Research Snapshot: Virtual care recommendations for individuals with eating disorders during COVID-19

Virtual care recommendations from the Canadian consensus panel for children, adolescents, and emerging adults with eating disorders during the COVID-19 pandemic and beyond

What you need to know

Children, adolescents, and emerging adults with eating disorders (EDs) are struggling due to the COVID-19 pandemic—evident from dramatic surges in new ED cases and hospitalizations around the world. Closures of ED day hospitals and long treatment waitlists have left those with severe EDs without any options for treatment. Despite the transition to virtual care for the delivery of outpatient ED services in Canada,there are no guidelines for the use of virtual care in this field. Identifying effective and viable virtual care options for EDs is essential, particularly during the present and post-pandemic era, when vulnerable ED populations are at significant risk of death should they not receive appropriate care.

In this project, a panel of stakeholders from across Canada developed the first Canadian clinical practice guidelines related to the provision of virtual care for children/adolescents and emerging adults living with EDs, as well as their caregivers, during the COVID-19 pandemic and beyond.   

 

This Research Snapshot is based on the article, “The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond,” which was published in the Journal of Eating Disorders 2021. https://doi.org/10.1186/s40337-021-00394-9.

Research Snapshots are brief, clear language summaries of research articles, presented in a user-friendly format.

What is this research about?

Throughout the COVID-19 pandemic, many youth are feeling isolated and experiencing uncertainty and lack of structure. Individuals with EDs are also experiencing negative impacts related to COVID-19, which include worsening symptoms, increased anxiety and risk of relapse. Social media posts have bombarded the public about “inevitable” weight gain related to staying at home. These posts may lead people to develop harmful concerns about what the ideal shape and weight and, among those with EDs, they may result in compensatory eating behaviours.

There has been a lack of direction in terms of the best options for virtual ED care during the COVID-19 pandemic. Although telehealth appears to be a promising alternative, it can be especially challenging with EDs. For example, it does not foster rapport building between the therapist and client, increases feelings of self-criticism associated with video calls, and removes the accountability with weigh-ins that is part of in-person sessions. As a result, the objectives of this project were to synthesize the best available evidence on: a) the impact of COVID-19 on children, adolescents, and emerging adults with EDs and their caregivers, and b) virtual treatments and other support and technologies for this population.    

This team conducted a study to try and answer the following questions:  

  1. What is the impact of COVID- 19 on children, adolescents, and emerging adults with EDs and their caregivers?
  2. What evidence exists on treatments that can be delivered virtually?
  3. What evidence exists on self-help approaches for children, adolescents and emerging adults with eating disorders and their caregivers?
  4. What evidence exists on other e-technology (e.g., email therapy, text messaging therapy, smartphone apps)?
  5. What evidence exists on virtual day hospitals, virtual group therapy, and virtual meal support?
  6. When should children, adolescents and emerging adults with EDs be seen in-person for evaluation? And how can medical monitoring be done at home?
  7. How do sex and gender impact virtual care?
  8. What are the gaps in the research evidence?

What did the researchers do?

The research team conducted a scoping review of all evidence pertaining to the impact of COVID-19 on the ED population, virtual ED treatment in the COVID-19 context, and research focusing on other novel technologies, online self-help support, and individual/caregiver experiences with online approaches,  from the last 20 years.  Included studies focused on various synchronous and asynchronous virtual approaches to treatment. This included telehealth/telemedicine, telephone support services, text messaging, smartphone apps, email, e-mental health platforms (e.g. mental health services delivered via the internet or other digital technologies), self-help, and moderated online forums.

Studies were not included if they focused on adults 25 years and older, did not include EDs or disordered eating behaviours, and any studies on social media. The research team rated the quality of included studies and then created recommendations for virtual care for children and adolescents (less than 18 years) and emerging adults (between 18–25 years) with EDs, as well as their caregivers. These recommendations and evidence profiles were presented to a panel of stakeholders from across Canada, including clinicians, researchers, parents, and those with lived experience. The panel discussed and voted on the recommendations, and ultimately developed high-quality treatment guidelines. 

What did the researchers find?

The researchers included and analyzed 14 research papers on the impact of COVID-19 on EDs, as well as 69 research papers on virtual care for EDs in their scoping review. 

They recommended the following approaches based on strong evidence:

  • For all ages: In-person medical evaluation, when necessary and international guidelines and criteria for admission.
  • For all ages: Equal access to treatment for equity-seeking groups and marginalized youth.
  • For emerging adults: Internet cognitive behavioural therapy (CBT)-based guided self-help.
  • For caregivers of emerging adults: Guided parental self-help CBT.

The researchers found weak evidence in support of the following approaches:

  • For children and adolescents: Telehealth family-based treatment (FBT) and online guided parental self-help FBT.
  • For caregivers of children and adolescents: Virtual parent meal support training and moderated online caregiver forums and support groups.
  • For emerging adults: CBT-based group internet interventions, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps.
  • For caregivers of emerging adults: Unguided caregiver psychoeducation self-help.

Limitations of the research

The researchers note that they were not able to examine sex differences due to the limited number of male participants in included studies and lack of information on the impact of sex on virtual care in the literature. Additionally, many studies included in the scoping review enrolled participants based on symptoms identified through ED symptom surveys instead of a professional diagnosis, which made it difficult to definitively recommend any virtual treatment for specific ED diagnoses.

How can you use this research?

Several gaps for future work were identified, including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents and emerging adults with EDs, as well as research on more intensive services, such as virtual day hospitals and virtual meal support therapy. The authors suggest that clinicians use these guidelines and recommendations to inform their clinical decisions on what are the most effective treatments that can be implemented for those with EDs during the COVID-19 pandemic and beyond.

About the researchers

Jennifer Couturier1,2 , Danielle Pellegrini1, Catherine Miller3, Neera Bhatnagar1, Ahmed Boachie4, Kerry Bourret5, Melissa Brouwers6, Jennifer S. Coelho7, Gina Dimitropoulos8, Sheri Findlay1,2, Catherine Ford9, Josie Geller7, Seena Grewal4, Joanne Gusella10, Leanna Isserlin6, Monique Jericho8, Natasha Johnson1,2, Debra K. Katzman4, Melissa Kimber1, Adele Lafrance11, Anick Leclerc2, Rachel Loewen12, Techiya Loewen13, Gail McVey4, Mark Norris6, David Pilon10, Wendy Preskow14, Wendy Spettigue6, Cathleen Steinegger4, Elizabeth Waite15 and Cheryl Webb1,2

  1. McMaster University, Hamilton, ON, Canada.
  2. McMaster Children’s Hospital, Hamilton, ON, Canada.
  3. Canadian Mental Health Association, Waterloo, ON, Canada.
  4. University of Toronto, Toronto, ON, Canada.
  5. St. Joseph’s Care Group, Thunder Bay, ON, Canada.
  6. University of Ottawa, Ottawa, ON, Canada.
  7. The University of British Columbia, Vancouver, BC, Canada.
  8. University of Calgary, Calgary, AB, Canada.
  9. Ontario Ministry of Health and Long-Term Care, Toronto, ON, Canada.
  10. Dalhousie University, Halifax, NS, Canada.
  11. Laurentian University, Sudbury, ON, Canada.
  12. Patient advocate, Woodstock, ON, Canada.
  13. Parent advocate, Woodstock, ON, Canada.
  14. National Initiative for Eating Disorders, Toronto, ON, Canada.
  15. Parent advocate, Ottawa, ON, Canada.