Expert Commentary

Eating disorders doubled at 38 US pediatric hospitals the first year of COVID-19, study finds

A biostatistician at Boston Children’s Hospital explains the findings and offers advice on reporting on eating disorders among children and teenagers.

eating disorders child teenager pandemic research
(Pixabay/Gino Crescoli)

The number of times children and adolescents were treated for eating disorders at 38 U.S. pediatric hospitals approximately doubled during the first year of the COVID-19 pandemic and remained elevated in 2022, finds a recent paper in Pediatrics, a journal of the American Academy of Pediatrics.

Even before the pandemic, emergency rooms at these hospitals were seeing more kids aged 10 years and older needing help for eating disorders — a group of psychiatric conditions characterized by an unhealthy relationship with food, including avoiding it, eating it in large quantities or purging it. Anorexia nervosa, binge eating disorder and laxative abuse are common types of eating disorders.

From January 2018 to March 2020, emergency room visits for eating disorders increased by 1.5 visits per month, on average, for youth. After COVID-19 began to spread and many schools and businesses closed, emergency room visits jumped by an average of 12.9 visits a month in the first year of the pandemic and then began to decline by 6.3 visits per month during the second.

The hospitals saw similar increases in inpatient admissions for children and adolescents with eating disorders, according to the study, led by Carly Milliren, a biostatistician at Boston Children’s Hospital’s Institutional Centers for Clinical and Translational Research.

Milliren’s coauthors are Tracy Richmond, the director of Boston Children’s Hospital’s Eating Disorder Program and an assistant professor of pediatrics at Harvard Medical School, and Joel Hudgins, an emergency medicine physician at Boston Children’s Hospital and assistant professor of pediatrics and emergency medicine at Harvard Medical School.

A ‘second pandemic of mental health’

The paper adds to a growing body of academic literature chronicling young people’s mental health struggles amid the pandemic. Two recent meta-analyses — a top-tier form of scientific evidence — find spikes in attempted suicide and depression across several countries, including the U.S.

“The stress of the pandemic is clear,” Milliren wrote in an email to The Journalist’s Resource. “We now talk about a second pandemic of mental health particularly in children/adolescents, the effects of which are still lingering, though the exact cause of this is unknown.”

Not only did inpatient admissions increase, but patients also required longer hospital stays, partly because it took so long for some kids to seek out or receive care, Milliren noted.

It can take many years to recover from eating disorders. The average course of an eating disorder is about three to six years, Milliren explained.

“We see many individuals who got sick with an eating disorder during the pandemic who continue to struggle,” she added. “Because care was difficult to access, many patients who got sick during the pandemic had delayed care and presented with more severe illness. This sets them up for [a] more protracted course of illness.”

To measure changes in the volume of youth seeking eating disorder-related care, Milliren, Richmond and Hudgins looked at medical billing data for kids diagnosed with eating disorders in the 27 months leading up to and 27 months after the pandemic began.

They extracted information for their analysis from the Pediatric Health Information System, a database containing clinical and financial details for millions of young patients within a network of not-for-profit pediatric hospitals.

Here are some of the other key findings outlined in their paper, “Emergency Department Visits and Hospitalizations for Eating Disorders During the COVID-19 Pandemic”:

  • The average age of a child or adolescent treated for an eating disorder at one of the 38 hospitals during the pandemic was 15.5 years. Slightly more than one-third of the patients studied were 14 or 15 years old.
  • The share of patients coming from higher-income communities rose slightly during the study period. Prior to the pandemic, about 7% of patients came from communities with a median income of $90,000 per year or higher. Post-COVID, 8.2% did.
  • The percentage of youth using private health insurance also grew. For example, prior to the pandemic, 65.9% of patients used private insurance to cover the cost of emergency room treatments for eating disorders. That number increased to 69.1% from April 2020 to June 2022. At the same time, the proportion of patients using public health insurance dipped — from 30.7% to 28.1%.
  • Anorexia nervosa was, by far, the most common eating disorder diagnosis. During the pandemic, 64.2% of children and adolescents who sought help for eating disorders from emergency department physicians were diagnosed with anorexia nervosa, as were 73.8% of youth admitted for inpatient care.

Tips for covering eating disorders

The Journalist’s Resource asked Milliren how journalists can improve their coverage of eating disorders. She made these four suggestions:

1. Stress that eating disorders are but one component of a larger mental health crisis affecting children and adolescents nationwide today.

“The needs of these kids are dire and need to be brought to national attention to really enact change,” Milliren wrote.

2. Make clear that eating disorders often are not obvious. Having a healthy weight does not mean a child or teenager does not have an eating disorder.

“Some of our most severely impacted patients are those who started at a higher weight, were encouraged by family, medical providers to lose weight, and present with what appears to be a normal or healthy weight,” Milliren wrote.

Some of those kids are profoundly ill, their vital organs weakened by sustained starvation, malnutrition or dehydration. They might have the same thoughts and disordered eating patterns as someone whose weight is very low as a result of anorexia nervosa, she added.

3. Correct the misconception that eating disorders only affect girls, particularly white girls from higher-income families.

Milliren pointed out that eating disorders often are under-recognized and under-diagnosed in boys and racial and ethnic minorities.  

A meta-analysis published in February in JAMA Pediatrics, a journal of the American Medical Association, suggests a substantial portion of boys have feelings about food and their body size that are associated with what researchers call “disordered eating.” The term refers to abnormal eating behaviors that may not meet the diagnostic criteria for an eating disorder.

The authors of this meta-analysis examined data from 32 academic studies published between 2008 and 2022, representing a total of 63,181 kids aged 6 to 18 years across 16 countries. The studies focus on how often boys and girls said ‘yes’ to the five questions on a common screening measure for eating disorders. Examples of the questions asked are, “Do you make yourself sick because you feel uncomfortably full?” and “Do you believe yourself to be fat when others say you are too thin?” and “Do you worry you have lost control over how much you eat?”

Across the countries studied, 22% of kids — and 17% of boys — reported having disordered eating. The authors note they only looked at data collected prior to the pandemic, which means their results do not reflect any shifts in disordered eating that may have occurred in recent years.

Milliren, Richmond and Hudgins found that about 80% of the kids treated for eating disorders post-pandemic at the 38 pediatric hospitals were white. About 4% were Black, 3% to 4% were Asian American and 7% were “another race.” About 14% of patients were Hispanic.

4. Ask local schools how they are helping identify and support students with eating disorders.

“Since kids spend so much time at school, they can be an important first line of defense for recognizing and dealing with eating disorders or other mental health conditions,” Milliren wrote. “Early identification is key for eating disorders to prevent serious complications and schools can help by providing environments where kids feel supported and able to share their concerns, especially for those with challenging home environments.”

Schools can also help students by encouraging discussions around nutrition, exercise and body image and promoting healthy habits “to try and counteract all the stigmatizing messages around weight and shape that are so prevalent on social media and just media in general,” Milliren noted.

For more details

Emergency Department Visits and Hospitalizations for Eating Disorders During the COVID-19 Pandemic
Carly E. Milliren, Tracy Richmond and Joel D. Hudgins. Pediatrics, January 2023.

Global Proportion of Disordered Eating in Children and AdolescentsA Systematic Review and Meta-analysis
José Francisco López-Gil; et al. JAMA Pediatrics, February 2023.

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