"We have never seen so much comorbidity in eating disorders."

"Teenagers are always the same, but the characteristics of how they exhibit the disorder or how they express it have changed. Now we find much more comorbidity , younger adolescents or even children with depression, a lot of anxiety, and personality traits that sometimes make the therapeutic approach difficult. Before, we saw, so to speak, 'purer' cases, anorexia, bulimia... Now we see more of a mixture : depression, anxiety, dysfunctional personality traits... And this makes the therapeutic approach more complex."

"What happened during the pandemic was a trigger. Many social changes were already underway, including an acceleration of daily life and the massive incorporation of women into the workforce, which makes work-life balance complex and children immersed in many activities, often with little parental presence and difficulties in setting limits for them."

Now we find much more comorbidity, adolescents or even children with depression, a lot of anxiety and with personality traits that sometimes make the therapeutic approach to eating disorders difficult.

What happened during COVID? Well, the most vulnerable people, especially teenagers and pre-teens, were completely isolated from their friends for many months, without going to school for almost a year and a half. Then, many parents returned to their workplaces, leaving their children alone in front of a screen and bombarded by social media, which often contained inappropriate information . In fact, many tell me they spent hours online looking at diets or exercise routines. But of course, it's also true that the message at that time was, "Since we're stuck inside, let's exercise, let's eat well," and during adolescence, it's difficult to discern which information might be harmful. And that's when some children and teenagers, perhaps the most vulnerable, had a breakdown . This situation left teenagers severely damaged. I think I've rarely seen so many minors with eating disorders, severe depression, high anxiety, difficulties relating to others, self-harm, and so on.

"Yes, before, the average age for onset of anorexia was fourteen, and fifteen for bulimia. Now, the average age of the people we treat is thirteen, but they start having thoughts at eleven and develop eating disorders at twelve, and we've even seen a nine-year-old girl. It's said that there's a precocious biological maturation, that girls, for example, are getting their periods earlier, and that this is happening earlier, but I think there's a key factor here, which is social media . I sometimes jokingly tell them they all seem like influencers , always well-dressed, made up… In fact, we're now seeing skin lesions in ten-year-old girls because they're using makeup products as if they were older, with the approval of their parents, who I think don't really know what they're doing and the risks involved. But this is what they see every day in the media, and this is what causes them to be so precocious in everything." I meet twelve-year-old girls who tell me they're having sex, and I'm stunned. It's frightening because they're not emotionally mature and don't really know what they're doing ; they're just doing it by imitation. They want to grow up faster, but their brains don't mature any faster.

Many girls want to grow up very quickly because that's what they see on social media, but their brains don't mature faster than normal and they don't have enough tools to manage their emotions.

Adolescence is the age of fears, insecurities, comparing yourself to others, avoidance… but now all of this is amplified through social media . Imagine being in a shop window all day, comparing yourself to others, feeling insecure, but without the emotional management tools that adults are supposed to have.

"Yes, indeed. What we're all seeing, and what we're finding incredibly difficult to change, is that the therapeutic techniques or frameworks we've used until now, such as hospitalization or day hospital care, aren't as effective as before. We need to change our therapeutic approach. In this regard, home-based care is proving very successful because it keeps the person in their familiar environment, and with the ongoing support of a therapeutic team and continuous family supervision, they gradually reintegrate into their daily life. And we also have to work with the family . If you don't work with the family, you don't make progress. This work can focus on empowering parents to give them back the ability to care for their son or daughter, so that the child can gradually regain the responsibility of caring for themselves; but, on the other hand, we also encounter families who need specific family therapy."

There are also a lot of new approaches emerging, such as mentalization therapies, trait-based therapies, which are starting to be used with children, or the use of technology, with simulators, virtual reality, etc."

Family intervention in an eating disorders unit

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"It's true that we need to raise awareness of mental health disorders, and lately they're being talked about more, but even so, I think eating disorders are still trivialized. People don't see what they're really like; they only see the tip of the iceberg and not all the suffering underneath . Now, we have to fight hard to get one more psychologist or psychiatrist, or a stable nursing staff... That's why it's important to be united when we demand and request resources . Many eating disorder units were created in the early 2000s, and a few more have been created in the last ten years, but that's where we've stopped. We need more, and we also need more professionals; otherwise, we won't be able to cope."

At this point, the role of family associations has been essential. They have been the ones who have lobbied the most to increase resources for the treatment of eating disorders. But I think these associations now have a problem with the lack of new members—those who mobilized years ago but are now getting older. I think that right now, younger parents, or professionals in the case of our association, find it difficult to join; perhaps it's harder for us to commit ourselves now.

"As far as prevention is concerned, I think very little is being done. It's an issue that needs to be addressed from childhood; if we start in adolescence, we're already too late. Prevention should be comprehensive and applicable to other mental health problems, not just eating disorders. It's crucial to teach boys and girls to be critical thinkers, to have good eating habits, to exercise, to improve their self-esteem, to equip them from a young age with tools to feel more self-confident, to be able to face life's challenges, to know how to say no and yes... In short, to love themselves. And this is learned at home, but also at school, in leisure activities, and in sports. I believe prevention should focus on this. It's very difficult to implement prevention programs specifically for adolescents ."

Mª Carmen Galindo

President of FEACAB

Federación Española de Asociaciones de Ayuda y Lucha contra la Anorexia y la Bulimia (FEACAB)

"If we join forces, we will be more effective in preventing eating disorders."

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"This association was founded in 1996 by Dr. Morandé—who sadly passed away—during the peak of eating disorders in Spain, in response to the need for more in-depth study of these disorders and for professionals to come together to exchange ideas, treatment methods, research, knowledge, and so on. It was also established to advocate for more professionals specializing in eating disorders. With these objectives in mind, we organize a congress every two years. This year, the Latin American chapter of the American Eating Disorders Association is also joining us. We also organize workshops at various centers throughout the year."

I believe it's essential that professionals from different disciplines come together, not only to offer consistent treatments and ensure everyone is on the same page , but also because the world of mental health disorders is very difficult, and eating disorders, specifically, are extremely difficult. It's also a way for us all to support each other, learn from one another, and not feel so alone. Sharing knowledge benefits not only the care of those affected but also ourselves. The problem is that people find it very difficult to join associations, and when some professionals retire, it's hard for us to attract new members.