The onset of loneliness, anxiety and depression in teens and adolescents during the COVID-19 pandemic has fueled a sharp rise in reports of dangerous eating behaviors.

The National Eating Disorders Association (NEDA) helpline saw a 54% spike in calls for support and resources to treat anorexia nervosa, bulimia, binge eating and other illnesses. Experts blame the surge on factors including stress, isolation and excessive use of social media during the coronavirus lockdown beginning last year.

Health care professionals have long known that eating disorders can be brought on by major life changes. Specialists say that for some young people who already were predisposed, the disruptions from COVID-19 triggered a full-fledged illness or a relapse from their recovery.

“Eating disorders are somewhat of a secret disorder. The more isolated you are at home, the more these types of disorders thrive,” said Joy Crabtree, a licensed psychologist at Cook Children’s. “These disorders often go hand-in-hand with anxiety disorder and depression, and the pandemic has played a role in that.”

At Cook Children’s, we initiated the Joy Campaign – a weekly series of stories addressing mental health issues in children and teens – in response to an alarming rise in suicide attempts in the past year. Eating disorders carry an elevated risk of suicide, particularly in those who suffer from anorexia. One out every of five deaths among anorexics is by suicide, according to the NEDA.

But the hopeful news: Although serious and complex, eating disorders can be treated through a combination of medical, behavioral and psychological tactics. Early diagnosis and intervention lead to better outcomes, Crabtree said.

Keep in mind a few key points:

• Eating disorders cover a spectrum of mental and physical illnesses that in the most severe cases lead to death. Anorexia typically involves severely restricted calorie intake, dramatic weight loss and distorted body image. Binge eating involves rapid and often secretive consumption of large amounts of food. Bulimia causes cycles of binge eating followed by forced vomiting, misuse of laxatives and/or excessive exercise. More information and other types of eating disorders are listed here.
• Eating disorders happen more commonly in girls and women, although boys and men can struggle too. The disorders affect people regardless of age, race or body shape.
• The American Academy of Pediatrics reported the estimate that 0.5% of adolescent females in the United States have anorexia nervosa, and that 1-5% meet criteria for bulimia.

Depression often co-exists with eating disorders. When it comes to adolescents, studies cited by the National Library of Medicine recommend a strategy of aggressively treating the depression and not just the unhealthy eating behaviors alone. Studies also recommend routine monitoring for signs of suicidal ideation, which surface when someone doesn’t want to live anymore.

The reported rise in new or recurrent eating disorders remains a relevant story, even as many of the COVID-19 restrictions have ended, because these illnesses require specialized and sometimes long-term care. As one dietitian put it … eating disorders don’t go away overnight. Treatment options range from outpatient visits to residential care to hospitalization for complications from severe malnutrition (heart disease, organ failure and electrolyte imbalance in the most extreme cases). But access to treatment isn’t always available.

In the past year, inquiries about eating disorders have trended up at Cook Children’s, although the medical center’s behavioral health Intake department doesn’t keep an exact count. Crabtree sees a tie-in to the general anxiety and depression that the COVID-19 pandemic inflicted. She listed contributing factors such as last year’s school closures, cancelation of extracurricular activities and separation from friends.

What else came into play during the pandemic? Lack of routine for sleeping and meals. Poor coping skills. Messages about food hoarding. Fears about weight gain. Pressure to look thin in social media photos and on the Zoom screen.

“Seeing yourself on camera, seeing others on camera, making those comparisons has played a role” in the rise of eating disorders, Crabtree said. “It was kind of a perfect storm, all this focus on food and bodies. It was very overwhelming.”

She urged parents to watch for signs of eating disorders in kids. Red flags include preoccupation with dieting, dramatic weight loss, withdrawal from friends, fatigue, dizziness, fainting, anemia, hair loss and menstrual irregularities. Anyone with concerns should contact their child’s pediatrician or call Cook Children’s to discuss referral options or possible psychological or psychiatric treatment, Crabtree said.

Getting started on treatment

Jean Mankin, a registered dietitian with Cook Children’s Outpatient Nutrition Services, works with primary care physicians to help with food allergies, obesity, picky eating and other issues. When it comes to someone with significant weight loss, Mankin starts by trying to determine whether the patient’s weight fluctuation is intentional.

“If you feel like they’re purposefully withholding food or telling you that they’re binge eating or purging, it’s important to get help,” she said. “A lot of kids are finding themselves having issues they didn’t have prior to the pandemic.”

Mankin emphasized that adolescents need to eat a well-balanced and sufficient diet because all vital organs and bone are rapidly growing and developing at this stage. Anxiety and depression can cause a dramatic decrease in appetite for some, and for others it can lead to stress eating or binging. As long as mental health problems go unresolved, the eating behaviors won’t improve, she said.

At Cook Children’s, patients with suspected eating disorders are referred to local specialists such as Carol Ann Darwin, a registered dietitian in Fort Worth who has met over her career with clients from age 8 to age 70. In April 2020, Darwin started seeing a big increase in anorexia and bulimia mainly among the 13- to 17-year-old set. She called the pandemic a nightmare.

“I went from working three days a week to working six days a week just to get these kiddos in,” Darwin said. Some individuals with eating disorders had to be hospitalized with feeding tubes until spots opened up in residential treatment centers, she said. Dietitians, therapists and treatment centers in North Texas and nationally still have waiting lists up to a month, Darwin reported.

The pandemic caused an onslaught of maladies that Darwin’s youngest clients bring up: isolation, stressful dynamics in a quarantined household, frustration with online school, loss of control. Food became a crutch to comfort and to alleviate loneliness. The challenges that were particular to 2020 compounded the usual causes of eating disorders, such as genetic predisposition and being bullied.

There’s no quick fix; Darwin typically meets with her clients in weekly nutrition consultations for two or three years – although the time frame can be less for those whose underlying depression and anxiety are mild. She said she prefers to use “gentle nudging,” rather than scare tactics, to motivate her clients to start eating appropriately.

“I’ve had several (clients) where I thought, ‘Would this have happened if COVID hadn’t come along?’ Maybe not,” she said.

Disconnection and disappointments

Dawn Dillon, a therapist in Fort Worth who has specialized in eating disorders since 1998, characterized the current demand for mental health services as an explosion. Disordered eating can come from the instinct to take action during times of uncertainty and fear, Dillon said. She drew an analogy to the people who rushed out to buy toilet paper in the early days of the pandemic. The same instinct applies to food and body image.

“We take all these things that are messy, uncertain or scary, and we manifest it through our body,” Dillon said. “Instead of saying ‘I’m scared, I don’t know what to do,’ it gets put onto the body as ‘I’m fat. There’s something to do with that – I can lose weight. I can sculpt. Or I can tone.’”

Eating disorders can originate out of a misplaced attempt to manage distress when someone feels stuck or trapped. Dillon listed a variety of scenarios that particularly applied to life for teens and young adults during the height of the COVID shutdown: Disconnection from social support. Disappointment when prom and graduation got called off. When will colleges and dorms reopen? So many unknowns.

Additionally, refusal to eat can be a way that teens, like toddlers, exert their separate identity. “In a home with no personal space and no autonomy, a lot of times eating disorders will creep up because it’s a way to assert boundaries,” she said.

Once a patient’s medical condition and food intake have stabilized, Dillon said, the mental health piece of treatment becomes vital to get to the root of the anorexia, bulimia or binge eating. Everyone involved in treatment stays vigilant for warning signs of suicide.

No one chooses to develop an eating disorder. Dillon’s current clientele includes first-timers as well as patients with persistent struggles in and out of treatment. Some patients who were handling recovery well prior to COVID-19 had to return for more therapy.

“From the research, we know that life-stage transitions are high-risk times,” she said. “You look at this pandemic, and it was a huge transition that nobody planned for, nobody expected, and nobody knew how to do it. So it makes sense that there would be a rise” in cases.

Dillon acknowledges it can be a terrifying experience for families to go through. Don’t blame yourself or make it a power struggle, she advised. “It’s hard on parents on a fundamental level, but it’s not their fault. The goal is to be aligned with your loved one as the two of you fight against the eating disorder together rather than the two of you fighting with each other.”

Ewing, who plays Dylan on the hit comedy Modern Family, opened up about how he obsessed over his looks in a recent op-ed piece in the Huffington Post. He says that he has faced eating disorders, depression and body dysmorphic disorder, a condition he describes as a “mental illness in which a person obsesses over the way he or she looks.”

Reid said that he would take pictures of himself, analyzing his looks, before deciding he needed plastic surgery. He said he felt ugly and that his looks were unacceptable.

Reid describes in great detail the horrible pain he went through during his initial surgery, cheek implants and yet felt the need to do it again. He says that no one gave him a mental evaluation, except to ask if he suffered from depression (he did), to learn of his history of eating disorders.

Joy Crabtree, PsyD., a psychologist at Cook Children’s, says that the insecurity and body dysmorphia often develops during adolescence, and they become more unhappy as they get older. In some situations, the discontent may develop in childhood, and start with a specific dislike for a certain part of their body or over focus on a perceived flaw.

“I like how the article makes the point that therapy is a great place to start before jumping into big cosmetic surgery decisions,” Crabtree said. “I think standard protocol requires some level of psychological screening for most bariatric surgeries as well.”

Crabtree says people sometimes don't think of boys dealing with these body image issue, but she treats boys struggling with eating disorders and their own looks.

One in 10 of those diagnosed with eating disorders are male. Moreover, nearly a third of adolescent boys participate in unhealthy weight control techniques, like skipping meals, smoking cigarettes, vomiting or taking laxatives (National Association of Anorexia Nervosa and Associated Disorders). The American Psychological Association says males are less likely to seek treatment for an eating disorder due to the perception that it is a disease that only affects women, but the shameful secret isn’t just a girl thing.

Issues with eating and problematic concern over weight usually begin during adolescence or young adulthood. According to Joy Crabtree, PsyD., a psychologist at Cook Children’s, “This is typically a higher time of stress in general, and also a time when bodies are changing quickly or rapidly; this creates more discomfort with their self-image. Additionally, sometimes males are involved in sports where there is a focus on either gaining or losing weight, which can contribute to eating challenges as well.” Crabtree notes that eating disorders tend to occur among those who have perfectionist tendencies. “Increased stress can be a contributor, as well as unreasonable goals or ideals for meeting or maintaining a certain weight in order to participate in certain sports,” she observes.

To tackle the issue, Crabtree says schools should make their staff aware that males can suffer from eating disorders in addition to female students. Coaches and athletic personnel should be careful not to set unrealistic standards for their athletes and reach out to students and their parents if they see unhealthy patterns developing. In the meantime, though, the responsibility to identify problematic concern over weight or an unhealthy relationship with food lies with a boy’s parents.

Parents need to remember that eating disorders can be even more problematic in young men due to their reluctance to come forward. Watch for boys who develop a focus on eating only “healthy” food, counting calories, step on the scale a little too frequently or exercise excessively. Crabtree recommends “ensuring your family has a healthy focus on body image in general without a frequent or specific focus on weight, food intake, calorie counting etc. Try to stress balance in food intake and activity or exercise for overall health.” In addition, get input from your primary care physician regarding whether your child is in the average weight/height range or needs to focus more on eating a more balanced diet.

For boys diagnosed with an eating disorder, the treatment approach would not necessarily be different than it would for a girl. Crabtree stresses, however, that “the clinician must be aware and sensitive to the fact that they may be more avoidant or resistant to treatment in general, as well as less inclined to be open or honest about the issue as it is not as frequently seen as a male issue or concern.” Parents can help their teenaged boys to gain perspective on what is typical or average and what is extreme and unhealthy. Just as with young girls, it is important to stress that the celebrities they see on television or in the media are not typically “average” bodies. Parents can’t change societal pressures, but they can foster healthy behaviors and a realistic outlook on body image within their own households.

About the author

Natalie Raymond is an associate marketing specialist at Cook Children’s. She graduated from Texas Christian University with a Master of Science in journalism and certificate in business in 2014, and has a background in strategic communication and health care communication. Natalie enjoys doing her part to help our patient families stay healthy and spends her spare time with her eight furry friends (also known as pets).

Pure knowledge of someone’s eating disorder is enough of a burden to create a second victim. I know because that was me.

Hearing the words “I have an eating disorder” from a 17-year-old girl to her best friend is not completely uncommon. And as that best friend, I can tell you the minute her mouth spoke those words, her problem was now mine.

She described to me in depth why she decided to tell me about her eating disorder now – the disappearance of her period, her fainting spells and being worried about her overall health. All things I would have never noticed yet in turn, made me feel like the worst best friend in the whole world.

When you receive that kind of information, without experience, how do you respond? Especially when your best friend begs you not to tell, it’s like asking a 17 year old – would you rather lose your best friend by choice or by chance?

I found myself eating less when I was around her because her thoughts were becoming mine. I started to lie for her, weakening my character and increasing my guilt. Her eating disorder was destroying her physically as well as emotionally, and bringing me along for the ride.

It has never been and never will be her fault. She cannot control that she has been overtaken by this disease and it’s important that she seek help from those she trusts the most. But as a caregiver, you can’t let the disease control you too. You have to stay healthy to give her the care she needs.

So what can you do?  For me, asking for help, regardless of her asking me not to tell anyone, was the best decision I could’ve made. I talked to my mom, my own pediatrician and my school counselor about what next steps could be taken to get her well again. Bottom line, I could not cure her on my own.

They say ignorance is bliss. But I learned at a young age, ignorance, in this case, can kill.
 

About the author

Caroline Gayler volunteers in the public relations department at Cook Children’s Health Care System. She is a senior at TCU majoring in Strategic Communications.