Reducing the Impact of Eating Disorders on Adolescent Girls

February 26, 2024 | Lexa Giragosian

Eating disorders are behavioral health conditions that affect physical and mental health through altered ideas about food, eating habits, weight, exercise, body image, and related factors. There are many different types of eating disorders, the most common including anorexia nervosa, bulimia nervosa, and binge-eating disorder. They are among the deadliest mental illnesses, second only to opioid misuse, and co-occur often with anxiety, depression, obsessive-compulsive disorder, substance use, and post-traumatic stress disorder. Their economic cost in the United States is $64.7 billion every year.

Eating disorder risk factors include experiencing weight stigma, bullying, limited social networks, trauma, and dieting, which can impact people of all ages, races, genders, and sexual identities. That said, adolescents are largely affected by eating disorders and experienced a 107.4% increase in eating disorder diagnoses from 2018 to 2022, which was exacerbated by the COVID-19 pandemic. The majority of parents reported their adolescents’ social media usage increased during COVID-19’s peak. Adolescent’s exposure to weight-stigmatizing content on social media also increased during this time and is correlated with increased rates of body dissatisfaction.

Social media usage can negatively influence body image and lead to body comparison, body dissatisfaction, and disordered eating—all contributors to eating disorder development. Reports indicate that adolescent girls use social media more than adolescent boys and are disproportionately affected by eating disorders, having a higher prevalence of eating disorders with increasing incidence compared to the general adolescent population. Further, according to a recent CDC study, pediatric emergency department visits among adolescent girls with eating disorders doubled during COVID-19.

State Policy Actions

Addressing youth mental health and social well-being is a top public health program and service priority area for several state and territorial health departments, as indicated by ASTHO’s 2023 Environmental Scan of Current and Emerging Public Health Priorities. Many states have recently proposed or enacted legislation that supports this focus, which may alleviate the impact of eating disorders on adolescent girls. Recent bill highlights include:

• New York SB-S5225: This active bill of the 2023-2024 session would add eating disorder assessments to the existing health certificate requirements for public school students.
• Louisiana HB 440: This legislation, passed during the 2022 session, requires schools to provide age-appropriate education about eating disorders as well as how to prevent them. Schools can incorporate this information into their current health education, physical education, or other related courses.
• Pennsylvania HB-148: The Pennsylvania House of Representatives passed this bill requiring schools to provide educational information to parents of children in 6th-12th grade about eating disorders as well as create a state task force to develop guidance and resources about eating disorders among adolescents. The bill is currently in the Pennsylvania Senate.
• California CA SCR14: A legislative resolution designated the week beginning on February 20, 2023, as Eating Disorders Awareness Week to improve awareness, visibility, and support.
• Colorado SB 23-14 and SB 23-17: These complementary bills created a program within the state health department dedicated to preventing eating disorders, limit the use of body mass index (BMI) in determining treatment criteria and appropriate care levels, and restrict the sale of diet pills to minors.
• Texas HB-18: The governor signed this bill in June 2023 which aims to regulate social media content available to minors. The new law requires social media platforms to develop and implement strategies to prevent the exposure of minors to negative material, including content that promotes, glorifies, or facilitates eating disorders.

Recommendations to Address Eating Disorders Among Adolescent Girls

Collaborate within Multidisciplinary Teams to Promote Eating Disorder Care Coordination

Diagnosing and treating eating disorders is a complex process that requires various players, such as primary care and mental health providers, dietitians, state health agencies, schools, clinics, and payers. Establishing care coordination systems for eating disorders with these players can improve diagnosis rates and access to appropriate treatment by developing services and partnerships, including referral pathways, provider training, and universal screening. They can be modeled after evidence-based care coordination systems for substance use disorders, which are effective in accomplishing these very goals. Vermont’s eating disorder workgroup recently developed a report for their legislature in accordance with these recommendations to improve care coordination and increase access to eating disorder services for all populations, including adolescent girls.

Implement Prevention Strategies in Schools

Focusing on school-based health systems offers an opportunity to improve adolescent mental health. School-based policy strategies to improve adolescent girls’ mental health may include incorporating eating disorder content into health education curricula, building staff capacity to address mental health concerns, and improving screening and treatment access for mental health issues such as eating disorders. Creating a supportive, accepting school environment that does not stigmatize weight is also an important role of schools in eating disorder prevention. The American Academy of Pediatrics provides additional key recommendations for schools and their collaborators regarding their role in addressing eating disorders among students.

Support Policy Action Limiting the Use of BMI as an Indicator for Eating Disorder Treatment

A stereotypical eating disorder patient is characterized as being “thin” with a low BMI; however, there are higher rates of disordered eating behaviors among those whose BMI classifies them as “overweight” or “obese.” There is an overreliance on BMI as a diagnosable criterion for eating disorders and a prevalence of weight stigma and assumptions in clinical care, contributing to the underdiagnosis of eating disorders. Even with a diagnosis, insurers often use BMI as an indication of treatment need, length of stay, and level of care, which inhibits access to appropriate treatment. In June 2023, the American Medical Association issued a new policy that recognizes the issues of using BMI to measure health as a step towards limiting the use of BMI.

Address Social Media Use in Programmatic and Policy Initiatives

Social media usage rapidly increased in recent years, and the effects on child and adolescent development are an ongoing concern. Evidence indicates that there is an association between social media usage and adolescent development of eating disorders due to unrealistic body expectations and diet culture outlined in media. The Surgeon General and the American Psychological Association developed guidance on addressing social media usage for children and adolescents, and specified strategies to support healthy social media use that can be utilized in public health initiatives.

Moving Forward

Eating disorders among adolescent girls are an urgent public health concern. State and territorial health agencies can move forward with prevention efforts by fostering care coordination, collaborating towards policy and programmatic developments in schools, improving access to care, and addressing social media usage. For more information about legislative trends related to eating disorders among adolescents, refer to ASTHO’s resource “Supporting Mental Health: Addressing a New Public Health Crisis,” from the 2024 Legislative Prospectus Series.