A Perfect Storm: Rise in Eating Disorders Among Teens During COVID-19

Eating disorders among adolescents have doubled since the start of the pandemic and patients are presenting with more severe symptoms.

© GETTY IMAGES / MONTAGE BY VIVIAN CHANG

The pandemic was cited as a trigger among 40% of newlydiagnosed teens.

Pediatric clinicians are sounding the alarm on the marked rise in eating disorders and symptom severity in children and adolescents during the COVID-19 pandemic. Eating disorders are the most deadly psychiatric condition in children, with 1 in 5 dying from suicide or medical complications related to the disorder.1,2 Experts have stressed that the need to take action is urgent.1,2

“We are seeing eating disorders rise in rates that I have never seen in my whole career,” said Jessica Peck, DNP, APRN, CPNP-PC, CNE, CNL, immediate past president of the National Association of Pediatric Nurse Practitioners (NAPNAP). As the COVID-19 pandemic surged, eating behaviors may have become an outlet for control among at-risk youth, said Dr Peck, who is also clinical professor at the Baylor University Louise Herrington School of Nursing in Dallas, Texas.

Eating disorders often have a protracted course and are di cult to treat, with only 31% of patients with anorexia nervosa recovering within 10 years.3 Early recognition and treatment of eating disorders is essential, Dr Peck said. But for children and teens, nding quali ed mental health providers may be di cult.

Currently, only 10 child psychiatrists are available for every 100,000 pediatric patients.4 Nearly 3 million children and adolescents do not have access to a school-based mental health professional, such as a school psychologist, counselor, or

social worker.5 The Children’s Hospital Association has called the mental health crisis among children and teens a national emergency and has called on Congress to take immediate action to fund services to stem this escalating crisis.6

Given this dearth of specialty psychiatric care, “we need to get better at integrating mental health services into primary care,” Dr Peck said, adding that effective screening tools are available and allow for early intervention.

Why Are Rates Rising?

The COVID-19 pandemic led to a profound disruption in school, sports, work, as well as social and leisure activities among people of all ages. For at-risk youth, the mental and physical effects of these disruptions triggered or worsened disordered eating behaviors. Additionally, the pandemic led to increased social media use, which has been linked to worsening symptoms in individuals with eating disorders, and increased video interactions, which may increase self-criticism and negative appearance-related comparisons.7 Altered food accessibility, food insecurity, and limited access to health care during the pandemic may also have played roles in the rising rates.7 Together, these changes have created a perfect storm of stressors in this vulnerable patient population.

At a center for pediatric eating disorders, data showed that 40% of newly-diagnosed adolescents cited the pandemic as a trigger for their disorder.8 Data on new-onset anorexia nervosa or atypical anorexia nervosa from 6 pediatric tertiary-care hospitals in Canada showed an increase from a mean of 24.5 cases per month prepandemic to 40.6 cases per month in the first wave of the pandemic (P <.001).9 A near tripling of hospitalization rates in newly diagnosed children and adolescents was also found, and the severity of eating disorder symptoms was worse in those diagnosed during the COVID-19 pandemic than in those diagnosed prepandemic, with more rapid progression, greater weight loss, and more profound bradycardia found.9

Similar findings were reported at C.S. Mott Children’s Hospital in Ann Arbor, Michigan, which saw a more than 2-fold increase in hospital admissions among patients aged 10 to 23 years with eating disorders during the first 12 months of the COVID-19 pandemic: 125 vs 56 hospitalizations on average per year during the same time frame for the previous 3 years.7 The rate of hospitalizations for eating disorders were highest near the end of the study period, between 9 and 12 months after the pandemic started.7

At Cincinnati Children’s Hospital Medical Center, youth hospitalized after the pandemic started were over 8-times more likely to be readmitted within 30 days of discharge compared with patients hospitalized prepandemic (P =.002).10

“We have patients who are coming in more malnourished and more entrenched in these eating disorder thoughts than I have ever seen before,” said Christina Cwynar, DNP, CPNP-PC, PMHNP-BC, during a NAPNAP TeamPeds Talks podcast. “I have encountered some of the lowest BMIs, some of the youngest patients [9 and 10 years old], and some of the most significant behavioral issues that I have ever encountered,” said Dr Cwynar, who is a pediatric NP at C.S. Mott Children’s Hospital and assistant professor in the Primary Care Pediatric Nurse Practitioner Program at Rush University College of Nursing in Chicago.

With wait lists at many eating disorder clinics of 6 months to a year even before the pandemic, the greater demands posed by COVID-19 have led to even longer delays in treatment. This inability to seek timely treatment is at least partially responsible for the greater symptom severity observed in clinical practice, Dr Cwynar believes.

These numbers may represent a small percentage of the number of children and teens with eating disorders affected by the pandemic as the studies only show those people whose illness led to hospitalization.7

Eating Disorders Defy Stereotype

Although the stereotypical patient with an eating disorder is a White thin teenage girl, less than 6% of people with eating disorders are underweight.2,11 Binge eating disorder, which commonly leads to weight gain, is more common than anorexia nervosa and larger body size is a risk factor for developing eating disorders.2,11,12 However, people with eating disorders who are overweight are half as likely to be diagnosed with these conditions as those with smaller body sizes.2

“We are also seeing boys and teens of color with eating disorders, and people who are normal weight to overweight having binge eating disorder,” Dr Peck said. In boys and young men, disordered eating may focus on leanness, muscularity, and weight control.12 Adolescent athletes are also at risk.2,12

Data show that Black teenagers are 50% more likely to engage in binge eating and purging compared with White teenagers, but are significantly less likely to be asked by a clinician about eating disorder symptoms and 50% as likely to be diagnosed or treated for these disorders.2 Bulimia nervosa is more common among Hispanic persons than their non-Hispanic peers, and Asian American college students report higher rates of food restriction and higher rates of purging compared with their White peers.2

Teens in the LGBTQI community have significantly higher rates of unhealthy and disordered weight control behaviors than their cisgender peers.12 The risk may be particularly increased in transgender youth.12

Genetics, psychological factors, and social influences have all been linked to eating disorders and adolescents with low self-esteem or depressive symptoms are at especially high risk.7

Screening in Primary Care

The American Academy of Pediatrics (AAP) recommends screening for disordered eating and unhealthy weight-control behaviors annually at well visits and evaluating BMI, growth charts, menstrual status, and vital signs. Patient reports of dieting, body image dissatisfaction, weight-based stigma, or changes in eating or exercise may indicate the need for further exploration.12

“There are many misconceptions about eating disorders and what characteristics or behaviors are used when someone has an eating disorder,” said Amanda Dietz, MSN, FNP-C, CPN, who works at the Eating Disorder Center at Children’s Mercy Kansas City in affiliation with the Department of Pediatrics at the University of Missouri-Kansas City School of Medicine in Missouri. Weight loss noted on growth curves is an easy way to identify concerning behaviors and should prompt the provider to ask more questions, Dietz said.

The most widely used screening tools to identify anorexia nervosa and bulimia nervosa are the SCOFF questionnaire and Eating Disorder Screen for Primary Care (ESP), both of which are freely available (see Screening Tools for Primary Care).13,14

In patients with suspected eating disorders, primary care providers should initiate a comprehensive medical, psychological, and suicide risk assessment, as outlined in the AAP guidelines. Normal laboratory results alone do not equal a medically stable patient and a holistic approach to assessment should be used, Dietz explained. In atypical anorexia nervosa, for example, patients meet all of the criteria for anorexia nervosa but their body weight remains within or above the expected range for age and height, which can lead to delayed diagnosis (Table 1).2,11,12 Clinicians may praise their patient for weight loss without being aware that the patient is at equal or greater risk for medical instability compared with their underweight counterparts. “Be cautious about encouraging rapid weight loss in some patient populations, especially pediatric patients,” Dietz said.

Patients who are being evaluated for eating disorders should undergo full psychosocial history that includes home environment, education level, activities, drugs/diet history, sexuality, and suicidality/depression (HEADSS) assessment.12 Equally important is the need to screen for common psychological comorbidities including mood and anxiety disorders, obsessive-compulsive disorder (OCD), attention-deficit hyperactivity disorder (ADHD), and alcohol and substance use disorders.1,2 The most commonly missed diagnosis in patients with disordered eating is ADHD.2

Treatment of Eating Disorders

Patients with mild nutritional, medical, and psychological dysfunction from eating disorders may be managed in the primary care setting in collaboration with mental health providers. Psychotherapy, such as cognitive-behavioral therapy, and nutritional repletion (replenishing the body with vitamin/ mineral supplementation and nutrients) are the cornerstones of treatment for eating disorders. Pharmacotherapy can be used as adjunctive therapy in select cases.12

The first step is to make sure the patient is medically stable and safe to continue treatment in the outpatient setting. “Primary care providers often feel overwhelmed and underprepared to support patients during their eating disorder treatment,” Dietz noted. “Remembering that treatment is a team approach and that your role is to focus on the physical aspect of care can be helpful.”

“The refeeding process not only can be psychologically difficult, but also physically,” Dietz added. For restrictive disorders, clinicians “should focus on supporting the very real symptoms associated with malnutrition such as heartburn, fullness, bloating, and constipation. If these symptoms can be alleviated, it can make eating less distressing for the patient.” For example, the AAP recommends use of osmotic or bulk-forming laxatives over stimulant laxatives for patients with constipation.12

When counseling families, Dr Cwynar likens the fear of food in patients with restrictive eating disorders to being trapped in a room with a tiger. During treatment, patients have to overcome that fear every time they eat. Patients overtaken by an eating disorder cannot think rationally, she said.

She recommended giving parents ground rules including a meal plan handout (Table 2) and emphasized that “there is no negotiation with eating disorders.” All meals should have time limits so that “the individual is not spending all day attempting to eat food and to allow the body to learn to eat in normal patterns and digest normally again.” In addition to restrictive

Screening Tools for Primary Care

SCOFF QUESTIONNAIREa

• Do you make yourself Sick because you feel uncomfortably full? • Do you worry you have lost Control over how much you eat? • Have you recently lost more than One stone (14 pounds) in a 3-month period? • Do you believe yourself to be Fat when others say you are too thin? • Would you say Food dominates your life?

EATING DISORDER SCREEN FOR PRIMARY CAREb

• Are you satisfied with your eating patterns? • Do you ever eat in secret? • Does your weight affect the way you feel about yourself? • Have any members of your family suffered with an eating disorder? • Do you currently suffer with or have you ever suffered in the past with an eating disorder?

a ≥2 abnormal responses are considered a positive screen b ≥3 abnormal responses are considered a positive screen

eating disorders, meal plans are useful to break the binge/purge cycles in bulimia nervosa and binge-eating disorder. Dr Cwynar recommends an online video (https://www.youtube.com/ watch?v=2O9nZAWCkLc) to families on inspiring trust rather than using logic when relating to children with eating disorders.

“As these kids get more and more entrenched in their eating disorder, carbohydrates that were once okay to eat are now off-limits and become a fear food” but parents should not cater to these fears, Dr Cwynar said. This is not the time to adopt a gluten-free or dairy-free diet in children with no history of intolerance or transition to vegetarian or vegan diets, she said.

Dr Cwynar suggested time limits of 30 minutes for meals and 15 minutes for snacks “so that the individual is not spending all day attempting to eat food and to allow the body to learn to eat in normal patterns and digest normally again.” If children and teens do not comply with the plan, the eating disorder behavior has consequences such as seeing a doctor or not being able to see friends or play sports, Dr Cwynar said.

“Since we view eating disorders as a separate entity from the individual suffering from them, we talk about how eating disorders take things away from the child,” Dr Cwynar explained in an interview. “For example, because [some] eating disorders cause individuals to restrict food intake significantly leading to bradycardia, electrolyte imbalances, and other medical complications that place an individual at higher risk for seizures and death, individuals often miss out on things like planned activities with friends related to needing medical care or being unable to engage in sports or other hobbies that they like because it is too dangerous for them to engage in these activities at certain times during their disease and recovery process,” she said.

Pharmacotherapy Fluoxetine is indicated for the treatment of bulimia nervosa in adult patients and other selective serotonin reuptake inhibitors (SSRIs) have also demonstrated efficacy in managing this subtype of eating disorders when used off-label. Although fluoxetine is not approved for bulimia nervosa in pediatric patients, it is approved for OCD in patients aged 7 years and older and major depressive disorder in children aged 8 years and older; thus, it is a reasonable option for pediatric patients in whom pharmacotherapy is being considered, according to AAP.12,15 In contrast, SSRIs have not demonstrated efficacy in the management of binge eating disorder or restrictive eating disorders, and are particularly not effective in acutely malnourished patients.12 For avoidant/ restrictive food intake disorder (ARFI), pharmacotherapy is targeted at treating comorbidities such as anxiety.12

Dr Cwynar noted that SSRIs are not a quick fix as they take weeks to become effective. Small doses of olanzapine, which has a faster onset (typically 15-20 minutes), used before meals may help with the anxiety and agitation symptoms. She

TABLE 1. Common Subtypes of Eating Disorders2,11,12

Anorexia nervosa • Significant and persistent reduction in food intake leading to severe weight loss; distorted body image; and intense fear of gaining weight • More common in young women and girls

Bulimia nervosa • Recurrent binge eating episodesa marked by feelings of lack of control followed by compensatory behavior such as purging (eg, vomiting, excessive use of laxatives, or diuretics), fasting, and/or excessive exercise • Occurs at least once a week

Binge eating disorder

Avoidant/ restrictive food intake disorder (ARFID) • Recurrent binge eating episodesa marked by feelings of lack of control and guilt, disgust, or depression • Episodes are not followed by purging, excessive exercise, or fasting • Occurs at least once a week for 3 months • Patients are often overweight or obese

• Lack of interest in eating, avoidance of food based on sensory qualities, concern about unpleasant consequences of eating • Leads to significant weight loss or failure to meet expected growth or weight gain, marked nutritional deficiency, reliance on enteral feeding or nutritional supplements, significant interference with psychosocial functioning • Behavior cannot be explained by another medical or mental disorder

Other specified feeding or eating disorder • Atypical anorexia nervosa: significant weight loss despite being within or above normal weight range • Bulimia nervosa of low frequency and or limited duration • Binge eating disorder of low frequency and or limited duration • Purging disorder: recurrent purging behavior without binge eating with the intent to control weight or body shape

aEating a larger quantity of food more rapidly than normal in a distinct time period (eg, 2 hours)

TABLE 2. Ground Rules for Parents of Children With Eating Disorders

• Follow a clinician-provided meal plan consisting of 3 meals and 2 to 3 snacks per day • Have child eat at a kitchen table with someone present and a time limit on meals (eg, 30 minutes) and snacks (eg, 15 minutes) • Present fully-prepared meals at set times with no negotiations • All healthy fats and spreads should already be incorporated into the meal • A child who does not finish a meal can be provided with a meal supplement • For children who have tantrums or fights during meals, paper plates and plastic utensils may be used • Physical restraint with a bear hug may be needed to calm a tantruming child down • For children who binge, providing appropriate portions of typically binged foods during meals may help prevent cravings and future binges • Do not allow children who binge and purge to use the bathroom unsupervised for an hour after a meal • Limiting exercise and access to scales, mirrors, and social media may be necessary • Have an emergency action plan in case the child’s condition worsens

RISE IN EATING DISORDERS ‘We are also seeing boys and teens of color with eating disorders, and people who are normal weight to overweight’ having binge disorders.

has also used the antihistamine hydroxyzine hydrochloride to treat the physiologic response to anxiety in patients with eating disorders, and noted that aripiprazole can help break the cycle of rigid circular thoughts in some individuals with eating disorders.16

Emergency Plans Parents should be given emergency plans such as going to the emergency department if a child has not eaten in 24 hours or going to the doctor to check electrolytes. Patients with more severe symptoms or who do not improve with outpatient care should be referred promptly to day-treatment or inpatient programs as waitlists for these centers are long. Medical admission should be considered for patients with severe bradycardia (heart rate <50 beats per minute), hypotension (<90/45 mm Hg), and hypothermia as well as dehydration and electrolyte disturbance, according to the Society for Adolescent Health and Medicine.17

Conclusion

Eating disorders are the most deadly mental health conditions in children and adolescents. The rising rates of eating disorders during the COVID-19 pandemic and the limited number of mental health specialists may lead to longer wait times. Primary care clinicians can play a key role in early diagnosis and management. ■

Kristin Della Volpe is Medical Editor of The Clinical Advisor.

References

1. Balasundaram P, Santhanam P. Eating disorders. In: StatPearls. StatPearls Publishing; 2022 Jan-. Updated December 19, 2021. https://www.ncbi.nlm.nih. gov/books/NBK567717/ 2. National Association of Anorexia Nervosa and Associated Disorder. Eating disorder statistics. Accessed February 9, 2021. https://anad.org/eating-disorders-statistics/ 3. Eddy KT, Tabri N, Thomas JJ, Murray HB, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. J Clin Psychiatry. 2017;78(2):184-189. 4. McBain RK, Kofner A, Stein BD, Cantor JH, Vogt WB, Yu H. Growth and distribution of child psychiatrists in the United States: 2007-2016. Pediatrics. 2019;144(6):e20191576. 5. The Education Trust. School Counselors Matter. Accessed February 17, 2022. https://www.schoolcounselor.org/getmedia/b079d17d-6265-4166a120-3b1f56077649/School-Counselors-Matter.pdf 6. Sound the Alarm for Kids. Sound the alarm for kids: we are in a national mental health emergency. Accessed February 17, 2021. https://www. soundthealarmforkids.org/a-national-emergency/#footnote-6 7. Otto AK, Jary JM, Sturza J, et al. Medical admissions among adolescents with eating disorders during the COVID-19 pandemic. Pediatrics. 2021;148(4): e2021052201. 8. Spettigue W, Obeid N, Erbach M, et al. The impact of COVID-19 on adolescents with eating disorders: a cohort study. J Eat Disord. 2021;9(1):65. 9. Agostino H, Burstein B, Moubayed D, et al. Trends in the incidence of newonset anorexia nervosa and atypical anorexia nervosa among youth during the COVID-19 pandemic in Canada. JAMA Netw Open. 2021;4(12):e2137395. 10. Matthews A, Kramer RA, Peterson CM, Mitan L. Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19. Eat Behav. 2021;43:101573. 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. 12. Hornberger LL, Lane MA; Committee on Adolescence. Identi cation and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279. 13. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999;319(7223):1467-1468. 14. Cotton MA, Ball C, Robinson P. Four simple questions can help screen for eating disorders. J Gen Intern Med. 2003;18(1):53-56. 15. Prozac. Prescribing information. Eli Lilly and Company; 2009. 16. Frank GK, Shott ME, Hagman JO, Schiel MA, DeGuzman MC, Rossi B. The partial dopamine D2 receptor agonist aripiprazole is associated with weight gain in adolescent anorexia nervosa. Int J Eat Disord. 2017;50(4):447-450. 17. Society for Adolescent Health and Medicine, Golden NH, Katzman DK, et al. Position Paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2015;56(1):121-125.

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