Eating disorders in the age of COVID-19.

Dear Editor,

We read with great interest the article “The Psychiatric Impact of the Novel Coronavirus Outbreak” by Carvalho et al. which importantly discusses the broad psychological effects of SARS-CoV-2 (COVID-19) including loneliness, worsening anxiety, distress and insomnia (Carvalho et al., 2020). Other studies have also reported depression and post-traumatic stress due to factors including risk of infection, social isolation, discrimination, and exhaustion (Torales et al., 2020). To date, very limited research has explored the impacts of COVID-19 pandemic on eating disorders (EDs).

Psychosocial stressors stemming from COVID-19 pandemic and resultant stay-at-home orders, may exacerbate ED-related triggers and present a challenging environment for individuals with anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (Hensley, 2020; McMenemy, 2020). For example, limited stock in grocery stores can compromise access to ‘safe’ routine foods, and food shortages may induce feelings of guilt during food purchases in AN patients recommended to adhere to high-calorie diets (Hensley, 2020). British Broadcasting Corporation News interviewed a woman previously hospitalized for AN, who stated: “I'm scared of how busy [grocery stores] are; the utter panic, the amount of people, the fact my safe foods aren't available, thinking I need to leave food for other people who actually need and deserve to eat and feeling like I don't, as I'm selfish" (McMenemy, 2020). In contrast, leisure time in combination with easy-to-access food within the home can trigger temptations to binge (McMenemy, 2020). Moreover, decreased social supports including limited access to health care professionals (HCPs), and social media content comprising diet and at-home-exercise advice to avoid the ‘quarantine 15′, can contribute to increased distress and ED-related behaviors (Hensley, 2020).

Furthermore, following the 2003 SARS outbreak, eating restrictions were found to trigger the development of psychological disorders in 26.2% (n = 49) of respondents of the General Health Questionnaire (GHQ) (Mihashi et al., 2009). As studies have reported a significant correlation between the GHQ and the Eating Disorders Symptom Impact Scale (EDSIS) (Sepulveda et al., 2008), the current COVID-19 climate may also potentially contribute to the risk of developing EDs in otherwise healthy individuals.

Appropriately managing EDs is crucial to mitigate the potential long-term impacts on individuals with these disorders. For example, individuals with EDs have greater suicidal risk under normal conditions (Smith et al., 2018), and additional COVID-19 pandemic-related stressors could further increase that risk. Thus, in order to minimize the impacts of COVID-19 pandemic on EDs, we encourage HCPs to continue to provide mental health resources to ED patients up to 6 months post-isolation (Torales et al., 2020), including virtual group therapy sessions and live meal support through the National Eating Disorders Association (NEDA). Further, we recommend that HCPs encourage ED patients to plan meals and purchase ‘safe’ food items with a long shelf-life in bulk, when available in store.

Overall, further research is needed to solidify evidence-based approaches for the management of EDs during the current COVID-19-induced crisis.

Author contributions

All the authors have contributed to and approved the final manuscript.

Declaration of Competing Interest

Ms. Monica Shah, Ms. Muskaan Sachdeva and Dr. Hariclia Johnston have no relevant financial nor nonfinancial relationships to disclose.