The hidden burden of eating disorders during the COVID-19 pandemic.

Eating disorders are disabling, potentially fatal, and costly mental disorders that substantially impair physical health and disrupt psychosocial functioning. Both international disease classification systems (DSM-5 and ICD-11) list seven major eating disorders. These include the well known diagnostic categories of anorexia nervosa and bulimia nervosa, binge-eating disorder, and three additional disorders: avoidant/restrictive food intake disorder, pica, and rumination disorder. There is also a category of otherwise specified feeding or eating disorders (OSFED).

In The Lancet Psychiatry Santomauro and colleagues reported on the hidden burden of eating disorders and showed that the inclusion of binge-eating disorder and OSFED in the analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, resulted in 41·9 million additional, previously unrepresented cases of eating disorders in 2019, with a revised estimate of the global prevalence of eating disorders four times higher than had been thought. Thus, eating disorders have a prevalence comparable to drug use disorders and are more common than bipolar disorders, autism spectrum disorders, and conduct disorders. The authors highlighted that due to insufficient data, they were unable to include other eating disorder diagnoses (avoidant/restrictive food intake disorder, rumination disorder, and pica).

Wu and colleagues analysed trends in prevalence and disability-adjusted life years of eating disorders from 1990 to 2017, on the basis of the GBD 2017 data. As expected, the authors found that the burden of eating disorders was highest in high-income countries, but a trend towards increasing eating disorder burden was observed globally, especially in east and south Asia.

One aspect contributing to the notion that eating disorders constitute a hidden burden is inherent in the disorders themselves: similar to other mental disorders and obesity, eating disorders are associated with considerable stigma and self-stigmatisation, typically as trivial and self-inflicted disorders. Such stigma might obstruct help-seeking behaviour and contribute to decreased visibility and poor general awareness of these disorders in society.

The COVID-19 pandemic has exacerbated the burden of eating disorders and simultaneously has highlighted the urgent need to raise awareness of these disorders. While the pandemic has impaired population mental health globally, it seems to have had particularly detrimental effects on people with or at risk of eating disorders. Multiple reports from different countries, in Europe, Australia, and North America, have shown an increase in the incidence of eating disorder behaviours or diagnoses in the community, or deterioration of eating disorders in patient populations, often with more severe symptoms and comorbidities since the start of the COVID-19 pandemic. Using electronic health records of 5·2 million young people, Taquet and colleagues demonstrated that the overall incidence of eating disorders increased during the COVID-19 pandemic by 15·3% in 2020, compared with previous years. The relative risk of eating disorders increased steadily from March, 2020, onwards, exceeding 1·5 by the end of the year. The increase occurred solely in women and girls and was primarily observed in adolescents and for anorexia nervosa. Lin and colleagues observed for their tertiary care children's hospital in the USA, an increase in adolescents and young adults presenting with eating disorders who needed inpatient or outpatient care during the pandemic.

Knowledge about the magnitude or the burden of any disorder is not sufficient to derive the necessary steps for action on research, treatment, and services. Writing about the links between the COVID-19 pandemic and eating disorders, Katzman stated, “unfortunately, it took a disaster like the COVID-19 pandemic to put the spotlight on eating disorders”, and “it is a wake-up call for making eating disorders a priority”. These necessary steps, however, require a clear agenda and corresponding funding, which we formulated for Europe in 2016. In the UK, a report by the All-Party Parliamentary Group on Eating Disorders called for action to break the vicious cycle of stigma and underfunding of research into eating disorders. Colleagues from Australia and the UK have also highlighted the need for a joined-up research agenda on eating disorders, to match increasing service demand among young people during the pandemic, with appropriately funded innovative clinical research.

Even before the COVID-19 pandemic, meta-analyses indicated the need to critically review and consistently develop treatment programmes, especially for adults with anorexia nervosa. For optimal care pathways, five steps are needed: first, an improvement in awareness and recognition in primary care to facilitate early engagement in treatment; second, a reduction in the time to access specialist treatment; third, an increase in the effectiveness of routine treatment with precision planning and continuous monitoring with the provision of augmentation strategies; fourth, optimisation of inpatient care by interventions that bridge the transition from inpatient services to home-based care and increase community support; and fifth, new rehabilitation approaches and treatment strategies for individuals who do not respond to standard treatment.

We declare no competing interests.