The COVID-19 pandemic has been associated with worsening mental health among teens, including increasing numbers of patients with eating disorders. In fact, research indicates that the number of teens with eating disorders at least doubled during the pandemic.
This is particularly concerning given that eating disorders are among the most deadly of all mental health diagnoses, and teens with eating disorders are at higher risk for suicide than the general population.
While experts don’t know exactly why eating disorders develop, studies show that body dissatisfaction and desire for weight loss are key contributors. This can make conversations around weight and healthy behaviors particularly tricky with teens and young adults.
As an adolescent medicine doctor specializing in eating disorders, I have seen firsthand the increases in patients with eating disorders as well as the detrimental effects of eating disorder stereotypes. I regularly work with families to help teens develop positive relationships with body image, eating and exercise.
Understanding the signs of a possible eating disorder is important, as studies suggest that timely diagnosis and treatment leads to better long-term outcomes and to better chances of full recovery.
Excessive dieting and withdrawal from friends are two signs of disordered eating.
Eating disorders defined
Eating disorders, which often start in adolescence, include anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding and eating disorders and avoidant restrictive food intake disorder. Each eating disorder has specific criteria that must be met in order to receive a diagnosis, which is made by a professional with eating disorder expertise.
Research suggests that up to 10% of people will develop an eating disorder in their lifetime. Medical complications from eating disorders, such as low heart rate and electrolyte abnormalities, can be dangerous and result in hospitalization, and malnutrition can affect growth and development. Many of the patients I see in clinic show signs of paused puberty and stalled growth, which can influence bone health, adult height and other aspects of health if not addressed quickly.
Teens are also at risk for disordered eating behaviors such as intentional vomiting, caloric restriction, binge eating, overexercise, the use of weight loss supplements and misuse of laxatives.
A recent study estimated that 1 in 5 teens may struggle with disordered eating behaviors. While these behaviors alone may not qualify as an eating disorder, they may predict the development of eating disorders later on.
Treatment methods for eating disorders are varied and depend on multiple factors, including a patient’s medical stability, family preference and needs, local resources and insurance coverage.
Treatment can include a team consisting of a medical provider, nutritionist and therapist, or might involve the use of a specialized eating disorder program. Referral to one of these treatment methods may come from a pediatrician or a specialized eating disorder provider.
Unpacking misconceptions and stereotypes
Traditional ideas and stereotypes about eating disorders have left many people with the impression that it is mainly thin, white, affluent females who develop eating disorders. However, research demonstrates that anyone can develop these conditions, regardless of age, race, body size, gender identity, sexual orientation or socioeconomic status.
Unfortunately, stereotypes and assumptions about eating disorders have contributed to health disparities in screening, diagnosis and treatment. Studies have documented negative eating disorder treatment experiences among transgender and gender-diverse individuals, Black and Indigenous people and those with larger body size. Some contributors to these negative experiences include lack of diversity and training among treatment providers, treatment plans without cultural or economic nutritional considerations and differential treatment when a patient is not visibly underweight, among others.
Contrary to popular assumptions, studies show teen boys are at risk for eating disorders as well. These often go undetected and can be disguised as a desire to become more muscular. However, eating disorders are just as dangerous for boys as they are for girls.
Parents and loved ones can play a role in helping to dispel these stereotypes by advocating for their child at the pediatrician’s office if concern arises and by recognizing red flags for eating disorders and disordered eating behaviors.
Warning signs
Given how common disordered eating and eating disorders are among teens, it is important to understand some possible signs of these worrisome behaviors and what to do about them.
Problematic behaviors can include eating alone or in secret and a hyperfocus on “healthy” foods and distress when those foods aren’t readily available. Other warning signs include significantly decreased portion sizes, skipped meals, fights at mealtime, using the bathroom immediately after eating and weight loss.
Because these behaviors often feel secretive and shameful, it may feel difficult to bring them up with teens. Taking a warm but direct approach when the teen is calm can be helpful, while letting them know you have noticed the behavior and are there to support them without judgment or blame. I always make sure to let my patients know that my job is to be on their team, rather than to just tell them what to do.
Teens may not immediately open up about their own concerns, but if behaviors like this are present, don’t hesitate to have them seen at their pediatrician’s office. Following up with patients who have shown signs of having an eating disorder and promptly referring them to a specialist who can further evaluate the patient are crucial for getting teens the help they may need. Resources for families can be helpful to navigate the fear and uncertainty that can come along with the diagnosis of an eating disorder.
Many misconceptions exist about eating disorders, including that they are about vanity or that people should just be able to stop.
Focus on health, not size
Research shows that poor body image and body dissatisfaction can put teens at risk for disordered eating behaviors and eating disorders.
Parents play an important role in the development of teens’ self-esteem, and research demonstrates that negative comments from parents about weight, body size and eating are associated with eating disorder-type thoughts in teens. Therefore, when talking to teens, it can be beneficial to take a weight-neutral approach, which focuses more on overall health rather than weight or size. I unfortunately have had many patients with eating disorders who were scolded or teased about their weight by family members; this can be really harmful in the long run.
One helpful strategy is to incorporate lots of variety into a teen’s diet. If doable, trying new foods as a family can encourage your teen to try something they haven’t before. Try to avoid terms such as “junk” or “guilt” when discussing foods. Teaching teens to appreciate lots of different kinds of foods in their diet allows them to develop a healthy, knowledgeable relationship with food. If you’re feeling stuck, you may want to ask your pediatrician about seeing a dietitian.
It’s important to remember that teens need a lot of nutrition to support growth and development, often more than adults do, and regular eating helps avoid extreme hunger that can lead to overeating. Letting teens listen to their bodies and learn their own hunger and fullness cues will help them eat in a healthy way and create healthy long-term habits.
In my experience, teens are more likely to exercise consistently when they find an activity that they enjoy. Exercise doesn’t need to mean lifting weights at the gym; teens can move their bodies by taking a walk in nature, moving to music in their rooms or playing a pickup game of basketball or soccer with a friend or sibling.
Focusing on the positive things exercise can do for the body such as improvements in mood and energy can help avoid making movement feel compulsive or forced. When teens are able to find movement that they enjoy, it can help them to appreciate their body for all it is able to do.
