The COVID-19 Pandemic and Eating Disorders: A Wake-Up Call for the Future of Eating Disorders Among Adolescents and Young Adults

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The COVID-19 pandemic has had a severe impact on individuals with eating disorders. Since the onset of the COVID-19 pandemic, eating disorder experts from across the globe have observed a substantial increase in the number and severity of new and pre-existing young people suffering with eating disorders compared to prior years. It appears that the COVID-19 pandemic has unmasked a global eating disorder public health crisis that was already building [[1], [2], [3]]. The COVID-19 pandemic has resulted in considerable health, economic, financial, and social consequences, all possibly contributing to the unprecedented increases in the number of reported adolescents and young adults (AYAs) with eating disorders. Although there have been many anecdotal reports, until now, there has been limited data [1,2] confirming this increase in volumes of eating disorders among AYAs.

The study published in this issue of the Journal of Adolescent Health by Lin et al. [4] is one of a few studies to capture both the extent and nature of this problem through systematic data collection and comparison to prepandemic data. Lin et al. [4] demonstrated the increasing volumes of inpatient and outpatient AYAs with eating disorders since the COVID-19 pandemic began. This research group examined the COVID-19-related trends in AYAs with eating disorders using interrupted time series regression to examine prepandemic and postpandemic monthly summary data. Postpandemic inpatient admissions, hospital bed days, and outpatient care-related inquiries significantly increased on average over time, compared to prepandemic stable volumes over time. Initially, outpatient assessments decreased precipitously following the implementation of COVID-19-related restrictions, and then rose quickly back to baseline. This study clearly illustrates the increased volumes of AYAs with eating disorders during the COVID-19 pandemic.

How do we understand these documented increases in volumes and to what extent has the COVID-19 pandemic affected eating disorders in AYAs? On reflection, the COVID-19 pandemic presents the “perfect storm” for eating disorders among AYAs. It is hard to imagine another set of rare circumstances that could have promoted as many risk factors for the development or exacerbation of eating disorders. COVID-19 has both magnified and contributed to the global eating disorder crisis. It is fair to say that those of us who treat young people with eating disorders were woefully unprepared to manage this eating disorder surge. Even before the COVID-19 pandemic, the prevalence of eating disorders was high; according to Galmiche et al. [5], the weighted mean lifetime prevalence for all eating disorders worldwide was 7.8 %. The longstanding underinvestment, inadequate eating disorder services and limited eating disorders resources coupled with the diversion of healthcare resources toward fighting the COVID-19 pandemic, has left young people at risk for, or those with pre-existing eating disorders vulnerable. The Lin study [4] highlights how the COVID-19 pandemic has hampered our ability to promptly identify and treat young people with eating disorders, in an already under-resourced system.

The implementation of public health mitigation strategies to contain the spread of the virus including mass home-confinement directives (including stay-at-home orders, quarantine, and isolation), physical distancing, hand washing, and mask wearing may have contributed to the increase in the number of cases [3,6,7]. Furthermore, the abrupt changes in day-to-day life for AYAs including school and work closures, lack of routine, disconnection from peers, restricted social connectivity, and reduction in extracurricular activities may also be contributing to the rise in cases [3,6,7]. Young people with eating disorders, in particular those with anorexia nervosa, are often isolated. The pandemic may have made this worse through quarantine. Increased internet use by AYAs secondary to virtual school, isolation, and physical distancing measures may be a factor in exposing young people to fat-phobic social media messages and the challenges of seeing oneself on screen (for virtual school, friends, therapy) for hours at a time. The impact of increased anxiety and stress among caregivers (job loss, financial difficulties) may also impact AYA health [3]. Furthermore, many AYAs with eating disorders have comorbid mental health issues, including depression, anxiety, and obsessive–compulsive disorder. These too, have been shown to be exacerbated by social isolation, increased focus on hand hygiene, and fear of contracting COVID-19 [3,8].

Care -seeking and healthcare delivery have also been influenced by the pandemic. Initial public health messaging advised avoiding unnecessary health care use to reduce transmission of the virus and to ensure capacity to accommodate surges in COVID-19 cases. In addition, and anecdotally, parents have expressed concern about coming to clinic or hospital for fear of contracting COVID-19. The fear of contagion has created uncertainty and anxiety among young people and their caregivers, as well as delay in young people seeking needed care. The reduction in emergency department use and elective assessments could also be contributing factors to the failure of young people with eating disorders to seek care. COVID-19 has forced modifications in healthcare service delivery for AYAs with eating disorders, with the temporary cessation of face-to-face assessments and follow-up visits, and temporary closure of day treatment programs [6]. Although virtual visits have helped to maintain continuity and provision of mental health and in some cases physical healthcare, this may pose a challenge for those AYAs who do not have access to technology. These restrictive measures undoubtedly have affected the health and well-being of AYAs across the board and, in particular, those with eating disorders.

The Lin et al. study [4] underscores this unprecedented eating disorder surge and is a wake-up call on how we need to re-examine how we do things. First, as a result of this pandemic, I am optimistic that eating disorders will finally be given the same priority and importance as other “physical” illnesses. As described by Treasure et al. [9], “Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning.” This is an opportune time to rethink prevention, early identification, and how eating disorder services should now be organized in the post-COVID-19 era and in the future, should another pandemic hit. We need to ensure that AYAs with eating disorders have rapid access to specialized eating disorder care, while balancing this care in the context of the public health mitigation strategies that aim to reduce the spread of COVID-19. Now is the time to consider new models of eating disorder service delivery that include targeted interventions and innovative approaches. For example, virtual interventions have accelerated during the pandemic and have been shown to be valuable, especially to maintain continuity of care for the increasing number of AYAs with eating disorders [10].

Furthermore, it is important to have an infrastructure to monitor the physical and mental long-term effects of the COVID-19 pandemic on AYAs with eating disorders. A recent review [11] of the literature on the burden of eating disorders (prior to the COVID-19 pandemic) showed that people with a current or former eating disorder are at risk of increased mortality, high rates of years lost due to disability, a reduced quality of life, increased cost, and problems with childbearing. What does this mean for young people at risk for, or those with pre-existing eating disorders in the context of the COVID-19 pandemic, especially when the timely identification and management of AYAs with eating disorders is crucial to mitigate the burden of these disorders?

As shown in the study by Lin et al. [4], the pandemic-precipitated surge in volumes of young people with eating disorders have placed a real burden on healthcare systems that are already overwhelmed. The demand for care has outweighed the supply. We must work with our respective governments to bolster public health funding and healthcare infrastructure to address this surge in eating disorders and their associated morbidities and mortalities in the future. More funding is needed to invest in eating disorder services and resources, increased training for healthcare professionals to allow for the prompt identification and treatment, as well as newly developed and evaluated approaches to treatment. New research initiatives are needed to better understand the impact of the COVID-19 pandemic on AYAs with eating disorders and to solidify evidence-based approaches for the management of these young people during this and potential future crises. Finally, the COVID-19 pandemic has contributed to the global eating disorder crisis. As a global community we must work together and share the lessons we have all learned in an effort to provide the best care for our AYA patients with eating disorders.

At present, it is unclear whether this eating disorder surge will continue, worsen, or improve with time [12]. Long-term data will be critical to elucidate eating disorder trends and the resultant health consequences attributable to the COVID-19 pandemic. However, Belkin et al. [13] expects that the negative mental health effects of COVID-19 “will remain massive, far reaching, and long term.” We must therefore be prepared to address this ongoing clinical burden and tackle the immediate and long-term unmet needs of young people with eating disorders.

Unfortunately, it took a disaster like the COVID-19 pandemic to put the spotlight on eating disorders. The eating disorder surge, underscored by the study reported by Lin et al. [4], is a wake-up call for making eating disorders a priority. It is time to recognize that eating disorders are serious, life-threatening mental health disorders with life-threatening physical consequences. It is time to rally together to ensure that eating disorders get the same priority as other illnesses. It is time to do better for young people suffering with eating disorders.

Do the best you can until you know better. Then when you know better, do better.

Maya Angelou