White Coat, Black Art

Teen shares how eating disorder unfolded as doctors grapple with surge in cases during pandemic

Throughout the COVID-19 pandemic, doctors have seen a surge in eating disorders in children and teens, exacerbating what they say was already a critical mental health issue in Canada.

Children and teens are presenting in higher numbers, with more severe cases, than before, experts say

RJ Cardinali, 15, of Hamilton, was hospitalized in September with a critically low heart rate and was treated for a month. The teen, who suffered from an eating disorder, saw his normally active life come to a standstill during the pandemic lockdown. (Submitted by Janice Savage)

When the COVID-19 pandemic first prompted lockdown measures nearly one year ago, 15-year-old RJ Cardinali's jam-packed schedule was blown wide open.

The Hamilton teenager's typical week involved school, basketball and hockey practices, shooting hoops for fun with friends and workouts at the YMCA.

"It brought him from go, go, go to full stop," his mother, Janice Savage, told White Coat, Black Art host Dr. Brian Goldman. "Basketball was not happening. He couldn't go shoot hoops with his friends. His house league hockey team was making it to Super Saturday — I think for the first time in RJ's hockey career, he was supposed to be playing in the finals — and that got cancelled at the 11th hour."

When the lockdown first started, RJ told Goldman his first take was, "OK, this is happening, an extended March break. Cool."

But, he said, "As time goes on, it was kind of like, 'Oh, well, I don't know when things are going to be back to normal, when sports are going to come back in play, so I might as well just try to stay in as good a shape as possible here.'"

Looking back now, RJ said he realizes he's had "a bit of body dysmorphia."

"I've always been a skinnier kid, but I've always thought that I was just, like, extremely big. So when everything shut down, it was like, 'OK, I have to expend the same amount of calories as I'm eating. And to a certain point it felt like ... 'OK, so if I can't burn all of them, I'll just eat as little as possible."

One day early in July, his mom looked outside where RJ was vacuuming the pool. "I realized I hadn't seen him without his shirt off in weeks and weeks and weeks. And he looked so skeletal thin that it was kind of a wake-up call," she said.

Eating disorder inquiries up during pandemic

By September, RJ was sent to the emergency department at McMaster Children's Hospital in Hamilton and admitted with a critically low heart rate of just 30 beats per minute. He stayed in treatment there for a month and is doing much better today.

Throughout the pandemic, doctors have seen a surge in eating disorders in children and teens, exacerbating what they say was already a critical mental health issue in this country.

"It has been unbelievably busy," said pediatrician Dr. Natasha Johnson, division head of adolescent medicine and medical director of the eating disorder program at McMaster Children's Hospital. "We've been seeing unprecedented volumes of very, very sick young people presenting for assessment and treatment of eating disorders. And it's been persistent for now almost a year."

Dr. Natasha Johnson, division head of adolescent medicine and medical director of the eating disorder program at McMaster Children's Hospital in Hamilton, says eating disorder patients are showing up much sicker than before the pandemic. (Submitted by Dr. Natasha Johnson)

While RJ happened to need a bed just as one was becoming available, Johnson said the unit has persistently had more seriously ill young people than it's had room for. As a result, those who need outpatient treatment increased 200 per cent, while referrals overall were up 90 per cent in the final months of 2020 compared with the same period last year, she told Goldman.

Johnson said her colleagues in other parts of the country report the same experience.

The National Eating Disorder Information Centre (NEDIC) says the volume of inquiries to its help line and online chat service has been up 100 per cent during the pandemic. Among people 25 and younger, calls have been up 87 per cent.

Patients are also showing up much sicker than before, Johnson said.

The typical standard of care for someone with an eating disorder is to have outpatient management and family-based treatment, or FBT, she said. In cases where it's considered unsafe for patients to be cared for at home, they're admitted to hospital.

"Some of those things would include a really low heart rate under 50, low blood pressure, abnormal blood work or signs of other organ dysfunction."

Johnson said this past year, the hospital has been seeing young people with heart rates in the 30s and 20s, significant kidney or liver dysfunction or even multiple-organ dysfunction — all stemming from severe malnutrition and rapid, significant weight loss.

"A number of the young people that we've seen have been pretty close to death, to be quite honest with you. It's very, very worrisome."

Patients suffering from a severe eating disorder may have compromised vitals, such as a low heart rate and low blood pressure. (Guillaume Souvant/AFP/Getty Images)

A spokesperson for BC Children's Hospital in Vancouver said in an email that among the children and youth assessed by its eating disorders program during the pandemic, 94 per cent needed to be hospitalized, compared with an average of 56 per cent in the five years prior.

Mother worried teen wouldn't survive

Before he entered care, Janice Savage worried that RJ would be among those who didn't survive his eating disorder.

On the evening before she and RJ's dad took their son to emergency, Savage tucked him into bed.

"And I remember standing at his door thinking, I really hope he wakes up because he was not doing well at all."

Eating disorders can be insidious, Savage said, noting that RJ wasn't outright refusing to eat, so it wasn't obvious at the dinner table. 

He was so depleted by the time we got the help for him, I shudder to think what would happen if we had waited another week or another hour even to make that phone call.- Janice Savage, RJ's mom

"He was so depleted by the time we got the help for him, I shudder to think what would happen if we had waited another week or another hour even to make that phone call," she said. 

Johnson said that people can be critically ill with an eating disorder without presenting in a really obvious way. For example, someone who has a larger body to start with may lose an enormous amount of weight in a short time but "not look emaciated."

"And yet their blood pressure is terribly low. Their heart rates are very low."

She encourages family members and clinicians alike to remember that eating disorders can affect people of all body sizes, all walks of life and all genders.

Why the pandemic spike?

Experts say that eating disorders are about much more than food — they're also about asserting some control when circumstances leave us with little power over a situation.

"Regimen has always been a thing in my life, so as soon as a wrench is thrown into the plan here, it's like, 'OK, well, now I've got to come up with something," RJ said. "Working out every single day was kind of this nice little consistency."

Prior to the pandemic, a typical week for RJ included school, basketball and hockey practices, shooting hoops for fun with friends and workouts at the YMCA. (Submitted by Janice Savage)

Susan Climie, executive director of the Looking Glass Foundation for Eating Disorders — a Vancouver non-profit that's seen demand for its community-based peer-support programs rise as much as 400 to 500 per cent during the pandemic — said isolation during lockdowns is behind some of the surge.

Isolation means being cut off from friends, mentors and other sources of support that help boost mental health in normal times, she said.

"Another thing with eating disorders specifically was right off the bat, there was all this talk about food shortages and hoarding," Climie said, a triggering scenario for anyone who struggles with an eating disorder.

Plus, the "body shaming" language thrown around on social media about gaining the "COVID 15" has fuelled negative feelings about potential weight gain, said Suzanne Phillips, program manager for NEDIC in Toronto.

WATCH | Hospital sees 'drastic' rise in youths struggling with eating disorders:

CHEO sees ‘drastic’ increase in youth struggling with eating disorders

CBC News Ottawa

2 months ago
1:06
Joanne Lowe, executive director of the youth services bureau at CHEO, says the hospital has seen a 63-per-cent increase in the number of youth seeking help for eating disorders since the start of the pandemic. 1:06

What can be done?

Those on the front lines of what some have called a shadow pandemic say they needed funding to expand treatment capacity for eating disorders even before COVID-19 — and that money is needed now more than ever.

Phillips said she'd like to see "more treatment, more supports in communities where people live."

She said that will take "an acknowledgement that eating disorders, aside from opiate addiction [recently], are the deadliest of all mental health illnesses."

Panic buying and food security issues at the start of the pandemic, as reflected by empty shelves at a store in Laval, Que., in March 2020, were among the triggers that have heightened the risk of eating disorders. (Ryan Remiorz/The Canadian Press)

Johnson, too, said she is worried about bad outcomes among young patients, given that eating disorders also put them at risk of other problems, including growth failure and delayed puberty.

"There are so many different medical and mental health comorbidities that can affect these young people long term," she said. "So even the ones who are not on death's door are at risk of serious complications."

Johnson said she shares the perspective of a number of other pediatric health-care providers who worry about young people being under lockdown, often unable to return to school and otherwise access community supports — such as friends, mentors, coaches and extended family. 

"We are advocating for, where possible — and being mindful of the impact of COVID — that young people be allowed to have some of those connections. I think that will build resilience and strength in them and help them deal with a lot of the stress that is being imposed by this pandemic," she said.

For help, contact the National Eating Disorder Information Centre for live chat online or over the phone, and to be connected with help in your community. nedic.ca 1-866-NEDIC-20 


Written by Brandie Weikle. Produced by Jeff Goodes, Willow Smith and Dawna Dingwall.

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