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Medical admissions for adolescents with restrictive eating disorders more than doubled at one hospital during the first 12 months of the COVID-19 pandemic, relative to the average number of admissions in prior years, a new study shows.
Doctors are seeing similar increases across the United States and in other countries.
Providers and health care systems “may need to rapidly adapt in response to increasing demands for care during the COVID-19 pandemic,” the researchers said in their study, which was published online in Pediatrics.
To assess whether admission patterns among adolescents with restrictive eating disorders changed during the pandemic, Alana K. Otto, MD, MPH, with the division of adolescent medicine at the University of Michigan, Ann Arbor, and colleagues reviewed the charts of patients admitted to C.S. Mott Children’s Hospital, also in Ann Arbor.
Their analysis included 297 admissions among 248 patients aged 10-23 years between March 1, 2017, and March 31, 2021. Patients had an average age of about 15 years. Approximately 90% were female, and most had a diagnosis of anorexia nervosa or atypical anorexia nervosa.
Indications for medical admission included physiological instability (for example, heart rate less than 50 beats per minute while awake or blood pressure less than 90/40 mm Hg), electrolyte derangements, and acute medical complications of malnutrition such as syncope. Other possible indications included uncontrolled purging, body mass index less than 75% of the median for age and sex, acute food refusal, and failure of outpatient treatment.
Eating disorder–related admissions per month were stable prior to the pandemic. Admissions then decreased in April 2020, but subsequently increased significantly throughout the study period. In all, there were 125 admissions between April 1, 2020, and March 31, 2021. During the previous 3 years, the average number of admissions per year was 56.
Patients’ insurance status was one factor that differed before and during the pandemic. Prepandemic, about 20% of admissions were for adolescents with public insurance. During the pandemic, however, the proportion with public insurance was approximately 9%, the researchers noted. Other characteristics were generally similar.
The study was retrospective and relatively small and only looked at patients with restrictive eating disorders who were severely ill and admitted for medical stabilization. It does not reflect adolescents with eating disorders in different settings, the authors noted.
Primary care pediatricians should be familiar with indications for medical admission, such as severe bradycardia, as outlined by the Society for Adolescent Health and Medicine, they said.
Unfortunately, the trend seems consistent across the nation, said Michaela M. Voss, MD, director of the the Eating Disorders Center at Children’s Mercy in Kansas City, Mo. “Our outpatient setting went from availability to get in immediately to a 6-month wait list.”
As in Michigan, Voss noted a drop in admissions as lockdowns started, followed by a spike in treatment demand that has not let up.
Voss described two of the more common presentations. In one, parents might note that their child had been getting into healthy eating and exercise before the pandemic and seemed fine. “But then COVID came, the lockdown happened, and they became overly obsessed with those things,” Voss said.
In the other presentation, kids with anxiety, depression, or OCD who lost access to their usual coping strategies and outlets developed eating disorders during the pandemic. “They focused on one of the few things they could during the lockdown, which was their own body, and then their anxiety, depression, [obsessive-compulsive disorder], and other mental health comorbidities presented as an eating disorder,” Voss said.
The increasing need for treatment over the course of the pandemic may reflect the time that it has taken for the disorders to develop, as well as the time that it takes parents to recognize the problem.
Not only are doctors seeing more cases, but patients are arriving sicker than usual, Voss said.
Major medical concerns for patients in starvation mode center on the heart, brain, and bones. In addition, refeeding syndrome poses an extreme risk, Voss noted.
The Academy for Eating Disorders has created a guide to help doctors recognize and manage risks for patients with eating disorders, which may be useful for primary care providers while they are trying to get a patient into more intensive treatment, Voss suggested. The American Academy of Pediatrics recently published a clinical report on the identification and management of eating disorders in children and adolescents.
At Johns Hopkins Hospital Children’s Center in Baltimore, “we have seen a pretty remarkable increase in the number of eating disorders in the child and adolescent space since COVID,” said Jennifer Leah Goetz, MD, a psychiatrist and medical director of the child and adolescent inpatient unit. “We have seen increasing numbers of kids presenting for acute medical stabilization and refeeding and for specific treatment for the eating disorder.”
It could be that, for people with a genetic predisposition to eating disorders, a confluence of factors related to the pandemic unmasked it. For example, children may have spent more time looking at themselves on virtual meeting platforms, which could stir lingering body image and appearance-related concerns in those who are vulnerable. And some teens who were not able to participate in athletics as usual started to watch what they eat more closely, Goetz said.
A Treatment Bottleneck
Patients with eating disorders “can be quite ill from a psychiatric and general medical perspective,” Goetz said. “Most psychiatrists are not particularly comfortable with the medical complications, and most internists or pediatricians are not particularly comfortable with the psychiatric complications. You end up with a patient population that can only see a really highly specialized group of individuals for care. And it is a problem. It was a problem before the pandemic, and it has been really exacerbated by what we have been going through with COVID.”
Natalie Muth, MD, MPH, RDN, a pediatrician at Children’s Primary Care Medical Group La Costa in Carlsbad, Calif., has also noticed the increase in eating disorders since COVID.
In-patient colleagues “have longer wait lists and more severe cases than they have ever seen previously,” said Muth, who chairs the American Academy of Pediatrics Section on Obesity and is an adjunct assistant professor at the University of California, Los Angeles. “In primary care, we are all having to better educate and prepare ourselves for identifying and managing patients with eating disorders.”
That could mean connecting with mental health professionals, registered dietitians, and higher levels of care. But that may be a challenge. “Accessing these resources has been more difficult due to the increasing incidence of eating disorders recently,” Muth said.
Voss acknowledged that childhood obesity is another concern for pediatricians. “However, there are appropriate and healthy and safe ways to address that,” she said. A patient with overweight or obesity who loses weight may not be doing so in a healthy way.
Clinicians should wonder if a patient’s weight is decreasing too fast. And they should ask patients questions that could help identify a problem, such as: What are they doing to cause the weight loss? Why do they want to lose the weight?
Voss added that eating disorders “do not discriminate.” While there may be a perception that all patients with eating disorders are White, upper middle–class females who are thin, “that is not the case,” Voss said. They “come in all genders, all races, all weight classes, and all ages,” she said, “and we see that variety.”
In general, there may be a need to shift how weight is discussed in clinics and society more broadly, Goetz said. Weight is an incredibly personal thing, and everyone’s genetics, metabolism, and life circumstances vary. At the same time, body mass index is not necessarily the best measure of a person’s health.
Asking a child, teen, or even an adult to go on a diet is not a benign intervention, Goetz noted. In addition, dieting is unlikely to help in the long term.
Emerging from lockdown, pressure to lose “COVID pounds” is a dangerous message for people with eating disorders, Goetz said. It also could be a dangerous message for people without eating disorders. “There are so many more interesting things about each one of us than our weight,” she added.
The study authors, Voss, Goetz, and Muth had no relevant disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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