The Age of Uncertainty: Eating Disorders in Adolescence at the Time of the COVID-19 Pandemic

When the Covid-19 pandemic started last March, kids had their lives uprooted, as remote schooling, separation from friends and family, and the lack of structure during quarantine became major lifestyle changes. In addition to navigating these changes, children and teens have lived in a state of constant unknowns. One of the biggest stressors prior to the pandemic was uncertainty: since March 2020 uncertainty is the first game that children and adolescents have been playing in their everyday life (Guessoum et al., 2020). During the Covid-19 crisis, combining puberty with high anxiety and uncertainty, a lack of structure, and constant pressure from increased engagement with social media were an onslaught of risk factors placed on young people: that’s pretty much a perfect storm for developing an eating disorder (Fernández-Aranda et al., 2020). The reasons why children or adolescents may develop an eating disorder are multifactorial, but the pandemic has left many young people isolated, uncertain about the future and less in control (Cotugno, 2021; D’Ambrosio, 2021).

Valentina, a 13-year-old girl, was always lively and outgoing, very active both in school and sports activities. However, following the restrictive measures imposed by the pandemic (March 2020), she wascd forced to spend a lot of time alone at home. As an only child, she began to feel more and more bored, and she started to spend most of her time on her smartphone. After some time, she showed a moderate weight gain. With the end of the first lockdown (May 2020), Valentina partially resumed her vibrant social life; she graduated from middle school and happily spent the summer holidays with her family. Shortly after the beginning of high school (September 2020), Italy was struck by a second lockdown, during which Valentina developed anxiety, depressive symptoms, and sleep disturbances (insomnia). In November 2020, both Valentina and her parents contracted the Covid-19 infection. The girl remained asymptomatic, while her mother and father developed a mild respiratory disorder with complete remission of symptoms. With the arrival of the Christmas holidays, Valentina became progressively more worried about her weight and body image. As a result, she began to restrict her caloric intake, losing fourteen kilos in only six weeks. In March 2021, she was admitted to Bambino Gesù Pediatric Hospital of Rome following a severe bradycardia episode associated with lipothymia. While hospitalized, Valentina received enteral nutrition through a nasogastric tube due to her malnutrition. After her discharge from the Pediatric Hospital, she was an outpatient at the Eating Disorder Unit, ASL RM1. Her story echoes that of many teenagers experiencing isolation and anxiety during the pandemic, spending hours every day in online classes, posting more on social media. Many may also have lost access to their usual routines and coping mechanisms: since the pandemic began, isolation, anxiety and hours upon hours of screen time have led to a surge in eating disorders among adolescents.

In Spring 2020, researchers and clinicians expressed concerns for the mental health of youth as the impacts of the Covid-19 pandemic took hold. Among those were concerns for individuals with eating disorders. As a clinician and Director of the Eating Disorder Unit, ASL RM1 in Rome, I worried about the impact of increased social isolation on individuals with an illness that is inherently isolating. My colleagues and I worried that the severity of an adolescent’s eating disorder would worsen under such stressful circumstances and that the risk of relapse among patients would increase. And as food insecurity, economic hardships and family struggles began to weigh upon households, our concerns for these vulnerable youth grew: the recent data coming from all Europe and USA tell us that our concerns were well-founded (Canadian Consensus Panel, 2020).

We have observed a significant increase in the number of adolescents with new onset eating disorders coming to the emergency room and to our outpatient clinic. In line with data coming from other countries, in Rome we observed a rapid 60%-70% increase in the number of youths seeking treatment of an eating disorder: the pandemic is as if Pandora’s Box opened, making the presence of eating disorders among adolescents more visible. In both the severity of the eating disorder and the number of people struggling, we’ve experienced a big increase in not only the volume of eating disorder patients, but also the number who are medically compromised due to malnutrition. While we were used to seeing patients who lost between 5 and 10 kilograms in a few months, we now see a higher frequency who have lost up to 20-25 kilos in a few months! More research is ongoing to quantify this wave of new onset or newly identified eating disorders among youth worldwide. While it will take some time to truly understand the effects of Covid-19 on the mental health of youths, we know that it has been indisputably impacted. Over the past year, the young have been isolated from friends, many are not attending in-person school full time, extracurricular activities are canceled or significantly impacted and social media use has increased. Many young people had had nothing to do during the first lockdown and so focused on healthy eating – which in some cases developed into an unhealthy obsession, and then into a diagnosable eating disorder (Cooper et al., 2020).

As kids in isolation have turned to TikTok and Instagram for their social interactions, they’re likely exposed to constant messaging about losing weight. The pandemic has limited the number of people that kids see each day, and their understanding of body image diversity can become biased towards what they see online: it starts to skew the understanding of what normal looks like. Teens are being inundated with content about how to avoid the “quarantine 15,” or take advantage of free time to adopt a new exercise regimen. Changing diet to lose weight or to keeping off the so-called “COVID 15” (gaining weight -15 pounds- during the quarantine) or increasing exercise to “get fit” or “stay in shape” for sport can seem innocuous to many, but for adolescents at risk of developing an eating disorder, weight loss for any reason can open the door to the development of severe medical and psychiatric illness.

Adolescents are growing, their brains are developing and their bodies are building bones and muscles. Their bodies should continue to gain weight through adolescence into early adulthood. Any significant change in eating or exercise behavior in an adolescent should be cause for concern, as should any weight loss. If a child falls off their historical growth curves it is important to take a hard look at their behavior. Concern about their weight, a reduction in the types of food they normally eat (e.g., cutting out sugar, reducing carbohydrates, becoming a vegetarian), and increasing exercise without increasing the fuel needed to exercise are all red flags that the weight loss or behavior is not healthy. For individuals with a genetic predisposition, weight loss can trigger the development of an eating disorder.   Once you’ve developed an eating disorder, you’ve now got an illness: it doesn’t just suddenly get better the minute lockdown’s lifted.

Eating disorders are severe, potentially fatal illnesses. They have the ability to disrupt normal adolescent development and need swift identification and treatment to prevent damage and reduce the likelihood of a longer course of illness. Eating disorders include anorexia, bulimia, binge eating, excessive exercise and other extreme measures related to diet. Although they can affect anyone, they’re most common among adolescent girls and young women, who are more likely to be preoccupied with their physical appearance and susceptible to social pressure to be thin. People with eating disorders can suffer from damage to the heart, brain, kidneys, liver, digestive and endocrine systems, skin and other organs. The fatality rate among anorexics is about 10%, making it one of the most deadly mental illnesses (Cotugno & Sapuppo, 2019). People with eating disorders are also at higher risk for suicide (Preti et al., 2010).

According to a CDC report released in March 2021, in the U.S. during the pandemic incidences of general anxiety, depressive, and adjustment disorders — all risk factors for an eating disorder — each rose between 80% to 90%. Eating disorders also became more prevalent, shifting from the sixth to the fifth most frequent disorder among those affecting teens (D’Ambrosio, 2021). Overall trends were similar for adolescents ages 19 to 22, but were less pronounced than for 13- to 18-year-olds (Canadian Consensus Panel, 2020).

All health care providers need to join in this fight against eating disorders. Especially during these stressful times, we encourage GPs and pediatricians to screen all patients who have lost weight for an eating disorder, even if their weight is considered to be in the “normal” range. Eating disorders occur in individuals of all genders, all ethnicities and all body sizes, making it crucial for providers to look beyond old stereotypes of who has an eating disorder. Many youths with an eating disorder will not express significant body dissatisfaction, but they may talk about wanting to be “healthy,” losing weight the “right way” and express fear of becoming fat. Importantly, they may engage in behavior to avoid weight gain, even after being told that is necessary for their health (Courtney, 2020).

In the view of the above we can summarize the factors which this pandemic may exacerbate the risk of developing eating disorders in three main pathways (Rodgers et al., 2020). One, the disruptions to daily routines and constraints to outdoor activities may increase weight and shape concerns, and negatively impact eating, exercise, and sleeping patterns, which may in turn increase eating disorders risk and symptoms. Relatedly, the pandemic and accompanying social restrictions may deprive individuals of social support and adaptive coping strategies, thereby potentially elevating eating disorders risk and symptoms by removing protective factors. Two, increased exposure to eating disorders-specific or anxiety provoking media, as well as increased reliance on video conferencing, may increase eating disorders risk and symptoms. Three, elevated rates of stress and negative affect due to the pandemic and social isolation may also contribute to increasing risk.

According to recent studies, we may finally assume that the pathogenic mechanism of social isolation in the development of eating disorders in early adolescence may rely on the immaturity of specific brain areas, In adulthood these brain areas modulate the non-specific neural response of midbrain areas to different stress stimuli. These studies have underlined the overlapping in neural response after social isolation and after fasting (Tomova et al., 2019; 2020). After isolation people felt lonely and craved social interaction: specific midbrain areas (substantia nigra and ventral tegmental area) show increased activation to social cues after isolation and to food cues after fasting: neural patterns in response to food cues when participants were hungry generalized to social cues after isolation. This midbrain neurophysiological overlapping between food and social craving is modulated by upper brain areas (prefrontal cortex and hippocampus), whose maturation process continue to be refined and stabilized during adolescence, in which executive functions reach adult levels of maturation (Murty et al., 2016). Social networking is the main reward that drives this psychological and neurodevelopmental process. As the recent researches in social neurosciences suggest, the dramatic increase of eating disorders in early adolescence, observed during the Covid-19 pandemic, may also be related to the incomplete development and integration of specific upper brain regions (hippocampus and prefrontal cortex), which modulate and differentiate the midbrain neural responses to hunger and to acute social isolation, the last one being the major characteristic of our life in the time of Covid-19 uncertainty.

References

Canadian Consensus Panel – Couturier et al. (2020): The COVID-19 Pandemic and Eating Disorders in Children, Adolescents, and Emerging Adults: Recommendations from the Canadian Consensus Panel pp 1-7

Cooper M., Reilly E.E., Siegel J.A., Coniglio K., Sadeh-Sharvit S., Pisetsky E.M. & Anderson L.M. (2020): Eating disorders during the COVID-19 pandemic and quarantine: an overview of risks and recommendations for treatment and early intervention, Eating Disorders, DOI: 10.1080/10640266.2020.1790271

Cotugno A. (2021): Disturbi dell’Alimentazione in adolescenza: caratteristiche cliniche e trattamento psicoterapeutico. In Bertaccini R. & Lambruschi F. (eds) Disturbi psicologici in adolescenza dell’adolescenza (in course of publication) Carocci Editore, Roma

Cotugno A. & Sapuppo W. (2019): Il trattamento cognitivo- comportamentale: dalle caratteristiche cliniche all’intervento multiprofessionale integrato. In Spitoni G. & Aragona M. (eds) Manuale dei Disturbi Alimentari, Carocci Editore, Roma

Courtney D., Chong Ng K., Yin Oh J., Amerie Baeg A., Rajasegaran K., and Chew C.S.E. (2020): Caring for Children and Adolescents With Eating Disorders in the Current Coronavirus 19 Pandemic: A Singapore Perspective. Journal of Adolescent Health 67 (2020) 131-134, https://doi.org/10.1016/j.jadohealth.2020.03.037

D’Ambrosio A. (2021): Eating Disorders: Another Consequence of COVID-19, MedPageToday, March 5

Fernández-Aranda F., Casas M., Claes L., Clark Bryan D., Favaro A., Granero R., Gudiol C., Jiménez-Murcia S., Karwautz A., Le Grange D., Menchón J.M., Tchanturia K., Treasure J. (2020): COVID-19 and implications for eating disorders Eur Eat Disorders Rev. 2020;28:239–245. DOI: 10.1002/erv.2738

Guessoum S.B., Lachal J., Radjack R., Carretier E., Minassian S., Benoit L., Moro M.R. (2020): Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown, Psychiatry Research 291, https://doi.org/10.1016/j.psychres.2020.113264

Murty, Vishnu, Calabro, Finnegan, Luna, Beatriz (2016): The role of experience in adolescent cognitive development: Integration of executive, memory, and mesolimbic systems. Neuroscience and Biobehavioral Reviews http://dx.doi.org/10.1016/j.neubiorev.2016.07.034

Preti A., Rocchi M.B.I., Sisti D., Camboni M.V., Miotto P. (2010): A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatrica ScandinavicaVolume 124, Issue 1 p. 6-17 https://doi.org/10.1111/j.1600-0447.2010.01641.x

Rodgers R., Lombardo C., Cerolini S., Franko D.L., Linardon J., Omori M., Fuller-Tyszkiewicz M., Courtet P., Guillaume P.(2020): The impact of the COVID-19 pandemic on eating disorder risk and symptoms Int J Eat Disord. 2020;1–5; DOI: 10.1002/eat.23318

Tomova L. , Wang K. , Thompson T. , Matthews G. , Takahashi, A. , Tye, K. , Saxe, R. (2020) The need to connect: Acute social isolation causes neural craving responses similar to hunger. bioRxiv preprint doi: https://doi.org/10.1101/2020.03.25.006643, available under aCC-BY-NC-ND 4.0 International license.

Tomova L., Tye K. & Saxe R. (2019): The Neuroscience of Unmet Social Needs. Social Neuroscience, DOI: 10.1080/17470919.2019.1694580