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The coronavirus pandemic has “caused significant disruptions in everyday life on a global scale.”1 As a result of stay-at-home restrictions and sudden unemployment, millions of people are isolated at home with a large amount of unstructured time on their hands, less opportunity to exercise and obtain healthy food, less support and increased stress levels. While these factors affect Americans across the board, people with obesity and/or eating disorders (EDs) are disproportionately affected by these unique and unprecedented challenges.
“We don’t know what the effects of all of these converging factors will be, especially given the heterogeneity of people who experience these conditions,” Rebecca Pearl, PhD, Assistant Professor of Psychology in Psychiatry and Director of Research, Center for Weight and Eating Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, stated in an interview.
In the meantime, it is important to be aware of eating-related issues that may arise in patients and to be prepared to offer potentially helpful tools during the 2019 coronavirus disease (COVID-19) pandemic.
Stigma and “COVID-15”
“COVID-15” (sometimes called “Quarantine-15”) is a term used to refer to the alleged 15 pound weight gain resulting from quarantine conditions.2 A quick search of the trending term “Quarantine-15” yields over 30,000 Instagram posts, not including thousands of other posts using similar phrases, Dr Pearl stated.
These posts convey strong messages, with many displaying “indulgent foods or workout plans” or featuring “blatantly weight-stigmatizing content, such as split-screen ‘before-and-after quarantine’ memes that show people in the ‘after’ screen with an exaggerated amount of weight gain, wearing ill-fitting clothing in an unflattering manner (sometimes in cartoon form), and eating excessive amounts of food.”1
The overall effect of this messaging is very deleterious, Dr Pearl noted, eliciting “common stereotypes” regarding people with obesity, including laziness, slovenliness, and lack of willpower. They additionally “suggest that having higher body weight is an unacceptable problem “to be avoided at all costs.” These messages reinforce the stigma faced by people who are overweight and obese, even at the best of times.
“Social media posts that stigmatize obesity and mock or diminish real struggles with weight and eating are harmful to people across the weight spectrum and they may be particularly detrimental to individuals with obesity who are actively trying to manage their weight,”1 noted Dr Pearl.
The Impact of COVID-19 on Eating Disorders
Equally problematic are quarantine-related messages regarding weight gain as an inevitable consequence of being homebound, promoting unrealistically thin ideals or recommending extreme weight control practices (eg, dangerously reducing caloric intake or over exercising), which can reinforce ED-related practices.
“Many eating disorder advocates have expressed concern about how these kinds of messages can trigger the drive for thinness, which is a common feature in eating disorder symptoms, and that is very concerning,” Dr Pearl said.
Indeed, the National Eating Disorders Association reported that it saw a 56% rise in interest in its instant messaging services the week of April 22 to April 29.3 Similarly, the UK-based ED organization Beat said it saw a 35% increase in people contacting its services since the UK lockdown was announced, as well as an 80% increase in the number of people contacting them via social media, and a 51% increase in the number of people using the organization’s online groups.3
Another driver of unhealthy eating patterns, especially in people with EDs, is food insecurity caused by predictions of potential food shortages in the media and a lack of resources due to the devastating economic downturn.4
“Food scarcity is a major issue for people with EDs, who already have a complicated relationship with food,” declared Ilene Fishman, LCSW, a psychotherapist specializing in EDs with practices based in Montclair, New Jersey and Manhattan and a co-founder of the National Eating Disorders Association (NEDA), serving on its executive board of directors.
For example, “some have particular compulsions or ways of organizing how and where they get their food and what types of food they will or won’t eat, and when that is disrupted, it causes anxiety,” she noted.
Many people with EDs find themselves eating more or less than they usually do, which can likewise create anxiety and stress, making ED symptomatology worse.
For people who rely on structured exercise that might include in-person classes at a gym or with a trainer, the disruption in exercise routine can be destabilizing, increasing anxiety and worsening symptoms, stated Ms Fishman.
Eating Disorders: Open Questions and Dilemmas
An article by Touyz et al raises as yet unanswered questions regarding management of EDs during COVID-19.4 Touyz et al ask, “Should people who are undernourished and with cardiovascular compromise be admitted” [to the hospital or a treatment center]?” Are medical risks associated with undernourishment greater now, in light of COVID-19, since individuals with anorexia nervosa, who are emaciated, may have an increased compromise of physical health?
On the other hand, some research has suggested that anorexia nervosa may “accord a level of resilience” to viral illness, perhaps because many people with this disorder have already been engaging in self-isolation.5 Touyz et al suggested that further research is necessary before these questions can be answered.4
Another challenge involves the continuation of partial hospital and full day programs. Although group programs such as cognitive behavioral therapy (CBT) have been successfully conducted online using video conferencing, it is questionable whether these programs can be effectively adapted to a video format, according to Touyz et al.4
However, Ms Fishman noted that many eating disorder facilities are continuing to service patients with EDs, not only for specific group activities such as CBT classes but also for more intensive programs. Moreover, some are continuing to accept patients into residential settings, while adhering to Centers for Disease Control and Prevention (CDC) guidelines. “It is important not to assume that these types of programs are closed or unavailable,” she emphasized.
Helping Patients Deal with Triggers
Common triggers that people report for overeating or binging are stress, unstructured time in the house, boredom, and the ready availability of food, perhaps in the pantry or cabinet, which would otherwise not be so easily accessible if they were at their office or other workplace, Dr Pearl said.
“Generally people who are bored while at home can go in and out of the kitchen during the day, which may not happen as much in a work setting, where structure is externally imposed by the work schedule,” she noted.
If children or teenagers are at home, the types of food constantly on hand may not be conducive to healthy eating, Dr Pearl pointed out. Teenagers who like to eat pizza and fries or young children who like candy may import food into the house that then create temptations for a person struggling with weight problems.
Additionally, anxiety can drive people to the refrigerator or pantry because food is often used as a way to cope with stress, find comfort, and self-soothe, Dr Pearl pointed out. “Although this is a common reaction to stress, it is particularly problematic in people who are prone to overeating or binging,” she added.
She recommended several strategies to mitigate these tendencies and address triggers.
· Breathing exercises, meditation, and similar mind-body techniques to reduce stress
· Turning to family, friends, spiritual/counselors, or professionals for support, comfort, and practical strategies
· Creating a routine to mitigate unstructured time
· Allowing oneself an indulgence or treat to reward oneself after a stressful day without feeling guilt or to find non-food alternatives for rewarding oneself
· Keeping healthy food on hand for snacking and (if possible) avoiding having unhealthy food in the house
· Engaging family members in cooking and preparing healthy meals
· Finding ways to move one’s body and be outdoors, despite some of the limitations under lockdown: walking or jogging in non-crowded areas while being mindful of social distancing or exercising at home with online videos, some of which are offered for free.
· Finding simple ways to move, even if for only a few minutes at a time. For example, jumping jacks, skipping in place, or using cans of food as small weights to carry.
For those with a history of EDs, physical activity can be used in moderation to improve mood and wellbeing, rather than focusing on burning calories. Ms Fishman agreed, adding that many people with EDs over exercise, so advice regarding exercise should be tailored to the specific needs of the individual patient.
The Role of the Psychiatrist
Ms Fishman emphasized that psychiatrists can play a critical role in addressing challenges that people with EDs are facing during this time and indeed at any time.
Be aware of local resources.
“Psychiatrists and other clinicians should familiarize themselves with local resources, such as therapists specializing in eating issues or facilities with specialized programs and ascertain what types of services they’re offering, so that appropriate referrals can be made when necessary,” Ms Fishman advised. It is important for clinicians to have this information at their fingertips at all times; but especially during the current pandemic, patients should be able to know immediately what options they have for treatment so that concerns about the virus do not pose an obstacles to seeking help.
Clinicians can also refer patients to reliable sources of online support during COVID-19. For example, the National Eating Disorders Association offers virtual support groups, a community online forum, free and low cost support, and a helpline to assist callers find resources that meet their individual needs.
Proactively ask about eating issues.
Dr Pearl recommended including questions about eating habits in the standard questions included in a psychiatric evaluation (eg, sleep, physical activity, mood, appetite, medication use, and self-care behaviors), rather than making weight a primary focus—unless there is a compelling medical reason to do so. Excessively emphasizing weight may exacerbate stress and stigma, adding fodder to the already unhealthy messages about overeating and weight during this time.
However, in the case of people with EDs, “it is important to proactively check in and see if they have concerns regarding their symptoms and how they are coping, and to address concerns accordingly,” she noted.
“Ask all patients how social distancing restrictions are affecting their relationship with food, their feelings about their body, their exercise patterns, and the ability to see treatment providers, such as other medical or mental health professionals or dieticians,” Ms Fishman suggested.
Ms Fishman added that clinicians should keep potential EDs on their radar with all patients. “There are some common stereotypes about people with EDs—specifically that they are young and female—but many men also have EDs and there are older adults who have suffered with EDs all their lives.”
Be cautious about medication changes.
“I generally advise not making big medication changes during this time, even though many people with EDs might be experiencing setbacks,” Ms Fishman cautioned.
“For example, if a person has been on a medication regimen that was working well—such as taking a particular selective serotonin reuptake inhibitor—perhaps increasing the dose temporarily or temporarily adding a small adjunctive dose of an anti-anxiety medication would be more useful than designing a whole new protocol,” she suggested.
Teletherapy can be an opportunity.
Psychiatric consultations or psychotherapy sessions conducted via video can provide unique opportunities by offering a window into patients’ home environments and also making it easier for some patients—particularly those who live at a distance—to receive treatment, Ms Fishman observed.
“Patients should be encouraged to continue with their therapy sessions or to begin psychotherapy anew, if they haven’t already been receiving it,” she stated.
Psychiatrists can be advocates.
Beyond providing direct patient care, Dr Pearl encourages psychiatrists and other clinicians to “drown out unhealthy social media messages” by promulgating alternative, more positive messages and directly addressing stigma with patients.
“If patients report weight gain, clinicians can convey messages of nonjudgmental acceptance, validating the unprecedented stressors during this time that can contribute to overeating or exacerbate EDs, and help patients devise strategies that will mitigate stress and contribute to building overall health,” she said.
References
1. Pearl RL. Weight Stigma and the “Quarantine-15”. Obesity (Silver Spring). 2020 Apr 23. [Epub ahead of print]
2. Everyone is terrified of getting ‘quarantine fat,’ and just enough already. Glamour. April 6, 2020. Available at: https://www.glamour.com/story/quarantine-fat-coronavirus-weight-loss. Accessed: May 7, 2020.
3. Khaliq A. People with eating disorders have suffered all their lives. Now they’re struggling even more. CNN Health. April 29, 2020. Available at: https://www.cnn.com/2020/04/29/health/coronavirus-eating-disorders-wellness-intl-gbr/index.html. Accessed: May 8, 2020.
4. Touyz S, Lacey H, Hay P. Eating disorders in the time of COVID-19. J Eat Disord. 2020;8:19.
5. Armstrong-Esther CA, Lacey JH, Crisp AH, Bryant TN. An investigation of the immune response of patients suffering from anorexia nervosa. Postgrad Med J. 1978;54(632):395-399.
