The disruption to our daily lives over the last year as a result of the COVID-19 pandemic has health professionals concerned about the impact on the populations mental health (Xiang et al., 2020).
Individuals with eating disorders (EDs) are among those at greater risk of detrimental effects on their mental health, with concerns that the increased negative emotional effect of the pandemic may make ED triggers and symptoms worse. In a study with patients recovering from an ED, over one-third reported a worsening in their ED symptoms and over half reported increased anxiety-related symptoms (Fernández Aranda, et al., 2020), with large population-based surveys also finding similar results (Wang et al., 2020; Phillipou et al., 2020). Further to this, research by Phillipou and colleagues also found that even those without an ED have reported an increase in exercise and restriction of food during the pandemic (Phillipou et al., 2020).
A recent research study (Nutley et al, 2021) set out to try and capture the ways in which the COVID-19 pandemic has affected individual’s mental health, and engagement with disordered eating behaviours.
Evidence suggests the COVID-19 pandemic may have had a negative impact on disordered eating behaviours.
Methods
To understand the impact of COVID-19 on disordered eating behaviours, the authors extracted and thematically analysed comments from discussion topics (known as subreddits) from the online forum Reddit. Reddit has been deemed valuable in collecting high-quality qualitative data due to the discussion communities it harbours (Jamnik & Lane, 2017).
The authors chose three subreddits which acknowledged EDs as their primary discussion topic: one about eating disorders in general (containing 43.5k members), one about anorexia nervosa (19.2k members), and one about binge eating disorder (35.7k members). Posts from January 1st, 2020, to May 31st, 2020 were extracted if they referenced the COVID-19 pandemic according to one of the following keywords: “coronavirus,” “COVID,” “quarantine,” or “pandemic”. All comments analysed were anonymous.
Extracted comments were inductively analysed by one researcher to find patterns and themes, resulting in the creation of a codebook. Two thirds of the posts were then randomly selected to be analysed in the same way by two additional members of the research team, to determine the level of disagreement, and to finalise codes. Similar codes where then grouped into themes.
Results
Six themes were identified are detailed below.
1. Change in eating disorder symptoms
This theme encompassed comments about eating disorder (ED) symptoms both increasing and decreasing during the pandemic, including comments about negative body image (such as body dysmorphia, insecurities or negative feelings towards the body), and fear of and discontent with weight gain.
2. Exercise routine
Some individuals mentioned over-exercising, whilst some were unable to exercise or had their usual exercise routines impacted due to facilities being closed. A change in exercise behaviour was associated with negative emotions such as anxiety or guilt.
3. Impact of quarantine on daily life
Some individuals’ comments related to moving/returning to a different environment or having their environment changed. For some, this included having to navigate triggering relationships from having to interact with people who negatively contributed to their ED thoughts or behaviours. This theme also encompassed worries about wanting to stockpile food, bingeing on food, or concerns about food shortages, due to a need to have access to foods considered ‘safe’.
4. Emotional wellbeing
This theme encompassed the negative emotional effects (such as guilt, shame, anxiety, depression, isolation, etc.) because of the pandemic and the associated disordered eating behaviours it caused.
5. Help-seeking behaviour
This theme included those who were receiving professional treatment for their ED during this time, and those whose treatment had been altered or who could not access treatment as a result of the pandemic. Comments that fell into this theme also came from individuals who were motivated to use the time during the pandemic to recover, and those who posted words of encouragement to themselves or others.
Some comments under this theme were also from individuals requesting advice or an ‘accountability buddy’ from other Reddit users to stick to their recovery plans, or those requesting advice on how to help someone else who was showing disordered eating or behaviours during the pandemic.
6. Associated risks and health outcomes
Finally, this theme encompassed comments from individuals regarding either substance use behaviour, or adverse health and physical pain associated with their ED.
The impact of the COVID-19 pandemic resulted in changes to routines, reduced access to treatment and support, and worries around food shortages. For many, the pandemic seems to have exacerbated eating disorder symptoms and disordered eating behaviours.
Conclusions
Considering the findings of this study, it appears that the COVID-19 pandemic brought increased psychiatric distress and exacerbated disordered eating and exercise behaviours for many people. However, there were others who it provided the time for them to focus on their recovery from their ED. The use of the discussion threads, the authors have concluded, seemed to provide “a therapeutic community for individuals to share their experience, seek advice, and provide support for peers with ED”.
Whilst many of the comments were from individuals describing the impact of the pandemic on their ED and emotional wellbeing, the subreddits were also used for advice, well wishes, and words of encouragement within the community.
Strengths and limitations
This study has many strengths:
- The use of public comments allowed the efficient collection of large amounts of information quickly (with a total of 305 comments collected over a period of 5 months).
- The comments were publicly available, which means that the information collected is not impacted by the research in any way (i.e. there is no researcher bias), and the comments left are in the individual’s own words.
- The relevance of the research to those with eating disorders was increased with the use of specific eating disorder-related forums, covering multiple diagnoses. This means it is more likely that the experiences of the impact of COVID-19 on those with EDs and disordered eating were captured.
However, there are various limitations to be addressed:
- Despite the fact that specific ED-related forums were searched, this does not mean that relevant conversations on this topic were not happening on more general forums. Additionally, only certain keywords were used to search for relevant comments, and so there is a chance that comments detailing different experiences or using different keywords may have been missed.
- Since publicly available comments were analysed, the research team were unable to collect any information about the participant population (i.e. demographics, diagnostic history, etc). Therefore, there is no way of knowing how diverse or representative the sample is of those with EDs, and comments could not be followed up with participants to gain further information (as you would be able to in a focus group or interview, for example).
- The time frame of comments only spans 5 months, which in light of the pandemic is relatively short. Restrictions have changed over the last year, moving from being strict to more relaxed and back again. Therefore, whilst the comments in this study provide a snapshot of experiences at the beginning of the pandemic, they are unable to show experiences over time, and the effects of the pandemic in the longer-term.
Whilst the researchers were able to collect and analyse a total of 305 comments over the course of 5 months, their search strategy might have meant that comments were missed, if individuals misspelled or used different keywords, or did not post in ED-related forums.
Implications for practice
Given that these Reddit forums were used largely to provide support and encouragement, future research may be needed to assess the use of social media forums as treatment for mental health, particularly at times when this might be the only form of support available (i.e. during periods of imposed restrictions and increased isolation).Whilst the findings from this research make it clear that many use these platforms as a therapeutic community, there are questions around the need for more regulations. Whilst some might provide a supportive lifeline, others could play a dangerous role in the exacerbation of symptoms, for example, the existence of pro anorexia or ‘pro-ana’ websites and forums.
The role of healthcare providers on forums is unclear. However, there have been suggestions for more education to help practitioners to utilise these platforms to communicate with patients, to improve quality of care and prevent the spread of misinformation (Pershad et al., 2018). For younger patients specifically, there has also been evidence of a preference of communication via such methods (Rensburg et al., 2016), which could possibly help during times when face-to-face treatment is not possible and treatment engagement via remote methods is poor and seen as ‘second best’ (Waller et al., 2020). However, there are ethical issues to consider (i.e. privacy), and so more research and discussion around these topics are needed, as it’s clear that these forums are being used.
Whilst forums and discussion threads such as the ones analysed in this study provided a therapeutic and supportive space, there may be a need for regulations to prevent the spread of misinformation or dangerous content.
Statement of interests
None.
Links
Primary paper
Nutley, S. K., Falise, A. M., Henderson, R., Apostolou, V., Mathews, C. A., & Striley, C. W. (2021). The impact of COVID-19 on disordered earing behavior: A qualitative analysis of social media users’ response to the global pandemic [HTML]. JMIR Mental Health, 8, e26011.
Other references
Fernández-Aranda, F., Casas, M., Claes, L., Clark Bryan, D., Favaro, A., Granero, R., … & Tresure, J. (2020). COVID-19 and implications for eating disorders [HTML]. European Eating Disorders Review, 28(3), 239-245.
Jamnik, M., & Lane, D. (2017). The Use of Reddit as an Inexpensive Source for High-Quality Data (PDF). Practical Assessment, Research, and Evaluation, 22(5), 1-10.
Pershad, Y., Hangge, PT., Albadawi, H., & Oklu, R. (2018). Social Medicine: Twitter in Healthcare (PDF). J Clin Med, 7(6), 121.
Phillipou A., Meyer D., Neill E., Tan, E., Lin Toh, W., Van Rheene, T., & Rossell, S. (2020). Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project (PDF). International Journal of Eating Disorders, 53(7), 1158- 1165.
Rensburg, SH., Klingensmith, K., McLaughlin, P., Qayyum, Z., & van Schalkwyk, GI. (2016). Patient–provider communication over social media: perspectives of adolescents with psychiatric illness (PDF). Health Expectations, 19(1), 112-120.
Rodgers, RF., Lombardo, C., Cerolini, S., Franko, DL., Omori, M., Fuller-Tyszkiewicz, M., … & Guillaume, S. (2020). The impact of the COVID-19 pandemic on eating disorder risk and symptoms (PDF). International Journal of Eating Disorders, 53(7),1166-1170.
Todisco, P., & Donini, LM. (2020). Eating disorders and obesity (ED&O) in the COVID-19 storm (PDF). Eating and Weight Disorders, 26, 747-790.
Waller, G., Pugh, M., Mulkens, S., Moore, E., Mountford, V., Carter, J., … & Smit, V. (2020). Cognitive-behavioral therapy in the time of coronavirus: Clinician tips for working with eating disorders via telehealth when face-to face meetings are not possible (PDF). International Journal of Eating Disorders, 53(7), 1132-1141.
Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China [HTML]. Int J Environ Res Public Health, 17(5), 1729.
Weissman, RS., Bauer, S., & Thomas, JJ. (2020). Access to evidence-based care for eating disorders during the COVID-19 crisis (PDF). International Journal of Eating Disorders, 53(5), 639- 646.
Xiang, Y-T., Yang, Y., Zhang, C., Liu, S., Liu, Z., Hu, S., & Zhang, B. (2020). Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed [HTML]. The Lancet Psychiatry, 7(3), 228-229.
Photo credits
- Photo by Brett Jordan on Unsplash
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- Photo by Brett Jordan on Unsplash
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I am a member of ED reddit communities and I am so incredibly upset, hurt, and betrayed that my experiences have been harvested and ripped out for researchers. Shame on them. I will seriously reconsider posting, and they are my only support. I cannot put into words my hurt and anger at this horrendously unethical research. But consent doesn’t matter, we’re just eating disordered non-humans to them I suppose. I’m also disappointed this was covered like a potentially valid study, not the non-consensual unethical invasion of support spaces it actually is.
100% agree with the other comment that the study team definitely crossed a line by extracting ED experiences from a reddit thread that is to be considered a safe space. I wonder if there was ethics approval involved? Would have been interesting to mention that in the Methods.