Trends in US Patients Receiving Care for Eating Disorders and Other Common Behavioral Health Conditions Before and During the COVID-19 Pandemic

The lay press has reported an increase in eating disorders during the COVID-19 pandemic.¹ We examined trends in health care for eating disorders from January 1, 2018, to December 31, 2020, alongside other common behavioral health conditions among a large cohort of commercially insured individuals in the US.

This cohort study used deidentified data and was deemed exempt by the institutional review board group of UnitedHealth Group. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

We counted the unique individuals per 100 000 members per month with outpatient or inpatient care and a primary diagnosis code (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]) for eating disorders (ICD-10: F50); alcohol use disorders (ICD-10: F10); depression, anxiety, and suicidality (ICD-10: F33, F34, F40, F41, T14); or opioid use disorders (ICD-10: F11). We excluded outpatient claims from members with inpatient claims in the same condition-month and emergency department claims.

This study included 3 281 366 individuals (2 053 432 females [62.6%]) with a mean (SD) age of 37.7 (16.2) years. Patient characteristics were similar across years, except that the age of patients with eating disorders decreased over time (Table). The number of patients with inpatient care for eating disorders remained approximately 0.3 per 100 000 members per month until May 2020 when it more than doubled to 0.6. This increase was seen across anorexia nervosa, bulimia nervosa, and other and unspecified eating disorders. The median (IQR) length of inpatient stays also increased from 9 (5-17) days and 8 (3-14) days in June to December of 2018 and 2019, respectively, to 12 (5-27) days in the same period in 2020. The number of patients with outpatient care for eating disorders increased from approximately 25 patients per 100 000 per month to 29 patients per 100 000 per month. Similar increases were not seen for the 3 comparison behavioral health conditions (Figure).

In this cohort study, we found that inpatient stays for eating disorders rose during the pandemic. Many aspects of the pandemic plausibly intensified eating disorders and their ascertainment. The pandemic may have promoted disordered eating behaviors among susceptible individuals. For example, obesity was frequently cited as a risk factor for COVID severity^2,3; grocery shopping became more fraught in the early pandemic because of contagion concerns, new rules, and rituals; and many bought large quantities of foods to minimize shopping frequency or fear of shortage.^4,5 Additionally, exercise may have become a focus of control or a compensatory mechanism for eating.⁶ Furthermore, the closing of schools and colleges may have helped families identify unhealthy eating or recognize its effects, and outpatient care may have been delayed until symptoms required hospitalization. This study was limited because the data was based on the commercial claims of a single insurer.

Accepted for Publication: September 22, 2021.

Published: November 16, 2021. doi:10.1001/jamanetworkopen.2021.34913

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Asch DA et al. JAMA Network Open.

Corresponding Author: David A. Asch, MD, Center for Health Care Innovation, University of Pennsylvania, 3400 Civic Center Blvd, 14-171 PCAM South Tower, Philadelphia, PA 19104 (asch@wharton.upenn.edu).

Author Contributions: Mr Buresh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Asch, Islam, Sheils, Doshi, Werner.

Acquisition, analysis, or interpretation of data: Buresh, Allison, Sheils, Doshi, Werner.

Drafting of the manuscript: Asch, Allison, Sheils.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Islam, Doshi, Werner.

Administrative, technical, or material support: Sheils.

Supervision: Sheils, Werner.

Conflict of Interest Disclosures: Dr Allison reported receiving grants from Novo Nordisk Investigator Initiated Study outside the submitted work. Dr Sheils, Dr Islam, and Mr. Buresh own stock in UnitedHealth Group, which is the parent company of their employer Optum Labs, outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank Yong Chen, PhD (University of Pennsylvania), for useful comments made on the manuscript. Dr Chen was not compensated for his time.