Eating disorders amongst children and young people during the COVID-19 pandemic

In England, almost 10,000 children and young people started treatment for an eating disorder between April and December 2021 - this is an increase of almost two thirds since before the pandemic and a quarter compared to the same period in 2020. Rather worryingly, hospital admissions for children and young people with eating disorders have increased by 90% in the last five years, from 3,541 in 2015/16 to 6,713 in 2020/21. The DSM-5, the handbook used by healthcare professionals to diagnose mental health disorders, characterizes eating disorders as “a persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning”.

It is hard to know from these healthcare related figures whether the spike in children and young people accessing treatment reflects a change in treatment-seeking behaviours, an increase in available services, or worsening of symptoms and increased prevalence of eating disorders. It is well known that many individuals suffering from eating disorders do not seek treatment or deny their symptoms, and experts have recently warned that we may have greatly underestimated their prevalence in the population. Nationally representative studies can help researchers and policy-makers in detecting the prevalence of eating disorders in a population.

The Mental Health of Children and Young People (MHCYP) survey series provides England’s Official Statistics on trends in child mental health, including percentage of children and young people who screened positive for possible eating problems. This was measured by children, young people and parents of children completing the five screening questions from the Eating Disorders Development and Well-Being Assessment (DAWBA) module. ‘Screening positive’ was defined as scoring above the threshold (endorsing two or more items for children and endorsing one or more items for young people) on the following questions:

• Has X ever thought s/he was fat even when other people said s/he was very thin?
• Would X be ashamed if other people knew how much s/he eats?
• Has X ever made themselves vomit/throw up?
• Do worries about eating, such as what to eat, where to eat and how much to eat, really interfere with X’s life?
• If X eats too much, does s/he blame himself/herself a lot?

MHCYP 2022 found that the proportion of children aged 11 to 16 years with possible eating problems increased between 2017 (6.7%) and 2021 (13.0%), and then remained stable between 2021 and 2022 (12.9%). A similar trend was observed in young people aged 17 to 19 years; the prevalence of possible eating problems rose from 44.6% in 2017 to 58.2% in 2021 and remained stable between 2021 and 2022 (60.3%). Across all age groups, the rate of possible eating problems was higher in girls than in boys.

It is important to note these figures provide only an indication of the prevalence of children and young people with possible eating problems and not an estimate of the prevalence of eating disorders. Understanding how these reports of screening positive for possible eating problems predicts the prevalence of eating disorders is vital in mobilising policy-makers and commissioners in developing evidence-based approaches.

A follow-up study examined the diagnostic accuracy of the DAWBA screening questions to explore whether the increase in possible eating problems detected in MHCYP 2021 reflected an increased population prevalence of eating disorders. Tentative evidence of increased population prevalence of eating disorders was found, particularly among young men. Obtaining DAWBA data from both parents and children as well as applying a higher cut off point improves accuracy, but at the expense of more missed cases. The prevalence of eating disorders and their relationship to eating difficulties requires further investigation and an additional follow-up study is planned for 2023.

The large increase in problematic eating between 2017 and 2022 is nevertheless worrying. The prevalence and mortality rate of eating disorders is highest in high-income countries, but there is still a global trend towards increased eating disorder burden. Eating disorders carry an additional hidden burden as they are associated with considerable stigma and self-stigmatisation, often being seen as trivial and self-inflicted disorders. This vicious cycle of stigma needs to be broken to encourage help-seeking behaviours, as early identification and prompt treatment are crucial. It appears the COVID-19 pandemic has exacerbated the burden of eating disorders, whilst simultaneously revealing their severity, and an urgent need for increased awareness.