Our findings demonstrate the urgent implication of the COVID-19 pandemic on youth with EDs. The large majority of participants reported worsening of MH and ED symptoms and many reported declining motivation to recover as a result of the pandemic. Individuals also reported high degree of environmental disruption, with well over half of participants expressing concern that their ED would worsen due to living in a triggering environment. The report of living in a triggering environment was further associated with marked increased risk of reporting worsening MH/ED symptoms relative to no report of concern for a triggering environment. More specifically, concerns for their ED worsening due to living in a triggering environment were associated with increased intrusive ED thoughts and decreased motivation to recover.
As hypothesized, the majority (over 70%) of adolescent and young adult patients with EDs reported increases in intrusive ED thoughts, anxiety, depressive symptoms, and social isolation due to the COVID-19 pandemic. This is consistent with other studies of the impact of COVID-19 on patients with EDs. Rates of ED symptoms (e.g., dieting, excessive exercise, purging), anxiety, and depression among adolescent and adult populations with EDs have been consistently higher during the pandemic compared to other years, as evidenced by a significant increase in the number of helpline calls and online instant chats with their National ED Centre in Canada.22 Termorshuizen et al. (2020) found that adolescent and young adult participants with AN reported increased restrictive eating and fear about finding foods to follow their meal plans while those with bulimia nervosa and binge eating disorder reported increased binge-eating behaviors.9 Another study found that more adolescents and adults with AN agreed rather than disagreed that their ED symptoms and sadness had worsened.10 Research suggests that individuals with EDs may be experiencing worsening ED symptoms due to feelings of social isolation, which leads to loneliness, fewer distractions, more time to think about food, and increased opportunity to engage in disordered behaviors.21, 23
Regarding individuals’ motivation for recovery in the context of COVID-19, rates of reporting a decrease versus an increase in their motivation were similar (29% and 26%, respectively). Recent studies have identified potential factors that contribute to an increase in motivation for recovery, including increase in social support that challenges ED behaviors, 9 positive influence from others (e.g., recovered role models, advocacy groups, mentors), support for pro-recovery beliefs and lifestyle changes, and non-judgmental comments around weight or eating.20 There is limited understanding of what contributes to decreased motivation during the COVID-19 pandemic. It is possible that the worsening quality of the parent-adolescent relationship or avoidance of negative or distressing emotions may be associated with decreased motivation to recover among adolescents with EDs.18, 24
The present study found that more than a half of the participants reported feeling concerned that their ED would worsen due to living in a triggering environment. This finding is consistent with Termorshuizen et al.’s (2020) study on COVID-19-related concerns and EDs, which showed that about 58% of their participants reported concerns about worsening of ED symptoms due to living in a triggering environment.9 While “triggering environment” was not defined in the survey measure we adapted from colleagues,9 some examples included social media content on weight gain during quarantine, a lack of structure, and being at home all day.9 Given the age range of our population, with many college-aged participants, the worry about a triggering environment could also be related to an abrupt return to one’s childhood home after being away at a university/college or living independently. Other COVID-19-related stressors that may further exacerbate ED symptoms include changes in daily schedule or routines21, 25 increase in financial stress,5 food insecurity,26 as well as family conflicts.10, 27 Living and spending a large amount of time at home may be triggering, as some adults who had recovered from an ED had felt judged by family at home.20 Family dynamics are important to consider given the age of the present study’s participants, as many returned home or were required to spend more time at home during the lockdown.
Our study highlights the impact of environmental stressors on individuals’ ED symptoms and motivation for recovery. We found that individuals who were concerned that their ED would worsen due to living in a triggering environment were 18 times more likely to report a decrease in their motivation to recover and nearly 24 times more likely to experience an increase in intrusive ED thoughts compared to those who denied any concerns about ED due to their environment. This is consistent with recent findings that lockdown restrictions, disrupted routines, increased time spent in a triggering environment, and decreased ability to engage in activities (including exercise) may lead to individuals’ frustration and feelings of restlessness.9, 25 These individuals may also experience beliefs that they do not need to eat as much as they did pre-COVID, which may further be reinforced by media attention to weight gain during lockdown for the general public.25, 28 Individuals with EDs may also experience loneliness, social isolation, decreased social support, and a lack of distractions related to COVID-19, which can lead to greater focus or rumination on food and disordered eating behaviors21, 23 and greater difficulty with coping with ED cognitions.29
These findings suggest that stressful environments—such as one brought upon by the current COVID-19 pandemic—may affect motivation to recover and ED/MH symptoms. The literature on COVID-19 has demonstrated the negative impact of COVID-19 on MH concerns (anxiety, depression, etc.). Our study examines the environmental changes related to the pandemic and their unique effects on ED/MH symptoms and motivation for recovery. To our knowledge, the present study is one of the first to look at COVID-19’s impact on MH/ED symptoms and motivation to recover among an adolescent/young adult population with an ED.
Despite its aforementioned strengths, the present study is not without limitations. Though it was made clear to patients that this additional survey was to assess the effects of COVID-19 on their ED, we cannot make a definite conclusion that the many changes related to COVID-19 pandemic caused these MH and ED changes. Additionally, “triggering environment” was not defined in the survey measure used. Participants were asked if they had concerns about their ED worsening due to living in a triggering environment and thus, respondents may have retrospectively chosen this as a reason to explain why their ED has worsened. Although the majority of patients from our full sample responded to the survey (56%), it is still unclear how the remaining participants would have influenced our results. Our moderate response rate was likely partially due to these being additional surveys sent off-cycle in order for data to be collected in a timely manner. However, reassuringly, the responders only differed from the non-responders on ED diagnosis. Additionally, the majority of our patients were white and/or had a restrictive ED diagnosis and thus, our findings can’t be interpreted for patients with other ED diagnoses (e.g. binge-eating disorder, bulimia nervosa) and other self-identified races and ethnicities. Due to small sample size, we carefully considered which variables to adjust for to avoid overfitting the model. Despite wide confidence intervals due to sample size, odds ratios were very large, indicating a compelling effect of the extent the COVID-19 pandemic has impacted patients living with EDs. Additionally, a sensitivity analysis collapsing “triggering environment” into “slightly concerned”/”no concern” vs. “somewhat concerned”/”very concerned” yielded similar overall results in adjusted analyses to the findings of the primary analysis reported in the results and tables. In order to provide a broader picture of how the COVID-19 pandemic impacted patients with EDs, future research should focus on the perspective of caregivers, as caregiver burden and stress may indirectly affect the MH and ED concerns of patients with EDs. Our findings illustrate the significant negative psychological impact COVID-19 has had on our patients with EDs and offers a potential explanation in environments impacted by the pandemic.