It is an honour to contribute to The Bridge with an update on eating disorders research. As everyone’s thoughts are dominated by the impact of COVID-19 on mental health and wellbeing, it seems pertinent to start by thinking how people with or at risk of eating disorders may have been affected. Research suggests that the impacts differ according to the type of eating disorder concerns and behaviours. For example, people with anorexia nervosa report increased dietary restriction and fears about not being able to find their preferred foods, while those with bulimia nervosa and binge‐eating disorder report increases in binge‐eating episodes and urges to binge. On the whole, patients are more concerned about the impact of COVID‐19 on their mental health than physical health. Ability to access and engage with treatment has additionally been of concern to many. Encouragingly, there have also been positive effects in terms of greater connection with family, more time for self‐care, and greater motivation to recover (1, 2). Fernando Fernandez-Aranda and colleagues have nicely summarized these and other potential effects of COVID-19 on this patient population in their European Eating Disorders Review editorial (3).
It is not only those with eating disorders who have found their eating has changed during this time. We know that eating is one of the behaviours that can change in all of us under stress, with roughly a third of us eating more and a third eating less. A number of factors may have come into play, including increases in stress and anxiety as a direct result of the virus and its effects, and the impact of social isolation and loneliness. Also, factors important in the early days of lockdown included the lack of food availability and, at the other end of the spectrum, overbuying of some food items such that the shelves dedicated to biscuits and crisps seemed to be the most empty, along with flour and eggs as everyone was baking. Whilst preparing nice meals and gaining new cooking skills is an enjoyable, family friendly hobby to while away the time and provide some pleasure and comfort, for some people it may have been associated with negative feelings, such as loneliness, anxiety or boredom, and that can lead to emotional over or undereating. In order to better understand the impact of COVID-19 on young people’s eating behaviour we developed and have ethics approval to undertake a UK survey for parents of school age children (age 4-17 years), and if their children are age 11-17 by self-report too. We aim to understand how COVID-19 has influenced young people’s eating behavior, and whether it has caused anxiety or distress about eating, weight, or shape, particularly in those with a history of eating disorders. We also hope to compare our findings with a sample from Spain where lockdown was more extreme and people were not able to leave the house for many weeks. Please follow us on twitter (@Imperial_CAMH) to take part, promote, and find out about the results of our study.
With prevention and school-based interventions high on the policy agenda at the moment, it seems timely to review implementation and effectiveness of eating disorders prevention. Schools have mandated duties around child measurement, and also around delivery of an emotional wellbeing curriculum as of September 2020. A challenge we face, however, is that there is not always synergy between the prevention agenda for obesity and that for eating disorders and other mental health problems. At times it could even be considered they are working against each other. For example, promoting positive body image is a primary objective of eating disorders prevention, and this can be perceived as at odds with efforts to identify (and label) people as overweight or obese. Eating disorders clinics are seeing more and more young people who have started their eating disorders journey as a result of being weighed in school and told they are overweight or obese, or being exposed to nutritional information that has been taken somewhat literally. For some time, eating disorders professionals have called for a joint approach to obesity and eating disorders prevention (4). We are a bit behind in the UK in this endeavour, and it is surprisingly hard, given the prevalence of both obesity and eating disorders, to get the issue taken seriously in terms of research. In the meantime, I have worked together with BEAT to develop a statement about the impact of anti-obesity strategies on the eating disorders population (5), and with Professor Philippa Diedrichs on an edition of Nine Truths about Eating Disorders specifically about weight and weight stigma for the Academy of Eating Disorders (6).
We anticipate a new wave of anti-obesity drives as a result of the association between COVID-19 and metabolic risk. One of the imperatives is to increase dialogue between the obesity and the eating disorders field, and I am delighted we seem to have found some common ground around the issue of weight stigma (7). Weight stigma is common across the population, including among children and health professionals. Stigma is thought to underlie weight related teasing, often a factor in eating disorder onset, and is one facet of the thin ideal thought to contribute to both the onset and maintenance of eating disorders by promoting primacy of weight and shape in self-evaluation. As training across professions about eating disorders is set to improve as a result of the recommendations of the Parliamentary Health Services Ombudsman’s report ‘Ignoring the Alarms; How NHS eating disorder services are failing patients’ (8), it is a priority that health professionals are trained how to talk routinely about weight and eating with young people in an informed and sensitive way. At the moment, eating difficulties tend to remain hidden because of feelings of shame and concerns about stigma.
Of course, not everyone will respond negatively to well-intentioned public health recommendations; for some they may be highly motivational. Nonetheless, it is important that people with eating disorders are not collateral damage in the rising tide of weight concern. Like others, we are investigating some of the factors that might put an individual at increased risk, as we move increasingly towards more personalised approaches to recognition and intervention. We are currently developing studies looking at how specific genetic and environmental risk factors might pinpoint vulnerability and identify therapeutic targets. As the knowledge base around neurodevelopmental risk factors for eating disorders grows, we are also interested in identifying how and when social communication difficulties in the context of eating disorders become clinically significant and the degree to which they might be modifiable if identified early enough.
Early identification is a cornerstone of successful early intervention. A particular challenge for the eating disorders field is that we are all exposed to the same environmental cues, and eating behaviour is so variable within and between individuals, and over the course of a lifetime, that it can be difficult to identify with sufficient specificity who will and will not go on to develop significant eating pathology. We have been trying to identify early signs that will tell us how to recognise eating disorders early by looking at the first things parents noticed in a cohort of young people presenting with eating disorders, and also at the sorts of trigger events families report that they associate with onset of the eating disorder, expecting these will be multiple and varied. We are also interested in which patients respond quickly to a brief early intervention approach (a six session parents’ group) and who needs more intensive treatment.
Last but not least, we are trying to understand the incidence of young people who present with Avoidant Restrictive Food Intake Disorder (ARFID) to secondary care, using surveillance methodology where paediatricians and child psychiatrists report all the cases they see over the course of a year. ARFID is an umbrella term for presentations where food is restricted in terms of amount and/or range for reasons that are not associated with weight and shape concerns. For example, fear of choking may lead to avoidance of solid food, or range of food may be restricted because of sensory aspects of food such as smell or texture. We hope that the results will also shed more light on the full range of presentations and clinical characteristics for this patient population, so that services can be planned accordingly. At the moment patients with ARFID are falling through the net in some areas.
This is just a snapshot of what is happening in the eating disorders space with children and young people. If you work in the NHS or academia and want to know more, consider joining the British Eating Disorders Society (breds.org.uk) where the conversation continues.
1. Termorshuizen JD, Watson HJ, Thornton LM, Borg S, Flatt RE, MacDermod CM, et al. Early impact of COVID-19 on individuals with self-reported eating disorders: A survey of ~1,000 individuals in the United States and the Netherlands. Int J Eat Disord. 2020.
2. Clark Bryan D, Macdonald P, Ambwani S, Cardi V, Rowlands K, Willmott D, et al. Exploring the ways in which COVID-19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers. Eur Eat Disord Rev. 2020.
3. Fernandez-Aranda F, Casas M, Claes L, Bryan DC, Favaro A, Granero R, et al. COVID-19 and implications for eating disorders. Eur Eat Disord Rev. 2020;28(3):239-45.
4. Irving LM, Neumark-Sztainer D. Integrating the prevention of eating disorders and obesity: feasible or futile? PrevMed. 2002;34(3):299-309.
5. Changes needed to government anti-obesity strategies in order to reduce their risk of harm to people with eating disorders https://www.beateatingdisorders.org.uk/uploads/documents/2020/7/anti-obesity-report-final-2.pdf; 2020.
6. Nine More Truths about Eating Disorders: Weight and Weight Stigma. https://www.aedweb.org/resources/online-library/publications/nine-truths-weight; 2020.
7. Rubino F, Puhl RM, Cummings DE, Eckel RH, Ryan DH, Mechanick JI, et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020;26(4):485-97.
8. Ignoring the alarms: How NHS eating disorder services are failing patients Parliamentary and Health Service Ombudsman; 2017 https://www.ombudsman.org.uk/sites/default/files/page/ACCESSIBILE%20PDF%20-%20Anorexia%20Report.pdf.