COVID-19 Especially Challenging for People with Eating Disorders

Woman having stress about weight loss, diet or gaining weight. Eating disorder, anorexia or bulimia concept. Young girl crying and sitting on the floor with scale. Underweight person sad about obesity
Participants in the United States and the Netherlands completed an online survey that evaluated the impact of COVID-19 on situational circumstances, eating disorder symptoms, eating disorder treatment, and general well-being.

Shelter-in-place restrictions, job loss, and the threat of COVID-19 itself have all caused an increase in mental health issues in the general community, with even harsher effects experienced by people with existing mental illnesses and mood disorders.

The pandemic has had especially “strong and wide-ranging” effects on people with anorexia and bulimia nervosa, a new study in the International Journal of Eating Disorders found. When people stockpile high-risk foods out of fear of food supply disruptions, people with bulimia face intense urges to binge. Anxiety around food availability also triggers the urge to starve, the study stated.

The researchers wanted to learn more about the impact of COVID-19 on people with eating disorders, as well as find out their treatment needs. Results will help clinicians and caregivers better care for these individuals during the pandemic and in future catastrophic events.

The study recruited over 1000 participants from the United States and the Netherlands (NL), aged 16 to over 60 years. Participants were onboarded between April 8, 2020 and May 15, 2020. During this time, the countries were at different stages of the pandemic and had different approaches to controlling the spread of the virus. Participants completed an online survey and agreed to be contacted monthly on 12 occasions.

Regardless of where they lived, participants had similar concerns. Most respondents (79% US, 66% NL) were concerned that their eating disorders would get worse as a result of a lack of structure. Respondents were also concerned that their eating disorders would worsen due to being in a triggering environment (US 58%; NL 57%), because they lacked social support (US 59%; NL 48%), and because they were unable to access food consistent with their regular meal plan (US 61%; NL 36%).

Feeling anxious about not being able to exercise was common in US participants (57%). Participants in the Netherlands were not asked this question. More than one third in both countries reported that they restricted food and engaged in other compensatory behaviors during the pandemic. Some (23% US, 14% NL) reported binge-eating on stockpiled food.

Regarding mental health, 68% of all participants screened positive for generalized anxiety disorder (GAD). Most (US 80%, NL 65%) reported increased anxiety compared to the same time period in 2019.

The researchers reported nearly half of both samples were not receiving treatment for their eating disorders. Of the participants who were, the transition to telehealth resulted in a perception of care being either somewhat or much worse (US 47%, NL 74%).

“Given the unclear level of satisfaction with early delivery of telehealth, clinicians should be direct in addressing what is working and what is not working in terms of telehealth sessions, and not assume that they are equivalent to face-to-face encounters,” the researchers wrote. “Frank discussions might allow patient and provider to work collaboratively to ensure care is being delivered effectively and compassionately.”

There were some limitations to the study. Due to the study’s rapid deployment, diagnoses of eating disorder were self-reported. Differences also emerged between the two countries in terms of sample composition, as well as each country’s approach to pandemic control. Thus, differences at the stage of the pandemic at deployment could affect responses. Finally, the study used predetermined questions that did not allow for an unbiased survey of respondents’ concerns.

The researchers caution clinicians to remember that people with eating disorders are especially vulnerable right now. “Both quantitative and qualitative data underscore the call for structure, especially around meals,” they wrote. “Clinicians should assess what structures do exist and be innovative in developing strategies to help patients structure their daily schedules and meals.”


Termorshuizen JD, Watson HJ, Thornton LM, et al. Early impact of COVID-19 on individuals with self-reported eating disorders: a survey of ~1,000 individuals in the United States and the Netherlands [published online July 28, 2020]. Int J Eat Disord. doi:10.1002/eat.23353