Eating Disorders and the COVID-19 Pandemic
In the wake of the COVID-19 pandemic, the number of children in the United States presenting with an eating disorder skyrocketed. We talk to eating disorder experts about why and what needs to happen to improve care.
In the wake of the COVID-19 pandemic, the number of children in the United States presenting with an eating disorder skyrocketed1. A category of diagnosis that includes a range of conditions, including anorexia nervosa, bulimia nervosa, binge eating disorder and avoidant restrictive food intake disorder (ARFID), these patients often face a complex road to recovery.
The COVID-19 pandemic has only exacerbated an already challenging treatment landscape. Not only are more children seeking help, but they are also more likely to be presenting with severe cases that require hospitalization2, stretching an already strained mental health system to its breaking point.
Here, we talk to a range of eating disorder experts across the country about what they’ve seen over the past three years. They discuss why the pandemic helped to spur this rise in cases, what needs to be done to better care for children facing these challenging conditions, and how pediatricians are critical partners in both treating patients and advocating for improvements to the system.
A Focus on Holistic Health
During the COVID-19 pandemic, adolescent medicine specialist and assistant professor of pediatrics at the University of Missouri-Kansas City School of Medicine Michaela Voss, MD, saw a couple of different paths emerge for children diagnosed with eating disorders.
The first group was likely to develop an eating disorder, pandemic or not – the lockdowns and uncertainty only exacerbated the trajectory these patients were already on.
“Those kids found themselves not having anything else to focus on,” she says. “Their eating disorder became primary, and restriction and exercise became their go-to thing to do while they were in lockdown.”
And then there were the children for whom the pandemic’s stressors pushed them toward an eating disorder. A co-morbidity like anxiety, depression or OCD often presented and then excessive exercise or restrictive eating became a coping mechanism when everything felt out of control.
The two paths combined for a wave of very ill children seeking help once lockdowns ended. As medical director of the Eating Disorder Center at Children’s Mercy Kansas City, Dr. Voss and her colleagues are still triaging the fallout of this rapid increase in cases.
“They were very medically compromised, so that resulted in our hospital admissions going up quite dramatically,” she says. “Not only were we admitting more kids, they were staying for longer because they were so sick.”
“The presentation is becoming much more complex. Most referrals are these kids that have trauma and multiple mental health diagnoses. Eating is thrown in there as one of those control mechanisms for other things.”
Dr. Michaela Voss
A paper she co-authored for JAMA Pediatrics, published in November 2022, analyzed data from 15 emergency departments across the country and found a “significant increase in both inpatient and outpatient eating disorder volume after onset of the pandemic that surpassed pre-pandemic patient care trends.” The authors warned that demand post-pandemic “will likely outstrip resources” and called on healthcare leaders to address ED capacity and staffing issues.
At Children’s Mercy, where they do inpatient medical stabilization and offer an outpatient treatment program, they’ve only started to recover from this influx by hiring additional providers and restricting the children they treat to those under 16 years old who present with anorexia nervosa or bulimia nervosa. With a waitlist of at least six months, Dr. Voss and colleagues wanted to prioritize the children with the fewest treatment options.
The crisis that emerged after the pandemic has highlighted an already fragile system, says Dr. Voss. Long-term prospective studies are needed to identify the best treatment options, yet research funding for eating disorders is hard to come by. She attributes this in part to the nation’s current focus on obesity in children as a top concern. Training to identify adolescents with eating disorders needs improvement too, especially as the children who need help are now more likely to have a host of overlapping conditions.
“The presentation is becoming much more complex,” she says. “Most referrals are these kids that have trauma and multiple mental health diagnoses. Eating is thrown in there as one of those control mechanisms for other things.”
“You’re talking about the positive changes. That in itself is so powerful because you’re not only appropriately treating the child, you’re also teaching them how to think about their bodies and their health in a good way, long term.”
Dr. Michaela Voss
General pediatricians can help address this challenging situation by screening patients for eating disorders. Simple and quick tools like the Eating Disorder Screen for Primary Care and the Screening, Brief Intervention and Referral to Treatment for Eating Disorders can identify children at risk. Dr. Voss also emphasizes that children considered overweight or obese are just as susceptible to eating disorders. Approaching conversations with care is key.
For those children considered overweight or obese, “It’s not just about weight loss. It’s about holistic health, and the weight is secondary,” she says. “How can they move their body for joy? How can they learn intuitive eating cues and what full and hungry feel like? How can they make a choice to eat what the body feels it nutritionally needs and not emotionally needs?”
In focusing these conversations on healthy habits, pediatricians have an opportunity to set children up for good relationships with their bodies.
“You’re talking about the positive changes,” she says. “That in itself is so powerful because you’re not only appropriately treating the child, you’re also teaching them how to think about their bodies and their health in a good way, long term.”
Empowering Families to Address Eating Disorders
Elizabeth Wallis, MD, medical director of the MUSC Health Center for Health Disorders, urges pediatricians to listen to their instinct when a child comes in with what may be an eating disorder. Instead of relying solely on BMI or weight trajectory, she suggests focusing on behavior.
“The most important thing in terms of screening is asking about behaviors or body image distortion,” she says. “Are they engaging in eating disorder behaviors, whether that’s restricting their food intake, whether that’s purging with vomiting or exercise or laxatives or something else? That’s not to say it’s not helpful to look at the weight trajectory, but don’t rely on that.”
Parents who bring concerns – like a child cutting out an entire food group or spending excessive time at the gym – can provide important insight even if the child’s weight still falls on the “normal” curve. Getting those children into treatment early can make a big difference when it comes to positive outcomes.
“We virtually never get referrals that aren’t appropriate…If [the pediatrician’s] gut is that there’s something concerning going on, they’re probably right.”
Dr. Elizabeth Wallis
As the director of the Division of Adolescent Medicine and in her role at the MUSC Health Center for Eating Disorders in Charleston, South Carolina, pediatricians are her eyes and ears in the community.
“We virtually never get referrals that aren’t appropriate,” she says. “And I think that there may be this fear – ‘I don’t want to make too much of this.’ If their gut is that there’s something concerning going on, they’re probably right.”
This work is especially important in the wake of the pandemic. The lack of opportunities for social connection for the past several years, combined with increased social media use, may all be factors contributing to the situation.
“A lot of teens in the setting of that really significant isolation — not being in school and maybe not doing the things they were used to doing, like playing basketball or being in theater — has led to a pretty substantial rise [in eating disorders],” she said.
This uptick in incidence, combined with a persistent misunderstanding about who presents with eating disorders, has meant more children being diagnosed late or not at all. White girls of high socioeconomic status have long been seen as the primary population affected by eating disorders, when about 25 percent of eating disorders develop in boys. Children from all different ethnicities and a range of backgrounds are affected.
“They are even more likely to be missed because there is still this misconception that there’s a certain population that’s affected by eating disorders,” she says. “We also know that LGBTQ kids and transgender youth are at particularly high rates, and again, a population that people don’t necessarily identify as having an eating disorder.”
When it comes to effective treatment, Dr. Wallis says for a long time there simply wasn’t enough research to support any particular approach. That has changed in the last 15 years, leading the MUSC Health Center for Eating Disorders and many other treatment centers to adopt family-based treatment (FBT) for children who are stable enough to receive outpatient care.
“The goal is to empower families to help their kid get back to a healthy weight,” she says. “One of the things we know about malnourished brains is that they don’t work very well and they can’t reason through things like the eating disorder.”
In FBT, parents or caregivers are partners in addressing the eating disorder, with an emphasis on proper nutrition so that the child’s cognitive ability is restored enough to handle recovery in the long term.
Dr. Wallis says she relies on pediatricians to identify children with eating disorders and to refer them as soon as possible to the best option for treatment in their area – whether that’s an adolescent medicine physician, dietitian, or full-fledged center devoted to eating disorders.
“We know that the sooner we treat kids, the less time they’re sick, the better their options in terms of a full recovery,” she says. “Pediatricians can be important partners in what I do, especially when primary care docs have such a long-standing relationship with families. Collaboration can be really helpful in getting families to engage and stick with treatment.”
Advocating for Preventive Health Care
Primary care pediatrician Peter Reed, MD, MPH, wants preventive behavioral health care to be available to all children from a young age. This stands to go a long way towards identifying and intervening with children who may go on to develop behavioral health disorders, he says.
“If you look back at their early childhood, you might see that there were some signs early on that they were prone to anxiety or there were clues early that they might be at risk,” he says. “What our healthcare system lacks is good preventive care to identify risk and prevent bad outcomes.”
At Pediatric Associates of the Northwest in Tigard, Oregon, Dr. Reed and his colleagues are trying to change this paradigm by pioneering behavioral health wellness visits as part of their childhood well visits. The goal is to have a baseline of knowledge about the child’s mental health needs, allowing them to be able to get them appropriate help if any challenges emerge.
“There’s a lot of active listening and sometimes motivational interviewing. It’s about helping people to work through in their own minds how they are going to manage things at home.”
Dr. Peter Reed
For eating disorders, this preventive approach, combined with longstanding relationships with families are key to identify and manage these challenging conditions. When an eating disorder is diagnosed, it can often be a difficult conversation with parents or caregivers that entails facing a hard reality.
“Sometimes parents are fully aware and maybe that’s why the patient is coming to see us,” he says. “Often parents are not aware at all, and so it’s breaking some hard news.”
Pediatric Associates of the Northwest is often a family’s primary point of contact for ongoing care. Although they do refer to outpatient programs for more severe cases, and have inpatient options for medical stabilization, they also walk with families as their child recovers. This involves presenting information with compassion and helping children and caregivers come to an understanding of how they plan to move forward.
“There’s a lot of active listening and sometimes motivational interviewing,” Dr. Reed says. “It’s about helping people to work through in their own minds how they are going to manage things at home.”
They also have clear protocols for office visits. Every child goes through the same check-in process: When they are weighed at the start of the visit, the child does not see the numbers on the scale. They also counsel families to remove any scales in the home and to focus not on weight, but on nutrition. The goal is to empower the family to work with their children on health.
“Sometimes you can’t tackle the mental piece until you’ve filled the tank a little bit as far as nutrition goes,” he says. “And so sometimes, especially at the beginning, it’s just talking about getting the meals done.”
Like so many pediatricians who treat eating disorders, these conversations have been happening more often in the wake of the pandemic. The female providers in the practice, who are more likely to see female patients, are seeing one to two patients with an eating disorder per day out of a total of roughly 70 to 80 patient visits per week. Dr. Reed sees roughly one to two patients with an eating disorder per month.
Moving forward, Dr. Reed sees advocacy as important to improving treatment for children with eating disorders. Mental health professionals have to be fairly compensated – especially when it comes to preventive health care. Pediatricians raising their voices together can make a difference.
“All of us, all the time, in our negotiations with insurance companies, need to be fighting for behavioral health parity and pushing for appropriate payment for the hard work that we’re doing,” he says. “It’s those conversations with the insurance companies, but also sometimes you need to be more publicly vocal too.”
 Otto AK, Jary JM, Sturza J, Miller CA, Prohaska N, Bravender T, Van Huysse J. Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic. Pediatrics (2021) 148 (4): e2021052201. doi.org/10.1542/peds.2021-052201 ↑
 Agostino H, Burstein B, Moubayed D, et al. Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada. JAMA Netw Open. 2021;4(12):e2137395. doi:10.1001/jamanetworkopen.2021.37395 ↑
A resident of Burlington, VT, Erin Post has a BA degree in English from Hamilton College, a graduate of the writing program at the Salt Institute for Documentary Studies, and she holds a Master’s degree in Public Health at the University of Vermont. In her spare time, she likes to bike, ski, hike, and generally enjoy the Green Mountains of Vermont. Visit her website to see more of her work at erinpostwriting.com.