Eating Disorders: Another Consequence of COVID-19

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In January, when Michael’s daughter lost interest in eating, he knew it was time to take action.

Michael, a New York City resident (he asked that his last name not be used), began noticing changes in his daughter’s mood prior to the new year. At the end of last summer, the vivacious and social 12-year-old began showing signs of depression, which were revealed through her eating habits. She declared herself a vegetarian, and refused to eat any meat besides chicken. She also stuck to a limited menu that included foods like pasta and pizza.

Changes in her routine only exacerbated struggles with eating. While Michael’s daughter started the school year on a hybrid, in-person schedule, her classes went completely remote in November because of COVID-19 outbreaks in New York. Remote schooling, Michael said, was tough, as it led his daughter to spend more time in isolation and on social media.

At the start of the new year, Michael and his wife noticed that their daughter was losing weight. “It became really apparent in the middle of January,” he told MedPage Today. “She didn’t want to eat at all.”

During the COVID-19 pandemic, clinicians have seen an increase in kids struggling with illnesses such as anorexia nervosa, binge eating disorder, and other eating disorders, they told MedPage Today. There are no epidemiological data to describe how the prevalence of eating disorders in kids may have shifted during the pandemic, but psychologists, nutritionists, and primary care providers said they’ve seen higher caseloads and increased referrals to eating disorder treatment centers.

“We have seen roughly a 30% to 40% increase in referrals to our clinic alone,” said Christine Peat, PhD, of the Center for Excellence in Eating Disorders at the University of North Carolina in Chapel Hill.

Cynthia Bulik, PhD, the founding director of the UNC center, said in an email that they “simply cannot provide adequate services at this point because demand for treatment is so high.”

This increase is not unique to UNC. Before the pandemic started, clinicians at Children’s National in Washington, D.C., saw 5 to 6 patients each day for an eating disorder. By the fall of 2020, that number had doubled.

Lisa Tuchman, MD, division chief of adolescent and young adult medicine at Children’s National, stated that her team noticed an increase in not only the volume of eating disorder patients, but also the number who are medically compromised due to malnutrition.

“In both the severity of the eating disorder and the number of people struggling, we’ve experienced a big increase,” Tuchman told MedPage Today. While she was used to seeing patients who lost between 20 and 30 lbs, Tuchman said she now sees a higher frequency who have lost up to 60 lbs.

In the U.S., around 9% of people will have an eating disorder in their lifetime. During the pandemic, incidences of general anxiety, depressive, and adjustment disorders in the U.S. — all risk factors for an eating disorder — each rose between 80% to 90%, according to insurance claims data. Pediatric emergency room admissions for mental health conditions rose by a quarter. Eating disorders also became more prevalent, moving up to the fifth most prominent mental health condition by August 2020.

The Perfect Storm

When the pandemic started last March, kids had their lives uprooted, as remote schooling, separation from friends and family, and the lack of structure during quarantine became major lifestyle changes. In addition to navigating these changes, children and teens have lived in a state of constant unknowns.

“One of the biggest stressors prior to the pandemic was uncertainty,” said Stephanie Zerwas, PhD, an associate professor of psychiatry at UNC Chapel Hill. “That’s been the name of the game this whole year.”

The reasons why children or adolescents may develop an eating disorder are often multi-factorial, said Zerwas, who also works as a private-practice therapist. During the COVID-19 crisis, combining puberty with high anxiety and uncertainty, a lack of structure, and constant pressure from increased engagement with social media were an onslaught of risk factors placed on young people. “That’s pretty much a perfect storm for developing an eating disorder,” Zerwas said.

Among patients recovering from an eating disorder, these unique risk factors also posed concerns. Last summer, Peat and Bulik co-authored a study showing that 79% of U.S. patients (who were 18 and older) had concerns that their eating disorder may regress due to a lack of structure during the pandemic. More than half of these patients also worried about a lack of social support, as well as being in a triggering environment.

“We know that eating disorders are conditions that tend to thrive in secrecy,” Peat, who also directs the National Center of Excellence for Eating Disorders, said in an interview. Combine that with increased isolation and time spent away from loved ones during the pandemic, and it almost becomes a “breeding ground.”

Social Media: An Exacerbating Factor

As kids in isolation have turned to TikTok and Instagram for their social interactions, Peat added that they’re likely exposed to constant messaging about losing weight. Teens are being inundated with content about how to avoid the “quarantine 15,” or take advantage of free time to adopt a new exercise regimen.

“We are kind of surreptitiously — sometimes actually, overtly — feeding kids these messages like, ‘there’s never a wrong time to hate your body,'” Peat said.

Emilie Burgess, RDN, a Boston-based dietitian who specializes in working with athletes who have eating disorders, said that she’s had many conversations with patients about following influencers who post diets and workout routines on TikTok since the pandemic started. “Adolescents are really just falling into, unfortunately, that black hole of social media,” Burgess said.

Zerwas said that isolation during the pandemic has limited the number of people that kids see each day, and their understanding of body image diversity can become biased towards what they see online. “It starts to skew the understanding of what normal looks like,” she said.

Early Detection

Openings at eating disorder treatment centers have filled up faster during the pandemic, leaving fewer spots available, so some have shifted their focus to early detection and prevention. In December, the American Academy of Pediatrics released guidelines on eating disorders in youth — urging attention to the “non-stereotypical” population.

Laura Windham, MD, a pediatrician at Chapel Hill Children’s and Adolescents Clinic, said that caseloads for nutritionists, psychologists, and counselors are “through the roof,” and she has helped more patients manage eating disorder treatment. Looking out for the patients who may not be medically “underweight,” or who do not fall under the category of a thin, white, teenaged-girl, Windham said, is critical.

“We are trained to look out for sort of the … kids who we think fall under the eating disorder stereotype,” Windham said. “We are learning to look at kids who fall outside of that stereotype, and kids with atypical eating disorders.”

Bulik said it’s critical for front-line providers in primary care to understand that “eating disorders are not a passing phase.” She added that these conditions may occur at any body size, and encouraged pediatricians to ensure they are equally vigilant in patients of all ages, sizes, genders, racial and ethnic backgrounds, and socioeconomic statuses.

Food insecurity — which more families have experienced during the pandemic — is also a potential risk factor for disordered eating. “People under-appreciate the impact that food insecurity can have on developing an eating disorder,” Bulik said, adding that without school breakfasts and lunches, many kids may not be getting adequate nourishment.

Routinely screening all kids and teens, and checking in with them about how they feel about their body, may be a significant population health intervention for pediatricians, experts said.

When Michael and his wife became concerned about their daughter’s eating patterns, which were later diagnosed as anorexia nervosa, they brought her to the emergency room.

By the end of January, they found space for her at an eating disorder facility near their home, where she was admitted as an inpatient. His daughter started eating meals again, and now attends cognitive therapy sessions as an outpatient. Michael’s family also partakes in family-based therapy, the gold standard for eating disorder care.

Now, Michael and his family have focused their efforts on supporting his daughter in understanding her illness.

“With anorexia, it’s really like it’s two people,” Michael said. “We’re helping her understand that it’s the eating disorder, it’s not her.”

  • Amanda D’Ambrosio is a reporter on MedPage Today’s enterprise & investigative team. She covers obstetrics-gynecology and other clinical news, and writes features about the U.S. healthcare system. Follow

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