The number of teens in need of treatment for eating disorders has skyrocketed during the pandemic and the demand for care will likely remain high for several years.

“Eating disorders are the second most common chronic illness in adolescents after asthma. The number of children and teenagers treated for this condition increased during the pandemic and demand for care will likely remain high for several years,” says Dr. Holly Agostino, director of the Eating Disorders Program, at The Montreal Children’s Hospital. She answers questions on this important issue.

Question: We know there was a huge increase in the number of adolescents seeking help for an eating disorder during the pandemic. What is the situation like today?

Answer: COVID-19 has had a huge impact on the prevalance of eating disorders. Across Canada, we saw the number of children seeking care double and hospitalizations triple. Why this happened is probably related to many factors: school closures, isolation, loss of routine, social media, and the increase in anxious and depressive symptoms due to the pandemic.

Fortunately, kids are back to their normal routines. However, for all of those who developed an eating disorder in the last couple of years, their symptoms won’t just get better now that they are back in school. The number of young people seeking care remains high and above average, and it will likely take many years before we return to normal wait times for specialized services.

Q: How prevalent are eating disorders among girls and boys?

A: Eating disorders are the second most common chronic illness in adolescents after asthma. Around 4 percent of adolescents can be affected by an eating disorder if we apply strict diagnostic criteria. When we look at partial forms, this number can rise to 10-15 percent.

In the past, eating disorders, in particular anorexia nervosa, were thought of as primarily female diseases. Now we know this is not the case. Up to 15-20 percent of patients diagnosed with anorexia are male and this proportion is even higher depending on the type of eating disorder.

It is important to remember that society also encourages an unrealistic body ideal for males too. Instead of valuing thinness, often males aim to have more muscular, toned bodies. The motivation might be slightly different in teenage boys, but the medical and psychological outcomes are the same. It’s important not to dismiss disordered eating symptoms in boys based on gender biases.

Q: What is an eating disorder?

A: Not every teen who dislikes something about their body or has some unusual eating patterns has an eating disorder. Although many disordered eating patterns involve weight loss, an eating disorder is not based uniquely on the number on the scale – it really is about the “space” these behaviours take up in a teen’s day-to-day life.

Patients affected will spend most of their day worrying about their weight, the next meal, what will be served, and how they will feel afterward. A lot of them may turn to other methods of weight loss (inducing vomiting, exercising excessively) to cope with the guilt around eating. For many, their self-worth becomes wrapped up in their ability to control their food intake and weight. It starts to affect all aspects of their lives (family dynamics, friendships, school performance) and the teens become powerless over the rules of their eating disorder.

Q: What are the different types of eating disorders?

A: There are many different types of eating disorders. An easy way to think about them can be to divide them into restrictive vs. binging forms.

Restrictive eating disorders are when a teen does not eat enough to remain healthy. This classically is anorexia nervosa - where a patient restricts their diet due to a desire to change their body and are fearful of gaining weight. Atypical anorexia nervosa is the same disorder except the patient’s weight remains in the normal range for their age and height.

Even though these patients may not look like what people associate with anorexia, it should not be misinterpreted as any less severe. Patients with atypical anorexia nervosa are often not thought to have a problem and as a result, their diagnosis may be delayed. Yet, by the time they seek help, they tend to be in an equally bad or worse medical condition than those who are underweight.

Another restrictive eating disorder that can present in pediatrics is avoidant restrictive food intake disorder (ARFID). Here, a patient can be afraid to eat but the fear is not based on a desire to be thin. Often, these patients have had a traumatic experience with food (choking episode or an allergic reaction) and their fear about this happening again stops them from eating. Although the reason behind the restriction is different, they can present with rapid weight loss and poor physical health as well.

In binge-based disorders, patients, for the most part, will eat normally but will have episodes where they eat large amounts of food without control which often leads to a high level of guilt and shame. In bulimia nervosa, this guilt drives patients to do some form of compensatory behaviour known as a purge (self-inducing vomiting, excessively exercising, or restricting their food intake). Sometimes patients may binge and not purge afterward as we would see in binge eating disorders. Although these patients rarely lose large amounts of weight, they are still highly focused on food, meals, and body image which impacts their idea of self-worth.

Q: What are the signs my child might have an eating disorder?

A: Unexplained weight loss is an obvious way in which eating disorders may be present, but at times symptoms can be more subtle. A child may complain of fatigue, dizziness, or may faint. In girls, some may lose their periods. Malnutrition can also affect sleep and mood and can worsen previous anxiety or depressive symptoms. Concentration and school performance can also suffer.

Parents can watch out for the behavioural symptoms of an eating disorder as well. Rigidity around food choices (refusing the types of food they used to eat) or portion sizes, or the “need” to exercise (vs. exercising for pleasure) can all be early signs of an eating disorder.

Q: Why do children develop eating disorders?

A: Sometimes eating disorders develop after a stressful or traumatic life event but in many cases, there is no clear cause. In fact, family-based treatment, which is the gold standard treatment for restrictive adolescent eating disorders, makes a point of not searching for the origin of the eating disorder. Once the diagnosis is made, we focus on taking control away from the eating disorder, helping the teen regain healthy habits around food, and then only near the end of treatment examine if outstanding mental health issues remain.

Q: What can parents do?

A: A big part of the treatment for adolescent eating disorders is empowering parents to take back control around meals in their homes. When a teen is affected by an eating disorder, they are not in a place to make healthy choices for themselves. Their eating disorder is driving their decisions.

Parents should see the eating disorder as a separate entity from their child and not cater to its demands. With help, parents should feel comfortable setting limits around exercise, food choices, and portions. The eating disorder may cause the child to act out when parents set limits but without confrontation, it will never go away.

Parents should prepare the food and the portions they think the teen needs, not what they are saying they want and support them through the meal. Food is their medicine and eating should not be optional. Similarly, it is ok to set limits around exercise, social events, etc. until better habits around food are re-established.

Q: Where can parents get help for their child?

A: Since COVID-19, wait times in both the public and private sectors for specialized eating disorder services have dramatically increased. A good place to start if parents have concerns is with their family doctor who may have an established relationship and medical history with the child. After the assessment, the physician may choose to refer them to specialized services depending on the needs of the family.

There are also a lot of good resources online or in print around family-based treatment and how parents can adopt this behavioural approach at home. Some of these are accessible on the Eating Disorder Program page on The Montreal Children’s Hospital website.

Q: Can someone with an eating disorder be cured?

A: Absolutely. In fact, outcomes are much better in adolescents than in adults. The most important thing is to seek help early if you have concerns, as the earlier treatment is started the better. However, families need to remember that eating disorders are chronic illnesses. They are not something that improves after a few visits – it takes time and effort from both the child and their family to really overcome all aspects of the disorder. With the family and treating team working together, most adolescents can achieve full recovery from their physical and emotional symptoms.

Let's talk!

On January 25, Bell Let’s Talk Day, let’s spread the word and help children and teens struggling with their mental health. Now more than ever, every action counts.