In spring 2020, researchers and clinicians expressed concerns for the mental health of youth as the impacts of the COVID-19 pandemic took hold. Among those were concerns for individuals with eating disorders. As a clinician in Children’s Hospital of Philadelphia’s Eating Disorder Assessment and Treatment Program, I worried about the impact of increased social isolation on individuals with an illness that is inherently isolating. My colleagues and I worried that the severity of an adolescent’s eating disorder would worsen under such stressful circumstances and that the risk of relapse among patients would increase. And as food insecurity, economic hardships and family struggles began to weigh upon households, our concerns for these vulnerable youth grew.
As we reflect on this year’s National Eating Disorder Awareness Week, and as we approach the one year anniversary of the pandemic’s overwhelming presence in the U.S., it’s clear that those concerns were well-founded.
We have observed a significant increase in the number of adolescents with new onset eating disorders coming to the emergency room and to our outpatient clinic. Recent data from the U.K. shows an almost 50% increase in the number of youth seeking treatment of an eating disorder, and more research is ongoing to quantify this wave of new onset or newly identified eating disorders among youth worldwide. While it will take some time to truly understand the effects of COVID-19 on the mental health of youth, we know that it has been indisputably impacted.
Over the past year, youth have been isolated from friends, many are not attending in-person school full time, extracurricular activities are canceled or significantly impacted, after-school jobs may be scarce and social media use has increased. During this time of disruption, we’ve seen people use the pandemic as an opportunity for behavior change (as one teenager told me, “there is nothing else to do, so I thought I might as well start running”). Some of these changes can be positive; however, providers and families need to acknowledge that things can go awry. Changing diet to avoid or lose the “COVID 15” or increasing exercise to “get fit” or “stay in shape” for sport can seem innocuous to many, but for adolescents at risk for developing an eating disorder, weight loss for any reason can open the door to the development of a severe medical and psychiatric illness.
Adolescents are growing, their brains are developing and their bodies are building bones and muscles. Their bodies should continue to gain weight through adolescence into early adulthood. Any significant change in eating or exercise behavior in an adolescent should be cause for concern, as should any weight loss. If a child falls off their historical growth curves it is important to take a hard look at their behavior. Concern about their weight, a reduction in the types of food they normally eat (e.g., cutting out sugar, reducing carbohydrates, becoming a vegetarian), and increasing exercise without increasing the fuel needed to exercise are all red flags that the weight loss or behavior is not healthy. For individuals with a genetic predisposition, weight loss can trigger the development of an eating disorder.
Eating disorders are severe, potentially fatal illnesses. They have the ability to disrupt normal adolescent development and need swift identification and treatment to prevent damage and reduce the likelihood of a longer course of illness. All health care providers need to join in this fight against eating disorders. Especially during these stressful times, we encourage providers to screen all patients who have lost weight for an eating disorder, even if their weight is considered to be in the “normal” range. Eating disorders occur in individuals of all genders, all ethnicities and all body sizes, making it crucial for providers to look beyond old stereotypes of who has an eating disorder. Many youth with an eating disorder will not express significant body dissatisfaction, but they may talk about wanting to be “healthy,” losing weight the “right way” and express fear of becoming fat. Importantly, they may engage in behavior to avoid weight gain, even after being told that is necessary for their health.
As we move forward this year, providers should continue to be on the lookout for disordered eating patterns in youth and researchers should include assessments of eating behavior/disordered eating in research focused on other psychiatric or health conditions. These disorders are likely far more ubiquitous than many realize. More education about eating disorders—including debunking myths and raising awareness of weight bias—is needed. And, as always, it is important to remember that weight is not an accurate indicator of health.