After Type 1 diabetes was diagnosed in Asha Agar Brown at age 5, she grew up surrounded by well-meaning people urging her to watch her weight.
She did. Too well. By age 16, she was starving herself. Then came bingeing, more starving, and overexercising. Finally, she discovered a trick to keep her weight down -- skipping insulin shots. "I would feel very, very tired, dizzy," she said.
This past summer, after contemplating suicide, Brown sought help. Her blood sugar level was so high that doctors at the Melrose Institute in St. Louis Park admitted her right away.
Brown, 25, is an example of why eating-disorder programs in Minnesota are growing. Two of the country's biggest centers are here, thanks to increased public awareness and, perhaps most significantly, the willingness of the state's insurers to pay for treatment.
Melrose saw almost 1,800 new patients last year, about 10 percent from outside Minnesota, while the St. Paul-based Emily Program drew 1,740 new patients this year, about 6 percent from outside Minnesota.
Those in the field say they are not sure if more people have eating disorders today, or if there are simply more places for them to seek help.
"I wonder if the patients haven't always been there, but they haven't had a lot of good treatment options available," said Dr. Leslie Sim, clinical director of the eating disorders program at Mayo Clinic in Rochester.
A relatively new field that really started around the 1980s, eating disorders have expanded to include not just anorexia nervosa, where people starve themselves, but also bulimia (overeating and purging), as well as binge eating.
Then there are new hybrid conditions such as diabulimia, which Brown suffered from, in which people with Type 1 diabetes deliberately give themselves less insulin than they need so they can lose weight.
About 24 million Americans have an eating disorder, with many more undiagnosed, according to the National Eating Disorders Association (NEDA), an advocacy group.
At a time when much of health care is in cost-cutting mode, eating disorder programs continue to grow. Sim said the six-year-old Mayo program, which treats children and adolescents by involving their families, has plans to expand.
The Emily Program, which grew from two locations a decade ago to six today, is opening a seventh next summer -- an adolescent residential facility in St. Paul's St. Anthony Park neighborhood.
"We've seen clients here as young as 8," said Emily Program founder Dr. Dirk Miller, who named the program after his sister, who recovered from an eating disorder.
Meanwhile, the Melrose Institute, part of Park Nicollet Health Services, opened a 39-bed facility last year in St. Louis Park and is considering opening another Twin Cities outpost.
Costly, and often lengthy, care
In many other states, families continue to struggle to get insurance coverage for treatment, said Lynn Grefe, the New York-based chief executive of NEDA. "Minnesota really is a leader because people with eating disorders can breathe here," Grefe said. "They should be a model for the rest of the country."
Those in the field point to a high-profile lawsuit 10 years ago as the catalyst. Then-Attorney General Mike Hatch sued Blue Cross and Blue Shield of Minnesota after the death of Anna Westin.
Westin had struggled with anorexia for years, and Hatch claimed the insurer had systematically denied treatment for children's mental health.
Blue Cross agreed to change its ways, and the Westins used their $1 million settlement to set up the state's first residential program to treat eating disorders, the Anna Westin house, now part of the Emily Program.
Today, "insurance companies in Minnesota, for the most part, recognize that these are serious illnesses that need to be treated and need to be treated aggressively," said Kitty Westin, Anna's mother.
Treatment costs can be substantial.
Residential costs at the Emily Program run around $36,000 a month. Less sick patients might come in once a week to see a therapist and a dietitian at a cost of about $1,100 a month. And unlike residential drug and alcohol addiction treatment programs, which typically last a month, patients with eating disorders may need to stay several months.
At Melrose, residential treatment can cost $1,600 a day, while higher-level inpatient care is about $1,900 a day.
Health insurance companies say they see the benefits of early diagnosis and treatment, potentially averting more serious issues down the road, such as bone fractures, heart disease, diabetes, infertility or even death.
"The cost of not treating is astronomical, both in human suffering and medical problems," said Dr. Murray Zucker, a medical director with OptumHealth, the care management arm of UnitedHealth Group. "From a cost-effectiveness standpoint, it makes sense to treat eating disorders as quickly as possible and in as efficacious a way as possible."
The next challenge for the field is measuring outcomes.
"The $10 million question is what constitutes recovery for an eating disorder," said Dr. Joel Jahraus, executive director of the Melrose Institute.
Because people's conditions are so varied, and their treatment regimens often so personalized, it can be hard to benchmark results. Right now, most programs survey patient satisfaction and look at improvement on an individual basis.
Asha Agar Brown continues to check in every two months with her doctors. She also has started teaching yoga classes again.
"I feel like a different person," she said.
Chen May Yee • 612-673-7434