Many Americans are becoming accustomed to discussing how pandemic-related lockdowns and remote engagement have changed our lives. The conversations tend to be mechanical and superficial, like discussing the weather, and often include references to changes in eating or jokes about “the pandemic 15” to reflect weight gain from sitting too much or too close to the homemade bread.
But for one segment of the population, pandemic-related changes in eating habits are no joke. As we and several colleagues reported in JAMA Network Open, data from a large national health insurer showed substantial increases in hospitalizations among people with anorexia nervosa, bulimia nervosa, and other eating disorders, such as binge-eating disorder, starting in the second half of 2020. Hospitalization rates for these conditions roughly doubled compared to the rates in the prior two years. And individuals admitted to the hospital tended to stay about 50% longer, suggesting the disorders were more severe.
We saw no changes in outpatient visits or hospitalizations for other common mental health conditions like depression, alcohol use, or opioid use, suggesting that the pandemic is having a particular effect on people susceptible to eating disorders.
Although it isn’t entirely clear to us why this has happened, understanding some of the reasons can help families and clinicians recognize these problems earlier and provide appropriate services.
First, messaging about the link between obesity and the severity of Covid-19 and on connections between self-quarantine and weight gain have likely been hard on people susceptible to eating disorders. These messages may have prompted some to engage in restrictive eating behaviors, such as refusing to eat certain foods or labeling foods as “good” or “bad,” which can lead to more severe weight loss in those with anorexia and to more severe binge eating and compensatory behaviors, such as vomiting or laxative use, among those with bulimia.
Second, especially in the beginning of the pandemic, grocery shopping became a more complicated and difficult task due to fears of contracting Covid-19 in public places like grocery stores, the limited availability of some foods and household items, and strict rules and rituals for shoppers. Food shopping, an already anxiety-provoking task for individuals prone to eating disorders, became even more difficult.
Third, during the pandemic, many people bought large quantities of processed, pre-packaged comfort foods to minimize how often they needed to shop and out of concern for food shortages. Being confined at home in close proximity to these foods likely led to increases in mindless eating and snacking for many people, as well as bingeing episodes for those prone to eating disorders, particularly since people had fewer distractions and distance from food.
Fourth, exercise was one of the few activities promoted as safe and healthy during the pandemic. For many individuals with eating disorders, exercise may have become a way to control an uncontrollable situation or a compensatory mechanism for eating. In one recent study, a majority of patients with anorexia who had participated in treatment in 2019 reported during the pandemic that they had increased concerns about eating, body shape and weight; a higher drive for physical activity; and more loneliness, sadness, and inner restlessness.
Fifth, social anxiety, stress, and depressed mood often go hand-in-hand with eating disorders and all worsened during this time.
These five factors likely increased eating disorder symptoms. But a collection of other circumstances may have made eating disorders easier to discover and, perhaps, harder to treat.
Stay-at-home orders, remote schooling, and the closure of college campuses may have helped families better identify unhealthy rapid weight loss or binge eating, or more clearly see its psychological burdens, leading family members to seek treatment for their loved ones. At the same time, outpatient facilities struggling to adapt their operations during the pandemic may not have had additional capacity to see these patients when their symptoms warranted a lower level of care, thus delaying treatment and intensifying the eating disorder. Similarly, fears of contracting Covid-19 may have influenced individuals and family members to delay seeking care until symptoms were severe enough to require inpatient care.
Food is a large part of life. For those with eating disorders, food and its rituals are also great sources of anxiety. Many people living with these disorders have struggled even more during the pandemic. As it shifts and society adjusts to a new normal, it’s important to recognize the burden the pandemic continues to impose on people with eating disorders. In a society where appearance is highly prized, eating disorders are often considered less important and more under the control of those who experience them than other mental health disorders. The pandemic highlights the need to understand the particular triggers for individuals with eating disorders, identify the symptoms, and provide appropriate and early treatment.
David A. Asch is an internal medicine physician, a senior fellow of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, and executive director of the Penn Medicine Center for Health Care Innovation. Kelly C. Allison is a psychologist and professor in the Department of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania and director of Penn’s Center for Weight and Eating Disorders.
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