HERSHEY, Pa. — Mental health issues clung to COVID-19 like remoras to a shark during the height of the pandemic. And among the most serious were eating disorders.

During 2020, eating disorders spiked among teenage girls, according to the U.S. Centers for Disease Control and Prevention. Worldwide, the numbers had already been increasing steadily. Today, about 30 million people suffer from these particularly cruel conditions that can lead to death if left untreated.

Quarantining, while essential to slowing the spread of the coronavirus during the pandemic’s deadliest months, was “almost like a perfect storm,” said Amy Ethridge, an occupational therapist and clinical psychiatric specialist in the Adolescent Medicine and Eating Disorders Program at Penn State Milton S. Hershey Medical Center.

The causes of eating disorders are “like pieces of a puzzle,” Ethridge said. Among the pieces is the constant drumbeat of ads and TV shows idealizing unattainable body types. Get fit. Lose weight. Sequester everyone with their TVs and cell phones, let anxiety and depression rise and mingle with other factors like heredity ― it’s little wonder eating disorders started to spread like wildfire.

“It is usually a response to stress, too,” Ethridge said. “The point is eating disorders are complex medical and psychiatric conditions that patients don’t choose and parents don’t cause.”

Ehtridge and Jamal Essayli, clinical psychologist and director of the Young Adult Eating Disorders Program at the Penn State Milton S. Hershey Medical Center who holds a PhD in clinical psychology, describes eating disorders, what they are, what they aren’t, why they’re so dangerous and, if you’re worried about yourself or someone you care about, what you can do to help.

What are (and aren’t) eating disorders?

For starters, eating disorders are not a choice. Patients don’t wake up one day and decide to give anorexia nervosa a try. Also, the sufferers aren’t all teenage girls. All age groups, genders, cultures and backgrounds can be affected, and the disorders can become life threatening.

Common eating disorder categories include:

• Anorexia nervosa — People with anorexia nervosa drastically limit the calories they consume and demonstrate fear of weight gain. People suffering from anorexia nervosa often have a distorted body image. Some warning signs include weight loss, anxiety and avoidance of calorie-rich or non-diet foods, and intense focus on their body image, weight, eating and exercise. 

• Atypical anorexia nervosa — People with atypical anorexia nervosa have the same clinical presentation and symptoms as those with anorexia nervosa, except that they aren’t underweight. A common misconception is that all people with eating disorders are underweight when in reality, people who experience eating disorders come in all shapes and sizes. In fact, “individuals in higher weight bodies are at increased risk for eating disorders, likely because they experience intense pressure to lose weight,” Essayli said. “It is critical that providers screen for warning signs of eating disorders like anxiety about eating in individuals who are not underweight, as these individuals often go undetected due to their weight status.”

• Bulimia nervosa — Those with bulimia nervosa also restrict their food intake with the aim of weight loss or to prevent weight gain. However, people with the condition often have binge-eating episodes, where they consume large amounts of food quickly. Often, they feel out of control about how much they eat. To compensate for the calories consumed during binges, they vomit, take laxatives or exercise to excess. Like people suffering from anorexia nervosa, people with bulimia nervosa often suffer from a poor body image. Early symptoms can include a chronic sore throat, swollen salivary glands, digestive issues and worn tooth enamel — a result of stomach acid in the mouth.

• Binge-eating disorder ― Someone suffering from binge-eating disorder also has episodes of out-of-control consumption of food, often in response to dieting attempts. People with binge-eating disorder sometimes eat when they aren’t hungry, often in secret. Unlike bulimia nervosa, however, people with this disorder don’t engage in behaviors like vomiting to compensate.

• Avoidant/restrictive food intake disorder ― This disorder is characterized by restrictive eating and food avoidance, but for reasons that are unrelated to body image. Someone with the disorder might avoid food because of severely picky eating, fear of choking or vomiting, or low appetite. In children, the disorder can lead to a lack of development.

How do you know if someone has an eating disorder?

Some of the patients with eating disorders do their best to hide their conditions. Also, don’t assume ― trust a medical professional to make an actual diagnosis. However, some warning signs can be discerned, depending on the type of eating disorder:

• Do they have a preoccupation with food and dieting? So do lots of people, right? Ethridge said people with eating disorders often take these feelings to extreme behaviors and it becomes all-consuming. You might notice excessive exercise, or that they seem anxious about what they will eat when going out to a restaurant.

• Do they refuse to eat certain types of foods? Outside of an allergy, you might notice someone restricting an entire category of food to lose weight. No carbohydrates is a common refrain, even though everyone needs them to survive. People with avoidant/restrictive food intake disorder also avoid foods, but not to lose weight, Essayli said. They may only eat a very small number of foods due to severe picky eating, or avoid solid foods due to fears of choking.

• Do they have strict rituals with their food? Some people chew excessively. Others are careful not to let two different kinds of food touch. Some people are insistent that they eat alone and refuse to take their meals with anyone else. Some people skip meals or take small portions.

• Do they express extreme concern with body size and shape? Again, many people do. But is their perception distorted and has it become an obsession?

• Do they show signs of purging? Do they take frequent trips to the bathroom? Do they show dental erosion?

How do I talk to someone about getting help?

“The best way is to express concern about the behavior,” Ethridge said. “Discuss what you have noticed has changed or has become difficult. Avoid simplifying the situation by recommending to ‘just eat.’ Be prepared for negative reactions and even denial of the issue. The intent is not to diagnose it, but rather help them get to treatment by starting with a medical evaluation.”

If they’re open to seeking help, they can visit the National Eating Disorders website and call the hotline.

The Adolescent Medicine and Eating Disorders Program at Hershey Medical Center also provides screenings. Representatives can be reached at 717-531-7235.

Programs like the one at Hershey Medical Center provide treatment for adolescents and young adults (ages 10 to 24) at various levels of care, including outpatient, intensive outpatient and partial hospitalization treatment. Patients in these treatment programs receive evidence-based care from an interdisciplinary team of experts, including therapists, dietitians, physicians, and psychiatrists. The programs use cognitive-behavioral therapy and family-based treatment to help people begin to recover.

Related content:

• The Medical Minute: When dinner table defiance could lead to health problems
• The Medical Minute: Eating disorders affect entire body

The Medical Minute is a weekly health news feature produced by Penn State Health. Articles feature the expertise of faculty, physicians and staff, and are designed to offer timely, relevant health information of interest to a broad audience.