Eating disorders during lockdown: the transcultural influence on eating and mood disturbances in Ibero-Brazilian population

The main aim of this work was to evaluate the impact of COVID-19 lockdown in eating symptomatology and general psychopathology in patients with EDs from Ibero-Brazilian countries, considering the CIES Scale, as well as other socio-cultural and contextual factors. We also performed between-groups comparisons regarding ED subtypes, age, and provenance.

A global trend towards the impairment of eating symptoms pre to post lockdown was described in all ED subtypes [7, 11], reaching statistical significance in the BN group. The last result contrasted with previous studies that described an absence of pre-post changes [14], or even a decrease in eating symptoms, among individuals with BN during lockdown [21]. In our study, surprisingly, these patients also reported a significant improvement in their eating style, similarly to the OSFED group. Likewise, changes in eating style were more alike between individuals with AN and BED, who reported eating style worsening. This result partially agreed with previous literature which referred to BED and BN as the ED subtypes with the highest negative impact on eating style [21]. In our case, a higher trend to control food intake and restriction in patients with AN [8, 9] whereas disordered eating such as grazing eating behavior among individuals with BED may support these findings [7].

Remarkably, the AN and OSFED group had significant differences in weight and BMI changes in comparison with the BED and BN groups, which also appeared to be more similar to each other. While a trend towards weight loss, with a consequent reduction in BMI, was observed in individuals with AN and OSFED, the opposite occurred in subjects with BED and BN [21, 31]. In fact, intra-group comparisons showed that the BED group reported a significant increase in weight and BMI after lockdown [21]. Restrictive measures, sedentarism, and food insecurity may be contributing factors [32]. However, our results revealed that neither of the two weight approaches were significantly superior to the other. Thus, a balanced weight change between ED subtypes may be deduced in contrast with previous literature [21].

Despite both groups of age (i.e., adolescent/young and adults) reported worse eating symptoms after lockdown, in the case of younger patients this change was statistically significant. Works related to young people with a diagnostic of ED showed a psychopathological impairment in the context of pandemic characterized by a higher difficulty in achieving goal weight, as well as a higher hospitalization rate [33]. Lower food security, changes in academic routines, and stress due to pandemic with affective implications have been pointed as some of the factors potentially involved [34]. However, we failed to find significant pre-post differences between adolescents/young individuals with EDs and adult patients neither in weight/BMI changes, eating symptoms, nor in psychological state. In the general population, younger age has been proposed as a contributing factor for suffering from a more negative impact on mental health during pandemic [18], including disordered eating [33, 34] and the development of an ED [35]. On the other hand, our results also contrast with the hypothesis of a higher resilience among younger patients in comparison with adults regarding people with EDs [21]. The global tendency to an impairment of the eating and mood symptoms in both groups during lockdown could partially contribute to explain our findings, in line with Monteleone et al. [19]. Indeed, an increased need for ED assistance has been described in the context of the pandemic in both adolescents/young and adults individuals with EDs [36].

While the younger group described a mild non-significant loss of weight, the adult group experienced a significant increase of weight and BMI during lockdown. Although our results have been adjusted by ED subtype, patients with younger age would presumably have a higher prevalence of AN and OSFED diagnosis than BED, more frequent among adult individuals [37]. Moreover, both groups showed an eating style worsening. In this regard, we hypothesize that the impaired eating pattern in younger patients could be more linked to restrictive behaviors and exercise practice, in line with the observed trend to control weight. On the other hand, changes in eating style among adults might be closely associated with increased food consumption (e.g., picking, binging), which, consequently, could be more probably linked with a weight increase.

To the best of our knowledge, this is the first study which includes European countries (Iberian countries, Spain and Portugal) with South American ones (i.e., Brazil). Previous studies analyzing eating and mood psychopathology between different continents are scarce without grouping European and South American countries [21]. Curiously, in the later work, authors reported that Asian patients seemed more resilient than European individuals with EDs, who reported worse eating symptomatology during the lockdown [21]. Using the same instrument (i.e., CIES), the present study did not find significant differences related to eating psychopathology, nor weight changes between European and South American individuals, regardless of the ED subtype and age. Indeed, we observed that the three groups of provenance reported a trend towards worsening of their eating symptoms. Despite these results would be in line with the global impairment of eating symptoms described among patients with EDs in the context of the lockdown [7, 8, 10, 11], it also highlights the need to design future studies that include large international samples to contrast whether the impact of the pandemic and lockdown on eating symptoms in individuals with EDs would be more similar between some continents, as well as which kind of socio-cultural and contextual features could be modulating this fact.

Interestingly, after lockdown, the self-reported anxiety and depressive symptoms evaluated with the CIES scale were higher and statistically significant than in the pre-lockdown in all the ED subtypes, age groups, and countries, and generally accompanied by an impaired ER [11, 19]. Even that a concern for patients with EDs was expressed from the beginning of the COVID-19 pandemic [7], current studies have supported that this population has been highly impacted by this health crisis [38, 39]. Going one step further, as a result of the between-groups comparisons, only the comparison between countries showed significant differences. Curiously, the Brazilian group described a worse psychological state in the context of the lockdown when compared with Iberian countries. In this line, a previous study found higher anxiety in the Brazilian population than in the Portuguese population [4], describing socio-cultural factors such as concern for health and finances as potential risk factors. Then, our results might also be considered in light of the existence of contextual differences during lockdown and socio-cultural aspects. As mood disturbances have been associated with a negative impact on eating symptoms among patients with ED [33], this study suggests whether those individuals with more adverse contextual conditions and a worse psychological state in the face of future similar adverse circumstances might be at greater risk of eating symptoms worsening in the middle and long term.

The scenario related to early pandemic and the restrictive measures adopted by governments differed between countries and could have contributed to the perceived emotional distress [2]. According to our results, the Brazilian individuals were those who had significantly higher percentages of people in charge, infection by COVID-19 and close people infected, in contrast with the other countries. This could be related to the fact that Brazilian patients were those who mostly kept working during the lockdown, with a presumably higher exposure to the infection added to the fact that social measures in the face of the pandemic appeared to be laxer. In this line, concerns related to both their own or their relatives’ health have been reported as potential stressors with a negative impact on mental health during the COVID-19 pandemic [22], as well as in previous health crises [23]. On the other hand, they also experienced higher financial losses during lockdown, which might be associated with a higher emotional distress.

In Brazil, as in other South American countries, aspects such as the lower social income of the population and a lack of infrastructures related to the public health system resulted in higher difficulties in access to treatment for mental health, including EDs. Despite all the participants of the study were already linked to specific treatment and aspects related to the evaluation of treatment during lockdown were not reported in this study, we hypothesized whether being subject to different socio-cultural and contextual conditions may have had an influenced in the adaptation and therapeutic adherence during this period and, therefore, in the perceived emotional distress. In this line, during the pandemic, most of the studies performed that reported the rapid implementation of telehealth care for EDs and other psychiatric conditions have been carried out in European, Australian, Asiatic, and North American countries so far [21, 40]. However, there is still a lack of information on the health policies of South American or African countries in this regard [24]. Then, both a regulation of the incomes and health care policies may be considered and improved in order to ensure that health care will be provided in those vulnerable populations despite the country of residence [24]. This fact becomes especially relevant when considering that poorer adaptive coping strategies to deal with emotional distress related to the pandemic and lockdown has been described as a factor of higher psychological vulnerability in patients with EDs [11,12,13]. Precisely, Brazilian participants showed lower resilience, which could also mediate the significant differences observed regarding greater emotional distress in this group.

This study has some limitations, such as a small simple size, an observational cross-sectional design, the lack of a control group, and the focus on the female clinical population already linked to a specific treatment unit, which could limit the generalization of the results. Besides, a voluntary participation, the retrospective collection of the data through a self-report way, and differences in the recruitment period between units are other limiting aspects, which could be associated with recall biases. On the other hand, some strengths should also be highlighted. For instance, the study contemplated potential co-founder factors in the analysis and the CIES is considered a validated and homogeneous psychometric instrument. However, future research is still needed to further investigate the clinical implications of mood disturbances related to pandemic situations on eating symptoms in the middle and long term, as well as potential meditational variables, such as sociodemographic and cultural factors.

In conclusion, the present study supports previous literature regarding the negative impact of the COVID-19 pandemic and lockdown on patients with EDs, adding a transcultural perspective with the inclusion of European and South American countries, and paying attention to the crucial role of mood disturbances and the sociodemographic context of the participants. Hence, more adverse contextual conditions, a worse psychological state, and poorer coping strategies may be potential contributing factors to the worsening of the eating symptoms in similar adverse situations.

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