Why Eating Disorders Have Escalated During the Pandemic

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The COVID-19 pandemic has triggered a marked surge of eating disorders (ED) among girls and women. This spike has alarmed many experts. For example, when Miniati and colleagues (2021) summarized studies from Australia, Europe, the Middle East, and North America, they concluded that the pandemic has fueled EDs around the world. More specifically, Agostino and colleagues (2021) reported that in Canada newly diagnosed anorexia cases increased from 24.5 to 40.6 cases per month and hospitalizations among these patients increased from 7.5 to 20 per month during the first wave of the pandemic from March to Nov. 30, 2020.

Taquet and colleagues (2021) found that in 2020 the overall incidence of eating disorders increased during the COVID-19 pandemic by 15.3% in the U.S. The increase occurred solely in women and girls with anorexia nervosa. Lin and colleagues (2021) also reported a significant increase in the number of eating disorder-related medical hospitalizations, hospital bed-days, and patient/parent inquiries after the onset of COVID-19 in their tertiary care children’s hospital in the USA.

Haripersal and colleagues (2021) observed a 104% increase in children who were hospitalized with anorexia nervosa compared with the three years previous to the COVID-19 pandemic in Australia.

Kurisui and colleagues (2021) suggested that the COVID-19 pandemic may have led to an increased prevalence of eating disorders in Japan.

When Tavolacci, Ladner, and Déchelotte (2021) examined the prevalence of eating disorders among French students, they found that eating disorders increased from 31.8% in 2018 to 51.8% in 2021 for women.

Why are so many women and girls, particularly, struggling with EDs during the pandemic? Researchers show that the extra stress during the COVID-19 drives the ED spike. When Rogers and colleagues (2020) further examined what exactly was stressful, they suggested several "pathways" that may have led to the jump in ED cases during the COVID-19 pandemic.

First, COVID has changed many people’s daily eating patterns. The restrictions during the pandemic may have disrupted routines such as regular meal times. This may lead to unstructured snacking and grazing and then feeling the loss of control of eating to trigger an ED. In their mixed-methods study, Branley-Bell and Talbot (2020) explored further how individuals experiencing eating disorders coped with the COVID lockdown in the U.K. Their study included 129 participants who were between 16 and 65 years old with 121 participants identifying as female. The researchers first noted that having more time, combined with a lack of clear routines, left space to ruminate more about weight, exercise habits, and meals. When feeling out of control with the pandemic itself, disordered eating may have been one thing that participants had control over. One participant explained:

“Normally when I am in control over everything I am able to do better. I currently have less control of being able to go out, my studying, work etc., and I feel subconsciously I am controlling this with food.”

Most participants (85.2%) reported that their symptoms had worsened when confined at home. Although structured mealtimes may be an important aspect of caring for eating disorders, these participants observed increased surveillance and pressure from others to eat more during the confines of the lockdown. They felt that people living with them were often critical of their eating behaviors. One participant commented:

“I have much less choice of what I eat and I have to eat most of my meals in front (and in scrutiny) of others and that is causing enormous stress.”

This led to feelings of being trapped, "incredibly low," or unhappy. Others found that being isolated from their families was a relief because there was less social pressure:

“Not seeing those close to me who would recognise my losing weight and deterioration has put me under less pressure to challenge my ED as I can unwitnessed lose weight without challenge from others which is less pressure for me.”

Second, the disruptions and restrictions have also changed many people’s daily physical activity patterns. Some activities were not possible at all due to facility closures. It was not always possible to turn to outdoor activities, as some restrictions limited the time outdoors or confined everyone indoors at all times. Rogers and colleagues speculated that the limited regular physical activity in combination with disrupted eating patterns may have led to weight concerns and, thus, heightened the exposure to EDs. Branley-Bell and Talbot verified this suspicion when they reported that their participants who increased their physical activity (36.5%) did so because of fear of weight gain or of the need to fill their days with activity. One participant explained:

“I was doing lots before but even more now partly because I actually like it, partly to fill the time, partly from an unhealthy driven mentality. Rest days now feel unnecessary because I'm resting every day if I'm not working.”

The researchers added that while others around the participants "policed" their eating behaviours, exercise may have been considered healthy as it was more difficult to determine when it turned excessive and, thus, unhealthy. The participants themselves were aware of this tension:

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“There is part of me that wants to do all of the exercise, to ‘get thin’ and to listen to the disorder. But there is also part of me that knows I need to moderate my exercise because it’s so triggering for me.”

The participants who did not increase their exercise levels resorted to restricting their eating further:

“Can't exercise as much / the way I was, and not getting as many steps, so being more restrictive with foods eaten, calories, and timing of eating (doing intermittent fasting again).”

Third, increased media exposure may trigger eating disorders. As pandemic restrictions were often reported to lead to weight gain, the media, and particularly social media, were filled with diet and exercise advice. The participants in Branley-Bell and Talbot’s study also accessed pro-ana websites and "thinspo" content in the media during the lockdown. The researchers noted that the social media echoed the message of “fear of gaining weight” that dominated the U.K. media at the time. They discovered that this type of messaging was particularly "triggering" for their participants:

“There is a lot going around social media such as putting on weight during COVID-19 due to not doing as much and that is really triggering for people like myself as straight away my head thinks, that can’t happen to me! I must change the way I am towards food etc.”

Added to the messages of excess weight was the emphasis on increased exercise during the COVID-19 pandemic that the participants found difficult to cope with:

“There is a heavier push on ALL social platforms to ‘stay for’ and ‘stay in shape’. Any coping mechanisms I did have before have changed. I struggle with exercise mainly, and with everything being in the spotlight it’s harder to look away from it and ignore it.”

Having to exercise at home could be thought to reduce the need to compare one’s body to others. This was, however, not the case for Bradley-Bell and Talbot’s participants. They compared their bodies or exercise levels to those they saw in the media:

“Watching workout videos judging myself for my lack of motivation to do anything and just how disgusting my body is compared to everyone else's out there. Everyone is doing self-improvement and I'm not.”

Finally, during the pandemic, many of us have worked from home and also spent more time online. Most participants (81.4%) in Branley-Bell and Talbot’s study were also more occupied with digital spaces. Communicating through video-conferencing is often thought to increase privacy and, thus, the numerous jokes about wearing underwear bottoms or "comfy" sweatpants while in the meetings. However, it may indirectly contribute to eating disorders, because there is an emphasis on close-ups of one’s face similar to “looking in the mirror” all the time while talking to others (Rodgers & al., 2021). One participant in Branley-Bell and Talbot’s study explained:

“Hav[ing] seen myself more…made me question if I [am] good enough or look good. Also, things have changed to online video conferencing. It’s just the amount of time seeing yourself.”

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The COVID-19 pandemic has also increased general levels of stress and emotional distress (Rodgers & al., 2021) and as a result, emotional eating can trigger binge eating. These stresses worsen with less social support available during the lockdowns and with restricted access to therapy and ED-specific care during the pandemic.

The pandemic has obviously triggered eating disorders and impacted, particularly, on women and girls’ psychological well-being. The researchers emphasize that these negative impacts are likely to be long-term, because recovery from eating disorders is often lengthy. It is clear that the COVID-19 pandemic has exacerbated eating disorders and the researchers now call for an urgent need to raise awareness of these disorders as well as the need for the further provision of care. In addition, there is more need than ever to highlight the harmful psychological effects of exercise promotion that focuses on unhealthy weight loss and the thin and toned "looks" in the media. Exercise is healthy when we work out to move better. This way, it is possible to feel energized and deal with the COVID-19 pandemic and life after it.