Kristina Saffran and Erin Parks, Co-Founders of Equip, on redefining the eating disorder narrative

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Erin Parks, PhD, Co-Founder, COO, and Chief Clinical Officer, and Kristina Saffran, Co-Founder & CEO, of Equip

In this episode, I sat down with the co-founders of Equip, Kristina Saffran and Erin Parks, Ph.D. Equip provides virtual, evidence-based eating disorder treatment. The company has expanded rapidly over the last few years. In February 2022, it raised a $58 million Series B funding round from The Chernin Group, Tiger Capital, General Catalyst, and other existing investors.

Erin, Kristina, and I discuss:

  • How they met and why starting a company together was the right move
  • What’s happening in a person’s body and mind when they have an eating disorder
  • Equip’s family-based treatment model and the company’s holistic approach to defining access
  • Why virtual care works well for eating disorder treatment
  • Lessons that Erin and Kristina have learned from each other as co-founders and their advice on navigating the co-founder experience

Beginning to 9:06: Kristina & Erin’s paths to Equip

  • From marketer to clinician: Erin describes her career path as a “twisty turny journey.” As a marketing and communications major in undergrad, she took a job out of college marketing Broadway shows in tertiary markets. After quickly realizing that the work wasn’t for her, she decided to pursue a long-standing interest in the sciences, leading her to a neuroimaging research job at the NIH, and she started taking neuropsychology classes on the side. She fell in love with the work, fascinated by how the brain recovered following traumatic events, and began a PhD in clinical psychology at UC San Diego.
  • Becoming an eating disorder expert: Erin had always known that she wanted to be a mother and had read that being a research professor enabled the highest quality of life for a working parent. She set off on this path. But when the recession hit, grant funding became harder to come by and Erin began thinking about clinical work. A fellowship opportunity came up at the UC San Diego Eating Disorder Center, an area of clinical psychology that Erin had never considered specializing in. Thanks to encouragement from friends, she took the fellowship and was lucky to receive excellent clinical training and mentorship from some of the best providers of evidence-based eating disorder care such as Dr. Walter Kaye. He taught her about the business of mental health and clinical operations, knowledge and experience that have been fundamental to building Equip.
  • Recovering from an eating disorder: Kristina joked that she has spent her entire life working in eating disorders. Diagnosed with anorexia at 10 years old, Kristina spent years in treatment and recovered. Helping others recover from eating disorders has been her life’s work. She started Project HEAL, a nonprofit organization, in 2008, to raise money for people who couldn’t afford treatment. It has become the second largest eating disorder nonprofit in the country.
  • Kristina’s early career: Because Kristina spent a lot of time in treatment as a child and adolescent, working with PhDs and MDs, becoming a clinician seemed like a great way to create change. She also had an interest in psychology and mental health. Due to an aversion to blood though, Kristina ruled out the MD route and set out to become a clinical psychologist after college. She moved to the Bay Area to work as a research assistant for two years, the typical prerequisite for a PhD.
  • From professional acquaintances to co-founders: Kristina and Erin met through professional networking and became friendly, running into each other at academic conferences a few times a year. They connected over their shared interests in the big issues surrounding eating disorders, like how 80% of people are not getting access to treatment. As time went on, Kristina prepared to get her PhD at UC San Diego and work as Erin’s research assistant. Right before making this transition though, she realized that getting her PhD wasn’t the best way to make the impact she sought. A few years later, Erin found that academia was also moving too slow for her. They decided to try a new approach together. Enter Equip!

“We would beeline to one another every six months at these academic conferences. I think a lot of academics like to talk about small micro issues, and we were always [asking about] the big issues like 80% of people are not getting access to treatment. How can we solve this?” — Kristina Saffran

9:06 to 12:18: Identifying strengths and recognizing gaps

  • Overcoming imposter syndrome: Despite Kristina and Erin’s deep knowledge of eating disorders, they initially thought they needed someone with a business background to join them as a third co-founder or that they needed to join a venture studio. With the help of investor and payor feedback, they eventually realized they were the best two people to found this company. Their collective 30 years of experience working with patients and families affected by eating disorders, Kristina as a patient and advocate and Erin as a clinician, became a core strength. While they might not have known everything about starting or running a company, both Erin and Kristina relied on their shared skill of bringing the right people to the table to help them get to where they need to be.
  • Relying on prior experiences building things: Although Erin and Kristina are first time founders of a venture-backed company, this is not their first time building things. Kristina started Project HEAL, which she shared was the best preparation for running Equip, especially as it relates to fundraising. As Project HEAL’s CEO, she spent 90% of her time fundraising and found nonprofit fundraising much more difficult than for-profit. Erin is also a builder, having expanded the UC San Diego Eating Disorder Clinic from 20 to over 100 employees during her tenure.

12:18 to 18:12: Eating disorders are brain disorders

  • The science of eating disorders: Kristina explained how eating disorders are brain disorders with some of the strongest neurobiological and genetic predispositions of all mental illnesses. A core feature of eating disorders is anosognosia, which is an ambivalence about recovery and not knowing how sick you are. This has meant that historically, treatment for eating disorders has focused on willpower — motivating someone to eat and like their body — even though we know that this approach is ineffective.

“Eating disorders are brain disorders. They have some of the strongest neurobiological and genetic predispositions of any mental illness. And, this is really why we know that in treating them we need to bring in people who understand them…You’re essentially fighting your brain upwards of six times a day…facing your greatest fear to do the things that will get you to recovery.” — Kristina Saffran

  • Eating disorders can affect anyone: Eating disorders encompass a number of diagnoses including anorexia nervosa, bulimia nervosa, and binge eating, among others. According to Erin, 9% of the US population — 30M people — will have an eating disorder at some point in their life. Eating disorders affect people across all ages, genders, ethnicities, races, and socioeconomic statuses. Some interesting specifics that Erin shared included that about 40% of people who suffer are men, and eating disorders occur at 5x frequency in the transgender population.
  • High mortality and comorbidity rates: Eating disorders have the second highest mortality rate of all mental illnesses and almost never occur alone. They’re highly comorbid with anxiety disorders, major depression, obsessive compulsive disorder, post-traumatic stress disorder, and substance use disorder. As a result, eating disorder treatment must be considered within the context of these other health issues.
  • Eating disorder research: I found Erin’s overview of eating disorders research especially interesting. A JAMA Psychiatry article by Dr. Cindy Bulik of UNC article revealed that in 2018 and 2019, research dollars invested in eating disorders translated to $9 per person with an eating disorder, yet were in the hundreds of dollars for Alzheimer’s and schizophrenia patients. Erin explained that this disparity is due to eating disorders being the black sheep of mental disorders. There’s a hypothesis that when a person is responsible for their illness, the issue receives less funding. This used to be true of schizophrenia and autism, for example, since many people considered these illnesses to be the parents’ fault, so we saw less funding for these illnesses. Eating disorders continue to be considered the fault of patients or their parents, leading to lower research investments. Similarly, another study by Dr. Bulik showed that eating disorders have fewer pages dedicated to them in academic research journals.

18:12 to 26:19: Equip’s treatment model: family-based therapy

  • Engaging the household: At a high level, family-based therapy (FBT) requires the healthy people in a patient’s household to structure a home environment that encourages healthy behaviors. This is in contrast to treating eating disorders as an individual illness, which doesn’t work because the affected individual’s brain is not working properly. Despite multiple clinical trials and published research demonstrating the efficacy of FBT, it has historically remained largely stuck in academia. Kristina shared the outcome of a study from decades ago that took 25 physically and psychologically healthy men and essentially starved them to evaluate the impact of starvation on the human body. The study’s authors found that participants began exhibiting the symptoms we now associate with eating disorders, making it clear that even for people not genetically predisposed to an eating disorder, the effects of starvation make it challenging for patients to find success through traditional treatment.
  • A multidisciplinary team: FBT includes a five-person team: a therapist, physician, peer mentor, family mentor, and dietician. Because only 20% of the US’ 5,000 eating disorder specialists are trained in evidence-based treatment methods, it can be extremely challenging to find this entire team in the community, have it covered by insurance, and coordinate care across these individuals. As a result, many people have resorted to residential treatment, which means starting at an intensive treatment level, despite there being no clinical evidence that this is the proper level of care. Erin shared how Equip is focused on training and managing clinicians in FBT because this is key to making treatment available outside of academia and at scale. Equip made the intentional decision to employ its people as W2 employees rather than 1099 ones. The company trains all of its providers themselves, monitors and supervises sessions, and grades providers on the fidelity to the model. The Equip team believes that providing ongoing, high-quality training is foundational to the success of their clinical model.
  • Building a life worth living: A final but critical element of Equip’s model is integrating treatment into someone’s daily life. In Kristina’s experience, inpatient treatment could feel safe and easy since it protected her from triggers and the complexities of real life. The hard part, she felt, was coming out and continuing it in real life. Additionally, going in and out of residential treatment makes it hard to engage with normal childhood and teenager things: have a real relationship or a job, go to soccer practice, participate in a school play, hang out at friends’ houses. Throughout our conversation, it became clear that one of Equip’s goals is to help patients construct a life worth living, which often means integrating the care experience as closely as possible into a person’s normal life.
  • A virtual-first model: Even though Equip launched during the Covid-19 pandemic, Kristina and Erin always knew that they needed to provide 100% virtual treatment in order to maintain access as their north star. They’re now convinced, with two years of operation under their belt, that a virtual-first model is best for eating disorders. Beyond getting in the way of the patient’s life, traditional treatment models also pose a major burden for parents. Equip has found that treatment works better when parents, grandparents, the babysitter, aunt and uncle — a person’s entire village — can provide support, which simply isn’t possible with brick and mortar.

26:19 to 29:39: The secret sauce - peer and family mentors

  • In-network coaching benefits: I shared with Kristina and Erin that the peer and family mentor roles are especially cool to see. We talk a lot about these sorts of roles in healthcare, but it’s fairly rare to see them because they’re not paid for under fee-for-service structures. Erin shared that while they’re becoming more popular in telehealth models, they’re still typically not covered. Ensuring that these services are in-network has been a priority for Equip.
  • The peer mentor role: A key part of the model are peer and family mentors, which Erin and Kristina called the secret sauce. Peer mentors have recovered from an eating disorder and are now Equip employees. Because eating disorders are egosyntonic, meaning patients who are suffering cannot recognize that they need to change their behavior, receiving support from someone who has gone through the recovery process before and seeing an example of what full recovery looks like is essential. Peer mentors and patients meet regularly to talk about how to employ the skills they learn, fight triggers, and ultimately build a life worth living.
  • The family mentor role: Pioneered at UC San Diego, the family mentor is similar to the peer mentor. The family mentor is someone who has helped a loved one through an eating disorder and typically works most closely with a patient’s family. They have shown to be particularly helpful in situations when the message would be less effective coming from a therapist or physician. For example, they can hold up a mirror to a parent and say, “I used to be like you and eat a salad while making my ill child eat fettuccine alfredo. However, what message does this send to your child?”

29:39 to 33:07: Expanding in-network partners

  • Filling coverage gaps: Treatments for eating disorders have been covered by insurance since 2008 when the Mental Health Parity Act was signed. That said, finding in-network services in the community remains difficult to impossible, leading to a proliferation of the residential treatment model (someone leaves their home for 30, 60, or 90 days and receives around-the-clock care). Some patients get better in residentials, but after insurance stops paying for these services, many are unable to find the appropriate levels of care when they return home. Equip builds a cost-effective lower rung of care that helps people engage with normal activities and routines like going to soccer practice and spending time with their siblings. Residential treatment models also have relapse rates that are as high as 50% within seven months of leaving, so there’s concern about their efficacy. Payers find the high expense and fairly low efficacy frustrating, which explains why they’re so excited to partner with Equip.

33:07 to 38:12: Equip’s bright future

  • Series B funding: Equip raised $58M in February 2022 from The Chernin Group, Tiger Capital, and General Catalyst, and it has exciting plans for its use of these funds. In the near-term, its services will be made available in all 50 states by June 2022, and the company is planning to expand the age groups it serves, going from people ages five to 24 to include adults.

“We’re making sure we’re not just claiming to be increasing access by throwing our treatment on the internet. Rather, we are making sure that we’re increasing access in all the ways that access is defined.” — Erin Parks

  • A new prevention-focused initiative: Equip is focused on a new initiative to disrupt the cultural narrative of eating disorders. Currently, eating disorders are largely viewed as a vanity issue and a choice. Equip wants to help people understand that eating disorders are brain disorders that impact a diverse population. To do this, Equip has been building a prevention program rooted in academic literature that isn’t new but hasn’t made it into the community setting. Through this program, they want to reach the 80% who haven’t yet been diagnosed.
  • Medicaid expansion: Working with more Medicaid plans is another priority for Equip. The team recognizes that Medicaid patients are under-resourced in many areas of their lives such as access to food and reliable technology. This requires them to think deeply about barriers to access. As a result, all families get assigned a family navigator that helps manage the things that get complicated when you’re dealing with an eating disorder. A family navigator could help a patient and their family get a 504 plan or IEP that allows the school to let a child eat between classes or during a class. Or, they might help someone get free wifi or send them a hotspot until they get reliable internet so that they can access Equip’s treatment. A family navigator might help a patient access SNAP benefits and help them make meals that are culturally and economically aligned with their needs.

38:12 to end: Lessons learned and the co-founder relationship

Editor’s note: I mentioned that we’ve never had two guests on one episode of The Pulse, but I’ve since remembered that we have! Check out our episode with the Co-Founders of Unite Us, Dan Brillman and Taylor Justice.

  • Dream big and everything doesn’t need to be perfect: When I asked Erin what’s a lesson that she’s learned from Kristina, she shared two: to dream big and everything doesn’t need to be perfect. Regarding the first, Katie Couric recently joined Equip as an advisor, thanks to some big dreaming. The leadership team had been discussing celebrities that would make great Equip advisors, and Erin had suggested someone like Katie Couric, who has had her own eating disorder journey, but didn’t expect that they would actually get her to join. Kristina’s response: let’s get Katie Couric, and they did! Related to the second, coming from academia, Erin is used to waiting years before sharing her work with someone, but she can’t do this in startup life. It’s simply not possible. To help her adjust to this reality, Kristina often reminds her that really only maybe 20% of things need to be perfect and the other 80% just need to get done.
  • Slow down and remember the why: Kristina also shared her response to this question, saying that Erin has helped her pause, slow down, and remember the why, the context, and the audience. This has helped Kristina think about if things need to get done today, if she can sleep on it, or even if she can wait a month and if the waiting will lead to a better outcome. The age gap between the founders also helps Kristina be a bit nicer to herself as Erin has more lived experiences. Erin has taught Kristina that making a mistake doesn’t mean that she’s not capable but rather that she’s human.

“We talk a lot about how there are no more brick walls in this job. There’s no lack of resources. There’s no bureaucratic academia. There are just puzzles. And there are some really hard puzzles. There are really complicated puzzles and nuanced puzzles. But there’s this feeling [that if we have] the right people around the table, and we have so many amazing people around the table — our team, our investors, our advisors — we can figure anything out and that feels really good.” — Kristina Saffran

  • Choosing a co-founder: In response to my question — what advice do you have on selecting a cofounder — Erin encouraged founders to have a co-founder. Starting a company can be a lonely experience even if it’s done with a co-founder because it’s hard for others to understand what you’re doing. She and Kristina are always surprised when people go through the experience without one. Kristina chimed in that picking the right co-founder is just as important as having one. She described the relationship like a marriage — it’s essential to select someone you enjoy spending time with, respect tremendously, can learn from, and can just laugh with. Early in their journey with Equip, Kristina and Erin asked each other questions like: What will we do when really bad stuff happens? What’s the mission that is going to continually inspire us? What kind of investors do we want around the table? What’s going to happen when we disagree? Both found the exercise foundational to developing an honest and open relationship that allows them to solve conflicts quickly.
  • Hiring: Finally, Equip is hiring across its team! Check out their open positions here: https://equip.health/careers/

We are so appreciative to Erin and Kristina for joining us on this episode of The Pulse Podcast! Subscribe for our new releases on Twitter, Spotify or Apple podcasts.

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