Understanding the surge in teen conversations about eating disorders
By: Prateek Puri
Tags: Mental Health, Teens, Data Science, Covid 19, Eating Disorders

Eating disorders and body image issues have surged amongst the teens who texted us during the COVID-19 crisis. We were not the only ones to notice this trend — teen admissions to eating disorder treatment programs have skyrocketed; eating disorder hospitalizations doubled in certain areas of the country during lockdown, and our partners at the National Eating Disorders Association (NEDA) have noticed a 58% increase in their helpline traffic over the pandemic¹.

This jump in disordered eating requires the attention of all adults working to support teens as they transition back to in-person schooling. Claiming 10,000+ lives per year in the US, eating disorders have the second-highest mortality rate of any psychiatric condition after opioid addiction. They also have a history of being undetected and under-diagnosed, which can lead to tragically low recovery rates and a lifelong battle for those affected and their families.

So, as schools are about to reopen across the country, our team at Crisis Text Line has been trying to better understand the dynamics behind the surge in eating disorders. We checked in with our partners at the NEDA, and with their guidance, sifted through 520,000 counseling transcripts on our platform to track how often eating disorders were discussed and what topics were driving these conversations. Here is what we found².

1. Teen conversations about eating disorders and body image issues surged on our platform in 2020.

Conversations with teens about eating disorders and body image issues increased on our platform in 2020 compared to previous years, based on analysis of over 500,000 Crisis Text Line conversations that took place between 2017–2020. The peak increase occurred in May 2020, where we noticed a 40% jump in these types of conversations over the 2017–2019 average for the month.

Figure 1: The top graph shows the percentage of conversations on our platform with school-aged texters (17 and under) that were assigned an eating disorder issue tag by our crisis counselors over the course of a year. In both plots, the monthly percentages for 2020 (red) are shown as well as the average monthly percentages for the years 2017–2019 (gray). The second graph shows the percentage of conversations on our platform with school-aged children that contained at least one keyword from our Eating Disorder Keyword List. In both plots, the 2020 time-series was constructed from a set of roughly 100,000 conversations on our platform, and the 2017–2019 data was constructed from a set of roughly 300,000 conversations. All age information about our users was self-reported through voluntary post-conversation surveys

We measured the increase in eating disorder activity on our platform in two ways. First, after every conversation with a user, trained Crisis Text Line counselors “tag” the conversation³ as belonging to one of several possible issues, such as depression/anxiety, eating disorder and body image issues, emotional abuse, and other⁴. Compiling these tags together, we tracked how the number of eating disorder tagged conversations changed on our platform over the course of 2020 as compared to previous years.

As a secondary measure, we also looked for conversations that contained at least one of several keywords commonly associated with eating disorders. We built our keyword list after collaborating with experts at NEDA, who helped ensure the list was comprehensive. While the context in which these keywords appeared wasn’t considered, tracking keywords gave us another way to monitor eating disorder activity on our platform that didn’t rely on potentially subjective crisis counselor evaluations.

Our keyword list (provided below) includes a mix of disorders (anorexia, bulimia, pica), food rituals (calorie counting, emotional eating), body image related expressions (bmi, fat, weight), and even laxatives. Aside from its use here, we hope this keyword list can also help other analysts who are screening for similar conditions by sifting through text-based datasets.

The two approaches told the same story⁵. Teens were significantly more likely to text us about eating disorders and body image issues in 2020 than they were in previous years.

Eating disorder-related conversations with teens began to surge on our platform in March 2020 and rose rapidly throughout April and May. Just eight weeks into lockdown, eating disorder activity on our platform had risen by nearly 50%. As the year progressed, however, eating disorder and body image conversations dropped, converging back towards the average of previous years.

Looking at the table below, it is also noteworthy that the most common keyword associated with these conversations was “weight” and not a specific expression related to eating disorders. (In the next part of this series, we will use machine learning to investigate words that may be indicative of eating disorders in Crisis Text Line conversations.)

Figure 2: This table contains the top ten keywords from our eating disorders keyword list that showed up most frequently in 2020 conversations (sample size = 103,016) with school-aged texters (17 and under). The appearance percentage displayed in the second column is defined as the percentage of conversations where a given keyword was mentioned at least once by the texter. Here, all texts submitted by a texter in a given conversation are scanned to identify keyword matches. See the article text for a full list of keywords in the list. All age information about our users was self-reported through voluntary post-conversation surveys. Since the context in which a keyword was mentioned was not considered, there may be situations in which non-eating-disorder-related behavior was also flagged (i.e. 3rd party conversations, or “binge watching” versus “binge eating”), although steps were taken to reduce these effects.

2. Mentions of “weight” and “body image” increased, but mentions of “anorexia” and “bulimia” decreased in 2020.

We identified which keywords from our NEDA list occurred most frequently in our conversations with teens to get a better handle on what topics were driving the surge in eating disorder activity on our platform. We noticed that activity around “purge,” “anorexia,” and “bulimia” decreased during lockdown. However, discussions around the keywords “weight” and “body image” increased over the same timeframe, with the latter increasing by over 100% in 2020 as compared to 2017–2019.

Importantly, a drop in keyword activity does not necessarily imply a drop in user behavior related to that keyword. Drops in words like anorexia or bulimia may have occurred because teens had limited opportunities to see a doctor (and receive a diagnosis) during lockdown and not necessarily because those conditions were less prevalent. Alternatively, the drops could signal a trend where general body image anxieties are dominating these conversations more than in previous years. (We are working on a model to better identify the linguistic signals of eating disorders in our data. We will share what we find on this blog soon. Let us know if you would like to get research updates.)

Figure 3: The chart shows eating disorder keyword appearance percentages in conversations with school-aged children (17 and under). All age information about our users was self-reported through voluntary post-conversation surveys. The percentages for 2020 conversations (red, sample size = 103,016) is displayed as well as the average percentages for 2017–2019 (gray, sample size = 320,049). The keywords “weight”, “eating disorder”, and “body image” saw the largest appearance percentage increase from 2020 as compared to previous years.

3. Bullying, self-harm, and OCD are co-occurring issues of texters struggling with eating disorders on our platform.

Effective screening is one of the strongest tools available for connecting those struggling with eating disorders to treatment. Eating disorders, highly secretive conditions, are notorious for being diagnosed too late, but teachers, parents, and other adults can play a decisive role in noticing when someone is struggling with disordered eating and getting them help.

Eating disorders often co-occur with other conditions that are easier to detect. By keeping these co-occurring conditions in mind, screeners like the ones used by NEDA have a much better chance of detecting an eating disorder when it exists. NEDA has an excellent set of resources dedicated to understanding co-occurring conditions of eating disorders, which include substance abuse, obsessive-compulsive disorder, and other conditions. Many of these findings are based on academic research conducted in inpatient settings or through self-reported surveys.

At Crisis Text Line, we have a unique insight into co-occurring issues. Unlike in most academic studies, our texters reach out to us unprompted, in the moment when they are experiencing a crisis. They may describe a range of issues with their Crisis Counselors, giving us a window into how different issues may co-occur in their lives organically in a non-clinical setting.

Sifting through over 500,000 teen conversations surrounding eating disorders and body image issues on our platform, we identified co-occurring issues by tracking what other issue tags surfaced most often in these conversations. We performed pairwise chi-squared tests (with controls for multiple testing) between eating disorders tags and every other tag in our issue tag list. In addition to these counselor labeled tags, we also created an automated keyword based tag for obsessive compulsive disorder (OCD), since this is a condition known to co-occur with eating disorders.

We found that conversations involving bullying, self-harm, and OCD often co-occurred with conversations involving eating disorders/body image issues. A conversation was more than 50% more likely to have an eating disorder tag if a bullying tag was present than if it was not. Each of the three conditions mentioned above has a distinct set of symptoms that, if identified, may allow screeners to pick up on eating disorders that could otherwise go unnoticed.

Figure 4: This table displays the issue tags (IT) on our platform that co-occur with eating disorder tags at statistically significant rates in conversations with school-aged children (17 and under) from 2014–2021 (sample size = 521, 875). All age information about our users was self-reported through voluntary post-conversation surveys. Column (1) conveys the percentage of conversations assigned the given issue tag that were also assigned an eating disorder tag, while Column (2) presents the appearance percentage of eating disorder tags in conversation not assigned a given issue tag. The last column displays the percentage increase of (1) from (2), which can be interpreted as the increase in likelihood of an eating disorder tag existing given the presence of the given tag. The large percentage increases here suggest that these conditions can be used as effective co-screeners for eating disorders. **While the self-harm and bullying tags were applied by our crisis counselors, the OCD tag is an automated tag generated based on the presence of the phrase “obsessive compulsive disorder” in conversations as well as derivative keywords. It was included in addition to the counselor tags in this analysis due to OCD’s known correlation with eating disorders in the academic literature. The correlation of gender/sexual identity, isolation, depression, anxiety/stress, suicide, physical abuse, racism, sexual abuse, relationship issues, and grief issue tags with eating disorder tags was also explored but found to be non-positive. Further, the emotional abuse, substance abuse, and COVID-19 tags were found to have positive correlations, but these correlations were not statistically significant.

Food routine disruptions, feelings of loss of control, and social media surges may have contributed to more conversations about eating disorders with teen texters in 2020.

So much of the pandemic and its effects have challenged our relationships with food. “Grocery store shortages, food hoarding, eating alone — the lockdown has reconfigured how and when we eat,” explains Elizabet Altunkara, Director of Support Services at the National Eating Disorders Association. These complexities could have strained an already complicated relationship that many young people have with food and their own bodies.

Grocery store shortages, food hoarding, eating alone — the lockdown has reconfigured how and when we eat.

And these issues were flying under the radar. During lockdown, teens spent less time eating amongst peers/teachers and less time interacting with school counselors, making it even more difficult for their conditions to be noticed by those who could intervene.

The twists and turns of the pandemic may have also provoked feelings of uncertainty and loss of control in many, which are known risk factors of eating disorders. “Eating disorders are often related to control and responses to emotions, especially traumas,” according to Allissa Torres, MSW, an expert of youth mental health and a member of the clinical team at Crisis Text Line.

Some experts also suggest the lockdown surge in teen social media use may have had an impact on body image perception, especially since these platforms were bursting with conversations on exercise challenges, pandemic bodies, and fears of re-entering society with extra weight.

Young people experiencing financial hardships or food scarcity may have felt a mounting pressure to monitor their food intake as well, and eating disorders and body image issues could have also been rising in tandem with other mental health issues. Crisis Text Line researchers and others have shown an increase in anxiety across all age groups during the pandemic, which could have contributed to deteriorating body image perceptions among young people.

We will continue to explore Crisis Text Line conversations to learn more about the reasons behind the surge in eating disorders in 2020. In the meantime, we worked with our partners at NEDA and internal subject matter experts at Crisis Text Line to provide the following insights that policymakers and school administrators can consider to address this trend as young people return to in-person education.

1. It is crucial for school staff to look for warning signs of eating disorders.

“Some schools do not have any resources at all for students who are suffering from eating disorders,” according to Elizabet Altunkara of NEDA. As a first step, it is crucial for all school staff to be aware of eating disorder warning signs and know the appropriate steps to take. NEDA has an online educator toolkit that teachers and staff can use to learn more about eating disorders and ways to help their students struggling with them. The document includes a list of behavioral, emotional, and physical signals that can be warning signs of an eating disorder in a school setting and detailed explanations of how eating disorders impact students’ cognitive ability and functioning at school.

2. Effective screening can help identify and address eating disorders before they escalate.

Eating disorders are often diagnosed too late, and when they turn into chronic conditions, they can be distressing for entire families and communities. Screening for these conditions and teaching students where and how to get help are critical steps to empower them.

School staff, primary care providers, and students can all play a role in the screening process. The NIH has published screening guidelines with four specific questions that can help primary care practitioners and others who regularly interact with teens to screen at-risk behavior. NEDA has also developed an online self-screening tool that is appropriate for individuals ages 13 and up. Crisis Text Line also offers resources and crisis support via web chat where those struggling with eating disorders and body image issues can chat with a Crisis Counselor (live).

Schools can invest resources in advertising on-campus counseling services if they exist. Struggling students can also be directed to NEDA’s free call, chat, and text options, as well as receive crisis support through their partnership with Crisis Text Line. Given that body image issues appeared nearly twice as often during lockdown as compared to years past on our platform, targeting additional resources to both screening and resource education on these issues may be warranted. For example, school-based body image prevention programs have proven effective in certain settings, some of which require minimal additional staff training.

3. Screening for known co-occurring conditions of eating disorders can help uncover eating disorders that might otherwise be difficult to detect.

Identifying and screening for co-occurring conditions can improve the chances of an eating disorder being properly diagnosed. NEDA has published a set of resources on co-occurring conditions of eating disorders, which include anxiety, depression, OCD, diabulimia, pregnancy, substance abuse, and PTSD. Through analyzing our own conversations with teens, we also found that OCD, self-harm, and bullying are conditions that tend to co-occur with eating disorders on our platform.

Next steps at Crisis Text Line

As teens across the United States reenter in-person education, we hope these findings can provide additional evidence to aid detection of at-risk teens in what may be an ongoing mental health crisis. We will continue to study conversations on Crisis Text Line’s platform to understand the language that our texters use to describe crises related to eating disorders and body image issues. In the next part of this series, we will use machine learning to identify conversations about eating disorders based on the words our texters use in conversations with Crisis Counselors.

Would you like to learn more about Crisis Text Line data?

We support communities across the nation and provide partners, journalists, and researchers with the data they need to make more informed decisions around mental health. Interested? Email us at research@crisistextline.org

We’d love to hear from you.

Notes

[1] NEDA observed a 58.8% increase in total helpline contact from June 2020-May 2021 as compared to June 2019-May 2020.

[2] Throughout the post, we use “teens,” “adolescents,” and “young people” interchangeably to mean school-aged people who are 17 years old or younger.

[3] Each counselor may have his or her own definition of what constitutes an eating disorder tag.

[4] The full list of counselor tags includes emotional abuse, physical abuse, sexual abuse, abuse (unspecified), anxiety/stress, grief, depression, isolation, bullying, gender/sexual identity issues, relationship issues, self-harm, substance abuse, COVID-19, racism, eating disorder/body image issues, and other. Crisis Counselors can check all that apply.

[5] Both measurements have potential sources of error in tracking eating disorder activity on our platform. For example, counselor tags are subjective and vary counselor-to-counselor, while direct keyword matching does not account for the context in which the keywords were mentioned. However, both measures indicate an increase in eating disorder activity on our platform, consistent with increases seen by other organizations (see introduction).