The impact of the COVID-19 pandemic on eating disorders risk and symptoms: a retrospective study

The COVID-19 pandemic's lockdowns and restrictions significantly altered lifestyles, potentially impacting mental health, particularly eating behaviors. Individuals with pre-existing EDs or obesity are especially vulnerable due to associated psychiatric comorbidities and metabolic anomalies. EDs, including anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and avoidant/restrictive food intake disorder (ARFID), are serious mental health disorders with significant physical and psychosocial consequences. Several factors contribute to ED development, including family environment, restricted activities, social media influence, emotional distress, fear of contagion, and limited access to care. Women are disproportionately affected compared to men. Studies during the pandemic have reported worsened ED symptoms and increased suicidal ideation and attempts. This study aimed to investigate the pandemic's effect on ED risk and symptoms in a sample of young Italian individuals using retrospective data from the Bambino Gesù Children's Hospital.

Existing literature highlights the detrimental impact of social distancing and quarantine on mental health, particularly the exacerbation of eating disorders. Studies have shown increased eating restriction in individuals with AN and more frequent binge-eating episodes in those with BN or BED during the pandemic. The first wave saw a rise in symptoms like anxiety and depression among adolescents with pre-existing EDs, while later waves witnessed a surge in suicidal ideation and attempts. The increased stress, isolation, and disruption of routine associated with the pandemic are believed to have contributed to these worsening symptoms. Previous research also established the association between various factors, including family history, social media exposure, and pre-existing mental health conditions, as risk factors for ED development. This study builds upon existing research to assess the impact of the COVID-19 pandemic within a specific Italian population.

This retrospective observational study analyzed 127 pediatric patients (117 females, 10 males) with EDs admitted to the Bambino Gesù Children's Hospital in Rome between August 2019 and April 2021. Of 230 initially enrolled patients, only those with follow-up data after 1, 3, and in some cases 12 months of antipsychotic therapy (127 patients) were included. Data were collected from electronic medical records, encompassing medical history, comorbidities, and laboratory results at admission (T0) and follow-up. Ethical approval was obtained. During hospitalization, patients underwent laboratory analyses (blood cell count, vitamin and mineral screening), electrocardiogram, echocardiogram, abdominal ultrasound, and magnetic resonance imaging. Treatment involved antipsychotics, often combined with other medications (serotonin uptake inhibitors, benzodiazepines, anxiolytics, lithium). Statistical analyses included Pearson correlation, Bonferroni's test, and two-way ANOVA to assess correlations and significant differences. A written informed consent was obtained from adult patients and parents of patients under the age of 18.

The study included 127 patients (aged 10-18 years), with 80.3% at the first onset of EDs and 19.7% experiencing relapse. A significant number (26%) had a family history of psychotic disorders. The majority (89.8%) had unspecified EDs, with a small percentage having AN (5.5%) or ARFID (4.7%). Patients exhibited various comorbidities, including high rates of amenorrhea (64% of females), lymphocytopenia (100%), neutropenia (38%), thrombocytopenia (13.4%), bradycardia (60.6%), and hypovitaminosis (93.5%). Significant vitamin deficiencies were observed, especially for vitamin C (27%), vitamin B9 (folic acid, 21%), and vitamin D3 (64.8% deficient or insufficient). High ferritin levels (56.6%) and alterations in thyroid hormones (TSH and FT4) were also frequent. A significant correlation (p < 0.0001) was found between lymphocyte count, body weight, BMI, and several vitamins (B1, B6, C, and D3). Antipsychotic treatment positively impacted body weight and BMI, with significant increases after 3 months of treatment. Echocardiographic and abdominal ultrasound revealed abnormalities in some patients. Two patients attempted suicide.

The findings highlight the significant impact of the COVID-19 pandemic on the prevalence and severity of EDs among adolescents in Italy. The high rates of comorbidities, including nutritional deficiencies and hormonal imbalances, underscore the complex interplay of factors contributing to EDs. The observed nutritional deficiencies (particularly vitamins C, B9, and D3) are crucial because these vitamins play vital roles in immune function and overall health. The significant correlation between lymphocyte counts and nutritional status supports the idea that these adolescents are at a higher risk for infections due to malnutrition. The positive effect of antipsychotic treatment on weight and BMI suggests a therapeutic pathway. These findings emphasize the need for comprehensive interventions that address both the psychological and physiological aspects of EDs in this population. The study's limitations (retrospective design, limited sample size) highlight the need for further research to understand the long-term consequences of the pandemic.

This retrospective study demonstrates the substantial impact of the COVID-19 pandemic on adolescents’ eating behaviors, revealing a high prevalence of EDs and associated comorbidities. The frequent occurrence of nutritional deficiencies, hormonal imbalances, and other physical complications underscores the need for comprehensive, multidisciplinary interventions targeting both mental and physical health. Future research should focus on prospective studies with larger samples to better understand the long-term consequences and develop effective preventative strategies.

The retrospective nature of the study limits the ability to establish definitive causal relationships between the pandemic and ED development. The relatively small sample size and the specific context of an Italian hospital population may limit the generalizability of the findings. Selection bias could exist due to the inclusion of only hospitalized patients, potentially excluding individuals with milder forms of EDs.