Critical Escalation of de Novo Pediatric Anorexia Nervosa

Anorexia nervosa is the psychiatric illness with the highest mortality rate, at nearly 6 times higher than the rate in the general population.¹ Anorexia nervosa classically manifests during adolescence, with a 9:1 female to male predominance, and is characterized by extreme undereating behaviors that result in malnourishment and medical complications such as osteoporosis, cardiac arrhythmia, and death. Despite high mortality and morbidity rates together with increasing costs of health care from frequent relapse and chronic course of illness, there are no mandated standards of care and few treatments with a robust evidence base, a situation that was highlighted as a crisis in care in the US by leading experts Kaye and Bulik.¹ Thus, reports of an overall deterioration of patients with eating disorders during the beginning of the COVID-19 pandemic are alarming.

The study by Agostino and colleagues² provides a critical new dimension to this dire context. Using data from 6 of the 10 tertiary pediatric hospitals in Canada that serve 90% of the populace, the authors conducted a cross-sectional analysis and found an increase in the number of de novo anorexia nervosa or atypical anorexia nervosa cases since the start of the pandemic. Agostino and colleagues² identified 1883 patients with a median (IQR) age of 15.9 (13.8-16.9) years (predominantly female children and adolescents [n = 1713 (91.0%)]) who were newly diagnosed with anorexia nervosa or atypical anorexia nervosa, as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), between January 1, 2015, and November 30, 2020. Atypical anorexia nervosa was characterized by a body mass index that was higher than 85% of the median percentile for age and sex.

In the 5 years before the pandemic, there were 24.5 new cases of anorexia nervosa or atypical anorexia nervosa per month. This mean number increased to 40.6 over the 9 months after March 1, 2020 (the start of the pandemic), for a 66% increase. The rates of hospitalization for the newly diagnosed anorexia nervosa or atypical anorexia nervosa also increased, and these patients had an overall more severe clinical picture at diagnosis, during this time.²

Although this study by Agostino and colleagues² may be the largest to date with such findings, another study has recently reported on the increase in the number of new anorexia nervosa among adolescents: Springall et al³ found a 63% increase in new anorexia nervosa cases in 2020 compared with the annual rates from the 3 previous years at a single pediatric tertiary hospital in Australia. There were no substantial differences in measures of illness severity in the newly diagnosed adolescents with anorexia nervosa, which contrasts with the findings from the study by Agostino and colleagues.² There may be many reasons for the observed differences, and Agostino and colleagues² acknowledged that the shift toward prioritizing evaluations for those with more severe anorexia nervosa symptoms during the pandemic may be a possible source of selection bias, which is important in considering their findings on the rates of hospitalization and symptom severity. Such need for triaging according to escalating volume of patients with eating disorders highlights the possibility that the observed incidence of de novo anorexia nervosa may have been diluted, and the true burden of illness may unfortunately be greater.

In the literature, the exacerbation of eating disorders during the pandemic has been associated with various psychosocial contributors.⁴ These factors include comorbid psychopathology (ie, anxiety, depression, and obsessive-compulsive disorder) that can interact with disordered eating behaviors and cognitive flexibility; school and community program closures as well as a lack of structured time and social interactions that can heighten disordered eating; media containing triggering messages about the risks of weight gain during the COVID-19 pandemic referred to as the Quarantine 15 (ie, after the Freshman 15 terminology); reduced in-person treatments in the community; and food security that could contribute to increased concerns regarding access to foods that follow rigid and disordered eating rules (eg, low calorie and low carbohydrate), which could be associated with compensatory increases in other forms of dietary restriction.⁵

Of particular interest in the study by Agostino and colleagues² is the observation that the largest increases in new anorexia nervosa or atypical anorexia nervosa cases and hospitalizations occurred in Central Canada, which had the highest COVID-19 infection rates early in the pandemic. The authors pointed to how this finding may be associated with the stricter confinement measures in those Canadian provinces, with likely worsening of psychosocial outcomes.

In future studies, it may be worth assessing whether the regional rates of COVID-19 are representative of the infection or exposure rates in the children and adolescents who were newly diagnosed with anorexia nervosa or atypical anorexia nervosa, and whether an association exists between symptom severity and a history of SARS-CoV-2 infection (ie, IgG). It is unknown whether any viral contributions can be found in the pathogenesis of anorexia nervosa, and future investigations could enhance the understanding of the biological processes of anorexia nervosa. For instance, the incidence of new-onset type 1 diabetes in adolescents has also increased during the pandemic,⁶ and a recent study uncovered novel mechanisms of type 1 diabetes pathogenesis in which SARS-CoV-2 attacks the insulin-producing β cells of the pancreas and serves as cell-specific precipitants of type 1 diabetes.⁷ Similar molecular investigations have not been conducted in anorexia nervosa research, but just as a genome-wide association study of anorexia nervosa that found a metabolic axis with a shared risk locus of type 1 diabetes,⁸ the increased incidence of newly diagnosed anorexia nervosa in the pandemic along with COVID-19–associated modulation of metabolic diseases may offer a unique opportunity for scientific progress toward a better understanding of this illness.

Agostino and colleagues² have added an important piece of knowledge to the current literature. Their findings remind us of the vulnerabilities of the pediatric patient population in this challenging era of the COVID-19 pandemic.

Published: December 7, 2021. doi:10.1001/jamanetworkopen.2021.37644

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kim Y. JAMA Network Open.

Corresponding Author: Youngjung Kim, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114 (ykim82@mgh.harvard.edu).

Conflict of Interest Disclosures: None reported.