By Carly Menker
Medill Reports

A 17-year-old girl diagnosed with anorexia nervosa dreaded holiday meals.

So, two years ago, instead of joining Thanksgiving dinner, she faked being sick all day and refused to come downstairs. The plan that fooled her family that day. But in a session with Julie Raymond, director of eating disorder services and licensed therapist at Cityscape Counseling in Chicago, she admitted the truth. She ate nothing all day and avoided the dinner because she didn’t want to eat around them or to hear them comment on her weight.

For adolescents with eating disorders, the season from Halloween to New Year’s can be extremely stressful. “Holidays are kind of binge-focused, meaning you’re not really listening to your hunger and fullness,” Raymond said. “It’s just kind of there’s all this food around you and you eat, eat, eat.”

Since 2016, the National Eating Disorders Association has consistently reported that for the more than 30 million people with anorexia, bulimia, binge-eating disorder and other eating-related disorders, the holidays can lead to unhealthy thoughts around food. Eating disorders are second only to opioid overdose as the deadliest mental illness, and 10% of those with eating disorders lose their lives as a result, with about 26% of those people attempting suicide, according to NEDA.

“(Holidays are) when most people restrict eating much of the day and then have a socially sanctioned binge in the late afternoon or evening,” said Dr. Ellen Astrachan-Fletcher, the regional clinical director in the Midwest of the Eating Recovery Center. “While for most people one day of disordered eating is just a holiday tradition, for someone with an eating disorder, it is an incredibly vulnerable position and a harrowing challenge.”

Could young people in the time of COVID-19 be restricting their food intake to try to regain a sense of control over their lives? Maybe, said Dr. Shairi Turner, chief medical officer at Crisis Text Line. According to NEDA and the Crisis Text Line, hospitalizations relating to eating disorders, overall helpline volume and the percentage of eating disorder and body-image conversations have increased over the past two years.

Despite new coronavirus variants and new safety questions, many families are gathering again.

“Uncertainty in the lives of people with eating disorders can be a trigger because these disorders are about control,” Turner said. “This holiday season specifically is one where we’re trying to get (back) to a new normal.”

Recognizing the signs of eating disorders in teens can be tricky. They may include the refusal to consume favorite meals, frequent trips to the bathroom after eating, discomfort cooking or being around food, isolation, increased irritation or mood swings, snacking in secret, talking about being on a diet or comparing one’s body to someone else in the family, said Nicole Bentley, senior director of intake services and clinical operations and licensed therapist at Cityscape Counseling in Chicago.

“Eating disorders are not only about the food,” she said. “A kid who is struggling with an eating disorder may also be struggling to make sense of their family dynamic, fit in with friends, feel loved or like they belong.”

Families should provide validation and care to adolescents struggling with an eating disorder during the holiday time. Dr. Anna Tanner, vice president of medical services at Veritas Collaborative, a nationwide health care system that merged with another system, The Emily Program, for the treatment of eating disorders, emphasized the importance of strategies and planning in advance.

A high-school age patient of Tanner’s used a bracelet. When she wore it on one wrist, she signaled that she was doing OK. But if she switched it to the other wrist, she let her know she needed support.

“I love that kind of family code where you don’t have to say much, (and) you don’t have to do much,” Tanner said. “You just are there to be supportive.”

Patients and caregivers can send a text, write a note, share a common space or even do a puzzle together. Tanner also suggested planning an exit strategy, with a code word, or change-the-subject idea, with a question about guests’ favorite part of the holidays when they were younger.

Dr. Jillian Lampert, the chief strategy officer at The Emily Program, recommended that adolescents focus on regulating their own eating by stopping when they are satisfied, providing self-care, getting at least seven hours of sleep and enjoying non-food-related holiday activities such as walking the neighborhood looking at decorations or spending time with family away from the dinner table.

“It’s really the taking care of yourself through rest, downtime, eating in tune with what your body needs and moving your body in a way that’s refreshing,” she said.

Limit time on social media sites, where it’s too easy to view pro-anorexia and pro-bulimia posts that contribute to anxiety, eating disorders, depression and suicide, Turner said. Even seemingly innocent holiday pictures can pose a problem.  “Food is going to be on social media and can be triggering,” she said.

Social media sites are aware of the dangers they impose on users. On Dec. 8, the Campaign for Accountability, a nonprofit watchdog group that runs the Tech Transparency Project, released a report in collaboration with Reset, an initiative engaged in programmatic work on technology and democracy. “Instagram continues to promote dangerous eating disorder information to vulnerable users including young teenagers, despite promises to remove such content,” the report said.

Avoid discussing food too. “If somebody starts talking about weight or calories at the table, who’s prepared to intervene and change the subject?” Tanner said. “Another really important part of planning for a safe and enjoyable holiday is also being prepared to establish boundaries with family members or friends that you haven’t seen in a really long time.”

Lampert suggests diverting the conversation.

“If you’re at a gathering and somebody launches into (saying), ‘Oh, I can’t believe after eating this or that after the new year,’ you (can) interrupt that conversation and say, ‘Hey, you know, I’d much rather talk about something that’s really meaningful, or ‘Hey, that’s not very helpful. Let’s talk about this,’” she said. “If we just keep letting those pass by, it won’t change.”

Carly Menker is a health, environment and science reporter for the Medill News Service and a Comer Scholar at Medill.  Follow her on Twitter @carlymenker.