In Colorado and nationwide, around one in 10 people will be diagnosed with an eating disorder in their lifetime. State lawmakers are trying to address that with a new pair of bills. 

The Senate Health and Human Services Committee advanced Senate Bill 14 and Senate Bill 176 on Thursday. 

If signed into law, SB 14 would create a statewide office dedicated to preventing disordered eating. SB 176 would regulate certain operations in eating disorder treatment facilities and restrict the sale of diet pills to minors. 

“Eating disorders are increasingly recognized as a leading cause of morbidity and mortality that impact thousands of Coloradans every year,” said Sen. Dominick Moreno, D-Commerce City, who is sponsoring both bills. “These bills are a strong first step toward better supporting Coloradans experiencing eating disorders and will help build a healthier Colorado for all.” 

Eating disorders are the second-deadliest mental illness, beat only by opioid-related deaths, according to the National Association of Anorexia Nervosa and Associated Disorders. Nationally, around 10,200 people die from eating disorders each year, with the most common eating disorders being anorexia, bulimia and binge eating disorder. 

Since 2019, the Eating Disorder Foundation in Denver said its average monthly sign-ups for support groups have increased 1,000%, which experts attribute to the mental health impacts caused by the COVID-19 pandemic. The Eating Recovery Center in Colorado similarly reported a “remarkable” uptick in patients in the last three years, particularly among teens and children. 

The Office of Disordered Eating Prevention  

Under SB 14, the Office of Disordered Eating Prevention would be created to inform youth, parents, schools and primary care providers about preventing, recognizing and treating eating disorders. The office would also fill gaps in access to eating disorder treatment and lead a grant program to fund research on the prevalence, causes and effects of eating disorders in the state.

The proposal for the bill came from the Colorado Youth Advisory Council, partly inspired by the experience of member Aimee Resnick. 

Resnick said she was teased and bullied for being “bigger” than her peers throughout middle school and early high school, leading her to begin starving herself. Resnick was eventually diagnosed with anorexia and, in 2020 at 15 years old, she attempted suicide due to her eating disorder. 

“I thought that losing weight was the only way to obtain social acceptance,” Resnick, now 18, said while testifying in support of the bill. “I didn’t realize at the time that I would lose myself in the process.” 

Resnick was one of more than a dozen residents who detailed their experiences suffering with eating disorders on Thursday, while asking lawmakers to pass SB 14. Many more spoke of their children, siblings, parents and friends who have experienced eating disorders. No one testified against the bill. 

Proponents said the research component of SB 14 is particularly important, as very little statewide data exist regarding eating disorders. They said this makes it difficult to advocate for state support, as they can’t point to how substantial the problem is statewide. However, one report in 2015 suggested that Colorado had the fifth-highest rate of eating disorders in the country among adolescents. 

The bill would provide $200,000 in grant funding for eating disorder research. Federal funding for eating disorder research amounts to only 73 cents for each person with an eating disorder, the American Psychiatric Association reported. This is compared to nearly $87 per person for schizophrenia and $59 per person for autism spectrum disorder.

While witnesses who testified on SB 14 were in unanimous agreement, lawmakers were more split. 

Committee members voted 6-3 to advance the bill to the Senate Appropriations Committee for further consideration. The vote was along party lines, with all Democrats in support and all Republicans in opposition.

Sen. Janice Rich, R-Grand Junction, said she doesn’t want to create another state office. From 2019 to 2022, state lawmakers and the governor added more than a dozen new state offices, a new state department and other governmental structures. This government expansion was recently criticized by Republican lawmakers, calling it unsustainable and financially irresponsible. 

“I appreciate this bill and I think it’s probably an important one,” Rich said. “If you could find one of these (new offices) that’s not really doing anything. … If you could find a way to maybe eliminate one of these and put a really important one in, I could probably get there.” 

Though, Coloradans who have struggled with disordered eating say another new office is well worth it to prevent others from going through the same thing. 

Emma Warford, a Highlands Ranch high school senior, said she started counting and limiting her calorie consumption in March 2020 as a “coping mechanism” to deal with the stress and isolation of the pandemic. That January, she was found to be severely underweight during a routine check up, and was diagnosed with anorexia.

Warford said she tried to get help, joining a six-month-long wait list to enter a residential treatment facility. But four months later, her heart rate plummeted and she was rushed to the hospital, where she stayed for the next six months. Warford eventually moved to Washington to receive treatment. 

“I’m so proud to say that, today, I’m recovered from my eating disorder. It was a long, hard battle,” Warford said. “There are too many young people out there that are struggling with the same issue I did, and it’s time we take a stand.” 

Warford said the Office of Disordered Eating Prevention could help prevent kids like her from developing eating disorders in the first place by informing schools, parents and doctors on how to identify early warning signs and to teach kids healthy coping mechanisms before they turn to disordered eating. 

SB 14 is backed by groups including the Eating Recovery Center, Children’s Hospital Colorado, Colorado Education Association, Colorado Psychiatric Society, National Alliance on Mental Illness, Youth Healthcare Alliance and Eating Disorder Foundation. No organizations are registered against the bill. 

Moreno said he is working with the Department of Public Health and Environment, which would house the Office of Disordered Eating Prevention, to make the bill less expensive to implement. The bill is currently expected to cost $426,000 through 2025 to pay for the office and grant program.

Amendments to “streamline the administration” of the program and lower the costs are expected to be introduced when the bill reaches the Senate floor. 

Treatment facilities 

SB 176 would establish rules around care practices in eating disorder treatment facilities, and prohibit private insurance carriers and Medicaid from using a patient’s weight or body mass index (BMI) to determine the patient’s needed level of care. 

Less than 6% of people with eating disorders are medically diagnosed as “underweight,” according to the National Association of Anorexia Nervosa and Associated Disorders. Despite this, numerous witnesses said they were kicked out of eating disorder treatment facilities or refused insurance coverage for their stays because their BMIs were not low enough. 

Emma Troughton said, in 2017, their eating disorder had gotten so bad that their period stopped, their hair was falling out, they couldn’t sleep due to starvation migraines and their body was freezing and covered in bruises from dehydration. Though Troughton sought treatment, they weren’t admitted until their BMI passed a certain threshold. 

When Troughton was finally allowed into a treatment facility, they were discharged in a matter of weeks. Though Troughton was still struggling with disordered eating, they had gained enough weight according to their BMI. When they were readmitted the following year, Troughton said they tried to violate their meal plan and eat less, so they wouldn’t gain weight as quickly and could continue receiving care. 

“Each time I was sent home because my BMI was acceptable to an insurance company, I relapsed,” Troughton said. “I’m lucky I lived, but I’ve seen too many of my fellow patients and friends die because their BMI dictated their access to care.” 

An amendment was added to the bill on Thursday, allowing BMI to still be used to determine the appropriate level of care for anorexia patients specifically, though it cannot be the “determining factor.” Insurance companies must also consider the patient’s eating behaviors, needs for support or supervision, laboratory results and potential co-occurring disorders. 

Another amendment removed a portion of the bill that said treatment facilities – in addition to insurance companies – couldn’t use BMI to determine a patient’s medical necessity or appropriate level of care. But the bill also adds requirements for treatment facilities to have a formal discharge policy provided to patients upon admission and, after discharge, to provide follow-up services for patients. 

These concessions were made after treatment facilities raised concerns that the bill would conflict with the American Psychiatric Association’s guidelines, which still use BMI as a key element in assessing patients and levels of care. 

The Eating Recovery Center, Colorado Psychiatric Society and Colorado Association of Health Plans all went from opposing or amending the bill, to neutral with these changes. 

The bill would also address what proponents called “dehumanizing,” “violating” and “punitive” practices in treatment facilities. 

During the hearing, former patients and employees of treatment facilities spoke of patients being forced to participate in public weigh-ins while wearing sheer, exposing robes; patients being examined while nearly naked by staff members of the opposite gender; non-binary or transgender individuals being misgendered in assigned bathroom groups; patients being watched by staff when using the bathroom; and, patients being tube fed or confined to their rooms as punishment for not finishing meals. 

“This is a crisis with our youth,” said Sen. Lisa Cutter, D-Jefferson County, who is sponsoring SB 176 with Moreno. “We must address outdated and harmful approaches to treating eating disorders and provide care that is respectful to each individual and on par with the latest research.”

SB 176 would establish several new requirements for treatment facilities, including providing private weigh-ins and medical exams when requested, prohibiting staff from being in a single bathroom stall with a patient, requiring appropriate bathroom accommodations for non-binary and transgender patients, and making bed-based and room-based care a last resort. The bill would also require the promulgation of rules, training and enforcement of current guidelines around forced tube feeding. 

Emily Mahn said she was a therapist at the Eating Recovery Center from 2016 to 2019 and witnessed many “problematic” occurrences. For group weigh-ins, Mahn said patients were practically naked in front of their peers and forced to do jumping jacks to prove they weren’t hiding items inside of their body to add extra weight. Mahn said some patients would cry uncontrollably, dissociate or say they felt “humiliated.” 

“When I voiced my concern about these policies to higher ups, I was dismissed and repeatedly fed the line that these policies were implemented in the patients’ best interests,” Mahn said. “I am happy to finally speak out publicly about the harm they cause and feel deep shame and regret for implementing them.” 

Other employees defended the treatment facilities, pointing out the often life-or-death cases they are forced to address. Forced tube feedings, they said, are only used when a patient could die otherwise. And practices like group weigh-ins come about from staffing shortages that make daily one-on-one weigh-ins difficult to facilitate.  

Maggie Moore said she’s been a therapist at the Eating Recovery Center for over six years. She said a patient’s care plan is crafted by them, their family and their care team, and while it is often challenging for patients, it is necessary. 

“The hard and sometimes uncomfortable work our patients do in treatment sets them up for recovery in the future and, quite frankly, it saves their lives,” Moore said. 

Finally, SB 176 would prohibit the sale of over-the-counter diet pills to Coloradans under the age of 18 without a prescription. 

Youth who use diet pills are six times more likely than non-users to be diagnosed with an eating disorder within three years, according to the National Alliance for Eating Disorders. A Harvard University study found that, in 2018, 490 people in Colorado visited emergency rooms due to adverse events linked with dietary supplements. 

The bill originally would have also banned the sale of dietary supplements to minors, but was amended to remove this component, with opponents saying it was “too broad.” The amendment also removed potential fines for retailers who violate the prohibition. These changes led the Natural Products Association and Colorado Retail Council to withdraw their opposition to the bill. 

The bill would still ban the sale of laxatives to minors. The Consumer Healthcare Products Association continued to push for laxatives to be removed from the bill on Thursday, saying they’re not meant for or marketed for weight loss – though laxatives are widely abused for that purpose by people with eating disorders. 

Moreno said the numerous amendments made on Thursday could lower the fiscal impact of the bill, which currently sits at around $1.2 million through 2025.

Lawmakers voted 7-1 in bipartisan support of SB 176, sending it to the Senate Appropriations Committee. One Republican voted “yes,” one was absent for the vote, and the last, Rich, said she voted “no” because she doesn’t yet know how much it will cost to implement.