Content Warning: The following feature describes eating disorders, disordered eating behaviors, and mental illness, which can be disturbing or triggering for some readers. Please find resources listed at the bottom of the article.
Gia* can remember precisely the first time she threw up after a meal—her family went to a restaurant right before she left for college. “I had lost a lot of weight. I just started freaking out like, ‘Oh my God, I’ve eaten something. This is going to throw my plan off entirely.’ And so I threw up,” says Gia. “Honestly, I want to say that I felt bad afterwards, but I just felt relieved.”
Gia approached her purging systematically. Throwing up was a response appropriate only to eating “an especially heavy meal.” She never imagined that she would soon be throwing up once a day, then multiple times a day, then after every meal she ate. Her eating disorder has ebbed and flowed over the last several years, but by the time she logged into online classes for the first time in her bedroom on a quiet, spring night in India, she was back in the throes of bulimia.
Going home to New Delhi after the University shut down in March 2020 meant adapting to a new timezone. Gia—a triple major—had to abruptly transition to a new schedule. She would wake up in the evening as her family went to bed, attend her many Zoom classes throughout the night, then go to sleep in the early morning.
“My schedule was quite literally just eating and then studying. I was so tired by the end of classes that I didn’t have time to FaceTime my friends because my sleep cycle was completely off schedule. I did not have much human contact. I wasn’t even getting sunlight. I really treat sunlight as a luxury now,” she says.
Suddenly, Gia was spending all of her meals alone, with no family or friends to keep an eye on her eating patterns. Isolated and stressed out, her eating disorder worsened.
“The first three months of the pandemic were really, really bad … That is when I developed my most unhealthy relationship with food,” she says.
Quarantine offered us something novel: limitless time in a limited space. Suddenly, we had all the time in the world to analyze our bodies in the mirror, to inspect our faces on Zoom, to track our daily caloric intakes, to journal our thoughts, to fixate on our daily routines.
For some, the pressure to use that time effectively made diamonds. People made habits out of going on daily walks and cooking meals. But for many others, the pressure overwhelmed them.
A recent survey published in the International Journal of Eating Disorders found that around 62% of respondents with a history of anorexia nervosa in the United States reported that the pandemic exacerbated their illness, with increases in food restriction and heightened fears about gaining weight during quarantine. Binge eating increased by 30%. When asked to rate their levels of anxiety for various COVID–19–related stressors, respondents with prior eating disorders cited barriers to exercise, concern over the lack of structure in their lifestyles, and inability to access food consistent with their diet plans the highest.
And it’s not just those with a history. The National Eating Disorders Association reports that calls to its hotline have increased by a margin of 70–80% during the past year.
Eating disorders are ranked as the second deadliest mental illness. Almost a third of people with eating disorders attempt suicide in their lifetime. Others have lifelong health complications, some of which can be fatal.
Yet the progression of an eating disorder is far less clean–cut than teen dramas portray it to be. A mere 6% of people with eating disorders qualify as “clinically underweight,” and many people don’t ever fit into any diagnostic criteria.
So when does keeping a strict keto diet and doing daily abs exercises become maladaptive? At what point can these behaviors be called an eating disorder? What is clear among these blurred boundaries is that the pandemic provides a breeding ground for eating disorder tendencies, plaguing those with a history of eating disorders and those without.
When asked to describe the development of her eating disorder leading up to the pandemic, Gia quotes her mother:
“You need to get a little thinner and look a little prettier.”
“Have you not been taking care of yourself?”
“You put on too much weight.”
“You’ve lost weight—you look great.”
Her mother doesn’t know about her bulimia. Gia doesn’t blame her for her eating disorder. Rather, she sees the criticism her mother doles out as a product of her upbringing.
“I think South Asian culture is very body–centric, especially for women. My mom constantly told me to lose weight. I don’t want to vilify her; she did it because she clearly loved me a lot,” she says. “But I think what ended up happening, for me, is that I started developing a really bad relationship with food. I’ll end up eating too much or even eating a normal amount of food, then feel guilty about consuming it.”
Gia put on weight prior to Penn’s closing—a side–effect of a stressful course load of upper–level computer science and math classes—and she worried how her mother would respond. She had developed a routine of losing a couple pounds in the weeks before she returned home from college. This time, she didn’t prepare.
“I went home, and my mom kind of freaked out ... She basically just told me, ‘You put on weight, and I think that you need to make healthier choices.’ I think for me, the funniest thing was that I was at a point where I felt the most confident in myself. I was maybe a few pounds heavier, but I just felt good about myself,” Gia says.
Gia took her mother’s claims seriously and went on a strict diet. Her family complimented her on her weight loss. Yet with rigorous classes and a nocturnal sleep schedule that prevented any social interaction, Gia couldn’t maintain the diet, and that’s when bulimia came back into her life.
“I had been really good about not throwing up after eating, but as soon as that happened, I started getting worried that, ‘Oh my god, I’m going to put on weight again,’” says Gia. “I kind of went down a spiral.”
As a clinical psychologist at the Children’s Hospital of Philadelphia, Dr. Alix Timko works with patients suffering from eating disorders every day. She is an assistant professor of Psychiatry in Penn’s Perelman School of Medicine and the director of psychiatric and behavioral health research in the Eating Disorder Assessment and Treatment Program at CHOP. Dr. Timko estimates that the hospital experienced a consistent 50% increase in new eating disorder cases calling the hospital and requesting treatment each month in the past year.
Dr. Timko explains that the line between eating healthier and restricting or getting fit and over exercising is incredibly thin. For many, reaching a caloric deficit and seeing weight loss can trigger the development of an eating disorder. And with the pressure to ‘glow up’ during quarantine constantly looming, “[this] scenario [is] playing out over, and over, and over again.”
She adds that inpatient treatment programs across the country currently have waiting lists upwards of six to eight weeks, which is an unprecedented figure in the world of eating disorder treatment. Many of these facilities have had to decrease their number of beds due to COVID–19 regulations. As clinicians across the country have had to meet an increased need for their services, they’ve had to do so through a screen. Telehealth visits have become standard practice, and they come with their own set of challenges.
“Anywhere from about one–third to one–half of individuals have reported difficulties accessing care … Not everybody has access to the technologies for telehealth. Not everyone likes using telehealth or being on video cameras,” says Dr. Timko.
Another complication: Every U.S. state has different laws regarding whether or not clinical psychologists can practice telehealth across state lines.
“If I’m working with a family who has a child with an eating disorder and that family lives in New Jersey, they would typically drive to Philadelphia to see me. In the pandemic, that wouldn't happen. But I’m not licensed to practice psychology in New Jersey,” says Dr. Timko. Initially, this meant that she may not have been able to treat those patients.
Some licensing laws changed rapidly in response. New Jersey instituted an emergency order so psychologists could apply for temporary permission to practice telehealth in the state if they lived outside of it. Similar emergency orders were implemented across the country.
Penn’s Counseling and Psychological Services (CAPS) also shifted abruptly to telehealth when students dispersed across the world last March. Dr. Valeriya Spektor, a staff psychologist at CAPS, says that the department transitioned quickly to a secure video–conferencing platform and phone sessions for students. Dr. Spektor is a member of the Eating Concerns Team, an interdisciplinary division of CAPS made up of doctors, psychologists, and nutritionists dedicated to holistically treating eating disorders in Penn students. Through this team, CAPS provides students with medical evaluations, nutritional counseling, group therapy, individual therapy, and recently, a support group for students struggling with body image concerns.
Gia was one of those students. She calls CAPS “her safe space.” Yet doing therapy sessions from her room in New Delhi presented a host of problems. For one, there was the obvious time difference. More importantly, there was little privacy.
“I’d be scared that my parents would hear me over the calls, which made life a lot harder. Being on campus and getting help is a lot easier than being at home, particularly when you don’t think your parents would really understand that you need help for something,” she says.
When Emma Van Zandt (C ’22) swapped her apartment at Penn for her childhood bedroom in Alexandria, Va., she was in the midst of what she calls “SOS Emergency Protocol.”
Emma first developed disordered eating in the sixth grade. In eighth grade, she lost so much weight that she had to be admitted into an inpatient care facility, where she was diagnosed with anorexia. After steadily gaining back the weight throughout high school, her anorexia was re–labeled as EDNOS, a catch–all term for people who don’t meet the stringent criteria for a specific disorder. When she came to Penn in the summer of 2018, she made the decision to stop her treatment altogether. She relapsed a few months in.
“I just wouldn’t eat,” she says. But there’s a narrative that lingers underneath that simple statement. Starving herself in anticipation of going out and binge drinking. Drinking on an empty stomach and getting sick. Watching her friends not eat all day to fit into dresses for date nights. Missing the scheduled dining hours at Hill House and using it as an excuse to skip dinner. Feeling freedom from the lack of supervision, and feeling out of control from that freedom.
In a sea of uncertainty, Emma says she clung to her eating disorder.
“It becomes a coping mechanism for other things going on in your life. It's a cyclical thing where it just makes everything worse, but it provides temporary comfort in the way you’ve been conditioned to seek comfort … getting smaller, restricting your food, having control over something,” Emma says.
During her sophomore year, Emma found a treatment facility in Philadelphia and resumed the progress she was making in high school. Right before the onset of the pandemic, she was in what she refers to as the “management phase.” Emma will be the first to say that there is no absolute recovery from eating disorders, only “quasi–recovery.” Her lifestyle is by design: a system of strict protocols and routines that protect against fixation and restriction.
She describes going home with the same pain in her voice as she describes her first year of college. Just as she had in her Quad dorm room, she sat in her childhood bedroom at a crossroads of whether to move forward in recovery or slide backwards into the familiar comfort that counting calories and skipping meals gave her. And if Penn was a shock to her mental health, the pandemic was a full–on collision.
“I really, really, really wanted to relapse and go back," Emma says. “You know mentally that you want to recover—you want to be eating three meals a day and doing what your therapist says—but everything about it goes against what your mind wants to do, which is to restrict and go back to that comfort. I felt myself sliding back into relapse, and that's why my therapist and I went very full–force into recovery mode. But it ended up feeling just so bad.”
Recovery mode at home began with a forced breakfast. Even if she wasn’t hungry, a bowl of oatmeal and a cup of coffee were non–negotiables. She ate lunch during class, and then dinner with her family. She made a routine out of eating, relying on the consistency of it to move her forward. “I shouldn’t have to go to that super intense, super regimented schedule just to live normally and not relapse. That’s a thing that I haven’t had to do for years,” Emma says.
When asked why she thinks eating disorders have risen so dramatically during the pandemic, Emma asks if I’ve heard of Chloe Ting. It’s not just the fitness YouTuber, but the at–home exercise craze that propped her up—the pressure to use quarantine to sculpt our bodies and emerge looking like Victoria’s Secret models. Even in Emma’s group chat with her friends, there was a daily suggestion for a quick way to get fitter, or at the very least, to avoid gaining the Quarantine 15.
“I would just love for people who haven’t struggled with a diagnosed eating disorder to be a little more conscious about the type of language that they’re using,” says Emma. “You never know what people are going through. It can be so detrimental … And it's so much harder if you do relapse to come out of it because of the situation that we’re in.”
Being at home also meant navigating the generational differences around eating that she sees between her and her parents. Her parents grew up in an era of “low–carb and South Beach diets,” a culture that she says doesn't align with modern understandings of nutrition. Their mindsets clash with Emma’s learned practice of intuitive eating, a theory of eating disorder treatment that encourages you to eat when you’re hungry instead of at restricted mealtimes and focuses on maintaining your body’s natural set weight.
“They grew up with these cycles of fad diets and demonizing fats. Suddenly, fats are good, and carbs are bad,” she says. “For someone that doesn’t struggle, it probably wouldn’t really affect them. But for someone who does, it’s more problematic.”
Her mother also suffered from bulimia when she was young and still exhibits a disordered relationship with food. Emma speaks about her mother’s shortcomings delicately and without judgment, seeing her own success as a testament to how far eating disorder treatment has advanced in recent years.
“She’s not as keenly aware of the way she views things as I would be, because I’ve gone through therapy. My therapist will say, ‘You’re not responsible for what she eats, and that doesn’t affect what you eat.’ You kind of pick and choose your battles—when do you say something because it really is affecting your mindset, and you’re not able to move past it,’” says Emma.
Emma stayed in Alexandria until fall 2020. “As I’ve come back to Penn and gotten some semblance of normalcy back, things have definitely improved, and they’re slowly getting back up to the place that they would have been otherwise," she says.
Marley* doesn’t binge eat. She just purges. She meets most of the criteria for bulimia but doesn’t fit perfectly into the tight corners of the DSM–5. She first threw up while working as a counselor at a summer camp when she was 17 years old. That summer, it was every meal that she ate. Her eating disorder has taken on different shapes in the years since, but it has always remained a consistent part of her life.
“It got really bad again when I went to college. I was making a push to improve it before the pandemic started. I was making strides to move in the correct direction—I had told a few friends and was getting a lot of support from them … Then everything was just super overwhelming and it wasn’t going to happen,” says Marley.
When she returned to her family home in Long Island, N.Y. in March, her mind was on strategy, not recovery. Worried that her parents would hear her throwing up, new behaviors cropped up in her life in place of purging: compulsive exercising, meticulous food and drink journaling, calorie counting, and weighing herself on a scale twice a day.
“My parents don’t know, and I’m very conscious of them finding out … I have one very salient memory of my mom thinking that she had heard me purging and being really upset outside the door, and that drives me to not let that happen again,” says Marley. “I would say that was often a barrier to me [purging], but I don’t think it really helped with the root cause. It just made me frustrated that I couldn’t.”
Some days, she would go on a long bike ride with her friend, followed by a run on her own, and then a workout video with her sister. Most days, her only meal—aside from a “meal–ish snack”—was dinner with her family.
But it wasn’t just her parents' watchful eye that stopped her from purging while at home. The health complications from regularly throwing up for the past several years have been beyond what Marley had ever anticipated. She has acid reflux and constant stomach aches. Her throat burns after meals. Her teeth have yellowed. When she purges now, which she still does sometimes, she often dry heaves and has memory blackouts.
“I don’t think I ever completely understood what making yourself throw up for three and a half years can do until it was three and a half years later,” says Marley.
“This is not what I signed up for.”
For the past 50 years, rates of anorexia in the United States have increased in girls aged 15 to 24. It’s probably not a coincidence that the primary demographic of social media users matches this statistic perfectly, with the majority of people on apps like Snapchat and TikTok being high school– and college–aged girls. The advent of social media has fed eating disorders in the last half–century, particularly in young–adult women who are more exposed to media and susceptible to body dissatisfaction. The pandemic exacerbated this already alarming trend, as our main means of connection with the outer world occurs through a screen. For many, this social isolation can bring about more than just boredom.
“Eating disorders are by their nature very isolating illnesses," Dr. Timko says. "As the pandemic has continued, we’ve seen across the board a decrease in social interaction, so you have people that are struggling against this illness that tends to isolate you now being faced with even greater social isolation.”
The lack of human contact has created a vicious cycle: people turn to Instagram to feel connected, but the app is a trigger for relapse in itself; they can’t access the same quality of in–person treatment to break the cycle; they’re burdened by a national pressure to get fit, get smarter, pick up a language, learn a new instrument; they continue to scroll through Instagram, only digging themselves deeper and deeper into a hole; they relapse.
This pattern is not novel. The term "Quarantine 15" might become obsolete as the world returns to normal, but its implications won’t go away. The pressure to be thin, to be beautiful, to be better than we are has always been lingering under the surface. COVID–19 hasn’t created the problem. It’s just given it a narrative.
Gia has since returned to Philadelphia. She’s thrown up twice since she moved back in with her friends. Cooking makes her less likely to purge—it’s something about the effort that goes into the food. She no longer thinks that you can look healthy. You have to feel it. Her weight is secondary to her mood, her energy, her happiness.
“I spoke to my friends about my eating disorder. They’ve been really good about making me feel like I look good as I am, and I think that plays a really big part in me not struggling as much,” she says. “We tend to think we’re the only people going through massive self–perception issues, but we’re not. At least in my friend group, talking about it opened up a dialogue about struggles that other people are going through.”
Gia knows she's not fine, but she also knows she’s not alone.
* Some names have been changed for anonymity.
Resources:
National Eating Disorders Association: 1-800-931-2237: A 24-hour-a-day helpline for those with disordered eating habits to seek treatment and get screened for eating disorders.
The HELP Line: 215-898-HELP: A 24–hour–a–day phone number for members of the Penn community who seek help in navigating Penn's resources for health and wellness.
Counseling and Psychological Services: 215-898-7021 (active 24/7): The counseling center for the University of Pennsylvania.
Student Health Service: 215-746-3535: Student Health Service can provide medical evaluations and treatment to victims/survivors of eating disorders, regardless of whether they make a report or seek additional resources.
Project HEAL: Penn’s chapter of Project HEAL, a national organization that can provide financial assistance to individuals struggling with eating disorders and unable to pay for treatment.
