Trapped in the House With an Eating Disorder

Anxiety, disrupted routines and loneliness are fueling people’s food issues as they hunker down during the Covid-19 crisis.
By Virginia Sole-Smith
March 31, 2021, 11:17 a.m. ET
New York Times

Malinda Ann Hill decided to resume treatment for her eating disorder almost as soon as she shifted to working remotely in March 2020. She knew even before the pandemic that isolation at home would be detrimental to her ongoing recovery from anorexia nervosa. “I had made a really distinct decision not to work from home, so that sent me into a tailspin,” said Ms. Hill, 49, who lives with her daughter in Wynnewood, Pa., and works as an art therapist and bereavement coordinator for a local hospital.

The community and structure of her workplace were helpful for someone who had struggled with disordered eating since her early teens. Sudden loneliness, mounting fears about the unfolding pandemic and a new lack of boundaries between work and home all helped tip off a relapse that Ms. Hill said had already been brewing.

“I thought maybe I should get back into treatment now,” she said. “Because this is going to be bad. And this is going to set off a lot of other people, too.”

Indeed, some doctors, therapists and dietitians who treat eating disorders, such as anorexia, bulimia and binge eating disorder, are reporting an overwhelming spike in the need for their services, with waiting lists growing at many practices and treatment centers across the country.

The National Eating Disorders Association reported a 41 percent increase in messages to its telephone and online help lines in January 2021 compared with January 2020. And in a study of about 1,000 American and Dutch people with eating disorders published last July, more than one-third of subjects reported that they were restricting their diet and increasing “compensatory behaviors,” like purging and exercise. Among the Americans, 23 percent also said they would regularly binge-eat stockpiled food.

“I’m seeing more clients, and I’m getting clients who are sicker when they come to me, because we cannot get them access to a higher level of treatment,” said Whitney Trotter, a registered dietitian and nurse in Memphis who provides one-on-one nutritional counseling for adolescents and adults of color with eating disorders. She noted that many in-patient treatment centers are fully booked due to the heightened demand.

The National Eating Disorders Association reported a 41 percent increase in messages to its telephone and online help lines in January 2021 compared with January 2020. And in a study of about 1,000 American and Dutch people with eating disorders published last July, more than one-third of subjects reported that they were restricting their diet and increasing “compensatory behaviors,” like purging and exercise. Among the Americans, 23 percent also said they would regularly binge-eat stockpiled food.

“I’m seeing more clients, and I’m getting clients who are sicker when they come to me, because we cannot get them access to a higher level of treatment,” said Whitney Trotter, a registered dietitian and nurse in Memphis who provides one-on-one nutritional counseling for adolescents and adults of color with eating disorders. She noted that many in-patient treatment centers are fully booked due to the heightened demand.

The uptick in her practice stems from a mix of relapse cases, like Ms. Hill’s, and disorders that have newly taken hold in the past year. “I’m treating more teenagers, and also more teachers, doctors, nurses and other first responders and essential personnel,” Ms. Trotter said. “An eating disorder can manifest as a trauma response. Our nervous systems were not meant to deal with a long-term pandemic.”

How food scarcity can stoke eating disorders

Early on in the pandemic, fears around grocery store shortages and food access re-triggered some people’s disordered eating. “I found myself lying awake at 3 a.m., thinking, ‘What if there is no more baby food at the store?’” said Aneidys Reyes, 33, a stay-at-home father in Madison, Wis., who had been in eating disorder recovery for more than six years before the pandemic.

Mx. Reyes, who was raised as a girl, said that their eating disorder originally began as a coping strategy for the gender dysphoria they experienced as a teenager. Now that they identify as transgender, the urge to restrict food is less connected to body image anxieties. “It’s weird for me, because it’s not the same old eating disorder,” they said. “But once I’m at a certain level of anxiety, then my brain is like, ‘Do you remember these neuropathways? What if it’s what you’re eating? What if your clothes don’t fit tomorrow?’ All these old, familiar thoughts come back.”

Even after grocery store shortages eased, patients who were being treated for eating disorders struggled with how pandemic rules required them to navigate eating with less professional support. “For a patient who would previously have spent the day at a treatment center having all their meals provided for them, a virtual program requires so much more autonomy than they would have previously had,” said Lauren Muhlheim, a psychologist in private practice in Los Angeles.

Ms. Hill deliberately chose an in-person treatment program, even during the early days of social distancing, because she knew she needed hands-on help making decisions around what and how much to eat. When her program switched to virtual support, she had to think about meal planning again. “Suddenly I had to be in charge of the food,” she said. “They wanted me to have more variety, but I didn’t want to go back to the grocery store. I started having panic attacks.”

Our societal tendency, on social media especially, to demonize quarantine comfort eating and pandemic-related weight gain hasn’t helped. “The pressure to have used the pandemic time to have gotten or kept in shape is a big theme,” said Dr. Muhlheim. Ms. Hill said that “diet culture noise” had felt louder to her in the past year.

Why treating eating disorders over Zoom is harder

The majority of residential eating disorder treatment programs have stayed in-person, but they are typically reserved for patients who need the highest level of care due to the severity of their eating disorder behaviors or related medical complications. The next step down is known as a “partial hospitalization program,” where patients live at home and manage some meals themselves, but attend a mix of individual and group therapy meetings, plus meal support sessions (where eating is monitored so patients cannot restrict food or purge afterward), for anywhere from six to 11 hours a day.

Many such programs, as well as individual outpatient services (where patients have daily or weekly check-ins with a therapist or dietitian), have shifted to a virtual treatment model. In addition to leaving patients to navigate food shopping and meal preparation alone, the virtual model makes meal support sessions trickier. “You can’t tell as well from a camera how much someone is eating,” Dr. Muhlheim said.

Dr. Muhlheim said that she is also concerned about the loss of casual interactions that normally take place between participants in group treatment. “You can only have one conversation at a time on Zoom,” she said. “You can’t just pull someone over to chat, so you lose a lot of that connection.” In fact, in a recent survey of 63 eating disorder patients, 68 percent said they would not choose to continue with online therapy once in-person services resumed.

But some therapists said they are thrilled that virtual services have increased access for patients who would otherwise not be able to travel for treatment. “For my teacher clients, especially, virtual therapy is much more accessible because they can do a session on a planning period or right at the end of the school day,” noted Ms. Trotter, the dietitian. Virtual care can also be more affordable than residential treatment programs.

Sometimes it’s even free. In March of 2020, Diane Summers, a nutrition therapist in Seattle, asked her colleagues if anyone had time to offer no-cost meal support via Instagram Live. “I was kind of hoping for maybe two or three people a day to go live,” she said. “But we were just flooded with willingness to be a part of the project.” Therapists and dietitians signed up in every time zone, enabling the account (@covid19eatingsupport) to offer live meal support 24 hours a day for several months of the pandemic.

When teens fixate on restrictive eating

Teenagers have been particularly vulnerable to developing eating disorders during the pandemic, both because adolescence is already the most common time for such struggles to emerge and because of the added pressures they face now. “It’s a combination of the loss of structure, the loss of peer connections and the loss of their usual activities,” Dr. Muhlheim said. “They have all this time and they decide to focus on an exercise program, or maybe it feels like running is the only thing they can really still do. But we know exercise is a huge trigger.”

That’s how it started for Lily, a 16-year-old high school sophomore in Los Angeles who said that body image anxieties weren’t a big part of her life until the pandemic. “I don’t think weight loss was ever on my mind at all,” she said. “It was more of, ‘I love running, I have all this time, so why not push myself and see how far I can run?’” She began working out every day to fill the time previously occupied by school and team sports. “Lily is super book smart and school comes easily to her, so she’s had a lot of extra time,” with the switch to remote learning, her mom, Nikki, explained. (The family asked to use only their first names to protect Lily’s privacy.)

After a few weeks of intensive exercise, Nikki noticed that Lily was eating less at family meals, too. “I wasn’t necessarily skipping meals, but I was trying to eat less meat and dessert and more vegetables,” Lily said. “I thought I was being healthy.” But she also became more fixated on her weight and further curbed her eating.

In those who are vulnerable to eating disorders, even unintentionally dipping into a negative energy balance, which happens when you expend more energy than you consume in calories, can trigger the rigid, restrictive mindset that is the hallmark of most eating disorders, said Dr. Kenisha Campbell, director of adolescent medicine outpatient clinical services at the Children’s Hospital of Philadelphia.

“Eating disorders are brain disorders because the brain cannot function without appropriate nutrition. So once the ‘eating disorder brain’ is in control, they can’t make any decisions around eating,” explained Dr. Campbell, who specializes in eating disorder treatment. “We have to feed the brain, so the brain can fight the eating disorder.”

By December, Lily often felt dizzy and had developed a resting heart rate of 40 beats per minute, which was dangerously low for her. She was put on bed rest by her family doctor, and a psychologist prescribed an intensive family-based treatment in which her parents planned meals and monitored everything she ate. On tough days, it felt like the whole family was trapped in the house with her eating disorder, Nikki said.

Lily knows that once going out for dinner or getting ice cream with friends is again an option, she’ll be presented with more challenges than she currently has when eating in the safety of her own home. “It doesn’t feel like I have to miss out on things because of my eating disorder,” she said. “I’m missing out on everything because of the pandemic.”

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Virginia Sole-Smith is the author of “The Eating Instinct: Food Culture, Body Image and Guilt in America,” and writes the newsletter Burnt Toast.