Eating disorder awareness: What you need to know

Since the COVID-19 pandemic began, more and more children and adolescents have developed an eating disorder. Dr. Catherine Gordon, professor of pediatrics at Baylor College of Medicine, specializes in treating children and adolescents with restrictive eating disorders. She explains who is most impacted by this trend and the risk factors that parents should know.

Question: We know the pandemic had a big impact on the mental health of adolescents, and the prevalence of eating disorders increased dramatically. Are we still seeing that trend now?

Answer: Disrupted schedules, missed opportunities and multiple unexpected stressors have arisen for young people and their families during the pandemic. A recent study suggested that 1 in 4 youth globally are experiencing depression and 1 in 5 show symptoms of anxiety. The prevalence of restrictive eating disorders has tripled since the beginning of the pandemic, and this trend has been sustained. Referrals to outpatient eating disorders programs have risen throughout the country with long waiting lists for new appointments. The volume of hemodynamically unstable inpatients – those with an abnormal heart rate, low blood pressure and other symptoms, including being at risk for loss of consciousness – with anorexia nervosa and other eating disorders has also increased. COVID-19 restrictions removed adolescents and their families from important sources of support, such as extended family members, places of worship, community centers, etc. Until we can fully rebuild our communities, this trend will likely continue. We also need more medical and behavioral health experts who are skilled to care for children and adolescents with eating disorders, including the ability to make early diagnoses.

Q: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), includes a new eating disorder diagnosis called Avoidant Restrictive Food Intake Disorder (ARFID). Can you explain what that is and why we might be seeing it more now?

A: ARFID is a type of eating disorder in which children or adolescents are extremely picky about what they will eat, and they often show little overall interest in eating. Sometimes ARFID is triggered by a traumatic event such as a choking episode while eating. Thereafter, the child is scared to eat, with some developing phobias around trying new foods. Because these children and adolescents eat such a limited variety of preferred foods, they often not only lose weight but also stop growing due to poor nutrition. Since the publication of the DSM-5, ARFID now includes a diagnosis to describe what used to be referred to as a selective eating disorder or food avoidance. Having a specific diagnosis also allows clinicians to better care for these patients, as a different care strategy is used for ARFID compared to other eating disorders. Likely some of the same pandemic-related drivers of mood disorders and other restrictive eating disorders are leading to a rise in ARFID cases.

Q: Eating disorders are often thought to occur primarily in adolescent girls, but there’s been a trend of more diagnoses now in other groups of patients, such as younger children and boys. Why do you think that is?

A: Despite the impression that eating disorders only occur in girls and women (i.e., assigned female at birth), recent data suggest that one in three people struggling with an eating disorder is male (i.e., assigned male at birth). In the U.S., eating disorders will affect 10 million males during their lifetime. Unfortunately, many assessment tools contain language designed for girls and women, and that can lead to a delay in diagnosis. The presence or absence of menstrual periods is also a useful sign that clinicians are only able to follow in girls and women. There are some data to suggest that clinicians are seeing diagnoses of eating disorders at younger ages during childhood. However, this trend could be explained by an increased awareness of eating disorders, which has led to earlier recognition. Additional studies are needed to understand these trends, including which children, adolescents and young adults who are most at risk.

Q: Which children and adolescents seem to be the most at risk for developing an eating disorder right now?

A: Adolescents and young adults are particularly vulnerable to developing eating disorders. Restrictive eating disorders are most common in the late teenage years and early 20s, and especially in young women. A family history of an eating disorder and the presence of anxiety (including obsessive-compulsive disorder) or depression increase the risk of developing an eating disorder. Other risk factors include history of overweight or obesity during childhood and engaging in sports where leanness confers a perceived advantage. Adolescents along the LGBTQ+ spectrum also have been noted to have more body dissatisfaction and are at risk to develop restricted eating or engage in bingeing and purging behaviors. The dietary habits of all children and adolescents should be monitored as we emerge from the COVID-19 pandemic. The world of youth was “turned upside down” during an important developmental period, and it may many takes years for them to recover.

By Molly Chiu