COVID-19, anorexia nervosa and obese patients with an eating disorder - some considerations for practitioners and researchers

Medical morbidity and risk of general hospital admission associated with concurrent anorexia nervosa and COVID-19: An observational study

OBJECTIVE

Investigate medical morbidity and risk of general hospital admission for patients with concurrent coronavirus disease 2019 (COVID-19) and anorexia nervosa (AN) who have not received severe acute respiratory syndrome coronavirus 2 vaccination.

METHODS

United Kingdom eating disorders clinicians contributed to a database of patients with an eating disorder and COVID-19. We used this to investigate demography, symptoms, hospitalization, treatment, and outcomes for those with AN.

RESULTS

We describe data for 49 patients (median age 21.5 years [interquartile range 17.0-33.5], 46 female) including 36 adults and 13 under-18-year-olds. Three (6.1% [95% confidence interval 1.3%-17.9]) were admitted to a general hospital. For this sample, the expected age-standardized hospital admission rate per COVID-19 case (based on the general population of England) was 2.6% and therefore not significantly different to the hospitalization rate we observed. Three (including two of those admitted to hospital) contracted pneumonia. One had severe pneumonia and was admitted to an intensive care unit. No deaths or use of mechanical ventilation were recorded.

DISCUSSION

To our knowledge, this represents the first study investigating medical morbidity or frequency of hospitalization for patients with COVID-19 and AN. We did not find evidence that patients with AN are at increased risk of severe COVID-19.

PUBLIC SIGNIFICANCE

Medical morbidity and risk of hospitalization associated with concurrent COVID-19 and anorexia nervosa (AN) had not, to our knowledge, been studied before. We used a database of patients with eating disorders and COVID-19 (to which United Kingdom clinicians had contributed) to investigate presentation, treatment, outcomes, and COVID-19 severity for those with AN and COVID-19. We did not find evidence that patients with AN are at increased risk of severe COVID-19.

Review of the unprecedented impact of the COVID-19 pandemic on the occurrence of eating disorders

PURPOSE OF REVIEW

To review the recent literature on the impact of the coronavirus disease-2019 (COVID-19) pandemic on incidence and severity of symptoms of eating disorders (EDs).

RECENT FINDINGS

A worrying increase of EDs in- and outpatients has been reported since the COVID-19 pandemic began in 2019/2020. Restrictions implemented during the pandemic to protect populations against COVID-19 increased the risk for onset and for worsening of EDs by disrupting eating and exercise routines, social isolation, lack of support, and limited access to healthcare. Substantial increases since the start of the pandemic have been reported for overall incidence (15%), hospital admissions (48%) and emergency department visits (11%) for EDs, with even higher increases among women and children or adolescents with an ED. During the pandemic, ED patients reported increased severity of ED-specific symptoms and increased anxiety, depression and suicidal ideations and -attempts. Treatments shifted largely toward online methods for continuity of care, despite concerns about the quality of care provided and difficulties in self-monitoring. Our review provides preliminary evidence for a similar effectiveness of online treatment to prepandemic face-to-face treatment. In-person assessment remains essential for detecting EDs and for those requiring medical admission.

SUMMARY

Although the ongoing COVID-2019 pandemic affected mental health globally, research shows that it particularly affected individuals with an ED diagnosis or at risk for an ED, especially women, children and adolescents, and those with anorexia nervosa.

Anorexia nervosa and COVID ‐19 infection: Clinical case report

The true risk of COVID‐19 infection in anorexia nervosa (AN) including the duration of viral RNA shedding and infectivity is still unclear. We report on a case of a patient with severe AN with a mild course of COVID‐19 and prolonged viral RNA shedding for at least 39 days after symptom onset. A careful evaluation of long‐term infectivity must include viral load, live virus isolation, and viral genome sequencing.

We report on a case of a patient with severe anorexia nervosa (AN) with unusually prolonged viral clearance, despite a mild course of COVID‐19. Careful evaluation and preventive actions should be tailored to each patient with AN requiring hospitalization considering the potential for disease transmission and viral mutation.

Predictors of Death, Survival, Need for Intubation, and Need for Oxygen Support Among Admitted COVID-19 Patients of the Veterans Affairs Greater Los Angeles Healthcare System

Introduction

While risk factors for severe COVID-19 infections have been well explored among the public, population-specific studies for the U.S. Veteran community are limited in the literature. By performing a comprehensive analysis of the demographics, comorbidities, and symptomatology of a population of COVID-19 positive Veterans Affairs (VA) patients, we aim to uncover predictors of death, survival, need for intubation, and need for nasal cannula oxygen support among this understudied community.

Materials and Methods

A retrospective review was conducted of 124 COVID-19 Veteran patients who were admitted from March to October 2020 to the VA Greater Los Angeles Healthcare System (IRB#2020-000272). Chi-square and Fisher’s exact tests were employed to assess differences in baseline demographic and clinical variables between Veterans who survived COVID-19 versus those who succumbed to COVID-19 illness. Multivariate logistic regression and Cox regression analyses were employed to assess predictors of outcome variables, including death, survival, need for intubation, and need for oxygen support (via nasal cannula). Covariates included a wide range of demographic, comorbidity-related, symptom-related, and summary index variables.

Results

Our study population consisted of primarily senior (average age was 73) Caucasian and African American (52.5% and 40.7%, respectively) Veterans. Bivariate analyses indicated that need for intubation was significantly associated with mortality (P = 0.002). Multivariate analyses revealed that age (P < 0.001, adjusted odds ratio (OR) = 1.16), dyspnea (P = 0.015, OR = 7.73), anorexia (P = 0.022, OR = 16.55), initial disease severity as classified by WHO (P = 0.031, OR = 4.55), and having more than one of the three most common comorbidities (hypertension, diabetes, and cardiac disease) and symptoms (cough, fever, and dyspnea) among our sample (P = 0.009; OR = 19.07) were independent predictors of death. Furthermore, age (P < 0.001, hazard ratio (HR) = 1.14), cerebrovascular disease (P = 0.022, HR = 3.76), dyspnea (P < 0.001, HR = 7.71), anorexia (P < 0.001, HR = 16.75), and initial disease severity as classified by WHO (P = 0.025, HR = 3.30) were independent predictors of poor survival. Finally, dyspnea reliably predicted need for intubation (P = 0.019; OR = 29.65).

Conclusions

Several independent predictors of death, survival, and need for intubation were identified. These risk factors may provide guidelines for risk-stratifying Veterans upon admission to VA hospitals. Additional investigations of COVID-19 prognosis should be conducted on the larger U.S. Veteran population to confirm our findings and add to the current body of literature.

Perceived weight gain and eating disorder symptoms among LGBTQ+ adults during the COVID-19 pandemic: a convergent mixed-method study

BACKGROUND

In this study, we further explore the role of COVID-19 pandemic-related stress, social support, and resilience on self-reported eating disorder symptoms (using the EDE-QS) and perceived weight gain among lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+ adults) in the US context during the COVID-19 pandemic.

METHODS

Employing a convergent mixed method design, we surveyed 411 individuals, and conducted qualitative semi-structured follow-up interviews with 43 LGBTQ+ -identifying survey respondents. Using OLS regression and multinomial logistic regression, we modeled eating disorder symptoms and perceived weight gain among LGBTQ+ individuals (n = 120) and cisgender and heterosexual-identifying women (n = 230), to cisgender and heterosexual-identifying men (n = 61). We also explored complementary interview narratives among LGBTQ+ people by employing selective coding strategies.

RESULTS

Study results suggest that LGBTQ+ individuals are likely experiencing uniquely high levels of pandemic-related stress, and secondly, that pandemic-related stress is associated with elevated eating disorder symptoms and higher risk of perceived weight gain. Nearly 1 in 3 participants reported eating disorder symptoms of potentially clinical significance. Social support, but not resilient coping, was found to be protective against increased eating disorder symptoms. Qualitative analyses revealed that LGBTQ+ individuals situated physical exercise constraints, challenging eating patterns, and weight concerns within their pandemic experiences.

CONCLUSIONS

Clinicians of diverse specialties should screen for eating disorder symptoms and actively engage patients in conversations about their COVID-19-related weight gain and eating behaviors, particularly with LGBTQ+ -identifying adults.

Metabolic Profiling from an Asymptomatic Ferret Model of SARS-CoV-2 Infection

Coronavirus disease (COVID-19) is a contagious respiratory disease that is causing significant global morbidity and mortality. Understanding the impact of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection on the host metabolism is still in its infancy but of great importance. Herein, we investigated the metabolic response during viral shedding and post-shedding in an asymptomatic SARS-CoV-2 ferret model (n = 6) challenged with two SARS-CoV-2 isolates. Virological and metabolic analyses were performed on (minimally invasive) collected oral swabs, rectal swabs, and nasal washes. Fragments of SARS-CoV-2 RNA were only found in the nasal wash samples in four of the six ferrets, and in the samples collected 3 to 9 days post-infection (referred to as viral shedding). Central carbon metabolism metabolites were analyzed during viral shedding and post-shedding periods using a dynamic Multiple Reaction Monitoring (dMRM) database and method. Subsequent untargeted metabolomics and lipidomics of the same samples were performed using a Liquid Chromatography Quadrupole Time-of-Flight Mass Spectrometry (LC-QToF-MS) methodology, building upon the identified differentiated central carbon metabolism metabolites. Multivariate analysis of the acquired data identified 29 significant metabolites and three lipids that were subjected to pathway enrichment and impact analysis. The presence of viral shedding coincided with the challenge dose administered and significant changes in the citric acid cycle, purine metabolism, and pentose phosphate pathways, amongst others, in the host nasal wash samples. An elevated immune response in the host was also observed between the two isolates studied. These results support other metabolomic-based findings in clinical observational studies and indicate the utility of metabolomics applied to ferrets for further COVID-19 research that advances early diagnosis of asymptomatic and mild clinical COVID-19 infections, in addition to assessing the effectiveness of new or repurposed drug therapies.