COVID-19 and eating disorders in young people

Over the past year, child and adolescent eating disorder services of the UK National Health Service have seen almost a doubling in the number of both urgent and routine referrals.¹ Although these services managed to meet recommended waiting times initially, waiting lists are now starting to grow.

Much has been said about the drivers of this observed spike in referrals and hospital admissions.² From social isolation to food insecurity, and from pressures to exercise and challenges to losing weight to loss of routines and disruptions in accessing face-to-face clinical services, it is difficult to think of a scenario that could have promoted so many risk factors for eating disorders at a societal level as much as the current situation. With a careful return to so-called normal life following the roll-out of vaccines, the challenges faced by young people with eating disorders and by the services that care for them will not suddenly disappear. Now is the time to assess the scale of the issue and its probable drivers, and to think of how to formulate a meaningful response.

Gauging the burden of eating disorders in young people is the first step towards mobilising policy makers, but these data are still unavailable in the UK. Whether the spike in referrals reflects broader behavioural changes in young people or exacerbations of symptoms in groups already at greater risk is hard to know. Many studies of young people's mental health during the pandemic used screening tools that do not detect eating disorders.³ A systematic review (preprint) of the impact of school closure on young people's mental health found no studies examining eating disorders.⁴ Population data are essential to capture presentations that might be missed in clinical settings. Beyond anecdotal evidence, little is known of how the pandemic has affected young people with behaviours such as purging and binge eating. Binge eating disorder is also accompanied by feelings of guilt and shame and might be more common in young people with higher weight. Yet, young people with binge eating disorders present to clinical services less often than prevalence studies would predict.

One concern is that the current rhetoric around the individual responsibility for weight loss could create further barriers for young people who already feel stigmatised to seek help. The pandemic has highlighted the profound schism that exists between the fields of obesity and eating disorders. Throughout the past year, public health messages have emphasised the dangers posed by excess weight in exacerbating the risk of worse outcomes of COVID-19. At the peak of lockdown, people were only allowed to leave the house for physical activity, other than for work or health-related reasons. Exercise became one of the few freedoms that remained, stressing its relative importance, and virtue, for children and young people. Alongside these messages, the government's new obesity strategy included adding information on calories to food outlet menus and using apps to support and track weight loss.⁵ Eating disorders clinicians, researchers, and activists have repeatedly shown that these strategies are ineffective for long-term weight loss in young people,⁶ and in fact aggravate eating disorder behaviours in those with established illnesses, and increase the risk of eating disorders developing in the general population.

The potential harms of obesity-tackling strategies have not yet been fully addressed by existing policies. Meanwhile, the number of young people presenting and requiring admission to health-care services for medical instability as a result of drastic dietary restriction is soaring. Many of these young people, who would have previously been classified as having overweight or obesity, can still have a so-called healthy weight, but their pulse, blood pressure, and blood tests tell an alarming story. That the situation will improve over the coming months is improbable. Whereas referrals for eating disorders increased during lockdown, they increased even more as lockdown measures were relaxed. This pattern might reflect greater help seeking, which had declined during lockdown,⁷ and the indispensable role that schools have in identifying mental health problems in young people; or it might be that returning to school, with all the social and academic pressures that it presents, might also constitute a period of heightened anxiety that could exacerbate the risk of eating disorders.

Addressing these challenges will require a multidisciplinary effort. First, it is of paramount importance that eating disorders stop being seen as a niche problem of the elite and are understood, instead, as public health concerns. A recent Finnish study found that one in six female adolescents and young adults and one in 40 male adolescents and young adults met the criteria for the diagnosis of an eating disorder.⁸ Population data are needed to complement clinical activity data to plan prevention, screening, and intervention services. More funding for eating disorder services is necessary, as well as new approaches to treatment, developed and evaluated through high-quality research. Innovative interventions are needed for specific populations, such as young people with binge eating disorders and those whose illness sits alongside conditions such as autism spectrum disorder. Finally, increased training for health-care professionals and teachers is also necessary to allow children at risk to be promptly identified and referred.

Parents play a crucial role in early intervention for young people with eating disorders,⁹ and need support with how to (and how not to) talk to their child about eating and weight concerns, when to seek help, and how to support their child through treatment. Similarly, we need to ensure that school environments provide balanced information and guidance on weight, food, body image, and exercise, and monitor the potential harms of school-based wellbeing initiatives in these areas. Lastly, it is crucial that policy makers working on campaigns aimed at reducing obesity listen to, and collaborate with, experts on eating disorders and body image. A science-informed, integrated public health approach to obesity and eating disorders is possible.¹⁰ COVID-19 has provided the imperative to make this possibility a reality.