A mixed but worrying picture emerges.
The COVID-19 pandemic has posed a number of risks for those with EDs. The risks include limited access to support networks during the lockdown, which might lead to reduced motivation to recover and worsening symptoms. Also, increased use of social media can lead to greater exposure to unhealthy body images, negative stories, and stressful local and national news. During the quarantine, a team in Australia sought to define how the COVID lockdown affected ED patients. As the authors pointed out, patients were exposed to increased anxiety, isolation, and depression. Increased access to food and irregular food patterns also increased the risks of an ED.
This has been the subject of a remarkable amount of study. Dr. Yunqi Gao and researchers at the Centre for Research on Ageing, Health & Wellbeing in Acton, Australia, analyzed epidemiologic studies before and after the main epidemic to learn how the COVID-19 epidemic was affecting ED patients (J Public Health. 2022.https://doi.org/10.1007/s10389-022-01704-4).
The inclusion criteria included epidemiologic studies of patients with diagnosed EDs and reported changes in ED symptom severity (either self-reported or through medical records) before and after the lockdown. Studies were excluded that featured populations without a primary diagnosis of EDs or those that did not include a comparison of ED symptoms before and during the lockdown. From an initial group of 132 articles, 21 potentially relevant studies were reviewed in full, and 11 studies were considered eligible. This is an impressive number of papers to be conceived of, written, and published in a 2.25-year period.
First results
Dr. Gao and colleagues found that during the lockdown women and younger patients were most concerned about their body image and appearance, had more difficulties regulating their eating, and overall were at greater risk of worsening ED symptoms. All the studies concluded that the pandemic lockdown was associated with a worsening of EDs, and led to higher levels of anxiety and depressive symptoms.
The severity of ED symptoms fell back to normal levels during the transition from lockdown to re-opening. However, some study participants reported relief of some symptoms during the confinement period; this was especially true among patients with AN. The possible explanation was that these patients continued to receive internet-directed therapy during the lockdown. The restrictions may also have led to more stable family relationships and fewer social stressors, reducing symptoms of AN.
Social isolation
The stay-at-home orders worsened social isolation and loneliness. Most study participants, except for essential workers, had to work from home or were unemployed. Numerous authors, including Branley-Bell and Talbot (J Eat Disord. 2020. 8:44), have written that spending time with friends and relatives can be an important source of motivation in the recovery of patients with EDs.
Another major problem for ED patients during lockdown was reduced access to in-person face-to-face treatment (Eur Eat Disord Rev. 2020. 28:86). Although some patients received online treatment (with teletherapy and videoconferencing) during the confinement period, they stated that online support could not replace the traditional support mechanisms of face-to-face treatment. During the COVID-19 pandemic peak, some psychiatric wards were downsized, closed, or converted into wards for coronavirus patients. ED patients experienced treatment suspension, cancellation of non-essential treatment, and reduced availability of hospital beds when needed.
Dietary restrictions
The lockdown measures placed restrictions on normal movement, and thus influenced the access o food. Robertson et al. reported that such a lockdown can affect people’s eating patterns and body image (Appetite. 2021. 159:105062). Most participants had irregular eating patterns and experienced worsened ED symptoms during the COVID-19 outbreak (Psychol Health Med.2020. 1-8. https:// doi. org/ 10. 1080/ 13548 506. 2021. 18836 87).
These authors’ findings align with those from a previous study demonstrating the association between dietary changes and increasing ED symptoms (Psychol Bull. 2004. 130(1). https:// doi. org/ 10. 1037/ 0033- 2909. 130.1.19). Lockdown might lead to food restrictions, unhealthy eating habits, depression, and anxiety symptoms, and might result in increasingly disordered eating symptoms.
Therefore, the combination of a health crisis (COVID-19 pandemic), social isolation (enforced lockdown), and negative emotions could lead to worsening ED symptoms and general psychopathology (anxiety and depression).
On the other hand, some positive results occurred as restrictions were lifted.
Some improvements may be seen as the pandemic’s grip loosens. For example, Fernández-Aranda et al. (Eur Eat Disord Rev. 2020.28:239) saw a significant lessening of ED symptoms among AN patients after restrictions were lifted. A possible explanation for this phenomenon is that patients were able to access support from internet-delivered therapy or could follow their pre-COVID treatment plan. Living with their parents may have increased social support and improved and strengthened personal relationships (Int J Eat Disord. 2020. 53:1780). In addition, during the period of isolation parents might have had a better opportunity to supervise their children and teens’ diets.
Further study is needed over the continued evolution of the pandemic and post-pandemic period to learn more about the risks and course for those whose EDs worsened during the pandemic (or did not worsen, which might be informative in different ways). We also need to understand what to expect for those who had the onset of an ED during the pandemic.
