COVID-19 pandemic and eating disorders in an Italian group of adolescents: a retrospective study

doi:10.21203/rs.3.rs-1994040/v1

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COVID-19 pandemic and eating disorders in an Italian group of adolescents: a retrospective study

https://doi.org/10.21203/rs.3.rs-1994040/v1

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published 26 Apr, 2023

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Background. Social distancing and quarantine imposed by the authority during the COVID-19 pandemic caused restrictions, which had a negative impact on eating behavior, especially among adolescents. We proposed a retrospective study aimed to identify the main indicators/predictors of eating disorders occurring in this pandemic period.

Methods.In this study, a group of 127 pediatric patients (117 females and 10 males) with eating disorders admitted to the Bambino Gesù Children’s Hospital of Rome (Italy), in the period between August 2019 and April 2021, was analyzed.

Results. We found that 80.3% of patients were at the onset of eating disorders and that 26% of patients had familiarity for psychotic disorders. Often these patients had comorbidities and alterations in blood parameters such as leukocytopenia, neutropenia, hypovitaminosis and hormonal problems that could affect their future.

Conclusions. Based on this study, we suggest that the therapeutic path of patients with eating disorders should guarantee not only psychological treatment, but also that of comorbidities.

Covid-19

pandemic

eating disorders

comorbidity

The lockdown imposed by the authority during COVID-19 pandemic, although effective in reducing the transmission of the infection, resulted in marked changes in the lifestyle of the general population (e.g., social distancing, isolation and quarantine, closure of the schools, businesses, gyms, and restaurants). Early reports suggest that social distancing and quarantine are having adverse consequences on mental health including high levels of stress, anxiety, depression, sleep disturbances, and in particular eating disorders (EDs) [1]. It has been observed that individuals with pre-existing EDs and / or obesity may be particularly vulnerable, due to the associated psychiatric comorbidities and metabolic anomalies [2]. EDs are serious mental health disorders that cause impairments in physical health, development, cognition, and psychosocial function and can go undetected for months or years. They are common in childhood and adolescence and often are followed by comorbid disorders such as anxiety, self-harm, and substance use [3,4]. Frequently, they have been associated with both suicidal and para-suicidal behaviors, as well as suicide [5].

The presence of EDs is mainly attributed to: i) family environment (e.g., parental psychiatric disorders, prenatal maternal stress); ii) restriction to daily activities and movements; iii) excessive exposure to harmful eating patterns on social media, emotional distress, fear of contagion, and low access to care [3].

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [6], EDs commonly observed in children and adolescents can be classified in: anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). The first is an eating disorder characterized by pathological problems of weight and shape that lead to reduced food intake and consequent low weight [7]. The second is an ED characterized by recurrent episodes of binges eating followed by compensatory behaviors (e.g., self-induced vomiting, misuse of laxatives, diuretics, or other drugs, fasting, excessive exercise) [8]. The third is characterized by recurrent episodes of bingeing associated with distress overeating or eating in the absence of hunger [9]. The last is characterized by avoidance or restriction of food, motivated by fear of the adverse consequences of eating or a lack of interest in eating [10].

Some studies state that, with respect to men, women have a higher risk of developing health problems related to EDs. The ratio of women to men for EDs has been reported to range from 4: 1 to 10: 1 and significantly increases during puberty [6]. A growing number of studies conducted during the pandemic have documented a worsening of eating disorder symptoms and syndromes in a variety of population groups [11-15].

Some studies showed increased eating restriction in people with AN, and more frequent binge-eating episodes in those with BN or BED [16-18]. In the first wave of the pandemic, an increase in symptoms such as anxiety, depression and eating disorders has been observed mainly in adolescents with pre-existing EDs. Instead, during the second and subsequent waves of the pandemic a surge in suicidal ideation and suicide attempts among adolescents has been reported in many countries [19].

Given the severity of these disorders, our study is aimed to: i) explore, in a sample of young Italian peoples, the impact of social restrictions imposed by Italian government during COVID-19 pandemic; and ii) identify the main indicators / predictors of eating disorders occurring in this pandemic period. This is a retrospective study based on data from the medical records of adolescents admitted to the Bambino Gesù Children’s Hospital of Rome (Italy) in the period between August 2019 and April 2021. Our findings could provide a framework for developing clinical and educational interventions to mitigate the short- and long-term negative impact of the pandemic on the future health of adolescents.

Patients

This is an observational study of a group of 127 (117 females and 10 males) pediatric patients with EDs admitted to the Bambino Gesù Children’s Hospital of Rome (Italy) in the period between August 2019 and April 2021. Patients were evaluated during hospitalization (T0) and 1 months and 3 months after antipsychotics treatment. The study was approved by ethics committee of the Bambino Gesù Children’s Hospital of Rome (approval number: 2526-OPBG-2021).

All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

A written informed consent was obtained from adult patients and parents of patients under the age of 18. Medical history, comorbidities, and laboratory findings were obtained from patient’s electronic medical records.

Procedures

During hospitalization, patients were subjected to: i) laboratory analyses for the evaluation of blood cells count and screening for specific vitamins and mineral deficiencies; and ii) electrocardiogram, echocardiogram, abdomen ultrasound, and magnetic encephalic resonance.

Treatments

After diagnosis, the patients were treated with antipsychotics drugs as follows: 23 patients with antipsychotics; 80 with antipsychotics in combination with serotonin uptake inhibitors; 9 with antipsychotics in combination with benzodiazepines; 2 with antipsychotics in combination with anxiolytics; 1 with antipsychotics in combination with lithium; and 3 with serotonin uptake inhibitors. Moreover, 9 patients did not receive any drug treatment.

Statistical analysis

Correlations were evaluated by using Pearson correlation (r correlation coefficient). To test the probability of significant differences, individual group comparisons were evaluated using Bonferroni's test. p < 0.05 values were considered statistically significant.

General characteristics of partecipants

A total of 127 patients (117 females and 10 males) with EDs, aged between 10 and 18 years, were included in this study. 74% of the patients lived on central Italy and 26% of patients in southern Italy. A very low percentage of patients included in this study was anorexic (5.5%) or had avoidant restrictive food intake disorder (ARFID, 4.7%), while 89.8% of patients had unspecified eating disorders. Except two patients who had a weight of 76.2 and 81.5kg respectively and a body mass index (BMI) of 24.3 and 28.2 Kg/m2 respectively, the other patients had a median weight value of 37.2 Kg (range 22.5 - 52.6 Kg) and median BMI value of 14.96 Kg/m2 (range 11.3 – 28.2 Kg/m2). As shown in the Table 1, 102 patients (94 females and 8 males) were at the first onset of the disease, while 25 patients (23 females and 2 males) had clinical relapse. In addition, 79 patients (75 females and 4 males) had previously been hospitalized and 33 patients (32 females and 1 male) had familiarity for psychotic disorders. Specially, they were familiar for depression (7%), anxiety (1.6%), EDs (4.7%), and psychosis (4%). Moreover, the patients had familiarity for diabetes (3.9%); hyperthyroidism (3.1%) and hypothyroidism (2.4%). During hospitalization, echocardiographic examination highlighted pericardial effusion in 10 patients (7.8%) and pericardial cleavage in 7 patients (5.5%). Abdominal echography in 9 patients revealed pathologies such as angioma, calculosis of the cholecode and modest fluid flap in the pelvic cavity. Nuclear magnetic resonance of the brain resulted in a pathological outcome in only 7 patients.

Table 1. General characteristics of ED patients.

Characteristics	Patients (n = 127)
Age, median (range)- years	14(range 10 – 18)
Sex	117 (92%) Females 10 (7.8%) Males
Body weight, median (range)-Kg	37.2 (range 22.5 – 52.6)
BMI, median (range)- Kg/m²	14.96 (range 11.3 – 28.2)
Patients first onset of EDs	102 (80.3%)
Patients with clinical relapse	25 (19.7%)
Patients previously hospitalized	79 (62.2%)
Familiarity for psychotic disorders	33 (26%)
Familiarity for diabetes	5 (3.9%)
Familiarity for hyperthyroidism	4 (3.1%)
Familiarity for hypothyroidism	3 (2.4%)

BMI, body mass index; EDs, eating disorders.

Comorbidity in ED patients

As listed in the Table 2, patients analyzed in this study had comorbidity. 64% of females had amenorrhea. All patients had low lymphocytopenia, while 38% of patients had neutropenia and 13.4% of patients had thrombocytopenia. A high percentage of patients had bradycardia (60.6%) and hypovitaminosis (93.5%), while a small percentage (7%) had hypercreatinemia and hyperazotemia. In addition, these patients also had disorders such as depression (14%), anxiety (3.9%), psycosis (4.7%), specific learning disorder (3.9%) or multiple psychiatric disorders (13.4%). Two patients had also attempted suicide.

Table 2. Comorbidities detected in ED patients.

Comorbidities	Percentage of ED patients
Amenorrhea	64% of female patients
Lymphocytopenia	100%
Neutropenia	38%
Thrombocytopenia	13.4%
Bradycardia	60.6%
Hypovitaminosis	93.5%
Effusion	10.2%
Hypercreatinemia	7%
Hyperazotemia	7%
Depression	14%
Anxiety	3.9%
Psychosis	4.7%
Specific learning disorder (SLD)	3.9%
Multiple psychiatric disorders	13.4%

Screening for vitamins and thyroid hormones

As previously reported, a high percentage of these patients had hypovitaminosis. In particular, a deficiency of vitamin A (6% of patients); vitamin B1 (7% of patients); vitamin B6 (9.4% of patients); vitamin B12 (6.3% of patients) and vitamin C (27% of patients) was detected (Table 3). Moreover, we found that vitamin D3 was deficient in the 22.8% of patients and insufficient in the 42% of patients. In addition, 56.6% of patients had high levels of ferritin, while 7.9% of patients had high levels of thyrotrophic hormone (TSH). Instead, 21% of patients had low levels of vitamin B9 (folic acid), while 21.3% of patients had low levels of thyroxine (FT4) (Table 3).

Table 3. Percentage of patients with variables having a different value from reference values.

	Patient percentage	Median values	Reference values
Vitamin A	6%	0.5 (range 0.4 - 0.7)	0.7 - 2.8 mM/mL
Vitamin B1	7%	27.3 (range 21.3 - 30.3)	32 - 95 ng/ml
Vitamin B6	9.4%	4.6 (range 0.5 – 8)	8.7 – 27.2 ng/mL
Vitamin B12	6.3%	199.5 (range 25 – 287)	300 – 900 ng/mL
Vitamin C	27%	15 (range 3.5 – 24)	26.1 – 84.6 mM/L
Vitamin D3	22.8%	15.96 (range 4.8 - 19.8)	< 20 ng/ml deficient
Vitamin D3	42%	25.3 (range 20.3 – 29.5)	< 30 ng/ml insufficient
Ferritin	56.6%	293 (range 155 – 990)	13 – 150 ng/mL
TSH	7.9%	5 (range 4.37 – 6.7)	0.51 – 4.3mlU/mL
Vitamin B9 (folic acid)	21%	3.54 (range 1.83 – 4.91)	5 -27.2 ng/mL
FT4	21.3 %	0.88 (range 0.71 – 0.96)	0.98 – 1.64 ng/dL

TSH, thyrotrophic hormone; FT4, thyroxine.

Correlations between variables

Considering that all patients have lymphocytopenia as comorbidity, we correlated leukocyte number with some variables. As shown in Table 4 we found that lymphocytes number correlated significantly (p < 0.0001) with body weight (rho = 0.08); BMI (rho = 0.016); neutrophil count (rho = 0.065), vitamin B1 (rho = 0.06); vitamin B6 (0.11); vitamin D3 (rho = 0.02); ferritin (rho = 0.089); sideremia (rho = 0.012); and cholesterol (rho = 0.18). Conversely, no correlation was found between lymphocytes number and vitamin A (rho = -0.14); vitamin B12 (rho = -0.07); vitamin B9 (rho = -0.11); TSH (rho = -0.06); FT4 (rho = -0.104); and triglycerides (rho = -0.19).

Table 4. Correlation between variables.

	Lymphocytes (rho values)	p values (<)
Body weight	0.08	0.0001
BMI	0.016	0.0001
Neutrophils	0.065	0.0001
Vitamin A	-0.14	0.0001
Vitamin B1	0.06	0.0001
Vitamin B6	0.11	0.0001
Vitamin B9	- 0.11	0.0001
Vitamin B12	- 0.07	0.0001
Vitamin C	0.12	0.0001
Vitamin D	0.02		0.0001
Ferritin	0.089		0.0001
Sideremia	0.012		0.0001
TSH	- 0.06		0.0001
FT4	- 0.104		0.0001
Cholesterol	0.18		0.0001
Triglycerides	-0.19		0.0001

BMI, body mass index; TSH, thyrotrophic hormone; FT4, thyroxine

Efficacy of therapy

Antipsychotic treatment positively influenced both body weight and BMI of patients. As shown in Figure 1, compared to T0, weight increased by 10.4% after 1 month and by 26.2% after 3 months of antipsychotic treatment. Body weight increase after 3 months was significant (p < 0.05). Similarly, the BMI increased by 12.3% after 1 month and by 15% after 3 months of treatment.

The COVID-19 pandemic resulted in restrictions, which had a negative impact on physical activity and eating behavior, especially among young population. Children and adolescents affected by pre-existing eating disorders, being more sensitive to social stress [20] and having difficulties to control emotions [21], may be particularly vulnerable. Hematological abnormalities, amenorrhea and alterations in hormone status are frequent comorbidity of eating disorders and are mainly related to malnutrition. In this retrospective study, we analyzed the medical records of 127 ED patients admitted to the Bambino Gesù Children’s Hospital of Rome (Italy), in the period between August 2019 and April 2021. These patients, aged between 10 and 18 years, were predominantly females (117 females vs 10 males). Many of them (80.3%) were at the onset of eating disorders. 26% of patients had familiarity for psychotic disorders and 26.5% had comorbidities such as depression, anxiety, psychosis, and SLD. Some patients (13.4%) had more than one psychotic disorders. Amenorrhea, lymphocytopenia, neutropenia and hypovitaminosis are the most frequent comorbidities detected in these patients. Amenorrhea was detected in 64% of females and 60.6% of them were underweight. Moreover, in patients with amenorrhea low serum values (< 0.3 mlU/mL) of follicle- stimulating hormone (FSH) and luteinizing hormone (LH) were detected in 3 and 36% of patients respectively. Interestingly, amenorrhea detected in these patients, in addition to low body weight, could also be due to hypothalamic dysfunction. Lymphocytopenia was found in all patients analyzed, while neutropenia was detected in 38% of patients. It is known that both hematological disorders are an adaptive condition observed in malnutrition, but completely reversible during refeeding and weight gain [22]. Lymphocytes and neutrophils are an integral part of innate immune system. In severe cases, a sustained nutrient deprivation can compromise the health of bone marrow and causing a sudden drop in their white blood cell count [23]. Hypovitaminosis was detected in 93.5% of patients. Among the vitamins evaluated, vitamin C, vitamin B9 (folic acid) and vitamin D3 were deficient in a higher percentage of patients (27, 21, and 64.8% respectively). Vitamin C is an antioxidant vitamin that modulates immune cell function and supports a Th1 cytokine-mediated immune response with sufficient production of proinflammatory cytokines [24]. Vitamin B9 plays an essential role in the synthesis of neurotransmitters and structural elements of neurons. Its deficiency has been associated with disorders linked to mental function such as depression and cognitive function impairment [25]. Vitamin D3 plays important roles in both cell-mediated and humoral antibody response and has antimicrobial and anti-inflammatory functions. Its deficiency may be related to cognitive impairment and dementia and increases the risk for acquiring several infectious diseases [26]. In patients with EDs vitamin D3 deficiency has been correlated with osteoporosis risk [26, 27], while in patients with long-term eating disorders might be responsible for the lack of the inflammatory response and the depressive symptoms [28]. In our study, we found that both vitamin C and vitamin D3 content correlated significantly (p < 0.0001) with lymphocytes count, suggesting an increased susceptibility of ED patients to infections. In adolescent, an excellent indicator of nutritional status is serum concentration of thyroid hormones, being they influenced by both the degree of leanness and the current weight trend. In our study, we found that 7.9% of ED patients had high levels of thyrotrophic hormone (TSH) and that 21.3% of patients had low levels of thyroxine (FT4). Increased levels of TSH and low levels of FT4 are typical of hypothyroidism, most often caused by autoimmune thyroid disease such as Hashimoto’s thyroiditis (HT). Literature data suggest an association between deficiency of some vitamins (D3 and 219 B) and a high risk of developing HT [29, 30]. According to the literature, in the patients analyzed we found that TSH correlated with vitamin B1 (rho = 0.025), vitamin B6 (rho = 0.21) and vitamin D3 (rho = 221 0.056). Moreover, we found that: i) 11.8% of patients had total cholesterol values higher than the reference values (median values 244.6 mg/dL) and ii) a correlation between total cholesterol content and TSH values (rho = 0.127) [31]. In addition, we found that 56.6% of patients had high serum ferritin levels, probably due to an increase in muscle catabolism that occurs during the loss of the menstrual cycle [32].

The COVID-19 pandemic has negatively affected teens' eating behavior. The data obtained in this retrospective study show adolescents who, experienced eating disorders during the pandemic, often have comorbidities and alterations in blood parameters such as leukocytopenia, neutropenia, hypovitaminosis and hormonal problems that could affect their future.

Therefore, on this basis we suggest that the therapeutic path of these patients should guarantee not only psychological treatment but also that of comorbidities.

AN: Anorexia nervosa; ARFID: Avoidant/restrictive food intake disorder; BED: Binge-eating disorder; BMI: Body mass index; BN: Bulimia nervosa; EDs: Eating disorders; FSH: Follicle- stimulating hormone; FT4: Thyroxine; HT: Hashimoto’s thyroiditis; SLD: Specific learning disorder; TSH: Thyrotrophic hormone.

Ethics approval and consent to participate

The study was approved by ethics committee of the Bambino Gesù Children’s Hospital of Rome (approval number: 2526-OPBG-2021). Informed written consents were obtained by adult patients and parents of patients under the age of 18.

All methods of this study were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no conflict of interest.

Funding

This research received no external funding.

Author’ contributions

Conceptualization, I.T.J., M.R.M., A.G.; data curation, T.C., C.M., L.G., C.C., C.G.; investigations, I.P.; writing-original draft preparation, E.S.; editing, R.V.; supervision, A.V. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

Not applicable.

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COVID-19 pandemic and eating disorders in an Italian group of adolescents: a retrospective study

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