People's lived experience with an eating disorder during the COVID-19 pandemic: A joint virtual issue of research published in leading eating disorder journals

Professional Digital Counselling for Eating Disorders in Germany: Results of the DigiBEssst Project Survey on the Perspectives and Experiences of Health Professionals, Individuals With Eating Disorders, and Carers

OBJECTIVE

The research project DigiBEssst examines existing digital counselling services for individuals with eating disorders (ED) and carers in Germany. It highlights their experiences with digital counselling as well as those of the expert counsellors involved, aiming to derive quality criteria for digital counselling in ED.

METHOD

A mixed-methods design was adopted. Analysing the websites of 181 professional counselling centers, the research team identified 86 counselling centers for ED that offered online counselling. Initially, 29 centres participated in an online survey. Subsequently, in-depth, semi-structured interviews were conducted with professionals (n = 15), individuals with ED (n = 13), and carers (n = 10). The data were analysed using descriptive statistics and structured content analysis.

RESULTS

Less than half of the German counselling facilities offered online counselling. The participants emphasised the need for a specific concept, counsellors' profound expertise in ED and online counselling, sustainable funding, sufficient personnel and time resources, and secure platforms to ensure data protection and quality management. Access to professional services requires informative, user-friendly websites, and social media presence.

CONCLUSIONS

The identified prerequisites and quality criteria for professional online counselling developed in this project can provide recommendations for the conceptualisation of digital counselling services.

Eating disorder debut cases during COVID-19 lockdown in adults. Exploring differences in treatment outcome contrasting with pre-pandemic onset cases

OBJECTIVE

Despite an increase in eating disorder (ED) cases during the COVID-19 pandemic, there are limited longitudinal studies exploring treatment outcomes. The aims of the present study were: (1) to compare the clinical features of patients with EDs whose onset was during the COVID-19 lockdown (pandemic cohort) against patients with EDs whose onset was prior to the pandemic (pre-pandemic cohort) and, (2) to compare therapy responses between the cohorts.

METHOD

The sample consisted of 115 adult women with an ED. N = 37 new ED cases (pandemic cohort) were diagnosed and included in the study during the pandemic (May 2020-May 2021); these patients did not have any previous history of an ED. We also included N = 78 ED cases (pre-pandemic cohort) diagnosed prior to the COVID-19 pandemic breakout (prior to March 2020). All ED subtypes were considered in both groups and several clinical variables were assessed.

RESULTS

At baseline, pandemic cohort reported lower levels of impulsivity and higher emotional regulation capacities than the pre-pandemic cohort; however, no differences were found in aspects of general psychopathology and ED related severity. Following treatment, the pandemic cohort showed higher rates of good outcome and lower rates of dropouts than the pre-pandemic cohort.

CONCLUSIONS

Although both cohorts showed similar ED-related symptoms and general psychopathology scores, treatment outcomes were more favourable in the pandemic cohort.

Prevalence and correlates of disordered eating at a large state university before and after the onset of the COVID-19 pandemic

BACKGROUND

Emerging adulthood is a transitory period in which disordered eating (DE) manifests; collecting data on the prevalence of DE among this population as well as demographic and behavioral correlates are important public health goals.

METHODS

Data from an annual survey of undergraduate students at a large state university from 2019 to 2022 were analyzed, allowing researchers to compare prevalence and correlates before and after the onset of the COVID-19 pandemic using two brief screeners: the SCOFF and Eating Disorder Screener for Primary Care (ESP). We hypothesized that rates of DE would be greater after the onset of COVID-19 as compared to before. We also hypothesized that those identifying as women, reporting higher alcohol or drug use, and contemplating suicide would have greater odds of reporting symptoms consistent with DE.

RESULTS

DE was significantly lower in pre-pandemic years compared to pandemic years: ESP pre = 38.01%(n = 704), pandemic = 48.79%(n = 645), p < 0.001; SCOFF pre = 22.82%(n = 422), pandemic = 31.46%(n = 414), p < 0.001. Logistic regressions showed women and students who contemplated suicide reported significantly greater DE, regardless of screener or time period. Inconsistent relationships were found between DE and current substance use.

CONCLUSION

These findings may inform targeted interventions for those most vulnerable to disordered eating.

A systematic review of COVID-19 and the presentation of avoidant/restrictive food intake disorder and avoidant/restrictive food intake disorder-like symptoms

BACKGROUND

The adverse effects of COVID-19 and the associated restrictions on eating disorder populations have been discussed in recent literature. However, little is known about the presentation of cases with avoidant/restrictive food intake disorder (ARFID) during this period.

AIMS

To explore the extent of the literature on the presentation of ARFID, and ARFID-like cases, during the COVID-19 pandemic.

METHOD

Cochrane Library, CINAHL (EBSCO), PsycINFO (EBSCO), EMBASE (Ovid) and Medline (Ovid) were searched for publications between March 2020 and May 2023. Google Scholar and reference lists were hand searched. At least two reviewers independently screened each paper. Narrative synthesis was used.

RESULTS

Seven papers were included: four case reports and three cohort studies (total ARFID sample of 46). Included papers were assessed as having high (n = 3) or moderate (n = 4) quality. Findings did not suggest an increase in ARFID cases during the COVID-19 pandemic, although it is unclear if this is because of a lack of impact or underrecognition of ARFID. A need for a multidisciplinary approach to differentiate between ARFID and organic causes of ARFID-like presentations (e.g. gastrointestinal effects of COVID-19) was highlighted.

CONCLUSIONS

Publications specifically pertaining to ARFID presentations during the COVID-19 pandemic have been few. Papers found have been of small sample sizes and lack subanalyses for ARFID within broader eating disorder samples. Continued surveillance is needed to evaluate any COVID-19-specific effects on the development, identification, treatment and outcomes of ARFID.

A Qualitative Exploration of Prominent Factors Contributing to the Aetiology of Child and Adolescent Eating Disorder Presentations during the COVID-19 Pandemic: The Perspectives of Patients, Parents and Clinicians

AIM

The aim of this study was to explore the prominent factors that contributed to the development of child and adolescent eating disorder presentations during the COVID-19 pandemic.

METHODS

This was achieved through a qualitative analysis of interviews gathered from (1) adolescent patients diagnosed with an eating disorder (ED) during the COVID-19 pandemic (aged 13-18) (n = 4), (2) parents of patients attending an ED service (n = 7) and (3) clinicians working within a specialist child and adolescent ED support service (n = 7). Reflexive thematic analysis was used to analyse the data and establish the most prominent aetiological factors reported.

RESULTS

The most prominent aetiological factors reported were (1) the accumulation of risk factors; (2) seeking control amid increased anxiety, stress and uncertainty; (3) social isolation; (4) an increased focus on exercise and "healthy eating"; (5) increased social media use promoting unhelpful attention towards ED triggers; and (6) a lack of both awareness and support services.

CONCLUSION

During the COVID-19 pandemic, the quantity and severity of ED presentations increased. The current study uncovered six themes perceived by patients, parents and clinical staff that contributed to the aetiology of ED presentations during the COVID-19 pandemic. It is hoped that the insight gained through this research study into ED aetiology may act as a basis for further research and support ED awareness, prevention and intervention in the future.

Virtually Accompanied Eating in the Outpatient Therapy of Anorexia Nervosa

BACKGROUND

Normalizing the eating pattern and weight recovery are the main objectives in treating anorexia nervosa (AN). Eating accompaniment through shared mealtimes is a common strategy in eating disorder management programs. This study aims to examine the impact on weight gain of an internet-delivered meal support group on patients with AN who were under ambulatory treatment with the Eating Disorders Unit of the UC Christus Health Network, Chile.

METHODS

An observational study of 54 female patients with AN diagnosis who participated in Online Meal Support Groups (OMSGs) three times a week was performed. Their weight, BMI and BMI%, was reviewed at the beginning of the sessions and at 45- and 90-day follow-up.

RESULTS

Patients showed significant weight gain during follow-up. At the 90-day follow-up, patients had gained 4.41 (SD ± 2.82) kg with an effect size of -1.563.

CONCLUSIONS

Statistically significant differences were found between the weight at the beginning of the intervention and at the 45- and 90-day follow-up, meaning that eating support online groups may be an effective intervention for weight gain and maintenance in patients with AN. These findings highlight the viability of developing cost-effective and more accessible interventions for AN and thus help reduce the duration of untreated disease and its consequences.

Autopsy of a failed trial part 1: A qualitative investigation of clinician's views on and experiences of the implementation of the DAISIES trial in UK-based intensive eating disorder services

OBJECTIVE

The DAISIES trial, comparing inpatient and stepped-care day patient treatment for adults with severe anorexia nervosa was prematurely terminated in March 2022 due to poor recruitment. This qualitative study seeks to understand the difficulties faced during the trial by investigating stakeholders' views on and experiences of its implementation.

METHOD

Semi-structured interview and focus group transcripts, and trial management and oversight group meeting minutes from May 2020-June 2022 were analysed using thematic analysis. Participants were 47 clinicians and co-investigators involved with the DAISIES trial. The Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework was applied to the interpretive themes to classify barriers and facilitators to implementation.

RESULTS

Five themes were identified: incompatible participation interests; changing standard practice; concerns around clinical management; systemic capacity and capability issues; and Covid-19 disrupting implementation. Applying the NASSS framework indicated the greatest implementation challenges to arise with the adopters (e.g. patients, clinicians), the organisational systems (e.g. service capacity), and the wider socio-political context (e.g. Covid-19 closing services).

CONCLUSIONS

Our findings emphasise the top-down impact of systemic-level research implementation challenges. The impact of the Covid-19 pandemic accentuated pre-existing organisational barriers to trial implementation within intensive eating disorder services, further limiting the capacity for research.

Exploring the impact of the COVID-19 pandemic on perceptual disturbances and dysfunctional eating attitudes and behaviors: A review of the literature

From the outbreak of the novel coronavirus 2019 (COVID-19) a new physical and social distancing environment has changed our lives and, more particularly, the way of perceiving oneself, as well as eating attitudes and behaviors. An increasing number of studies have highlighted a risky scenario in terms of negative perceptions of one’s body as well as disordered eating and eating disorder patterns in both clinical and general population. With regard to this postulate, this literature review posits two main concepts—perceptual disturbances and dysfunctional eating attitudes and behaviors—in the general and (sub-)clinical populations, to provide an understanding of these phenomena during the COVID-19 pandemic. The main objective of this article is to provide a comprehensive and critical review of published scientific literature about perceptual disturbances (i.e., negative body image, body image disturbances, low body esteem) and dysfunctional eating attitudes and behaviors, including disordered eating (e.g., restrictive eating, binge-eating episodes, overeating, emotional eating) and eating disorders features in community (i.e., general population) and clinical and sub-clinical samples worldwide during the COVID-19 pandemic. The PubMed, ScienceDirect, Ebsco, and Google Scholar databases were searched. The initial search produced 42 references. Scientific publications from March 2020 to April 2022 were included, and among the works compiled, only published research articles have been retained. Purely theoretical papers were also excluded. The final selection consisted of 21 studies, covering both community, clinical (i.e., eating disorder population), and sub-clinical samples. The details of the results are discussed taking into consideration the potential impact of changes in the way we perceive ourselves and interact with others (e.g., the popularity of videoconferencing and the over-use of social network sites due to social isolation) as well as changes in eating attitudes and behaviors, physical activity and exercise (e.g., as an emotional response to the insecurity generated by the pandemic context), in community and (sub-)clinical samples. The discussion sheds light on two outcomes: (1) a summary of findings with methodological considerations; (2) an intervention continuum to deal with the consequences of the COVID-19 pandemic; (3) and a final conclusion.

Perceptions and experiences with eating disorder treatment in the first year of COVID-19: A longitudinal qualitative analysis

OBJECTIVE

The COVID-19 pandemic created significant challenges in accessing and receiving treatment for individuals with eating disorders (EDs). The purpose of this study is to explore perceptions of and experiences with ED treatment during the first year of the pandemic among individuals with past and self-reported EDs in the United States.

METHODS

Online surveys were administered to adults (N = 510) with a past or current self-reported ED at 13 timepoints between April 2020 and May 2021. Using longitudinal qualitative analysis, 5651 free-text responses were examined to capture experiences with ED treatment and generate inferences of change over time.

RESULTS

We categorized results into four sequential, temporal quarters and identified patterns that explained participants' perceptions of facilitators, barriers, and experiences with ED treatment over time: Quarter 1. Treatment Disruption and Reorienting Recovery; Quarter 2. Accumulating COVID-19 Stress and Virtual Treatment Woes; Quarter 3. A Continuation of Inadequate Care; and Quarter 4. Ongoing Adaptation and Adjustment to Uncertainty. Participant experiences were marked by numerous barriers to accessing care, challenges adjusting to virtual treatment, unmet treatment needs, and beginning acceptance of telehealth.

DISCUSSION

Our findings present a timeline to help evaluate challenges related to navigating the switch to virtual care which created significant disruption to ED recovery. Participants spent much of the first year trying to adjust to unemployment, loss of insurance, and lack of access to in-person treatment. Future research should identify additional strategies to improve the receipt and experience of care for EDs.

PUBLIC SIGNIFICANCE

Our findings suggest that individuals with eating disorders were significantly challenged by accumulating COVID-19 stress, worsening symptomatology, and limited access to effective treatment during the first year of the pandemic. This knowledge can guide clinicians, treatment centers, and policy makers in addressing the behavioral health needs of individuals impacted by disordered eating amidst emergent public health crises.

The impact of the COVID-19 pandemic on eating disorders in U.S. military veterans

PURPOSE

The COVID-19 pandemic has had a profound impact on mental health around the world. Although there have been reports that the incidence of eating disorders (EDs) has increased during the pandemic, few longitudinal studies have examined recent changes in EDs. Men and women with military histories may be particularly vulnerable to EDs, underscoring the importance of investigating the impact of the COVID-19 pandemic on EDs in this population.

METHOD

We examined whether early-pandemic (Time 1; T1) posttraumatic stress disorder, depression, anxiety, and stress symptoms were associated with change in probable ED diagnostic status 1 year later (T2). We also investigated relationships from early pandemic mental health symptoms to change in ED diagnostic status from T1 to T2 via pandemic-related life circumstance pathways (health, financial, social, etc.). Participants included a population-based sample of 372 U.S. veterans who completed the T1 and T2 surveys.

RESULTS

Early pandemic mental health was significantly and positively associated with probable ED diagnostic status. Social and health satisfaction as well as physical health pandemic impacts mediated the associations between mental health symptoms and ED diagnostic status.

DISCUSSION

Findings highlight the importance of bolstering social connection, health-promoting behaviors, and access to ED treatment among veteran men and women impacted by the COVID-19 pandemic.

PUBLIC SIGNIFICANCE

The COVID-19 pandemic has had a profound impact on mental health, including eating disorders (EDs). We found that early pandemic mental health symptoms were significantly associated with changes in U.S. veterans' ED diagnostic status 1 year later. Mental health symptoms increased ED diagnoses via their impact on social and health satisfaction, as well as physical health impacts of the pandemic. Findings highlight the importance of increasing social connection, health-promoting behaviors, and ED treatment access among veteran men and women, who may be particularly vulnerable to EDs, during the COVID pandemic.

The impact of the COVID-19 pandemic on referral numbers, diagnostic mix, and symptom severity in Eating Disorder Early Intervention Services in England

OBJECTIVE

First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway which aims to provide timely, well-coordinated, developmentally informed and evidence-based care for young people with eating disorders (EDs). This article investigates the impact of the COVID-19 pandemic on FREED patient presentations and service provision in England.

METHOD

Data from three services spanning the pre- to post-pandemic period were included (January 2019-September 2021; n = 502 patients). Run charts were created to analyze changes in monthly baseline patient data (e.g., referral numbers, duration of an untreated ED, diagnostic mix, and average body mass index for patients with anorexia nervosa [AN]).

RESULTS

Significant increases in referral numbers were found from September 2020 onward, coinciding with the end of the first UK national lockdown. The percentage of AN presentations significantly increased after the onset of the first national lockdown (April 2020-December 2020). No other significant change patterns were identified.

DISCUSSION

There have been substantial increases in referral numbers and presentations of AN to FREED services whereas illness severity seems largely unchanged. Together, this suggests that increased referrals cannot be attributed to milder presentations being seen. Implications for the implementation, funding, and sustainability of the model are discussed.

PUBLIC SIGNIFICANCE

Our research suggests that early intervention eating disorder services across England faced significant increases in patient referrals and presentations of anorexia nervosa over the COVID-19 pandemic. This increase in referrals is not due to a rise in milder eating disorder cases, as baseline symptom severity remained stable across the pandemic. Investment in early intervention for eating disorders must therefore match increased referral trends.

Course and predictors of eating disorder symptoms, anxiety symptoms, and pandemic-related eating disorder concerns among adults with eating disorders during the first year of the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic and public health mitigation measures have negatively impacted individuals with eating disorders (ED). We evaluated changes in and predictors of ED symptoms, pandemic-related ED concerns, and anxiety symptoms across the first 12 months of the COVID-19 pandemic among individuals with self-reported EDs in the United States (US), Sweden (SE), and the Netherlands (NL).

METHOD

Participants in the US (N = 510), SE (N = 982), and NL (N = 510) completed an online survey assessing ED symptoms (binge eating, restriction, compensatory behaviors, and anxiety about being unable to exercise), general anxiety symptoms, and pandemic-related ED concerns about accessing food, lack of structure and social support, being in a triggering environment, and food and treatment costs. In the US and NL, respondents completed surveys beginning April 2020 and continuing monthly for a year. In SE, respondents completed baseline surveys in May 2020, a six-month follow-up around December 2020, and a 12-month follow-up in May 2021.

RESULTS

Three patterns emerged: (1) a curvilinear course with the highest level of symptoms at baseline, declining through November 2020, and increasing through the rest of the year; (2) a linear declining course over time; and (3) a stable course with no changes. Worries about COVID-19 infection, lockdown, concerns about lack of structure and social support, and concerns about accessing food consistent with one's recovery meal plan predicted increases in ED symptoms.

DISCUSSION

ED symptoms tracked with pandemic-related concerns in people with EDs. Conceptualizing predictors of symptoms may inform therapy and public health resources that reduce the impact of pandemics on mental health.

PUBLIC SIGNIFICANCE

Our findings suggest that the COVID-19 pandemic had negative impacts on people with eating disorders, including amplification of mental health symptoms and stressors around peak periods of infection and COVID-19 restrictions. These findings inform medical providers, policy-makers, and community-based supports about the information and resource needs of this group to ensure efficient dissemination in future public health emergencies and during the ongoing COVID-19 pandemic.