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Eating disorders: what's behind the rise?

22 July 2021

Why have eating disorders among children and young people rocketed during the pandemic? Is there enough support and awareness generally? Journalist Anna Scott examines the issues and asks how you can help.

The number of children and young people diagnosed with eating disorders across the UK has risen sharply during the pandemic. A snapshot survey of paediatricians across England, Scotland and Wales suggests doctors saw a three- or fourfold increase in cases of children and young people with eating disorders at the end of 2020 (Royal College of Paediatrics and Child Health, 2020).

The rise is not a new phenomenon. ‘There had been a national rise in rates of eating disorders before the pandemic,’ says Dr Luci Etheridge, consultant paediatrician at South West London child and adolescent mental health services (CAMHS) community eating disorders service. ‘Between 2016 and 2020, rates of referrals for eating disorders doubled across England. Since March 2020, this has doubled again [Marsh, 2020].’

Increased awareness of the issues has contributed to the rise. ‘We were seeing more and more referrals because eating disorders were starting to go up the agenda and being spoken about more,’ says Gemma Oaten, patron and manager of SEED Eating Disorder Support Services. ‘Now the referrals are through the roof – and all kinds of disorders are rising across the board. We get referrals from people as young as six to people as old as 90.’


Eating disorders: the signs

  • Skipping meals/avoiding eating around others/disappearing to the bathroom after a meal
  • Restricting food intake
  • Over-exercising and compulsive behaviour
  • Misuse of laxatives/diuretics
  • Weight gain/loss/fluctuations
  • Difficulty concentrating
  • Tiredness/irritability
  • Obsessive and/or rigid behaviour
  • Self-harm
  • Low confidence/low self-esteem/perfectionism
  • Social withdrawal

Who is affected?

Eating disorders don’t discriminate. ‘There’s an unhelpful stereotype [that they] only affect young women, but that’s not the case,’ says Tom Quinn, director of external affairs at Beat, an eating disorder charity . ‘Anyone of any age, gender, race, sexuality or background can become unwell with an eating disorder. It’s estimated that anorexia nervosa makes up around 8% of cases, avoidant/restrictive food intake disorder (ARFID) 5%, binge eating disorder 22% and bulimia nervosa 19%. The remaining percentage is thought to be cases of other specified feeding or eating disorder (OSFED), where symptoms don’t precisely match a diagnosis [Beat, 2021a].’

Within the CAMHS eating disorder service, Luci has noticed that many of the young people ‘restricting’ food don’t have typical anorexia nervosa. ‘Many have other difficulties, such as depression and self-harm, and restricting eating is a means of suppressing feelings and regaining some control when the rest of life is so challenging. We are also seeing a number of young people, especially young women, who we think are likely to have autism spectrum disorder and are restricting eating as an “express of distress” that they can’t always show in other ways.’

Dr Amy Wicksteed, clinical psychologist and chair of the British Psychological Society’s Faculty of Eating Disorders, says that, of the 1.25 million people affected by an eating disorder in the UK, 25% are male (Beat, 2021b). ‘The typical age of onset [of eating disorders] is mid-adolescence,’ she says. However, ‘there has been a 33% increase in over-50s diagnosed with an eating disorder and a significant rise in hospital admissions for eating disorders in people from a black African background in 2019-2020, compared with 2017-18 [Thomas, 2020].’

Greater numbers of younger people are being treated for eating disorders too: 66 children aged 10 and 11 were admitted to hospital for treatment in England in 2016. By 2020, this figure had more than doubled to 132 (NHS Digital, 2021).
 

The impact of lockdown

The pandemic represents a ‘perfect storm of potential precipitating factors’ that cause a rise in eating disorders, Amy suggests. So, while eating disorders have complex causes, some of the aggravating factors, such as social media, have become more of an issue during a period where people are confined to interacting and engaging with people online and on social media – mediums, as Amy says, ‘which are recognised as having the potential to undermine self-esteem and increase preoccupation with external appearances’.

Government health messages highlighting the risks of obesity and the importance of exercise are also an issue. ‘[They are important messages] but often delivered without the necessary caveat that the guidance is not relevant for all,’ Amy says.

Gemma agrees: ‘Obesity is linked to binge eating,’ she says. ‘It’s not about people being lazy. [The policy of] calories on menus sends completely the wrong message. We have lost connection with ourselves, our minds and our bodies – everything is done through a screen.’

The lockdown has exacerbated many of these factors. Dr Bijal Chheda-Varma, a practitioner psychologist based in London, says parents may have become more aware of what their children were doing and their eating habits because everyone has been together at home during lockdown. ‘A breakdown in the system of socialising, which is crucial to all ages, but particularly young teens and young adults, has been a variable in triggering distress, boredom and obsession with body image,’ she says. ‘During the pandemic, people have been forced to “sit” with their own vulnerabilities and hence became more preoccupied with their issues. Food was also the only, or biggest, source of comfort and stability, offering a quick dopamine boost when all else was taken away.”

‘An early spot from a professional could make all the difference. School nursing staff are in a great position to spot the early signs of eating disorders’

Service provision

But in a cruel twist, the impact of the pandemic on non-Covid-19 health services across the UK has meant ‘people suffering from eating disorders have not accessed services as much as they would otherwise’, according to Evri Anagnostara, chair of Unite’s Mental Health Nurses Association. ‘It also meant that waiting lists for support in the community, such as psychological input, have grown even longer, meaning that some people will wait longer to access services.’

Health services have also had to adapt to online provision – conducting remote consultations, adapting support from group sessions to individual, reducing their contact with people. ‘I have no doubt that people have not accessed services in fear of contracting Covid-19, perhaps because they did not want to be a burden on the NHS, or because they didn’t know how to go about it,’ Evri adds. She expects a surge of people accessing eating disorders services, ‘and perhaps more complex presentations’, now that the services are reopening.

Substantial investment and funding are needed to ensure that skilled staff are available to help people across the UK. ‘[Services should] organise around the needs of children and families and recognise that many people have complex needs,’ Luci says. ‘I would like to see better integration of physical and mental healthcare to support this as well, so that we work as teams around children and young people, rather than asking young people to fit inside a diagnostic box.’
 

While service provision isn’t the same everywhere across the UK, the introduction of integrated care systems pathways in England means services will be more responsive to people regionally and closer to home for people. ‘Nevertheless, while there is much more to be done, namely investing heavily in psychology services for eating disorders and in relevant education of key stakeholders, such as school nurses, I am increasingly confident that support for young people is becoming increasingly more available,’ Evri adds.

However, even before the pandemic, government-commissioned reviews in Northern Ireland and Wales had found NHS eating disorder services lacking. The Northern Ireland report highlighted a need for more provision across the country (Department of Health, 2016). Services in Wales were found to be ‘significantly under-resourced’ and only the most severe cases are treated appropriately (Welsh Government, 2018). A report in Scotland published during the pandemic has also found that current service response is ‘geographically inequitable’, ‘underfunded’ and ‘focused on the severely ill and anorexia, to the detriment of other eating disorders’ (Scottish Government, 2021).
 


A mother’s story:  ‘I began to notice compulsive over-exercising’ 

There was a slow build-up to my daughter’s eating disorder that began with harmless things, like wanting to be as healthy as possible, being vegetarian and being active and sporty. During lockdown there was a lot in the media about keeping fit. She was working out every day with her dad at home, but she started using weights that I always thought were too heavy for her at 13.

She was always slim, so it was hard to see much difference until we saw her in a swimsuit on a half-term break in October 2020. I began to notice what seemed to be compulsive exercising – she offered to walk our neighbours’ dog every day. Using a tracking app, I saw that she was spending the time trying to run 5km round our local field. I started to insist she weigh herself. When she dipped into the ‘below healthy’ level on the NHS BMI scale, I looked for help.

I rang 111 and they arranged for a GP from our surgery to call me. The doctor ordered blood tests, and called me back a week later, saying there were markers consistent with over-exercising and referred us to CAMHS.

After an initial online consultation, for two months we visited the CAMHS clinic and saw nurses, who weighed her, took her blood pressure, took her blood sugars and gave her nutritious shakes if it was too low, which it often was. Because of her very low weight (33.9kg at its worst), my daughter was fast-tracked.

My daughter’s school had also noticed a change in her wellbeing and we were assigned a counsellor. Our counsellor put the onus much more on us as parents to take responsibility, which was tough to hear, but we needed that advice. It can sometimes seem an invasion of privacy to watch your young teenager 24/7.

I didn’t know anorexia could manifest itself as compulsive behaviour – instead of body dysmorphia – and perhaps it’s more likely to manifest itself this way in younger children trying to take control of something in a very restrictive environment. Sadly, my daughter had to relinquish control to us over virtually everything. I even had to sleep in her room for a while to stop any secret exercising.

My daughter’s initial clinic care could have been improved with some more in-depth knowledge about exercising and eating disorders, rather than just on the eating side. There is so much in the media about losing weight, being slimmer, being more active.

My daughter didn’t grow in height for a year and has still not developed at age 14, despite the fact that she is, thankfully, well on the road to recovery.


 

The role of CPs

With appropriate services, eating disorders are very treatable, and early detection hugely benefits recovery. ‘The earlier the recognition or diagnosis means the behaviours get less time to become more entrenched and complex,’ Bijal says. ‘When a young teen or adult receives treatment within the first six months of their symptoms emerging, the better the prognosis.’

One issue, however, is that the longest delay in getting help for an eating disorder is because people may not realise they are ill. ‘An early spot from a professional could make all the difference,’ Tom says. ‘School nursing staff are in a great position to spot the early signs of eating disorders.’

There are a range of symptoms that community practitioners (CPs) can look out for (see Eating disorders: the signs above, and, as Bijal points out: ‘None of these behaviours are a concern in isolation, or if they happen sometimes. A pattern emerging in these behaviours is to be noted.’ But CPs must also be prepared to have open conversations about eating disorders.

‘I believe education about eating disorders should be part of the PSHE [personal, social, health and economic] curriculum and school nurses can support this,’ says Luci. ‘They can also support families in being able to seek help, as many will be understandably confused by what they are noticing in their child. Many of our referrals start with the school nurse.’

If you suspect someone has an eating disorder your first step should be to ‘bring it up sensitively and simply state what you have noticed’, Luci says. ‘Don’t be surprised if there is denial at first. However, if you remain worried then it is okay to ask again and offer some more information.’

Health visitors can also play an important role in providing a practice approach to support the whole family. This could apply to parents or carers suffering from eating disorders. ‘It can be very challenging for someone who is distressed by food and eating to maintain a sense of normal eating for their children, so practical help with meal planning and support for under-fives is important,’ Luci adds. ‘Health visitors can help families to get the right support for younger children if they have an older child with an eating disorder.’

If a CP suspects a client or member of a client’s family has an eating disorder after an initial assessment, they should refer them to a community-based, age-appropriate eating disorder service for further assessment or treatment, according to NICE guidelines (see Resources below). Signposting to services and support and ongoing check-ins are also essential.

As Evri concludes: ‘Both school nurses and health visitors are privileged in their position to work so closely with young people. Often they will be the first and most trusted clinician to come into contact with this patient group. Having an enquiring mind and being open to engaging with young people is the first and most important step they can take.’


Resources:


References:

Beat Eating Disorders. (2021a) Statistics for journalists. See: beateatingdisorders.org.uk/media-centre/eating-disorder-statistics (accessed 18 June 2021).

Beat Eating Disorders. (2021b) How many people have an eating disorder in the UK? See: beateatingdisorders.org.uk/how-many-people-eating-disorder-uk (accessed 18 June 2021).

Beat Eating Disorders. (2021c) Types of eating disorders. See: beateatingdisorders.org.uk/types (accessed 18 June 2021).

Department of Health. (2016) Minister announces further work on eating disorder services. See: health-ni.gov.uk/news/minister-announces-further-work-eating-disorder-services (accessed 18 June 2021).

Marsh S. (2020) Sharp rise in number of children in England seeking help for eating disorders. The Guardian. See: theguardian.com/society/2020/dec/16/shape-rise-in-number-of-children-in-england-seeking-help-for-eating-disorders (accessed 18 June 2021).

NHS Digital. (2021) Monthly eating disorder admissions for 10 to 18 year olds. See: digital.nhs.uk/data-and-information/supplementary-information/2021/monthly-eating-disorder-admissions-for-10-18-year-olds-april-2016-to-january-2021 (accessed 18 June 2021).

Royal College of Paediatrics and Child Health. (2020) Paediatricians warn parents to be alert to signs of eating disorders over holidays. See: rcpch.ac.uk/news-events/news/paediatricians-warn-parents-be-alert-signs-eating-disorders-over-holidays (accessed 18 June 2021).

Scottish Government. (2021) Eating disorder services review: summary recommendations. See: gov.scot/publications/scottish-eating-disorder-services-review-summary-recommendations/pages/2/ (accessed 18 June 2021).

Thomas T. (2020) NHS hospital admissions for eating disorders rise among ethnic minorities. The Guardian. See: theguardian.com/society/2020/oct/18/nhs-hospital-admissions-eating-disorders-rise-among-ethnic-minorities (accessed 18 June 2021).

Welsh Government. (2018) Eating disorder service review 2018. See: gov.wales/sites/default/files/publications/2019-09/welsh-government-eating-disorder-service-review-november-2018.pdf (accessed 18 June 2021).

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