Eating disorders are rising rapidly as the pandemic puts the lie to kids’ ‘resilience’

Jordan There’s a whole lot we won’t know about the long-term impact of this pandemic until we see it happening. One thing we are beginning to realize is that the impact just isn’t visible, especially when we’re talking about children, especially when we’re talking about teenagers. Raise your hand if you’ve heard about how kids are resilient in response to the latest round of canceled activities, virtual school or celebrations held outside at a distance. Keep your hand up if you’ve even told yourself that, trying to justify the measures you need to take to keep your kids safe. As necessary as those precautions have been, and in many cases still are, there’s a cost. It starts with mental health, it doesn’t end there.

A perfect example of how this adds up over time can be found by looking at eating disorders. These numbers have increased at such a rapid pace over the past two years, the programs for them across the country are full, doctors are overrun, and teens are struggling. These disorders often hide in plain sight, only becoming evident when they start to impact a person’s physical health. The early warning signs for them though, the ones we try to catch, those tend to show up in changes to routines and to normal habits. And those things don’t really exist for kids and teenagers these days. So accepting that this pandemic is not ending tomorrow, what can we do to take care of teens and others? Because it’s not just teens who are struggling with eating disorders right now, or who are on their way to that place. And for all of us, how has this pandemic changed our relationship to food, to the daily routines that we used to count on to nourish us? And how will that make itself known down the line?

I’m Jordan Heath-Rawlings, this is The Big Story. Dr. Ayisha Kurji is a consultant paediatrician in Saskatoon and an assistant professor of paediatrics at the University of Saskatchewan. Hello, Dr. Kurji.

Dr. Kurji Hello.

Jordan Maybe we could start with something really basic here for people who don’t often have conversations around this topic. What exactly defines an eating disorder?

Dr. Kurji That’s a great question. And there’s specific definitions for each type of eating disorder, but when you’re thinking about eating disorders in general, probably a good way to think about them is any abnormal or disturbed eating behaviour that also affects either your health or your function. So it can affect your physical health or your mental health, but also how you can function in society and with others.

Jordan Again, another ignorant question, but one I need cleared up: how many eating disorders are there? I think the general public assumes when they hear that term anorexia and bulimia, are there others?

Dr. Kurji There are, and as we learn more, we’re probably coming up with more and more categories. Anorexia and Bulimia Nervosa are probably the ones that people know about the most. There’s also things like binge eating disorder where you may eat more than would be typical in a normal amount of time. Feeling a loss of sense of control over that kind of like you might in bulimia nervosa, but you don’t do anything to compensate for that, and you just have that bingeing piece and not that purging, or fasting, or exercise that sometimes goes with bulimia nervosa.

There’s also another one called ARFID or avoidant restrictive food intake disorder. And in that one, it’s something that causes you to eat less than you would normally eat but it’s not because you have issues with your body image. Maybe for example, you might have some anxiety around food because you’re a child who choked and now are really scared of choking again, so you would decrease what you’re eating. Or maybe you had the stomach flu and started to throw up, and so now you don’t want to eat because you’re worried that you might throw up. And in that case, you’re eating less, it’s causing you to not meet your body’s needs for food. But it’s not because you have concerns with your body image. So there’s lots of different kinds of eating disorders.

Jordan I think when a lot of people think about eating disorders, they think of them as a mental health issue, is that how they’re categorized?

Dr. Kurji It’s a really good question. And often they are, because if you think about where the diagnostic criteria and medicine comes from with them, they’re listed in our diagnostic and statistical manual from the psychiatry side of things. So often you’re right in that they are kind of classified in that mental health realm, but they actually can have huge devastating effects on your physical health as well. So they’re actually a disorder that encompasses both physical and mental health. Anorexia nervosa, for example, has the highest mortality of any of the psychiatric illnesses. And lots of that is because of the physical effects.

Jordan Forgive me for these basic questions, but I’m trying to situate the problem before we get into the urgency of it. So who do they typically impact? Again, I think the image is teenage girl, but I know that that’s not accurate.

Dr. Kurji So it is in the sense that most eating disorders do typically affect teenagers or young adults and typically females. But what we’re learning is that eating disorders in general can actually affect everyone across the age spectrum and both genders. Younger kids can have eating disorders. We’re seeing more in sort of that pre-teen age group. When you think of that one we just talked about, that ARFID, that one can affect younger kids as well.

And part of what we’re learning is some of our screening tools are really focused on how females might present with an eating disorder and not necessarily how males might present, and so maybe we’re missing a few. Typically, we kind of talk about 90% female, 10% male, but they’re also in general, a type of illness that are often under-diagnosed. And so we’re probably missing more than we know of.

Jordan In terms of how many we know of, your piece in The Conversation had an urgency to it. What kind of data are you looking at that’s prompting you to sound the alarm bell?

Dr. Kurji So this is part of one of my special hats that I wear in Saskatchewan, is I do the medical care for kids with eating disorders, along with a new paediatrician who’s just started. But what we noticed in the pandemic is that we were seeing more and more of these. And actually there was a study that just came out that looked across Canada in the pandemic. What we saw is new onset cases for anorexia nervosa increasing by about 60%, and hospitalizations for anorexia nervosa tripled, compared to what it was before the pandemic. And that’s why we have that urgency I think.

Jordan Does the research that you just cited, or even some of your own anecdotal encounters with people dealing with these issues, offer any clues as to what’s driving the increase specifically?

Dr. Kurji So I think part of it is, if you think back to, you know, the very beginning of the pandemic where everything just all of a sudden stopped, school stopped, sports stopped. You couldn’t see your friends anymore. All of a sudden the coping strategies that you might use to cope with anxiety or cope with whatever’s going on, they’re all gone. And you also think about kids who have routine to their day. You know, you wake up, you eat breakfast, you go to school. That’s also gone. So sometimes it becomes really easy to sleep in, skip breakfast. And then kind of set your day off with just eating a bit less. You don’t have the same supports and scales and things that you would normally go to to kind of help keep your mind off of things.

The other thing is you don’t have those things to do, so maybe more time on social media and media. And we know there’s a link between time that you spend on those things and eating disorders, for sure. Especially if you’re looking at that sort of, quote unquote, ideal body image of what we think a body should look like and spending more time searching that and reviewing that and kind of feeling like maybe I should look like that or try to look like that might be part of it too.

Jordan How does the, slide, I guess, for lack of a better term, towards an eating disorder progress? Because to me, you’re talking about hospital admissions for anorexia nervosa, sort of beginning with a shock to the routine and you sleep in and you miss breakfast. Like I’m trying to figure out how it gets from A to B.

Dr. Kurji Part of it, I think, is if we don’t recognize and don’t catch it, then it kind of continues to progress along the way. Part of it is also depending on where your body size and shape was at to start with, maybe if you were what our society thinks of as overweight and you start to lose weight, you might get positive reinforcement for that weight loss. Even if it wasn’t done in the healthiest way. And so then it fuels you to continue to go down that road.

And what we know is, as your body loses weight, and as your body doesn’t get enough nutrition, your mind is not getting enough nutrition either. And when your brain is malnourished, it really changes actually the way the brain functions. So what we might see as someone who is really thin, your brain is seeing someone who’s really big, and what we might see as a really normal sized portion of food, or a small sized portion of food, your brain might be seeing as a really big portion of food.

And so you start to really feel that cycle. Where now you have someone who thinks that they might be really big when they’re not, who thinks they’re eating too much food when they’re not, they continue to restrict, they continue to lose weight. Their brain continues to malfunction and it fuels that process. And then you end up with someone who’s got very rigid food rules and continues to lose weight and becomes medically very, very sick. And we know the faster you lose weight, the faster your body, the more your body can become more unstable with that, in terms of physical effects of that. And that’s part of how you end up in the hospital.

Jordan In a few minutes, we’ll get to what people can do personally, when they begin to notice signs, or how you can work with somebody in your life who’s battling this. But as a country, province, health care system, whatever level you want to look at it from, what should we be doing about this? Because, you know, as we look at a new variant and the threat of new lockdowns, like the pressure of the pandemic, doesn’t look to be letting up just yet.

Dr. Kurji One, I think we all need to be aware of what the kids are struggling with, whether it’s eating disorders, depression, anxiety. We need to recognize that kids are really struggling with this pandemic. And while we’re trying to get through it, we need to be increasing awareness and education for parents, for families, for teachers to know what to look for so that we can recognize things earlier. We need to be giving healthcare resources so that our teams can manage with the increase and get kids the help that they need as fast as they can, because especially with eating disorders, we know early recognition and early treatment improves outcomes. So if we can catch these kids sooner, we’re going to end up with better outcomes later.

And the other piece is, as a society, we know what we need to get through the pandemic. So I think the more that we can try and decrease the spread, everyone getting vaccinated, following the distancing and the masking and all of that, is the way that we can decrease COVID so that we can actually get this pandemic to be over with and done and get back to some normal normalcy for our kids.

Jordan On a personal level then, what are things that parents, friends, anybody, should be looking for as those early signs and symptoms you mentioned, to catch a potential disorder before it becomes problematic?

Dr. Kurji So sometimes we think about it as watching weight, and obviously changes in weight, someone losing weight quickly, that is definitely a red flag. But like we just kind of talked about, we know that when you’ve lost a lot of weight, especially if you lose it quickly, that sets you up for more risk for your physical health. So trying to catch it before then would be great.

The couple of areas that I try and think about or ask families to watch for is changes in eating behaviour, and changes in exercise behaviour. So when we talk about changes in eating behaviour, all of a sudden someone’s starting to pay more attention to calories, starting to restrict foods. You know, these foods are good foods and bad foods, and I won’t eat the bad foods. Whether it’s what I call fun foods: chips, popcorn, French fries, ice cream pie, cake, that kind of thing. If all of a sudden those fun foods are starting to disappear. That’s something to be worried about. Sometimes people will restrict whole food groups. So all of a sudden carbs are bad, or proteins are bad or certain types of proteins are bad. And if it’s a big change from what they used to do, then that would be something to watch for as a red flag, absolutely. The big thing is that rigidity that’s starting to happen around food. Good food, bad food, rules around how I eat.

Other things you might see from an eating point of view are changes in how they eat. So maybe playing with their food a lot more. Saying they’re not hungry so that they don’t have to eat with other people. All of a sudden wanting to eat more by themselves. Sometimes the way you eat something might change. For example, if you have a sandwich, we normally would pick it up and eat it, instead they might start breaking it into small bites to take bites of. And that way you make more crumbs so we can eat less of it. So that could be a warning sign too.

In terms of exercise, all of a sudden wanting to exercise more in a very different way than they used to, but also things like being really compulsive about that exercise. If you miss a workout, it’s the end of the world. I have to do something differently because I missed my workout. Maybe I have to work out extra tomorrow. Maybe I need to eat less because I didn’t work out. Those types of things and lots of, again, that rigidity. If you see that rigidity around food and exercise that’s definitely a warning sign too.

Jordan How do you open that conversation with somebody that you suspect is developing a problem? I think we’ve all been told that raising the issue of a person’s weight to them is not socially correct. Certainly people grappling with this stuff probably don’t want to talk about it. How do you do it sensitively?

Dr. Kurji It’s such a good question. Part of it is we’re all really scared to bring it up. Like you said, we don’t want to talk about weight and it’s not about necessarily weight it’s about health. So I try and bring it up in terms of the behaviours that I’m seeing.

I’ve noticed that exercise is becoming really important to you, to the point where it’s really almost the most important thing. Can you tell me what’s going on with that? Or I notice that, you know, you’re eating more in your room when we’re not around. Tell me what’s up with that. And start to open that conversation that way.

It is important to know, we know we talked about that malnourished brain, and if someone is really, really struggling with their eating, it can make it really hard for them to really even see that there’s a problem, so they can get really defensive and it can lead to a lot of arguments. So something that I kind of talk to my patients and families about is remembering that there’s the person and what they want, and then there’s the eating disorder and what the eating disorder wants. So when you’re struggling with those conversations, remember maybe you’re not really having a conversation with the person, you’re having a conversation with the eating disorder and that can kind of help reframe it.

And when there is that argument and that defensiveness and the, ‘no, I don’t have a problem’, maybe that’s the eating disorder talking. And so it can kind of help us remember that it’s not the person that we’re having the conversation with that’s struggling, it’s the eating disorder. And maybe they don’t really understand what’s going on because the eating disorder has taken over so much. And if you’re noticing that and you can’t have that rational conversation, Then I would say it’s absolutely time to get someone else involved, like their family doctor to help with that.

Jordan Well, that leads to the next question. I realize this is a big ask, so you can be very general with this, but I would like to get a sense of what a course of treatment for some of these disorders looks like. We talked about mental health, is this a psychiatric problem with drugs and prescriptions involved? Is this therapy based? How do you typically approach it?

Dr. Kurji From a paediatric lens, the most important piece of it, I think, is that it’s a team that when needs to be involved. Because like you said, there’s so many parts to it. So a paediatrician or family doctor for the medical piece, sometimes a psychiatrist, depending on how unwell you are and what local resources are available. I think the key pieces to the team would be a dietician and a counsellor or therapist who has experience with eating disorders to help tackle it.

: We know in kids, the best evidence for treatment for an eating disorder is family-based therapy. So often, especially if you have that malnourished brain, the person involved is going to have a lot of trouble making decisions and trying to help get their health back on track. And that’s why the importance of the family is so key. And the involvement of family is so key.

Initially if someone’s really malnourished, we almost take away the control that the individual has over their food and behaviours and give that to their family, because we know their brain’s not at the place to make those decisions and kind of make the right choices for their health. So food becomes medicine. This is how much you need to have. We’re going to sit with you and we’re going to support you to get you there. And we’ll get you eating and get your brain nourished. Once your brain is nourished, then we can focus on more of that individual piece and kind of your individual strategies and talk more about the body image and the fears and stuff that happens. But if we try and do that before your body and your brain are nourished, it’s actually really hard.

In terms of medicines, it’s tricky as well. So often when your brain is malnourished, you might have sadness and anxiety that might need treatment. Often, the best treatment is restoring health with food and restoring nutrition. So sometimes we find that the medicines don’t work as well because your brain’s not nourished and malfunctioning. And the best treatment is nutrition. It is a little bit different depending on which eating disorders you have. So some eating disorders, medicines may play a bigger role in that because they may actually help with the symptoms of the eating disorder, but it’s kind of a bit dependent on what you have.

Jordan I have one final question for you, but before I ask that, I realized that we started with a bunch of, you know, perhaps misconceptions that people have around eating disorders. Are there any we didn’t cover? Things that the general public doesn’t understand about this that they probably should now that it’s increasing so rapidly?

Dr. Kurji I think probably some of the biggest ones are that it isn’t a mental health issue only, and not knowing that it is actually devastating to your physical health. And also sometimes people tend to think of it like a choice. They know, even if someone is struggling with an eating disorder and they know they need to eat more, thinking they’re choosing not to eat more when actually their brain isn’t really functioning well. So it’s more than just a choice, and it’s so much harder than just “eat more.”

The other thing that sometimes I hear, especially when someone is struggling with eating, is malnourished, or even in the context of athletes who really train really hard and may not quite have that right energy balance. It’s about periods. So one of the things we know is when your body’s not getting enough nutrition, it kind of shuts off your period. And it does that by decreasing estrogen. And there is a school of thought out there, or a myth out there that if you’re training really hard and you lose your period, that’s okay. It’s just because you’re training really hard. And really that’s a sign of an energy imbalance. It doesn’t mean you have an eating disorder, but it means your body’s not getting enough nutrition. So that’s another sign that I ask families to watch for is any changes in your period. If it becomes lighter or more irregular, that’s a sign your body’s not getting enough nutrition and we need to do something.

Jordan My last question is less about eating disorders specifically, but around how you think, if you even think this, that the pandemic has changed our relationship to food? I know personally being at home all the time and having snacks whenever I want, or more importantly, whenever I don’t want and you just get busy and you forget to eat, like I’m much less on a regular schedule and I wonder if that’s something that you’ve seen a lot of.

Dr. Kurji Definitely, and you hear about COVID-19, people have been talking about their weight gain with COVID, and definitely we’re sitting at home. Maybe we’re just more inactive. I think for some people it’s changed their relationship with food, for sure. Whether it’s good or bad is depending on the person. For some people they’ve taken this as an opportunity to be home and eat healthy and have a bit more time to prepare meals, which has really been quite positive. For some families, it’s become a lot more stressful, a lot harder to kind of manage that.

So I think the key thing that we need to remember about it is food isn’t good or bad. Food doesn’t have value in the sense that this food is a good food and this food is a bad food. There’s a place for all different foods in our lives. And we need to remember that and give ourselves grace about that. And remember that you can have health at every size. Even if you’ve gained some weight in the pandemic, that’s okay. It doesn’t mean you’re unhealthy. Small bodies don’t mean health and big bodies don’t mean not being healthy. It’s about what goes along with that and what else are you doing.

So it shouldn’t be really just about food, but how is our health overall? How do we move our body? Are we enjoying life? Are we able to do all of the things that we want to do? And taking that more broad look at things can hopefully help us reframe our health.

Jordan That’s great advice for all of us. Thank you so much for this, Dr. Kurji.

Dr. Kurji Thanks for having me.

Jordan Dr. Ayisha Kurji from the University of Saskatchewan. That was The Big Story for more head to thebigstorypodcast.ca Find us on Twitter at @TheBigStoryFPN. Talk to us via email, thebigstorypodcast@rci.rogers.com [click here!].

A little programming announcement for you: for the next few days. we’re going to be taking a look ahead to the stories we plan on covering frankly, the most in 2022. After we do that look ahead, we’ll be taking a break as we usually do over the holidays returning on January 4th, but we will have a few special treats dropped in for you along the way. So keep checking the feed, if only to hear me learn what the heck is up with Hallmark Christmas. This is a big thing, apparently. Who knew?

And as always, thanks for listening, I’m Jordan Heath-Rawlings, we’ll talk tomorrow.

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