DOI: https://doi.org/10.21203/rs.3.rs-2311280/v1
The COVID-19 pandemic-associated social restrictions brought various challenges among the youth, including mental health issues and disordered eating patterns. It, therefore, becomes imperative for clinicians to know the extent and causative factors of the problem.
To explore the prevalence and possible mediation role of the COVID-19 pandemic in causing mental distress and disordered eating behaviors among Indian adults between 18–35 years old.
This was a month-long, community-based, cross-sectional study conducted via an online questionnaire. The Coronavirus Impact Scale (CIS), Depression, Anxiety, Stress Scale (DASS-21), SCOFF questionnaire for eating disorders, and Three-Factor Eating Questionnaire-Revised 18-item version (TFEQ-18) were used. In addition, the mediation effects of the psychosocial impact of the pandemic, psychological distress, and disordered eating behaviors, were tested using PROCESS v4.0 by Andrew Hayes.
49% of the subjects (n = 101) reported stress and discord in their families due to the pandemic. 10% of the respondents reported features suggestive of moderate depression and anxiety, while almost 10% of the participants suffered from a likely eating disorder, requiring further clinical evaluation. A positive association was observed between psychosocial stress due to COVID-19 and depression (r = 0.366, p < 0.001), anxiety (r = 0.402, p < 0.001) and stress (r = 0.416, p < 0.001). Also, on mediation analysis, the pandemic-induced psychological distress was found to significantly affect disordered eating patterns (b = 0.104, CI = 0.09, 2.17).
The COVID-19 pandemic has caused or aggravated significant psychological distress and, in turn, has indirectly mediated disordered eating patterns among the younger population, who are already at higher risk for developing mental disorders.
In 2020, the World Health Organization declared the COVID-19 pandemic a public health emergency of international concern.[1] To date, the Indian population has experienced three "waves" or surges of COVID-19-related parameters, characterized by extraordinarily high infection and mortality rates, with the second "wave" in 2021 being particularly devastating and substantially more severe, resulting in a considerable loss of life and livelihood across the nation.[2]
Since the onset of the pandemic, governments all over the world, including the Indian Government, have been implementing various public health measures, including the imposition of lockdowns, restriction of movements outside, and disallowing public gatherings to limit the spread of the disease apart from pushing for mass vaccination drives.[3, 4] These measures, however, resulted in an unprecedented impact on the lives of the general public, affecting their daily routines, means of livelihood, family lives, and, lastly, their mental health.[5]
Physical inactivity and poor mental health are two of the most significant risk factors for morbidity from various diseases worldwide. Limiting physical activity, such as exercising, puts the elderly, children, and those with pre-existing medical conditions in the category of vulnerable populations.[6] However, during the second "wave" of the COVID-19 pandemic in India, young adults were found to be especially vulnerable to the effects of the imposed restrictions as they stifled the educational and financial aspirations of the youth. This, specifically, was found to have a significant impact on the youth's mental health.[7] In a recent survey by Lokniti, India, 6277 people between the ages of 15 and 34 were interviewed across eighteen states. One of the characteristics evaluated was mental health difficulties. It was seen that about half of the sample population reported feeling sad, losing interest in daily activities, and being affected by loneliness.[8] In another Indian systemic review studying mental health implications in response to the COVID-19 pandemic, the authors reported stress, anxiety, depression, insomnia, denial, anger, fear, and, alarmingly, suicides as the most common psychological reactions to the psychosocial stressors posed by the unprecedented situation.[9] Several studies in Asia have also reported a higher prevalence of post-traumatic stress disorder (PTSD) after COVID-19 within the general population.[10, 11] With such significant restrictions on lifestyle and increasing mental health problems during the pandemic, it was speculated that individuals' eating behaviors would also be affected.
Disordered Eating Behaviors (DEBs) are typically described as troublesome eating behaviors (such as bingeing, food restriction, and other inadequate methods to lose or control weight) which occur less frequently or are less severe than those required to meet the full criteria for the diagnosis of an eating disorder.[12] Previous studies have shown significant associations between DEBs, such as conscious restraint, uncontrolled and emotional eating, eating disorders and obesity.[13, 14] In Australia, the impact of COVID-19 on eating disorders and disordered eating behaviors was supported by the Butterfly Foundation's National Helpline, which noted a 116% increase in contacts since the beginning of the pandemic.[15] In another global online survey, it was seen that dietary behaviors, particularly the consumption of unhealthy foods, losing control over one's eating, skipping meals, and snacking, had a robust unfavorable correlation with COVID-19.[16] However, on the contrary, an Indian survey found that healthy meal consumption patterns had improved in their sample population and consumption of harmful foods had decreased, particularly among younger people (under 30 years old).[17]
While it is clear that the COVID-19 pandemic has had some effect on the eating patterns of individuals, the extent of the impact is unknown. Rodgers et al. described three possible ways the COVID-19 pandemic and the high rates of psychological discomfort are linked to make an eating disorder more likely to occur: The first approach contends that disruptions to daily routines, restrictions on outdoor activities, and social distance limits might lead to a rise in weight and form worries, undermining the protective factors against eating disorders, including social support and adaptive coping mechanisms. The second and third pathways are linked to increased exposure to anxiety-inducing media and adopting erratic eating habits.[18] Pre-pandemic research associating stress, depression, anxiety, and other unfavorable mood states with a detrimental effect on eating behaviors supports this hypothesis. [19–21]
Therefore, this study aimed to estimate the prevalence of disordered eating patterns among youth during the pandemic and to investigate for any connections between the psychosocial effects of the COVID-19 pandemic on people's mental health and disordered eating behaviors among young adults during India's second COVID-19 lockdown.
This community-based cross-sectional study was conducted over a month in 2021 during the second wave. A non-probability consecutive sampling method was used. Youth aged between 18 and 35 years old, with proficiency in the English language at the intermediate level, and possession of a gadget (smartphone/ laptop/tablet) with internet access were included in the study. Overall, 114 replies were received. The final sample consisted of 101 participants after excluding participants (n = 13) who had missing data on more than 20% of the items on at least one of the variables under investigation.[22]
The data collection was exclusively done online using Google Survey forms. A link for accessing the anonymous online survey, along with a consent form and an information sheet containing the study's nature and aims, was publicized on social networks. The survey was in English and took approximately 15–20 min to complete. Participants provided their online consent and were informed about the risks/benefits of participation and their right to quit the survey at any point. The study was implemented after approval by the University ethics review board.
The study tools collected information from the history concerning the previous month from the date of assessment. The instruments used are-
Sociodemographic and lifestyle questionnaire: Participants were asked about their sociodemographic details and lifestyle, social isolation conditions in the context of the second wave of the COVID-19 pandemic, number of hours of sleep in a week and physical activity (number of days of 30 min or more of physical activity in one week).[23] Anthropometric data Weight (in kilogram) and height were self-reported. Body Mass Index (BMI) was calculated for each participant and classified according to WHO BMI guidelines for Asian populations.[24] In addition, subjects were asked about their perception of body weight change (increase, decrease, or maintenance) during the lockdown period.
Disordered Eating Behaviors Screening Questionnaire: This questionnaire was adopted from the study by Ramalho et al. and included five questions (one per eating behavior) concerning the frequency of disordered eating behaviors in the last month, which were: meal skipping, graze eating behavior, loss of control over eating, objective overeating and binge eating episodes. [25]
SCOFF Questionnaire[26]: The SCOFF questionnaire is a simple, five-question screening measure used in clinics to assess for the possible presence of an eating disorder. It was developed in the United Kingdom by Morgan and colleagues in 1999. The SCOFF questionnaire utilizes an acronym (Sick, Control, One, Fat, Food), and a score of two or more yes to the above five questions suggests a likely eating disorder.
Coronavirus Impact Scale (CIS)[27]: It comprises ten questions rated on a four-point Likert scale (0 = none/no change to 3 = severe) which asks the participants to rate the extent of how the COVID-19 pandemic changed their life in terms of their routines, financial or food security, and access to social support and mental health care, the experience of stress and interpersonal discord due to the pandemic, history of diagnosis of coronavirus of self, immediate/extended family members and close friends. In this study, the overall COVID-19 psychosocial impact score was calculated as the sum of participants' answers to all ten questions, as suggested by the original authors.
Depression Anxiety Stress Scales (DASS-21)[28]: This instrument has 21 items on three items: depression, anxiety, and stress, with the score on each subscale ranging between 0 and 21 points. Higher scores on each subscale correspond to more negative affective states in adults.
Three-Factor Eating Questionnaire-Revised 18-item version (TFEQ-R18)[29]: It consists of 18 items divided into three scales, corresponding to current dietary practice and measures three different aspects of eating behavior: restrained eating (conscious restriction of food intake to control body weight or to promote weight loss), uncontrolled eating (the tendency to eat more than usual due to a loss of control over intake accompanied by subjective feelings of hunger), and emotional eating (the inability to resist emotional cues). The items are rated on a four-point response scale (definitely true/mostly true/mostly false/ false). Responses to each of the 18 items were given a score between one and four, and item scores were totalled into scale scores for cognitive restraint, uncontrolled eating, and emotional eating. The cognitive restraint scale comprises six items, the uncontrolled eating scale consists of nine items, and the emotional eating scale includes three items. The raw scale scores are then transformed to a 0–100 scale [((raw score − lowest possible raw score)/possible raw score range) × 100]. Higher scores in the respective scales indicate greater cognitive restraint and uncontrolled or emotional eating.
For data analysis, the IBM® SPSS® Statistics 25.0 (SPSS Inc., Chicago, IL) was used. Descriptive statistics were used to describe participants' sociodemographic and clinical characteristics. Kurtosis and skewness values for main variables were below |2.0|, denoting a normal distribution. Pearson's correlation coefficients were used to find statistical associations between variables under study and to define the final mediation model to test. To explore the relationships among the psychosocial impact of the pandemic, psychological distress (anxiety, depression, and stress), and disordered eating behaviors, mediation effects were tested using PROCESS v4.0 by Andrew F. Hayes.[30]
The maximum number of participants in the study sample belonged to the age group of 25–29 years and were of the male gender. Sixty-four participants (63.4%) were single or never married. Regarding employment status, 90 participants (89.1%) were employed, of which 55 were medical professionals (61.1%).
Participants' mean self-reported BMI was 24.78 kg/m2 (SD = 4.47). 20.8% of participants (n = 21) were overweight, while a total of 51 participants had obesity (50.5%) (according to WHO cut-offs for Asian populations). Considering the respondents' perception regarding weight variation during the lockdown period, 56 individuals (55.4%) reported more than a five per cent increase in weight. Regarding lifestyle habits, most participants, i.e., 48.5% (n = 49), stated to sleep approximately 5-7hours daily. Moreover, 31 participants (30.7%) reported practicing at least 30 min or more of physical activity for two to three days/per week.
| CHARACTERISTICS | n | % | |
|---|---|---|---|
| AGE (years) | 18–24 years | 13 | 12.9 |
| 25–29 years | 56 | 55.4 | |
| 30–35 years | 32 | 31.7 | |
| Gender | Male | 56 | 55.4 |
| Female | 45 | 44.6 | |
| Employment Status | Employed | 90 | 89.1 |
| Unemployed | 11 | 10.9 | |
| Marital Status | Unmarried | 64 | 63.4 |
| Married | 35 | 34.7 | |
| Divorced/ Separated | 2 | 2.0 | |
| BMI (kg/m2) | Mean (SD) | 24.78 (4.47) | |
| Underweight (< 18.5) | 2 | 1.98 | |
| Normal Range (18.5–22.9) | 27 | 26.73 | |
| Overweight (23-24.9) | 21 | 20.79 | |
| Obese (I) (25-29.9) | 42 | 41.58 | |
| Obese (II) (> 30) | 9 | 8.91 | |
| Perception of weight change during the lockdown | Weight maintained | 32 | 31.7 |
| Weight increased (> 5% body weight) | 55 | 54.5 | |
| Weight Decreased (> 5% body weight) | 14 | 13.9 | |
| Approx. number of physically active days/ week, i.e., spending a minimum of 30min/days to exercise | Once/ week | 20 | 19.8 |
| 2–3 times/ week | 31 | 30.69 | |
| 3–5 times/ week | 20 | 19.8 | |
| Everyday | 23 | 22.77 | |
| Never | 9 | 8.91 | |
Table 2 shows the severity of psychosocial impact among the sample population as graded on the Coronavirus Impact Scale. Overall, subjects reported mild to moderate changes in their daily routine, stress levels and life status due to the pandemic.
| CIS CATEGORY | MILD | MODERATE | SEVERE |
|---|---|---|---|
| Daily Routine | 51 (50.5) | 13 (12.9) | 4 (3.9) |
| Family Income/ Employment | 36 (35.6) | 14 (13.8) | 3 (2.9) |
| Food Access | 37 (36.6) | 10 (9.9) | 2 (1.9) |
| Medical Health Care Access | 38 (35.6) | 10 (9.9) | 6 (5.9) |
| Mental Health Treatment Access | 33 (32.7) | 15 (14.8) | 5 (4.9) |
| Access To Extended Family and Non-Family Social Supports | 38 (35.6) | 18 (17.8) | 5 (4.9) |
| Experiences Of Stress Related to Coronavirus Pandemic | 34 (33.7) | 29 (28.7) | 9 (8.9) |
| Stress And Discord in The Family | 49 (48.5) | 20 (19.8) | 9 (8.9) |
| Personal Diagnosis of Coronavirus | 28 (27.7) | 13 (12.9) | 3 (2.9) |
| Number Of Immediate Family Members Diagnosed with Coronavirus | 23 (22.7) | 20 (19.8) | 8 (7.9) |
| Number Of Extended Family Members/ Close Friends Diagnosed with Coronavirus | 28 (27.7) | 29 (28.7) | 17 (16.8) |
Regarding eating behaviors, 22 (21.8%) participants skipped their meals for at least for and more than one week, 52 participants (51.5%) had grazing eating behavior, 51 participants (40.6%) reported a loss of control over eating, 28 participants (27.7%) reported objective overeating and 20 participants (19.8%) reported having frequent binge eating episodes. On the TFEQ scale, 22 participants (21.8%) reported some form of disordered eating behavior. 12 subjects (11.8%) scored high (score > 9) on the emotional eating scale, nine participants (8.9%) scored high (score > 27) on the uncontrolled eating scale, and eight participants (7.9%) scored higher on the cognitive restraint scale (score > 18). Also, eleven participants (10.8%) were found to be at risk for or already suffering from a likely eating disorder, as seen on the SCOFF questionnaire.
Of 101 participants, 14 (13.8%) reported mild depressive symptoms, four (3.9%) reported mild stress symptoms, and ten (9.9%) reported having moderate anxiety symptoms during the pandemic period.
D. ASSOCIATIONS BETWEEN THE PSYCHOSOCIAL STRESS AND DISTRESS DUE TO COVID19 PANDEMIC AND DISORDERED EATING BEHAVIORS DURING LOCKDOWN
A significant positive association between the psychosocial impact scores due to covid and all psychological distress variables (p < 0.001). However, no statistically significant associations were observed between the psychosocial impact of the COVID-19 pandemic with BMI, age, gender, marital or employment status, or any of the disordered eating patterns.
| VARIABLE | R-VALUE | P-VALUE |
|---|---|---|
| AGE | -0.1 | 0.3 |
| BMI | -0.07 | 0.5 |
| DEPRESSIVE SYMPTOMATOLOGY | 0.37 | < 0.001 |
| ANXIETY | 0.4 | < 0.001 |
| STRESS | 0.42 | < 0.001 |
| UNCONTROLLED EATING | 0.2 | 0.05 |
| EMOTIONAL EATING | 0.15 | 0.13 |
| COGNITIVE RESTRAINT | 0.15 | 0.13 |
According to the above findings, the COVID-19 pandemic's psychological effects during the lockdown were correlated with depressive symptoms, anxiety/stress levels, uncontrolled eating, and emotional eating (Table 3). Based on this data, mediation model in which the psychological distress (depressive symptomatology, anxiety, and stress levels) experienced due to the COVID-19 pandemic is related to disordered eating behaviors (uncontrolled eating) was evaluated, as shown in Fig. 2 (on next page).
There was no significant direct mediation between the psychosocial impact of the COVID-19 pandemic on disordered eating behaviors (b = 1.11 CI=-0.98, 3.16). However, the indirect effect of the psychosocial impact of the COVID-19 pandemic via psychological distress on disordered eating was found to be significant (b = 0.1, CI = 0.09, 2.17). It, therefore, suggests a part of the mediating effect of COVID-19-related psychosocial issues on disordered eating patterns via a significant, indirect effect of psychological distress.
The study attempted to examine the mediating relationships between the psychosocial impact of the COVID-19 pandemic and disordered eating behaviors in a community sample. We found that the change brought about by the COVID-19 lockdown was significantly associated with psychological distress, indirectly mediating some forms of disordered eating behaviors. Our findings thus suggest that individuals who experience changes in various domains of their daily life will experience increased psychological distress, resulting in more disordered eating. This finding, in turn, is hypothesized and supported by studies by Philippou and Ramalho. [13, 25]
According to numerous studies on psychological distress, people in crises frequently experience chronic psychological trauma that might result in depression, anxiety disorders, or substance abuse. [31] Additionally, it was found that those forced to stringent pandemic control techniques, like isolation and quarantine, report feeling depressed, anxious, lonely, and bored, with some even attempting suicide. [32] In this context, disordered eating patterns may serve as a maladaptive means to cope with the adverse events due to the COVID-19 pandemic during the lockdown. [33, 34]
In this study, 55.4% of participants perceived an increase in body weight during the peak of the COVID-19 pandemic period. While lack or decreased physical activity may mediate some of this change, this percentage is still much more significant than the studies by Dey and Ghosh. [17,35−37] Furthermore, although this is a self-report of perceived weight variations among the general population, it calls for attention to the impact of lockdown on overweight and obesity rates, as reported in some previous studies. [38, 39] The perceived weight gain may indicate underlying disordered eating attitudes/behaviors and body image issues, making it a target for clinical attention.
The participants in our study reported a high prevalence of disordered eating behaviors on screening. These figures point towards a significant presence of unhealthy dietary patterns in the community, as seen in studies by Ghosh, Basu, and Kumar, wherein higher snacking and food consumption were seen during the pandemic-induced restriction phase.[37, 39, 40] A similar study conducted among the Australian population, where eating behaviors of adults were compared to their pre-pandemic behaviors, suggested an increase in food restriction and binge eating behaviors, thus, illustrating the significant impact of lockdown periods on eating behaviors.[13] However, in a cohort study conducted in the USA, the prevalence of disordered eating behaviors during the COVID-19 pandemic was similar to earlier measurements done before the pandemic. Also, poorer stress management and more significant stress, depressive symptoms, and financial difficulties were significantly and positively associated with concurrent disordered eating in this cohort.[41] Thus, there are two substantial implications from the above findings- there needs to be robust, large-scale screening for psychological distress in the youth and educating the youth about stress management, especially now, as the conditions are being restored to pre-pandemic levels. Secondly, as many of these patterns serve as a precedent for developing clinical eating disorders, early detection and treatment become crucial to prevent long-term disability and morbidity.
Another crucial data is that 10% of participants were already at risk for or likely suffering from an eating disorder at the time of the survey and required detailed clinical evaluation. Given that a brief, self-report screening instrument devised initially in the context of Western culture was used in this study, it is challenging to comment precisely on the nature and extent of this problem in India. However, as studies by Taquet and Lin have suggested, there has been a definite upsurge in reported eating disorders during the COVID-19 pandemic. [42, 43] In the Indian context, however, eating disorders are still under-researched and under-reported. Moreover, culture bears a strong influence on the presentation of eating disorders in India, as suggested by the presence of culturally sanctioned fasting practices, the presence of the "Non-fat phobic" variant of anorexia, and likewise.[44] Given such ambiguity, there is an imminent need to develop culturally sensitive instruments for diagnosis and generate locally relevant epidemiological data about eating disorders from the larger community and hospital settings to formulate targeted interventions.
Our study attempted to study mediation patterns between various variables in developing disordered eating behaviors, which have not been studied in the Indian context until now. However, the generalizability of this study is limited due to its cross-sectional nature and the choice to only include individuals with working internet access, which inhibits causal hypotheses from being tested. Moreover, the psychological and eating behavior assessment was self-reported which may be affected by recall bias and stigma associated with psychological issues. Finally, we did not include adolescents in this study, who are usually considered at risk for developing eating disorders. Therefore, our recommendation for future work will be to examine the above variables longitudinally to confirm causality in a diverse sample and to use face-to-face assessments for better accuracy. In addition, studies on the frequency of help requests to healthcare services related to disordered eating behaviors will reinforce these study results.
To conclude, among other things, the COVID-19 pandemic has caused significant psychological distress among the youth. Moreover, it has indirectly mediated disordered eating patterns among the younger population at higher risk for developing mental disorders. Overall, the presented findings help to understand the impact of lockdowns on individuals' eating behaviors in the face of large-scale disasters such as a pandemic and may help develop innovative intervention strategies to prevent and reduce the early adverse effects of lockdowns. Thus, mandatory screening for mental disorders, especially among the youth, becomes imperative for clinicians to formulate targeted community interventions in the long term.