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Navigating Virtual Treatment for Eating Disorders

Kelsey Tyler

The seamstress gave the tag a quizzical look. “You’re a full size smaller,” she told me.

Some brides might be elated to learn they’d lost weight in the months leading up to their wedding. But when I tried on my wedding dress for the first time, four months after I ordered it, I was devastated to feel the loose bodice around my waist.

“I’m going to gain weight. Can we not take the dress in yet?” I asked the seamstress. To convince her that I’d soon fill out my dress, I told her I was on a weight-gain plan, per my doctor’s orders. But that was a lie. I wasn’t currently seeing the physician who’d been monitoring my anorexia recovery for almost three years. Because of the pandemic, he’d switched to telehealth for all routine care. I only saw him for weigh-ins and vital-checks, which I considered in-person services, so paying out of pocket for video chats seemed pointless. I relied on those appointments more than I realized, though, because without consistent monitoring by a doctor, I’d reverted to old habits.

I knew I needed to get back on track before my slip-up became a full-on relapse.

Triggers on top of triggers

The pandemic hasn’t been easy on anyone. For those with eating disorders, several studies indicate an increase in anxiety and symptoms of their conditions, such as food restriction, binge eating, purging and excessive exercising. The specific triggers and responses tend to vary by the disorder.  

For many people in the US, the pandemic has reduced food options in some way over the past few months. For someone who has anorexia, it can be extremely distressing to lose access to foods that are “safe” and consistent with their meal plan. “If they were unable to physically go to a grocery store or if they could not navigate or afford an online delivery service, the default option is restriction,” says Cynthia Bulik, founding director of the University of North Carolina Center of Excellence for Eating Disorders.

Meanwhile, foot shortage concerns and subsequent stockpiling of energy-dense foods like pasta early on in the pandemic may have triggered people with bulimia and binge-eating disorders. “These are often the types of foods that people with binge-type eating disorders explicitly keep out of the house to remove the temptation to binge,” Bulik explains. 

There’s also the fact that people with eating disorders often cut themselves off from others. “By being forced to self-quarantine, there’s less availability for connection and support,” which can lead to coping in less healthy ways, says Rebecca Berman, clinical training specialist at eating disorder treatment facility the Renfrew Center.

Finally, conversations about quarantine weight gain only compounded the mental-health impact of gyms closing and workout routines being upended in other ways, Bulik notes. She co-authored an April-May survey of 1,000 people with self‐reported eating disorders. More than half of respondents reported frequently feeling anxious about not being able to exercise

That was me. I believe that if not for the coronavirus, I would have kept up with my recovery, instead of restricting my caloric intake and going overboard with exercise. And without an upcoming wedding, I would have managed pandemic-related anxiety better. But the combined effects of both stressors got to me. Despite having ready access to treatment from a doctor and dietitian, I fell back into the familiar embrace of anorexia, comforted by the sense of control it gave me.  

Navigating a Different Kind of Care

A lot of healthcare, including talk therapy and many sick visits, can be done via telehealth. Virtual ED treatment is possible, but research suggests the abrupt shift to online care prompted by COVID has been a mixed experience for patients. In a small study published online in the Journal of Eating Disorders, some people with eating disorders who shifted to telehealth said the quality of care fell short compared to their pre-pandemic face-to-face visits.

Successfully adapting in-person ED treatment to a virtual setting can require reimagining several different services. Therapy, a critical component of ED treatment, is fairly adaptable — but not without some thoughtful adjustments. “Therapists cannot assume that virtual care is a perfect replacement for traditional psychotherapy, and work with their patients to optimize and personalize the digital treatment,” Bulik says. This could include making sure patients and providers are in private spaces where neither can be overheard, and tweaking the setup if patients are preoccupied by, or otherwise uncomfortable with, seeing themselves on screen. For example, some patients angle their cameras to display only their heads; others change their settings so they can’t see themselves at all.

Therapists and dietitians also figured out how to provide meal support remotely: A patient positions their camera so their food is in view of their provider for the entire meal. As they eat, “we talk about how they’re feeling and being in the moment, rather than distracting themselves,” Berman explains. “The goal is to help them build emotional tolerance so they can do hard things and have real, sustainable change.” 

Weigh-ins, however, proved especially challenging.

“Weighing is absolutely the most difficult thing to adapt to virtual treatment,” says Bullik. “In person, we can see if someone appears to be losing weight or looks unwell, but this basic visual contact is very distorted on a screen.” 

Typically ED patients are discouraged from keeping scales at home in order to prevent obsessive weight-checking. But when in-patient visits hit pause, some providers and treatment facilities like the Renfrew Center asked some nonresidential patients to buy scales and step on them in front of their webcams, so they could do weigh-ins during virtual visits. Then, just as they would have done pre-pandemic, providers discuss patients’ feelings, sensations and thoughts in that moment.

As with most healthcare during the pandemic, virtual ED treatment remains a work in progress for many providers. “We found ways to make it feel like [patients and providers] are in the same room, and we train staff to be animated and connect through the screen,” Berman says. Both she and Bulik hope that telehealth continues to be an option. “People can always come up with reasons not to come into treatment — they’re getting married, going to college, they just got a promotion,” Berman says. “This helps us find ways to make treatment happen.” 

Of course, convenience is only a selling point for virtual care if you can access it. February and July, an estimated 12 million Americans lost their jobs and, as a result, insurance coverage. “In our survey, 45 percent of individuals with active eating disorders were not receiving treatment — and that was in April,” says Bulik. “Our fear is that unemployment is going to keep rising, health insurance coverage will decrease in parallel and more people will be left without treatment teams. We could be facing a real converging disaster: mental health problems increasing, telehealth being cut off and loss of insurance.”


My doctor didn’t offer video weigh-ins. (Even if he had suggested the idea, I might have rejected it, knowing that owning a scale might lead to unhealthy behavior.) I decided to stop seeing him until in-person care returned. I’d be fine, I thought. I’d resume our visits when life went back to normal.  

Then I tried on my beautiful wedding dress. The size I ordered should have been form-fitting, but it was baggy. I knew I couldn’t wait for normal. I’d worked too hard on my health to let a slip become something more permanent, and I was lucky enough to have the resources to get care during a pandemic. My doctor’s office may have been closed, but telehealth was available. It was up to me to make it work. 

I was already familiar with virtual care. In addition to seeing a doctor for quarterly weigh-ins, I’d been doing monthly video visits with my dietitian for the better part of a year. During appointments, we discussed new goals, such as eating more diverse foods and not measuring portions, and also touched on the psychological challenges of confronting irrational thoughts. Our sessions were helpful … until COVID. As my anxiety surged, I began exercising more and eating less — and lying to my dietitian about it all.

“Recovery from eating disorders is often tenuous — it can go well when things in your life are going well, you don’t have large stressors, and you are able to access resources and support,” Bulik says. “Accountability plays an important role. Clinicians have to work really hard to maintain the rapport virtually and work toward radical honesty.”

When we met the day after my dress fitting, I confessed to all the skimpy meal portions and extra workouts I’d been hiding. I was ashamed that I needed concrete proof of weight loss to realize I’d veered off course. To make me more accountable, we started meeting every other week (and I started telling the truth). And to make it harder to lie about what I’m eating, she asked me to use a different app to log meals. Since that meeting, I’ve been uploading photos of my meals instead of typing in what I ate.

When I went in for a second dress fitting in August, my dress was still loose. So I let the seamstress take it in. Three weeks later, the waist felt tight. I reflected back on my sessions with my dietitian: Focus on why I’m getting married. The dress has no bearing on my happiness. I can just get it taken out if I need to. Plus, I saw my doctor when his office re-opened in late August. My weight was the same as when I’d last seen him in November. I was back on track. 

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