Eating disorders are exploding, hurting adolescents who have trouble finding care

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From the early days of the pandemic, researchers worried that the heightened stresses of lockdown and the limits on mental health care would intensify the risks of eating disorders for adolescents and young adults. As a medical student rotating in the psychiatric emergency room, I witnessed firsthand how those fears have been realized.

Eating disorders among young people have exploded across the nation. For many, the inability to get timely care is spiraling into increasing self-injurious behaviors by cutting or burning and worsening suicidal ideation.

At the beginning of my rotation in April, I met a 16-year-old girl who attributed her new eating disorder to virtual schooling. Staring at a computer screen for several hours a day, she became preoccupied with her appearance and hated how she looked. Feeling a general loss of control over surrounding events, the only way she could reclaim a sense of agency was by altering her dietary habits.

Within a few weeks, she became fearful of food – sometimes eating no more than 100 calories a day. While several family members tried to place her into a residential treatment program, they were unsuccessful: the wait-time was months. Most of the psychiatrists within her insurance network weren’t accepting new patients, either. Without getting the help she needed, her condition worsened, and she started cutting herself with a razor.

“I even looked up how many pain medications I needed to take to not have to wake up the next day,” she told me tearfully. She’d also researched how to tie a noose with a belt and reported having frequent thoughts of walking into traffic. But one afternoon when her parents noticed blood pooling around her ankles, they knew that she wasn’t safe at home and brought her to the psych ER.

Doctors and researchers had predicted that limitations on physical activity, worsening anxiety, uptick in screen time and heightened social media exposure would propel body weight fluctuations and preoccupation with appearance, precipitating a rise in disordered eating.

Unfortunately, they were right.

Across Lehigh Valley Health Network’s eight primary care pediatric offices sprinkled throughout Pennsylvania, the number of kids being treated for eating disorders has more than doubled: from nine in 2019 to 19 in 2020. And at the Louisville Center for Eating Disorders – the only eating disorder specialty center in Kentucky – the outpatient part of the facility has gone from a small to nonexistent wait list pre-pandemic to a wait list of over 130 adolescents and adults.

“Our intensive outpatient program has seen such a huge spike in patient calls since the pandemic started that many of them are needing to go out of state to receive care,” said Cheri Levinson, the center’s clinical director.

Wait lists have also grown at UChicago Medicine’s Eating Disorders Program, going from four or five adolescents pre-pandemic (with wait times of a few weeks) to almost 40 adolescents, with wait times of four to five months in some cases.

“In my program, which only provides outpatient psychotherapy and medication management, the number of admissions we can accept is dependent on clinician availability,” said Jennifer Wildes, director of the Eating Disorders Program. “However, our adolescent census has doubled in the past year from approximately 15 patients in active treatment to 31 currently.”

At the Eating Recovery Center’s network of 30 sites across seven states, there has been a nearly 90% increase in new patient calls, representing about 2,000 new calls, in January and February of 2021 compared to the same two-month window in 2020.

“Anecdotally, we are also seeing child and adolescent patients coming to us with more comorbidities than we were before the pandemic began,” said Harry Brandt, regional medical director of the Eating Recovery Center’s Eastern Region and chief of psychiatry at the University of Maryland St. Joseph Medical Center.

“Given the unprecedented volume and lack of high-quality treatment options available right now, we are continuing to do everything we can to create more space for these kids because we know that their prognosis is better when we can get them into treatment quickly and then back home with their families,” he said.

Another patient I took care of was a nonbinary adolescent in their midteens who restricted their diet to protest parents who vilified their identity. With school closings forcing them to spend more time at home – while having limited to no access to their usual social support networks – the only way they could regain an element of control over their lives was by modulating what they ate.

Over time, their relationship with food changed drastically and issues of self-image arose. Compounded with parental lack of acceptance for their nonbinary identity, their suicidal ideation exacerbated.

“I came to the ER today because my friend forced me to,” they said. “He was concerned about how much weight I’d lost. But I guess I also freaked him out by mentioning a few times how I wanted to jump off the bridge this weekend.”

I also took care of an 18-year-old patient whose eating disorder was precipitated by parental job losses and food insecurity overlying a diet-sensitive, genetic condition. The only stockpiled cans of food at home made him sick and he had to restrict meals. His relationship with food changed significantly. Over two months, he lost more than 30 pounds, and frequently felt lightheaded. At the same time, his depression became all-consuming.

“I’ve never felt this low in my life, and if I stay home, I’m afraid I’m going to hurt myself,” he told me during our triage interview.

Unfortunately, I met so many more adolescents in the ER who had either developed a new eating disorder over the course of the pandemic or had acute exacerbations of something previously diagnosed. In many of these cases, they or their family members recognized that something was wrong. In the setting of an overwhelmed system, however, they were unable to be linked to treatment. Without help, their emotional health worsened into a full-blown psychiatric crisis.

To meet the heightened demand, many organizations are trying to expand resources in real-time.

For example, the Eating Recovery Center’s nationwide network of sites has added space for 70 more child and adolescent eating disorder patients, including 60 new beds for inpatient and residential treatment.

“Also, after years of providing virtual treatment in three states, we quickly expanded that last year and now provide virtual treatment to kids, adolescents and adults across 19 states,” Brandt said.

While these changes will improve access for an additional segment of adolescents, many will unfortunately continue to string along on wait lists.

“We need to prioritize getting kids safely back to school,” said Jason Nagata, a pediatrician and researcher at the University of California at San Francisco with expertise in eating disorders. “I don’t think adolescent [medicine] doctors have witnessed anything at this scale.”

UCSF’s inpatient eating disorders unit has also seen an unprecedented surge in hospitalizations, nearly doubling since the beginning of the pandemic. School disruptions and pandemic-related anxieties have also had ancillary psychiatric effects.

“When a teen loses control in many aspects of their lives, which is a common occurrence under pandemic restrictions, they may turn to eating and exercise as a way of re-exerting control,” said Scott Hadland, chief of adolescent medicine at MassGeneral Hospital for Children in Boston.

“Like eating disorders, substance use disorders also worsen as anxiety intensifies, with many substances like alcohol, marijuana, nicotine and opioids providing temporary relief,” he said. “Unfortunately, for both eating disorders and substance use disorders, these coping mechanisms are maladaptive and unsurprisingly, adolescents can have serious – even deadly – health consequences.”

As coronavirus vaccination continues, and schools restart classroom learning, teachers and other school personnel can play a critical role in identifying and intervening in disordered eating.

“Eating disorders can affect people of all genders, sexual orientations, races, ethnicities, socioeconomic backgrounds and sizes,” Nagata said. “You can’t necessarily tell that someone has an eating disorder just based on their appearance. If anything feels off or a kid is obviously preoccupied with their appearance, body, or weight in a way that worsens their quality of life, an honest and nonjudgmental conversation is warranted.”

Schools could also consider incorporating eating disorder awareness in health education classes.

“These conversations can be formulated around discouraging the skipping of meals, vomiting, and the use of diet pills and weight loss supplements to promote a positive body image,” Nagata said. “Preventing bullying and weight teasing should also be a priority as research shows that weight teasing has a lot of downstream adverse consequences in the development and persistence of eating disorders.”

Parents should also regularly engage their teens in nonjudgmental conversations around self-image, weight concerns and other psychiatric comorbidities and look into getting their kids evaluated by pediatricians.

“It is important to remember that restrictive eating is only one form of disordered eating and should not be the only criterion for evaluation,” Nagata said. “Among boys, self-image disturbances and disordered eating can also present as muscle dysmorphia, where individuals have an exaggerated belief that their body is insufficiently muscular or lean, often leading to excessive exercise, performance-enhancing substance use and a different form of psychiatric down spiral.”

Health professionals can screen for many of these conditions, provide anticipatory guidance to parents about warning signs of eating disorders and work with an adolescent to address specific concerns. But the reality of appointment backlogs and provider wait-times might interfere with evaluation and treatment plans.

And for adolescents from cultural backgrounds where seeking mental health help is heavily stigmatized, getting professional help might not be an option even if appointments are available.

In such cases, online forums for adolescents with disordered eating, anonymous helplines and peer-to-peer accountability might be the only viable measures to prevent life-threatening emergencies.

My ER experience keeps me worried about the emotional roller coaster this pandemic has been for teenagers, and its effect on eating disorders, comorbid psychiatric illnesses and suicidality.

But I am hopeful that community support among educators and health-care professionals, parents and peers can help provide these adolescents a bridge to necessary care and help them create a brighter and healthier future for themselves.

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To reach the National Eating Disorders Association’s helpline, call or text 800-931-2237. More information about support, resources and treatment options can be found at nationaleatingdisorders.org.

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Lala Tanmoy Das is earning a combined doctor of medicine and PhD degree in the neurobiology of addiction at Weill Cornell Medicine in New York.