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

The COVID-19 pandemic led to widespread restrictions (social distancing, isolation, school and facility closures) associated with adverse mental health consequences, including elevated stress, anxiety, depression, sleep disturbances, and eating disorders (EDs). Children and adolescents with pre-existing EDs or obesity may be particularly vulnerable due to psychiatric comorbidities and metabolic anomalies. EDs in youth (anorexia nervosa, bulimia nervosa, binge-eating disorder, and avoidant/restrictive food intake disorder) impair physical, cognitive, and psychosocial functioning and are often comorbid with anxiety, self-harm, and substance use. Females are at higher risk than males, with risk rising during puberty. During the pandemic, studies reported worsening ED symptoms and increased restriction or binge behaviors, and later waves saw increased suicidal ideation among adolescents. This study aimed to explore, in an Italian pediatric sample, the impact of the COVID-19 pandemic on ED risk and symptoms using retrospective hospital data from August 2019 to April 2021.

Prior research during COVID-19 documented worsening ED symptoms across populations, with increased restriction in anorexia nervosa and more frequent binge episodes in bulimia nervosa and binge-eating disorder. Early pandemic data indicated exacerbations mainly in adolescents with pre-existing EDs; subsequent waves showed increased suicidal ideation and attempts among youth. Broader literature highlights higher ED risk in females, links between EDs and psychiatric comorbidities (anxiety, depression), and vulnerabilities related to stress reactivity and emotion regulation difficulties. Reviews and surveys from multiple countries reported changes in eating and exercise behaviors, barriers to care, and aggravation of symptoms, underscoring the pandemic’s role as a stressor amplifying ED risk and severity.

Study design: Retrospective observational study at Bambino Gesù Children's Hospital (Rome, Italy). Population: 230 ED patients were enrolled; analyses included 127 pediatric patients (117 females, 10 males; ages 10–18) who had follow-up at 1 month, 3 months, and in some cases 12 months after antipsychotic therapy. Period: August 2019 to April 2021. Data sources: Electronic medical records at admission (T0) and follow-up. Procedures: Laboratory analyses included complete blood count and screening for vitamin and mineral deficiencies; cardiovascular assessments (electrocardiogram, echocardiogram), abdominal ultrasound, and brain MRI. Treatments: Pharmacotherapy after diagnosis included antipsychotics alone (n=23), antipsychotics plus serotonin reuptake inhibitors (n=80), antipsychotics plus benzodiazepines (n=9), antipsychotics plus anxiolytics (n=2), antipsychotics plus lithium (n=1), serotonin reuptake inhibitors alone (n=3), and no drug treatment (n=9). Ethics: Approved by the Bambino Gesù Children's Hospital ethics committee (2526-OPBG-2021); informed consent obtained. Statistical analysis: Pearson correlations (p<0.05 significant), Bonferroni tests for group comparisons, two-way ANOVA (JMP 10) to assess associations between hematological changes and comorbidities; regression analyses exploring links between hematologic changes and bradycardia, amenorrhea, anxiety, and depression.

Sample characteristics: 127 ED patients (117 female, 10 male), ages 10–18; 74% from central Italy, 26% from southern Italy. Mean hospitalization ~24 days (range 3–83). Diagnoses: 5.5% anorexia nervosa, 4.7% ARFID, 89.8% unspecified ED. Anthropometrics: Median weight 37.2 kg (22.5–52.6), median BMI 14.96 kg/m2 (11.3–28.2); two patients weighed 76.2 and 81.5 kg (BMI 24.3 and 28.2). Disease course: 102 (80.3%) at first onset; 25 (19.7%) relapse. Prior hospitalization: 79 (62.2%). Family history: psychotic disorders 26% (including depression 7%, anxiety 1.6%, EDs 4.7%, psychosis 4%); diabetes 3.9%; hyperthyroidism 3.1%; hypothyroidism 2.4%. Imaging/cardiac: Echocardiography showed pericardial effusion in 10 (7.8%) and pericardial cleavage in 7 (5.5%); abdominal ultrasound revealed various pathologies in 9; brain MRI abnormal in 7. Comorbidities: Amenorrhea in 64% of females; lymphocytopenia 100%; neutropenia 38%; thrombocytopenia 13.4%; bradycardia 60.6%; hypovitaminosis 93.5%; hypercreatinemia 7%; hyperazotemia 7%; depression 14%; anxiety 3.9%; psychosis 4.7%; specific learning disorder 3.9%; multiple psychiatric disorders 13.4%; two suicide attempts. Vitamin/hormone abnormalities: Deficiencies—vitamin A 6%, B1 7%, B6 9.4%, B12 6.3%, vitamin C 27%; vitamin D3 deficient 22.8% and insufficient 42%; low folate (B9) 21%; high ferritin 56.6%; high TSH 7.9%; low FT4 21.3%. Correlations (all p<0.0001): Lymphocyte count positively correlated with body weight (rho 0.08), BMI (0.016), neutrophils (0.065), vitamin B1 (0.06), B6 (0.11), C (0.12), D3 (0.02), ferritin (0.089), sideremia (0.012), cholesterol (0.18); no correlation with vitamin A (-0.14), B12 (-0.07), B9 (-0.11), TSH (-0.06), FT4 (-0.104), triglycerides (-0.19). Regression analyses found no association between hematological changes and bradycardia, amenorrhea, anxiety, or depression. Treatment response: Antipsychotic treatment increased body weight by 10.4% at 1 month and 26.2% at 3 months (3-month increase significant, p<0.05); BMI increased by 12.3% at 1 month and 15% at 3 months.

The study indicates that adolescents with EDs during the COVID-19 pandemic frequently presented with malnutrition-related complications, including lymphocytopenia, neutropenia, bradycardia, amenorrhea, and widespread hypovitaminosis. Significant positive correlations between lymphocyte counts and body weight, BMI, and several vitamins (B1, B6, C, D3) suggest nutritional status influences immune parameters, implying increased infection susceptibility in malnourished patients. High rates of vitamin D3 insufficiency/deficiency and folate deficiency align with known roles in immune and neurocognitive functions. Thyroid abnormalities (elevated TSH in 7.9%, low FT4 in 21.3%) are consistent with hypothyroid patterns seen in malnutrition and may have clinical implications, as does hypercholesterolemia in a subset (11.8%, median 244.6 mg/dL) and elevated ferritin in over half, possibly reflecting muscle catabolism. Antipsychotic-inclusive treatment regimens were associated with significant weight and BMI gains over 3 months, indicating short-term improvements in nutritional status. Overall, the findings support that the pandemic period coincided with increased ED burden and clinically significant comorbidities in adolescents, underscoring the need for comprehensive medical and psychological management, including monitoring and correction of vitamin and hormonal abnormalities.

The COVID-19 pandemic negatively impacted adolescents’ eating behaviors, with many ED patients exhibiting hematologic, nutritional, and hormonal abnormalities that may threaten future health. This retrospective analysis highlights frequent comorbidities—leukocytopenia, neutropenia, hypovitaminosis, and thyroid alterations—and demonstrates improvement in weight and BMI with treatment. The results provide a framework for integrated clinical and educational interventions to mitigate short- and long-term impacts and emphasize treating medical comorbidities alongside psychological care.