There are no results from any large-scale study that tracks changes in eating disorders among tweens and teens since the start of the pandemic yet, but early indicators and experiences from healthcare providers point to a surge.
Since March 2020, the National Eating Disorders Association reports a 40% increase in calls to its helpline; 35% of those callers were ages 13 to 17, according to the New York Times. In February, pediatricians in the United Kingdom warned of a “tsunami” of pandemic eating disorders. And here in North Carolina at the UNC School of Medicine’s Center of Excellence for Eating Disorders, providers have seen the numbers who need help skyrocket.
“Our clinic has never been this inundated,” said Camden E. Matherne, a licensed psychologist and assistant professor at the center. “And I think that’s honestly true across the mental health system. At our clinic, with the referrals, we’re scheduled out for months, and we’ve never been this scheduled out in terms of new patient referrals. I have a lot of colleagues and friends in the community, and literally everybody is on a wait list. For the first time, we’re at this stand still.”
Even in-patient programs, which are required in some cases of severe eating disorders, are full, she said. “I have never, in my career, experienced that level of where do people go to get treatment,” Matherne said.
People’s eating habits have shifted in big ways since the start of the pandemic as they’ve lost jobs, worried about what food was available when grocery shelves went bare or started stress eating because of all of the challenges that COVID has presented. For kids and teens, social isolation and boredom have long been predictors of eating disorder onset, Matherne said. And they’ve experienced both of those in spades during the pandemic.
Studies also show that kids are dealing with higher levels of depression and anxiety, which can trigger an eating disorder. Some may have started spending more time on social media where they see dangerous messages about what a “healthy” body looks like and start cutting out food groups or over-exercising to try and look more like that person they follow on TikTok. Others might have started grazing more throughout the day and then feel bad about it and start cutting back.
“One of the reasons that kids think to go to that is because we live in a culture that talks about how we should look and how we should eat,” Matherne said. “When that’s underlying all of this, and then you throw this huge stressor on top of it and remove normal socialization.”
Getting pizza with friends, having a birthday party, enjoying team dinners with your basketball team or spending time with a youth group are all activities that can pull a child who is struggling with an eating disorder or starting to struggle with one back toward normalcy, Matherne said. But during COVID, they were shut off from many of those activities.
For parents worried about their own kids, Matherne shared some of the warning signs and what we all can do to help kids who are struggling.
What are the warning signs of an eating disorder?
Look for observable changes in portioning or the variety of food a child eats, Matherne said. When she talks with parents of a child with eating disorders, they’ll often mention that their child simply wanted to start eating healthier and they were excited that they were serving themselves more fruits and vegetables.
“And then all of a sudden, it just took this turn,” she said “That’s the classic story. On the one hand, of course every parent wants to eat a balanced diet. But any time a kid makes a significant, observable and noticeable change in their eating, that’s a red flag. You want to pay attention to it.”
It doesn’t mean it’s bad necessarily. “Some kids do need to eat more fruits and vegetables,” she said. “We’re all about moderation and a variety of fruits and veggies are good and protein and dairy are good and carbohydrates are good. Some kids have a deficit in that area, and they need more fiber and nutrition in that way.”
But most teenagers aren’t worried about their fiber levels. “When a kid starts to think about that and makes changes on their own, that’s always a, ‘huh.’ Don’t take it as a good thing,” she said.
The key, she said, is making sure that kids are still eating a balanced diet with fruits and vegetables, but also ice cream, cupcakes and pizza “because those foods in moderation are OK as well,” she said.
Another warning side is missing food or empty wrappers. “Teenagers can be very gross, some of that’s a little bit normal,” she said. “But if there seems to be a pattern of not eating a lot in front of the family and you see missing food or hidden food, that’s a warning sign.”
Remember: Kids are really good, intuitive eaters. “It’s unusual for kids to make eating changes,” she said. “When you notice a major shift, and especially seriously reducing or eliminating certain food groups, it’s a huge red flag. Teenagers shouldn’t be eliminating food groups. And they shouldn’t be dieting in general.”
What should parents say to their child if they noticed a change in pattern?
Communication is always good, Matherne said. Don’t become the food police. Instead, ask opened-ended questions with the message that you want to ensure they’re eating a wide variety of foods.
Say something like, “Hey I noticed this, what’s going on there. Tell me more what you’re thinking. I want to be helpful to you to make sure you’re staying balanced,” Matherne recommended.
“Talk early and frequently,” she said. And if you get pushback or anger, that’s another warning sign.
What should a parent do if they are worried or see one or more of the warning signs?
When any warning sign emerges, Matherne recommends checking in with the pediatrician as the first line of defense. They can make referrals, do blood work and check the child’s other vital signs. Health consequences of an eating disorder are wide-ranging and can include risk of heart failure, pancreatitis, intestinal obstruction, brain changes and, for girls, the loss of their period.
Matherne also recommends that parents check out online resources to understand treatment and what’s involved.
What is treatment like?
Treatment could require an in-patient hospital stay or take place completely at home. But a big part of the process is so-called refeeding, the work to help someone with an eating disorder begin to eat again in a healthful way and regain any weight they might have been lost. “Any time a kid is exhibiting restrictive eating behaviors or disordered eating behaviors, the guidelines are really regular eating,” Matherne said.
Refeeding involves eating every three to four hours each day — usually three meals and two to three snacks a day. “And those need to be balanced,” Matherne said. “Snacks are two to three food groups, so apple and peanut butter, cheese and crackers, yogurt and granola.”
Meals should include four to five food groups. “It doesn’t have to be all perfectly laid out, but they need to eat all the food groups and they need variety,” she said.
Family-Based Treatment also is considered a best approach to treatment. As FEAST explains, FBT is a family therapy approach that includes both parents and kids during sessions with a trained therapist. Parents take over all food decisions for their child during the first phase of treatment. Kids gain more freedom as they move through the three phases. This can be an intense process for both kids and parents. As the child struggles to eat, a therapist can give parents the words, resources and support to get them to the table.
“The dangerous thing about eating disorders is that the more negotiation there is, the kid is getting continuously deprived nutritionally, which also is going to strengthen the eating disorder,” Matherne said. “A more deprived brain is going to have less energy to think clearly. … When a brain is starved, it thinks about food all the time, which then promotes eating disorders.”
Said Matherne: “Parents are agents of change, and can be the kid’s greatest resource when they are empowered to really rescue their kid from this eating disorder. From my standpoint, the most important and critical thing about FBT is that it empowers the parent and makes them feel comfortable again. … The role of the therapist is to coach the parent and empower them to feel confident to do what they need to do.”
In-patient therapy is usually recommended when the amount of weight the child has lost is significant, if lab work is abnormal or if refeeding syndrome, a potentially fatal complication, is possible. In other cases, an in-patient program might be best when a child becomes violent or aggressive around eating or when a parent has their own history of an eating disorder.
What does recovery look like?
FBT includes three phases. After the first phase, kids start transitioning back to serving themselves and picking their own meals. By phase three, therapists work more individually with the child to tackle any anxiety or general adolescent concerns. All three phases can take as long as a year.
Weight recovery is key, Matherne said. And so is eating recovery.
“Clinically, what I’m looking for is are kids eating regularly and is their weight maintained,” she said. “Then there is physical recovery. Is their period back? Is their bone health back on track? And socially and emotionally, are they back in normal activities? Is there flexibility with their eating? When they go to youth group, can they eat the pizza and the brownie. When their friends spontaneously want to go get ice cream, can they do that? To me, the markers are the emotional and social recovery. … Our goal is that your friends in your life matter more than these restrictions — that that outweighs this desire to maintain the perfect number.”
What is the prognosis?
The good news is that prognosis is good. Studies show that about half of patients achieve full remission within a year, Matherne said. Another 25% to 35% have significantly improved within a year.
“What I tell parents is that I have no reason to expect your kid won’t recover,” she said. “I can’t tell you the exact timeline. Typically, when there’s difficulty, there’s a co-occurring issue like trauma or chronic stress. And those are treatable, but the recovery trajectory just looks a little different.”
When she meets with parents, more often now than ever, she tries to be hopeful. “I tell them, ‘You can do this,'” she said. “We’re going to deal with the other stuff when we get there. But this initial part of treatment you can do, And then we’ll determine our next steps.”