Adolescents' Acute Care Use for Eating Disorders Has Risen

Fran Lowry

October 04, 2023

Emergency department (ED) visits and hospital admissions for eating disorders have increased significantly among adolescents during the COVID-19 pandemic, according to new research.

In a repeated cross-sectional study that examined population-based data from January 2017 through August 2022, ED visits increased by 121% above expected levels, and hospital admissions increased by 54% above expected among patients aged 10 to 17 years during the pandemic.

Dr Alene Toulany

"We are hoping this study continues to heighten awareness of the importance of eating disorders, and also to bolster support for eating disorder programs so that we can adequately care for patients and address the increasing demand for treatment and services," lead author Alene Toulany, MD, an adolescent medicine specialist and researcher at the Hospital for Sick Children in Toronto, told Medscape Medical News.

The study was published in the Canadian Medical Association Journal .

"A Pressing Concern"

The researchers used linked health administrative databases that included all patients in Ontario who were eligible for the Ontario Health Insurance Plan, which is publicly funded. They compared observed and expected rates of ED visits and hospitalizations for eating disorders between a prepandemic period (January 1, 2017, to February 29, 2020) and a pandemic period (March 1, 2020, to August 31, 2022). The researchers examined the following four age categories: adolescents (ages 10 to 17 years), young adults (ages 18 to 26 years), adults (ages 27 to 40 years), and older adults (ages 41 to 105 years).

Among adolescents, the observed rate of ED visits during the 30 pandemic months studied was 7.38 per 100,000 population, compared with 3.33 per 100,000 before the pandemic (incidence rate ratio [IRR], 2.21).

The rate of ED visits among young adults increased by 13% above the expected rate. It reached 2.79 per 100,000, compared with 2.46 per 100,000 in the prepandemic period (IRR, 1.13).

Among older adults, ED visits increased from 0.11 per 100,000 in the prepandemic period to 0.14 per 100,000 in the pandemic period (IRR, 1.15). The rate of ED visits among adults remained approximately the same.

The rate of hospital admissions among adolescents increased by 54% above the expected rate during the pandemic. The observed rate of hospital admissions before the pandemic was 5.74 per 100,000, vs 8.82 per 100,000 during the pandemic (IRR, 1.54). Hospital admissions remained stable or decreased for the other age groups.

"Eating disorders have increased globally in children and adolescents during COVID," said Toulany. "There are a number of risk factors contributing to this pandemic rise, including isolation, more time on social media, decreased access to care (as many in-person services were not available due to the pandemic), as well as fear of getting infected. All of these could contribute to an increased risk of developing an eating disorder or of making an existing one worse."

Regardless of the cause, more investment in eating disorders research and eating disorder programs for adolescents and adults is needed, she said.

"The pandemic served as a catalyst, because it started to shed light on the prevalence of eating disorders, especially in young people. But it's very important that we recognize that this has been a long-standing issue and a pressing concern that has been consistently overlooked and underfunded," said Toulany.

Surging Eating Disorders

Commenting on the findings for Medscape, Victor Fornari, MD, director of child and adolescent psychiatry at Zucker Hillside Hospital/Northwell Health in Glen Oaks, New York, said, "Our experience in the United States parallels what is described in this Canadian paper. This was a surge of eating disorders the likes of which I had not experienced in my career." Fornari did not participate in the current study.

Dr Victor Fornari

"I've been here for over 40 years, and the average number of our inpatients in our eating disorder program has been three to five and about a dozen patients in our day clinic at any one time. But in the spring of 2020, we surged to 20 inpatients and over 20 day patients," Fornari said.

"We can speculate as to the reasons for this," he continued. "Kids were isolated. School was closed. They spent more time on social media and the internet. Their sports activities were curtailed. There was anxiety because the guidance that we were all offered to prevent contagion was increasing people's anxiety about safety and danger. So, I think we saw dramatic rises in eating disorders in the same way we saw dramatic rises in anxiety and depression in adolescents, as well."

Fornari also cited social media as an important contributing factor to eating disorders, especially among vulnerable teenagers. "Many of these vulnerable kids are looking at pictures of people who are very thin and comparing themselves, feeling inadequate, feeling sad. Social media is one of the reasons why the rates of psychopathology amongst teens has skyrocketed in the last decade. The surgeon general recently said we should delay access to social media until age 16 because the younger kids are impressionable and vulnerable. I think there is wisdom there, but it is very hard to actually put into practice."

Worsening Mental Health

"I thought this was very relevant research and an important contribution to our understanding of eating disorders during pandemic times," said Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia. "It also dovetails with my own experience as a practitioner." Sherry was not involved in the research.

Dr Simon Sherry

The pandemic has been difficult for people with disordered eating for many reasons, Sherry said. "There was a massive disruption or 'loss of normal' around food. Restaurants closed, grocery shopping was disrupted, scarcity of food occurred, hoarding of food occurred. That meant that eating was difficult for all of us, but especially for individuals who were rigid and controlling around the consumption of food. In this COVID era, you would need flexibility and acceptance around eating, but if you had a narrow range of preferred foods and preferred shopping locations, no doubt the pandemic made this a lot worse."

Certain forms of disordered eating would be much more likely during the pandemic, Sherry noted. "For example, binge eating is often triggered by psychological, social, and environmental events," and those triggers were abundant at the beginning of the pandemic. Boredom, anxiety, depression, stress, loneliness, confinement, and isolation are among the triggers. "COVID-19-related stress was and is very fertile ground for the growth of emotional eating, binge eating, or turning to food to cope. Eating disorders tend to fester amid silence and isolation and inactivity, and that was very much our experience during the lockdown phase of the pandemic," he said.

Sherry agrees with the need for more funding for eating disorders research. "We know in Canada that eating disorders are a very important and deadly issue that is chronically underfunded. We are not funding disordered eating in proportion to its prevalence or in proportion to the amount of harm and destruction it creates for individuals, their family members, and our society at large. The authors are absolutely correct to advocate for care in proportion to the prevalence and the damage associated with eating disorders," he said.

The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health, the Ministry of Long-Term Care, and the Canadian Institutes of Health Research (CIHR). Toulany, Fornari, and Sherry reported no relevant financial relationships. One study author reported receiving personal fees from the BMJ Group's Archives of Diseases in Childhood and grants from CIHR, the Ontario Ministry of Health, the Centre for Addiction and Mental Health, and the Hospital for Sick Children. A second author reported funding from CIHR.

CMAJ. Published October 3, 2023. Full text

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