Demographic and clinical characteristics of adolescent patients with eating disorders before and during the Covid-19 pandemic

Background

With the onset of the Covid-19 Pandemic, the frequency of eating disorders (EDs) rose dramatically, with increased referral rates to both outpatient and inpatient centers for eating disorders, particularly in youth [1], [2], [3]. Several studies have attempted to explain the increases. Some suggest that the pandemic may have instigated an increased focus on body image and exercise and “getting fit.” Others note that food scarcity and fewer grocery store visits could have resulted in restrictive behaviors for some and binge-eating behaviors for others [3]. Additionally, the pandemic resulted in much more sedentary time at home which brought about weight gain in many patients, ultimately motivating patients to utilize restriction and other ED behaviors to try to lose weight, which in some adolescents triggered an eating disorder. It has now been several years since the initial onset of the pandemic and the rapid increase in EDs has slowed. However, there continues to be an overall increase from baseline, with some sites reporting close to double the number of new eating disorder presentations among adolescents [3], [4], [5].

For outpatient ED treatment, one of the main settings used are Divisions of Adolescent Medicine in academic medical centers. Patients seen in these settings generally present for an initial ED evaluation and are then followed regularly by an adolescent medicine physician, in conjunction with a registered dietitian and often a psychotherapist and/or psychiatrist. These sites have been the focus of various studies over the years. In 2011–2014, a consortium of 11 Divisions of Adolescent Medicine, including our Division (and led by the Division of Adolescent/Young Adult Medicine at Boston Children’s Hospital), studied weight outcomes for patients at one year from their initial visit [6], [7], [8]. In response to these studies, our Division conducted a study of the adolescent patients presenting to our outpatient office from May 1, 2014-April 30, 2015 and followed them for three years from their initial visit. That study looked at demographic and clinical variables upon presentation, throughout treatment and at their final visit, offering a longer view of the course and outcome of eating disorder care of all adolescent patients regardless of their treatment duration. The study found that even for those who fell out of care earlier than recommended, there were statistically significant decreases in ED behavior at the final visit [8]. In addition, the study provided many details about the characteristics of patients with EDs presenting to our Division prior to the pandemic.

Although several studies have reported the increased presentations of EDs during the pandemic, little is known about the characteristics of eating disorders during this time. This current study evaluates the demographic and clinical characteristics upon presentation and at the final visit in adolescent ED patients seen by our Division during the pandemic. Using the data obtained from the first study, the current study compares the adolescent ED patients seen during the pandemic to those patients seen prior to the pandemic.

Materials and methods

Results

Discussion

At the start of the pandemic, most healthcare settings experienced a major increase in patients with eating disorders in both inpatient and outpatient settings [1], [2], [3]. As such, our study finds that the monthly rate of new eating disorders in an outpatient setting nearly doubled during the pandemic (40.6 patients/month compared to 23.8 patients/month). The rise in EDs has been a topic of conversation for many clinicians. This study is the first study that we know of to directly compare the characteristics and outcomes of patients with eating disorders before the pandemic, compared to during the pandemic.

The main finding of our study confirms a null hypothesis: For most variables, there were no significant differences between eating disorders before and during the pandemic. However, a few differences were found in race, DSM-5 diagnosis, weight status in AN patients (those in CG being more likely to have a lower %IBW), comorbid anxiety in AAN and follow up recommendations at the initial and final visits.

One of our most interesting findings is the difference in DSM-5 diagnoses given to patients upon presentation. As shown in Table 1, the frequency of AN slightly increased and the frequencies of AAN and ARFID greatly increased. Thus, the overall increases in rates of EDs during the pandemic came mainly from AAN and ARFID. AAN is a diagnosis given to a patient who has lost weight due to restrictive eating and inappropriate energy intake, as in AN; however patients with AAN have a weight and BMI that is not underweight (the DSM does not give discrete numbers, but we used over 85 % IBW and/or BMI over the 10th percentile). Thus, patients with AAN are likely to have had a higher starting weight prior to their illness. Therefore, the rise in AAN may reflect the fact that there has been a general increase in the average weight of the adolescent population in the years leading up to the pandemic and during the pandemic [9], [10], [11]. In other words, since there are more patients at higher starting weights, when they lose a distinct amount of weight through behaviors associated with AN or AAN, they end up still at a weight that puts them in the category of normal or overweight, which gives them an AAN diagnosis. Thus, this speculation does not propose that the CG AAN patients were “more” overweight prior to illness than the EG AAN patients. On the contrary, the CG AAN patients showed a slightly lower maximum weight than the EG AAN patients. Rather, the speculation proposes that there were more patients who had an overweight BMI prior to illness than the EG patients. This could be studied further and may shed light on the concurrent rise in patients with AAN and with overweight/obesity. Alternatively, these results may be somewhat skewed by the fact that we did not study patients who presented through the Emergency Department. Patients who are severely underweight (and carry a diagnosis of AN) may “appear sicker” and thus present more readily to the Emergency Department and undergo hospitalization and would have been excluded from this study. With this in mind, it is possible that there were several new cases of AN that were excluded from the study. A further study on eating disorder presentations in the Emergency Room setting could clarify the changes in DSM-5 diagnoses.

ARFID, which is an eating disorder of food restriction not related to body image or a desire to lose weight, also greatly increased in frequency in the Covid Group. We suspect that this is likely due to greater ARFID awareness among the pediatrics community, prompting pediatricians to refer for what was formerly called “picky eating.” ARFID itself was only introduced into the DSM in 2013 [12]. It is therefore not surprising that there were far fewer referrals to Eating Disorder Centers for ARFID in the 2014–2015 group. As the condition has become more widely known as an eating disorder, patients are more readily referred to be treated formally for the disorder. Interestingly, ARFID was the one group that showed a difference in age, and thus in height – CG ARFID patients were on average older. This is a particularly impressive finding, because in our Division, as ARFID awareness has increased, we have noticed younger patients being referred to our practice and have made a pointed effort to take younger patients with ARFID.

To understand the changes in race, we must address the limitations in the answer choices. Patients in EG had been documented as either White, Black/African American, Asian, Other or Unknown if they had not answered the questionnaire. At the time of that data collection, there was no option to collect information on ethnicity (White/Non-Hispanic or Hispanic). For the Covid Group, we repeated the same options for race but also recorded ethnicity. For all patients, “unknown” was selected when patients did not select a race on the questionnaire; those patients are excluded from our reported data here. Several patients identified as “Other” race in both the 2014–2015 group and in the Covid group. We see that 41 % of those who identified as “other” race also identified as Hispanic or Latino under ethnicity. For the remaining 59 % of those who identified as “other” race, some identified as Alaskan/Pacific American, and others did not enter in another race. Keeping the above in mind, the race findings show that significantly fewer patients in the Covid group identified as White, and many more identified as Other. The changes in race, which overall suggest that eating disorders are affecting a more diverse population, reflect greater societal demographic changes. The New York City Metropolitan area has a wide ethnic and racial diversity so it is not surprising that the changes in race in patients with EDs reflect this [13], 14]. It is worth noting that this study looked only at race and ethnicity, and not socioeconomic status (SES). This would be relevant to look at as well in the discussion of race and ethnicity, and further studies may address this topic in greater detail. Above all, this information should be used to emphasize the important point that eating disorders affect adolescents of all backgrounds. To date, several studies have documented the increase in eating disorders in minority populations, those of lower SES and gender diverse youth [15], [16], [17].

Another marker of the pandemic has been the grave increase in overall mental health disturbance in adolescents. Many studies have documented rises in depression, anxiety and other psychiatric disturbances among adolescents starting during the onset of the pandemic [18], 19]. Several organizations, including the American Academy for Pediatrics, began declaring the rise in mental health disturbance in children and adolescents a national emergency or crisis [20]. So too, we found a significantly higher incidence of comorbid anxiety and/or psychiatric care in the Covid Group, particularly those with AAN and ARFID. This likely represents an overall greater incidence in anxiety as was seen generally throughout the pandemic. However, the CG patients did not have any higher incidences of depression or self-injurious behavior (SIB), and patients with AN did not have a higher rate of comorbid anxiety. One reason for this could be that the eating disorder acted as the “coping mechanisms” for the patients’ anxiety and thus patients were not more likely to engage in SIB. This could also explain why AN patients had the same rate of anxiety, but had significantly lower BMIs. In other words, the anorexia brought them to a more severe weight status and seemingly “offset” the comorbid psychiatric illnesses. Interestingly, the rates of anxiety in ARFID CG patients was less than that of ARFID EG patients. ARFID is known to have a strong comorbidity with anxiety disorders and less of an overlap with depression disorders, we would have expected anxiety rates in these patients to either stay the same or increase [12], 21]. Perhaps when the ARFID diagnosis originally was established around the time of the EG patients, it was more commonly noted as problematic and requiring treatment in those with co-morbid anxiety. However, as “ARFID awareness” increased, it became clear that patients without anxiety could still be suffering from ARFID and would benefit from treatment. Of course, it should be noted that the finding most consistent with the rising mental health issues among adolescents is the actual increase in the frequency of eating disorders that our study found, as eating disorders are a mental illness in and of themselves.

Finally, our study shows significant differences in the physician recommendation for follow up both at the initial visit and final visit. In the original study on the 2014–2015 group by Dave et al., this measure was used as a marker of eating disorder severity. In our practice, physicians generally prefer to see patients who are “more sick” – with eating disorder thinking/behaviors – more frequently. However, in the Covid group, both at the initial visit and at the final visit, patients were generally more likely to have follow-up visits spaced farther out. In this case, the most likely reason is due to the overwhelmingly higher amount of eating disorders thereby decreasing each physician’s availability to see patients as frequently as in 2014–2015. Notably, the recommendation for higher level of care was marginally increased in the Covid group at both initial and final visits, supporting the idea that the further spaced visits did not correlate with lower disease severity.

Although this study only looks at those patients presenting at the start of the pandemic (September 2020–May 2021) and for the following two years, the rates of eating disorders have in fact remained relatively elevated even now several years after the start of the pandemic. This has been documented in other studies and also at our office, where we have found that the rates of eating disorder presentations has started to decrease, but has not yet returned to what it was prior to the pandemic [2], 3]. Thus, we believe that these trends in eating disorders continue to be relevant in the current adolescent eating disorder population.

Conclusions

The pandemic was associated with significantly more eating disorder patients. Some differences can be interpreted as pandemic related – a stress on adolescent mental health increased ED prevalence, which necessitated that follow up visits be spaced farther apart given limitations in physicians’ abilities to see an increased patient volume. Other differences pertain to overall societal changes – a wider racial distribution may represent the growing diversity of the New York City metropolitan area and the increased proportion of AAN may represent the increase in patients who are at a higher premorbid weight. Still, for most characteristics, there was no difference. Thus, despite the increase in patients with eating disorders, most of the clinical nature of the disease remained the same. As the frequency of eating disorders remains elevated, this study can help guide us in examining the overall changing trends – and those trends that stayed the same – of eating disorders. Further areas of study should include patients who initially presented to the emergency department and were hospitalized upon presentation.