Eating disorders during the COVID-19 pandemic

Following the Eating Disorders Awareness Week, which took place in the United Kingdom in March 2021, this article examines the impact of the COVID-19 pandemic and lockdowns on individuals with eating disorders.

This article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. If you think you or someone you know might have an eating disorder, please seek the advice of your GP or other healthcare professionals.

What are eating disorders?

Eating disorders (EDs) are mental health conditions where the control of food is used to cope with difficult situations or feelings. Unhealthy eating behaviours can include limiting the amount of food eaten, eating very large amounts of food at once, or worrying about the body or shape, amongst others. While female teenagers aged between 13 and 17 are most commonly affected, EDs affect people of all ages, genders and backgrounds.

How many people suffer from eating disorders?

Statistics on the prevalence of EDs vary widely. Recently, a group of researchers performed a systematic literature review of several studies carried out between 2013 and 2018 that reported the prevalence of EDs. They found that EDs were highly prevalent worldwide: on average, 7.8% people had been diagnosed with an ED at some point in their lifetime. The same review also separately analysed studies undertaken between 2000 and 2006 and found a lower average prevalence of EDs (3.5%), suggesting their prevalence is increasing. However, this observed increase could result from a variety of factors, including changes in their classification (which was revised in 2013) or the proportion of individuals seeking help, as well as increased awareness of these conditions.

In the UK, not enough research has been carried out to draw firm conclusions, but it is estimated that 1.25-1.37 million people suffer from an ED. The situation seems to be getting worse. In England, hospital admissions for EDs have risen 37% between 2016-17 and 2018-19. According to Dr Agnes Ayton, of the faculty of eating disorders at the Royal College of Psychiatrists (RCP), this is likely to reflect an increase in the number of people becoming seriously ill, rather than increased awareness, since people are only admitted to hospital when the situation is life-threatening.

In Northern Ireland, the charity Eating Disorders Association (EDA NI) estimates that 18,000-20,000 live with an ED at any one time. The Regulation and Quality Improvement Authority reported in 2015 that, every year, around 50-120 develop anorexia nervosa and 170 people develop bulimia nervosa. A total of 22 people with an ED died between 2008 and 2019. The prevalence of EDs also seems to be rising: in total, the number of people diagnosed with an ED increased by 90% between 2011/12 and 2018/19 (from 272 to 518 people diagnosed). In the same time period, the number of hospitalisations also increased (1,587 to 2,292), as did the number of emergency cases (225 to 452).

Causes and consequences of eating disorders

It is not known exactly what causes an ED, but it is likely to result from a combination of different factors, including genetics, life events and social pressures. While the reasons behind the apparent increased prevalence of EDs are complex, according to Dr Agnes Ayton, at the RCP, “anecdotally, [they] could include increasing pressures on children in schools, and advertisements encouraging unrealistic ideas of body image”. Social media may also have a role to play; for instance, a study has found more frequent Facebook use to be associated with greater disordered eating and the maintenance of weight/shape concerns.

EDs can have devastating effects on people’s lives. In fact, the most fatal mental health disorder is anorexia nervosa (AN), one of the most common types of EDs. A 2011 meta-analysis of 36 studies revealed there is an average of 5.1 deaths per 1,000 people with AN per year, which corresponds to a 5.86 times higher death risk for people with AN. This can be explained partly by the physical complications of the disease and partly by the increased rate of suicide (one in five individuals with AN who died had committed suicide). All EDs can lead to a range of negative symptoms, both physical and psychological, as well as impacting on other aspects of an individual’s life, such as social, work, leisure and family life.

Impact of lockdowns on individuals with eating disorders

Lockdowns have had a negative impact on children and adults’ mental health. In June 2020, UK mental health charity Mind reported a worsening of mental health in more than half of adults (59%) and over two thirds of young people (68%) during the period of lockdown restrictions.

EDs have been no exception to that. Indeed, Beat, the UK’s ED charity, has reported a 95% increase in people accessing support from February to December 2020. Moreover, in Northern Ireland, a consultant child and adolescent psychiatrist has attributed the recent sharp rise in the number of hospital admissions for young people suffering from EDs to the pandemic.

Several studies have supported these observations. For instance, a study published in August 2020 found a negative impact of the pandemic, specifically lockdowns, on individuals with EDs in the UK, with around 87% of participants reporting a worsening of symptoms (and over 30% reporting their symptoms to be much worse). Some of the factors underlying this are:

• Disruption to living situation, routine, and perceived control (e.g. increased scrutiny and/or pressure from others to eat more);
• Social isolation and reduced access to support networks;
• Changes to physical activity rates, with some participants reporting a decrease and others an increase (driven by anxieties about weight gain);
• Reduced access to healthcare services;
• Changes to the individual’s relationship with food, since lockdown can result in a shortage or excess amounts of food in the house, or provide individuals with a reason to justify a lack of supplies; and
• Increased exposure to triggering messages such as the general public’s “fear of gaining weight” during lockdown and public health initiatives promoting healthy eating and exercise.

Similar results have been reported by many studies, including: a recent UK-based study; another one that analysed social media posts; and others with subjects from different countries, including Italy and Australia. The latter study, for instance, found increased restricting, binge eating, and purging, as well as changes in exercise behaviours, in a proportion of individuals with EDs, even in the early stages of the pandemic. Worryingly, the study also reported increased rates of disordered eating behaviours (restricting and binge eating) in the general population, which may lead to negative health implications if they continue. A first-person account of some of these experiences has been provided by BBC News.

What can be done?

Generally, there is a lot to be done with regards to raising awareness of EDs and improving services for patients. For instance, the 2015 Review of Eating Disorder Services in Northern Ireland, commissioned by the Department of Health, Social Services and Public Safety, made a total of 26 recommendations for improvement in the ED services in Northern Ireland, upon consultation with a number of stakeholders, including users of ED services. Some recommendations include focusing on early intervention and the needs of users, and reviewing the skill mix within services. These have been endorsed by ED charity Beat, which called for their full implementation.

However, as highlighted in the previous section, the pandemic has both exacerbated existing issues and created new ones, which need to be addressed. One study has provided a number of suggestions, such as:

• Providing accessible treatment options, including remotely delivered treatments through phone or web-conferencing (some patients have reported positive perceptions of tele-therapy), guided self-help, digital tools for self-monitoring, and online support groups;
• Targeting the specific eating and food related challenges that have arisen as a result of lockdowns;
• Developing media consumption strategies; and
• Increasing valued activities and helpful social connection.

Finally, it may be important to consult ED specialists when designing initiatives that promote healthy eating and exercise. These have become particularly common during the pandemic, coming from a range of entities such as chartered professional societies, the World Health Organization, and governments. One example is the “Better Health” campaign, launched by the UK Government in July 2020. While this campaign was well received by some, such as the British Heart Foundation, others, such as ED charity Beat, argued that it may be damaging for some people. Indeed, findings from a study suggest that the campaign could exacerbate mental health difficulties for individuals with EDs due to its focus on weight loss and perceived fat-shaming approach.

Conclusions

Eating disorders affect a great number of people and can have serious consequences in their lives. Recent research suggests that lockdowns, used by many governments to control the COVID-19 pandemic, have a negative impact on individuals with eating disorders and can contribute to an exacerbation of symptoms. A number of strategies may need to be employed in order to address this.

If you are affected by any of the issues in this article, the following organisations may be able to help:

Further information:

https://www.bbc.co.uk/programmes/articles/2DRkg4JC7SLT3B7hlrn6DKN/information-and-support-eating-disorders