Like many girls in high school, Ella (not her real name) had days where she struggled with self-esteem.
“I was able to cope with it because I had sports, I had friends, and I had school. Then the pandemic hit in March (2020) and I lost all of that,” said Ella, who looks younger than her 15 years.
“I wanted to do something proactive to help me cope, so I turned to exercise. I’d run almost every day. I went for bike rides and for hour-long walks.”
A runner herself, Ella’s mom Alice (also not her real name) was pleased to see her daughter embracing such healthy habits during the dreary months of lockdown in their home town of Ottawa, Canada. But it wasn’t long before she noticed that if Ella wasn’t exercising, she appeared nervous and edgy.
“She couldn’t sit down. She could no longer enjoy things like watching a movie because she felt she needed to be active all the time,” Alice said.
“I couldn’t stop. I don’t know why. I just couldn’t,” Ella said. “A one point, I didn’t even like exercise. I just felt like I had to do it.”
Ella said her need to exercise escalated. In June 2020, she told her mother she was losing weight.
“It was almost like she was controlled by an alien,” Alice said. “One minute she’d be fine, but it you tried to get her to eat or stop exercising you would see in her eyes that she would become very intense.
“I was no longer talking to Ella. I was talking to this alien, or whatever it was.”
Alice’s growing concern turned to fear. She and her husband began searching for a dietitian, counseling or any sort of support services. “It took months for us to be able to get access to those services at that stage of the pandemic.”
A growing problem
Across town at the Children’s Hospital of Eastern Ontario, Dr. Mark Norris was busier than he’d ever been. As a specialist in pediatric eating disorders, Norris was used to being summoned to the emergency room to evaluate a young patient.
By early summer, “I was being called to the emergency room more than I ever had been in my career,” Norris said. Urgent consultation requests by worried parents also shot up, he said.
The increased demand for services began “almost immediately” after the lockdown eased in June, he said, and his team “soon had more patients in hospital than I’d ever witnessed.”
Eating disorders are often triggered or exacerbated by stress, so like many specialists, Norris was worried the upheaval caused by the pandemic would trigger youth (and adults) who were in recovery from known eating disorders to relapse.
While that did happen, Norris said he was surprised to find many of the youngsters showing up in his ER had never shown previous signs of an eating disorder.
He was part of a team that assessed 48 adolescents in mid-2020 about their experiences with an eating disorder. When asked what they thought activated their illness, 40% of the children blamed effects of the pandemic, Norris said.
There were other startling findings as well.
“In the first six months of the pandemic especially, we noticed that patients were presenting at weights that were lower than we had been accustomed to regularly seeing prior to the pandemic, and that these patients were getting sick very quickly,” Norris said.
“Our data suggested that in addition to lower weight, patients were also reporting higher levels of impairment, and were more likely to require admission to hospital on medical grounds.” Norris and his team would later publish these results in the June 2021 Journal of Eating Disorders.
Inquires at other pediatric hospitals in Canada and the US found a similar surge of youth being evaluated and hospitalized for eating disorders during the summer and fall of 2020. One family physician Norris reached out to, Dr. David Little, worked as a clinical informaticist at Epic Health Research Network, which produces electronic medical records.
“Dr. Norris suggested we look at the data in the EPIC database, which has over 100 million patients in the US,” said Little, a family physician in Verona, Wisconsin.
“In 80 hospitals, we found a 25% increase in admissions for eating disorders after the pandemic began in March (2020) as compared to pre-pandemic trends,” Little said.
The rise was even steeper when looking at girls specifically – 30%, Little said. “What’s really interesting is that when we looked at other mental health diagnoses – anxiety, depression and even suicide attempts – we saw slight increases. But nothing nearly as dramatic as the 30% increase in adolescent girls being hospitalized for anorexia and other eating disorders.”
Statistics show calls to eating disorder hotlines from youth – and adults – have skyrocketed during the pandemic.
Chelsea Kronengold, the associate director of communications for the National Eating Disorders Association, said the association’s helpline has experienced “a 107% increase in contacts since the start of the COVID-19 pandemic.”
“Despite being two years into the pandemic, our helpline volume is still on the rise,” Kronengold told CNN via email. Based on contacts from people who disclosed their age, she said the majority of people reaching out for help in 2021 were between the ages of 13 and 24.
It’s not the child’s fault
After scheduling delays, Ella was finally evaluated in September 2020. But according to her mother, that specialist considered her weight loss to be “borderline,” and decided to have the family undergo regular blood tests and other vital checks until an in-patient bed in the eating disorders unit was available.
“By now she was running half marathons on her own,” Alice said. “It was out of control. I didn’t know how to keep her in the house. I’d be riding my bike next to her terrified that something was going to happen – that she didn’t have enough energy to be doing this.”
Weight alone is an imperfect criteria for treatment, experts say, but there was a required threshold before Ella could be considered for in-patient services.
Months went by without Ella meeting that criteria, and finally in January “it was our family doctor who said, ‘You need to go into emergency.’ We went in that morning, and after a couple of hours, they admitted Ella,” Alice said.
“They said her blood work was not safe, and her vitals were in a rough situation. And I remember feeling tremendous guilt about the whole thing, you know, like ‘How could I have let this happen?’
“But they told us (Ella) is basically being controlled by an illness right now,” Alice continued. “She is not herself. You’re talking to somebody who is unable to process information in the way she used to.”
Norris was Ella’s doctor. He told her family to externalize the illness – to view the eating disorder as an outside entity or “bully” that was threatening their child: “It’s a disease, not something that’s wrong with the child and certainly not the child’s fault.”
With children and adolescents, he explained, this “bully” will want to be in control.
“It will try and isolate the child, try to limit support that the eating disorder may see as threatening,” he said. “And so the eating disorder slips under the radar, if you will, because the individual has found ways to be able to have some of these symptoms and not to alarm the caregiver in the house.
“Although there may be a part of their brain that certainly recognizes that they need help, there’s another part that may not be interested in getting help or may not see a need for help,” Norris said.
“My job is to help the child understand that although certainly much of their brain feels that the eating disorder is there to help, in reality, it does not.”
Today, Ella says she is doing well, finishing up her final year in high school and looking forward to university. She continues to be an out-patient with Dr. Norris and his team.
“Dr. Norris assured me that full recovery is possible, but it can take time,” Ella said. “We keep a week by week summary of all of my improvements, and looking back I definitely feel like I have come a long way. But there’s still a way to go.”
Eating disorders are generally born when internal distress increases, Norris explained. While there is no single cause, experts say food insecurity, childhood trauma and abuse, gender role concerns and stressful life events can all contribute. Recent research indicates that genetics may play a role as well.
Now, it appears the fallout from Covid-19 may be a leading example of such stress.
“Evidence that is emerging would suggest that the pandemic itself is acting as a significant trigger,” Norris said.
Eating disorder resources
During the pandemic, children are often turning to other activities that increase their vulnerability and susceptibility to eating disorders, he said. “Much of what we hear from youth speaks to social isolation, or social malnutrition if you will.”
That includes engaging in more solitary activity, “such as exercising on their own as opposed to group activities,” Norris explained. “For others it’s spending more time online, visiting websites and looking at social media that might not be in their overall best developmental interests.”
An overwhelming demand for services likely means that cases like Ella’s are not seen as quickly as needed, a fact that worries specialists like Norris.
“It’s important to try and get to patients as quickly as you can, because the longer an eating disorder is in place, the harder it is to treat,” Norris said.
“Awareness is the number one message,” Little said, “not only for health professionals, but for families, for parents, for kids, for the school systems, and for the community at large. Because by the time these kids get access to the medical profession, they’re pretty sick.”
There’s yet another issue: Most of the in-patients at Norris’s hospital were hospitalized due to anorexia nervosa, a type of eating disorder that manifests with an intense fear of gaining weight due to a distorted body image. Many people suffer such extreme weight loss that they become medically critical and often get available in-patient beds, Norris said.
However, there are many other types of eating disorders, including bulimia, in which people binge eat and then purge, which may not be getting the expert help they need, he said.
“It’s really challenging. Despite the fact that we know so many people are suffering, there’s only a limited number of providers with the expertise to treat an eating disorder,” Norris said. “Clearly we do our best for the ones that have to be admitted in those life threatening states, but for every patient that gets admitted to hospital, there are a number of patients that aren’t.
“Are those patients going to be able to access a level of care that will put them on a course that leads to recovery?”