BALTIMORE — For almost two decades — from high school to when she was a 35-year-old graduate student — Alicia Castaneda Hatfield struggled with an eating disorder without ever talking with a doctor about it.
Some months were better than others, and she’d eat enough to get through the day. Then, her recovery would slip, and she’d start severely restricting her calories again.
She experienced her biggest relapse while studying for her degree in social work in Sacramento, California. But this time, she didn’t struggle alone. Her therapist caught the warning signs, connected her with a registered dietitian, and, for the first time, she had help maintaining her recovery.
“That was wonderful,” said Castaneda Hatfield, who is now pursuing a doctorate at the University of Maryland School of Social Work in Baltimore. “But then, the pandemic hit.”
The coronavirus outbreak’s sudden destruction of eating routines and treatment schedules and the way it amplified stress and isolation were especially devastating for people in recovery from an eating disorder or at risk of developing one. Inpatient stays for eating disorders rose nationwide during the pandemic, and emergency department visits for eating disorders doubled among teenage girls.
Health care providers in Baltimore who treat eating disorders said demand for care increased over the last three years, especially among adolescent girls. Patients also are sicker, they said.
Thinking back to when she was younger, Castaneda Hatfield realizes that she didn’t know just how harmful an eating disorder could be. Anorexia nervosa has the highest mortality rate of any mental disorder, and can damage a person’s kidneys, heart, digestive tract and thyroid, among other bodily functions.
“An eating disorder is the type of emergency that needs to be taken care of,” Castaneda Hatfield said. “This isn’t something that you can just sit on and hope that it gets better.”
A significant increase
For the past decade, Dr. Sarah Edwards — a psychiatry professor at the University of Maryland School of Medicine — has answered calls to a hotline for primary care and emergency medical doctors with mental health questions.
Before the pandemic, it wasn’t uncommon for a few years to go by without her being asked to consult on a patient who might have an eating disorder. But the number of doctors reaching out to the consultation service to ask about eating disorders jumped from 20 in 2019 to 63 in 2022, Edwards said.
“For the number of calls to increase threefold?” she said. “It’s really significant.”
Edwards, also the psychiatry director at the University of Maryland Children’s Hospital, said there has been an increase in young people in the hospital’s outpatient psychiatry program who struggle with disordered eating, which can be the precursor of an eating disorder.
There also has been an uptick in young people admitted to the hospital for other medical reasons, but who have a co-occurring eating disorder — or are being admitted for medical reasons caused by an eating disorder, Edwards said.
Demand for treatment also escalated at Sheppard Pratt’s eating disorder center, said Dr. Weronika Gondek, the Towson facility’s medical director.
There’s typically a waitlist at the center, she said. And patients arriving for treatment are more ill than they were before the pandemic, with many presenting medical complications caused by their disorder.
Some patients have been struggling for two or three years without help, while others developed their disorder earlier than when doctors would expect — as young as 8 or 9 years old, Gondek said.
The pandemic created specific challenges that made it harder for doctors and teachers to notice the warning signs of an eating disorder, Gondek said. Primary care visits plummeted during the early months of the pandemic. Doctor’s appointments — and school — moved online, making it more difficult for adults to recognize significant fluctuations in a child’s weight.
The outbreak also amplified and added stressors that made people more likely to develop an eating disorder or to relapse, Gondek said.
Grocery shopping became less routine, so people often had more or less food at home than they were used to.
Social media use among teens skyrocketed during the pandemic, with an increasing percentage of children between 8 and 12 reporting they use at least one platform. Fatphobia and diet culture have flourished over the last three years, as weight loss companies promise to help people lose the “quarantine 15.”
The last three years also disrupted people’s social lives.
“It is an isolating illness to start with,” Gondek said of eating disorders, “but the pandemic has definitely highlighted this difficulty.”
A changing patient pool
The eating disorders program at Johns Hopkins Hospital also saw a significant increase in patients seeking treatment during the pandemic.
The waiting list for the program’s seven-bed inpatient service grew significantly longer than before the pandemic, and doctors were swamped with patients requesting outpatient consultations, said Colleen Schreyer, the program’s clinical research director.
Staff members also saw changes in the patient pool, Schreyer said.
The patient population skewed younger. During the pandemic, 44% of those admitted to the inpatient program were 13 to 17 years old, compared with 29% before the pandemic, according to a study Schreyer and her colleagues published in November.
Teenagers admitted to the hospital during the pandemic also reported experiencing greater eating disorder and depressive symptoms compared to what similar teens reported before the pandemic, according to the study.
Schreyer and her colleagues also found that more male patients were admitted to the inpatient program during the pandemic, increasing from 6% of patients to 14%.
That increase was likely propelled by a shortage of eating disorder treatment programs that treat men and boys, said Dr. Angela Guarda, director of Johns Hopkins’ eating disorder program.
“Many programs in the U.S. only treat females,” she said, “so, by default, if there are more patients out there, we’re going to get a higher percentage of males when all the beds are full because there’s less space for them anywhere.”
On a broader scale, there is a shortage of clinicians who can treat eating disorders, Guarda said. There are fewer outpatient specialty treatment programs than before, she said, and most training programs for psychiatrists, psychologists, dietitians and other mental health workers don’t provide adequate education on how to treat eating disorders.
“It’s like a forgotten specialty,” she said. “In the pandemic, there was generally an increase in numbers of people requesting care. And many clinicians said, ‘I can’t treat eating disorders. I’m full of other patients.’”
It’s also becoming increasingly difficult for lower-income people with Medicaid, as well as those with Medicare, who are either elderly or have been disabled by their eating disorder, to access care, Guarda said.
Because most eating disorder care centers are private, for-profit residential treatment settings that don’t accept public insurance, Guarda said, “some of the sickest patients have the least access to care.”
Flying under the radar
Research shows that Black, Indigenous and other people of color — groups that have suffered more mental health declines during the pandemic compared to white people — face additional obstacles when seeking help for an eating disorder.
Black teenagers are 50% more likely than white teenagers to exhibit bulimic behavior, such as bingeing and purging. Hispanic teenagers are also more likely to struggle with bulimia than their non-Hispanic peers.
But overall, mental health workers are significantly more likely to be white. Last year, 82% of mental health counselors were white, compared with 15% who were Black and 10.5% who were Hispanic, according to data from the U.S. Bureau of Labor Statistics.
There is a similar shortage of clinicians who are people of color in the eating disorder field, said Ericka Leonard, a clinical social worker and therapist based in Baltimore who provides therapy for eating disorders, trauma and domestic violence.
Leonard, who is Black, said she believes the shortage has dissuaded patients from seeking care.
“I also have talked to clinicians who are hesitant to be in the eating disorder space because it is so white,” she said.
It’s important to have a provider who looks like you, who can relate to the nuances that come with being a person of color, Leonard said. More people would feel safe and open enough to reach out for support if there were increased representation in the treatment of mental health and eating disorders, she said.
Castaneda Hatfield suspects that her race played a role in why it took doctors so long to notice something was wrong.
She’s half-Mexican, and said her body doesn’t look like a white person’s. When she was dangerously sick with an eating disorder, she was still at a “healthy” weight, according to her body mass index, a value calculated from a person’s weight and height.
The BMI, which was designed in the 1830s using a sample of white, European men, has faced criticism in recent years for not being relevant to the bodies of women and people of color, and for not taking into account a person’s muscle mass, lifestyle or other health-related factors.
After graduating from her master’s program in 2019, Castaneda Hatfield went a few months without seeing a therapist or dietitian. When a severe illness landed her in intensive care during the pandemic, a doctor told her she needed to lose weight and recommended bariatric surgery.
His comments triggered a relapse, she said, so she cobbled together a treatment team over Zoom. Then she moved across the country to Baltimore, leaving her therapist and dietitian behind.
She was nervous about the move, but she and her husband quickly made friends, she said. She also found support in joining Body Liberation Baltimore, a group that aims to provide a safe space for people with bodies of all sizes and abilities who have been harmed by diet culture and fatphobia.
Castaneda Hatfield gets angry now when she thinks about how much of her life she spent with a foggy brain from not eating enough, just so she could be thin.
“I hope that girls coming up have access to that rage of, ‘We’re more than what we are to the male gaze,’” she said. “When we eat food and we power our bodies, our brains can do amazing things. I feel like I wouldn’t be in this Ph.D. program, I wouldn’t have been able to earn my master’s or any of my degrees, without having my hand in recovery.
“Because when you’re just dizzy in bed all day,” she paused, “your potential is just waiting.”
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