-1098.
- Garner, D.M. (2004). Eating Disorder Inventory-3: Professional Manual. Odessa, Florida: Psychological Assessment Resources.
- Garner, D.M., Olmsted, M.P., Bohr, Y., & Garfinkel, P.E. (1982). The eating attitudes test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871-878.
- Garner, D.M. & Garfinkel, P.E., 1979, Psychological Medicine, 9, 273-279.
- Olmsted, M. P., A. S. Kaplan, et al. (1996). “Rapid responders to intensive treatment of bulimia nervosa.” International Journal of Eating Disorders 19: 279-285.
- Safer, D. L. and E. E. Joyce (2011). “Does rapid response to two group psychotherapies for binge eating disorder predict abstinence?” Behaviour Research and Therapy 49: 339-345.