An Analytical Review of the Causes of Eating Disorders in the COVID-19 Pandemic in Adolescents

Abstract

This study reviews a selection of the literature on the social causes, including family, media exposure, and access to healthcare resources and social support, and personal factors of eating disorders (EDs), such as anorexia nervosa, bulimia nervosa, and binge eating disorder, in the year of COVID-19 in adolescents. This study also explores the independent influences and possible relationships of these variables that may worsen the risk and symptoms of EDs. By analyzing the global significance of understanding EDs in COVID-19, this study provides its implications to society, family, and professional care to increase the quality of life for adolescents with EDs.

1. Introduction

Eating disorders (EDs) are characterized by significantly damaged physical health or psychological functioning that results from disturbed eating behaviors [1]. People with EDs have lower hopefulness and resilience than those without EDs [2]. Given people with EDs have an excessive focus on food consumption and distorted views of their body images and their psychological vulnerability, the COVID-19 pandemic has increased the ED risk and aggravated ED symptoms by reducing protective factors against EDs and increasing obstacles to ED-related treatments and care [1, 3].

The influence of the COVID-19 pandemic on adolescents with EDs is pronounced. The increasing number of ED diagnoses was especially noticeable among adolescent females in Catalonia [4]. Accordingly, the need for outpatient treatment and inpatient admissions increased steadily after the pandemic [5]. For instance, there is a significant admission rate in 15 to 19-year-old female Italian adolescents [6]. In responding to these needs, both medical inpatient and outpatient interventions in treating adolescents and young adults with EDs saw a dramatic increase after the COVID-19 pandemic [7]. Furthermore, the COVID-19 pandemic is an impetus for the deterioration of ED symptoms and recovery [8]. As evidenced by Gao [9], more than 40% of adolescents with EDs experienced a reactivation of ED symptoms. Both adolescents with anorexia nervosa (AN) and their parents suggested that eating habits had become worse as well as overall emotional distress, such as greater anxiety and depression [8]; 49% of previous patients aged between 17 and 46 with bulimia nervosa (BN), who were hospitalized in Germany, reported the declined quality of life and exacerbated ED symptoms [10]. Apart from relapse of ED symptoms, 93.3% of the primary causes for hospital admission for adolescent with EDs were self-injurious behaviors and suicide risks [11].

Realizing the severity and urgency of preventing and treating EDs during the COVID-19 pandemic, this study aims (1) to provide an overview of social causes, such as family, media exposure, and access to treatments and social support, and personal causes of EDs in the COVID-19 pandemic; (2) to analyze the association of social, family, and personal causes of EDs in the COVID-19 pandemic; (3) to analyze the integration of different causes on EDs; (4) to discuss applications of this review in professional care, family, and social contexts; and finally (5) to contribute to the current literature review to focus on adolescents.

2. Methodology

This paper is a review based on a selection of 41 current research studies searched and collected using Google Scholar and one printed book source in the field of AN, BN, and binge eating. This review also includes the relevant literature in the fields of nutrition, medicine, and psychology to explain the medical comorbidity and nutritional deficits of adolescents with EDs and the causes of EDs in the COVID-19 pandemic. The definition of EDs is acquired from DSM [1]. To explain the exacerbation of EDs in adolescents, the data are taken from recent peer-reviewed research or reviews. These statistics are reliable to explain the serious influences of COVID-19 on adolescents with EDs because the data come from well-known psychological journals, and the studies were conducted during or after the COVID-19 pandemic. The quality of each source was assessed, and the appropriateness was determined for this paper. Some of the inclusion criteria were: (1) The source had to be relevant to the universal causes outside or within the COVID-19 pandemic; (2) The target population had to include adolescents and/or their parents or the source could build on the discussion on adolescents with EDs. One of the exclusion criteria was that the source comes from non-academic websites, blogs, or news reports rather than academic journals.

Discussions were undertaken with adolescents with Eds, and conclusions were drawn by providing potential social and clinical practices to assist adolescents with EDs in the COVID-19 pandemic. The major emphasis of this paper is on the causes of EDs in the year of the COVID-19 and how it affects adolescents and their families personally and socially.

3. Literature review

3.1 Causes

3.1.1 Social causes

According to Shah [12], it is hard for people with AN, BN, and binge eating disorder to adhere to normal eating habits under compulsory stay-at-home policies, which means COVID-19 deteriorates ED-related risk factors, increasing the risks of developing EDs. For instance, according to Sidor [13], quarantine has influenced people’s eating habits, which can lead to eating more or eating less during stressful events and binge eating, consequently resulting in substantial weight change. It is possible that quarantine has broken a regular, balanced, normal, and flexible eating habit [14].

First, the quarantine breaks the consistent living schedules of individuals with EDs. A regular eating habit refers to having a set of meals and a snack routine, such as eating snacks every 3–4 h and eating according to feelings of hunger and satiety [14]. For both people with and without ED, limited food selection makes people reasonable to skip meals or restrict calorie consumption, exacerbating the tendency of food restriction [15, 16]. Quarantine increased the risk for BN and binge eating as well, especially for overweight individuals, who have faced intense dietary risks during quarantine [13]. In a study focused on the Polish population, participants reported problematic eating habits, such as eating food while not hungry and frequently overeating [13].

Second, the amount of food storage during quarantine disturbs the nutritional eating habits of people with EDs. A balanced eating habit is defined as eating a wide variety of foods and nutritious foods with protein, fat, and carbohydrates. From the perspective of food storage, among people who have experienced ED, nearly 70% of them claimed that their relationship with food has altered due to food shortage or excessive amounts of food [15]. When people with AN purchase foods in grocery stores, the unavailability of foods that are tailored to their routine results in fear and panic, and the need to comply with suggested high-calorie eating plans results in feelings of guilt [12]. The negative feelings of fear, panic, and guilt can lead to emotional eating [17]. In research concentrated on the Italian population and including nearly 80% female participants, 44% of the participants reported a dietary diet before the COVID-19 pandemic, which emphasized females’ predisposition to food restriction [17]. In addition, lots of studies have shown the relationship between food insecurity and binge eating and BN [16]. Food insecurity refers to the disruption of food consumption or changes in eating habits due to limited financial resources [16]. Since people have insufficient money to buy enough food, this restriction increases the risks of binge eating because of food cravings, biological effects of starvation, and complementary economic difficulty [16].

Third, the living situations of individuals with EDs were disrupted by the pandemic as a result of relationships with others. A flexible eating habit means eating without plans [14]. People can eat foods they do not like sufficiently in social situations or when traveling [14]. In a study consisting of the UK population who have experienced ED, 85.2% of the participants reported their symptoms became severe due to this change because their challenges to live with their partner and family members have significantly affected their eating behaviors during quarantine [15]. For example, some participants described they felt extremely stressed eating in front of others and restricting their food choices. Some individuals reported their reluctance to eat more at the request of their families and felt out of control over their food choices in every meal [15]. The sustained pressure to manage eating behaviors in demanding surroundings can essentially limit people with EDs’ capacity to eat flexibly in scrutiny of others.

Besides the influences of quarantine, family situations, media exposure, and the availability of social support and healthcare professionals aggravate the negative impacts of imposed stay-at-home policies. For those people who are required to recover their weight, living in families with food shortages poses extra pressure on them since family members feel shame for consuming more foods within a limited food resource [16]. People spend more time on entertainment at home, and food is easily accessible, which increases the risks of binge eating [12, 15]. The diminished social supports and restricted accessibility of healthcare resources and advocacy for home exercise to prevent “quarantine 15,” the average of 15 pounds weight gained during the pandemic, all contribute to distress and ED-related behaviors.

At first hand, the COVID-19 pandemic has posed severe challenges for primary caregivers of adolescents with EDs. Primary caregivers of ED offspring reported higher levels of psychological distress compared to primary caregivers of healthy offspring [18], and primary caregivers’ capacity to help their children with EDs was influenced by COVID-19 [19]. During quarantine, adolescents with EDs spend an increasing amount of time at home, which is an unstructured environment that disrupts their daily routines [20]. To alleviate the pressure on decreasing structured routines, adolescents with EDs engage in more ED cognitions and behaviors and are increasingly vigilant of their caregivers’ management of their disordered behaviors [20]. Although primary caregivers face barriers to diverting adolescents with EDs from their disordered perceptions and behaviors, the pandemic has posed new difficulties, forcing primary caregivers to devote more time at home supervising and helping their children [20].

Given the noticeable quarantine stress and extra responsibility of caring for adolescents with EDs, primary caregivers may deal maladaptively through aggression, splitting, and/ or fragmentation, which can pose burdens on adolescents who live in this high-pressure family environment [16, 20]. According to Khrosavi [16], family pressure intensifies feelings of loneliness and isolation, which are common etiology of AN. Maunder [20] showed a high possibility of growing expressed emotion during the quarantine, which had significant negative effects on the treatment adherence and recovery of adolescents with EDs and consequently worsened the load on primary caregivers. Expressed emotion refers to “attitudes and behaviors communicated towards the child with an ED and includes critical comments, hostility, and emotional over-involvement [20].” Consistent with this finding, those primary caregivers who ignore their children’s emotional needs being instructive, hostile, and caring about their children excessively may result in family disconnection, leading to a higher risk of developing EDs [21]. Moreover, the necessity of balancing the working and family life of primary caregivers and the quarantine of every family member creates pressure on everyone [20]. Mealtimes can grow particularly burdensome for families of adolescents with EDs, resulting in emotional outbreaks and high levels of expressed emotion [20].

Secondly, media exposure provides a rational context for the development of EDs in the year of the COVID-19 pandemic. An observational study has shown that there was an increased discussion on social media about COVID-19 infections; neuropsychological symptoms, such as anxiety; and medical conditions, such as psychiatric disorders, during the start of the quarantine during the pandemic [22]. When the pandemic spread globally, people mentioned more about weight loss, anxiety, generalized pain, and depression on social media [22]. Switching attention to social media use, Vall-Roqué [23] concluded that the COVID-19 quarantine might have affected social media sites (SNS) use, which resulted in increasing body image disturbances in adolescent and young women. The average time spent on SNS among the population of Spanish adolescents and young women who follow appearance-related Instagram rose significantly during the COVID-19 quarantine; using Instagram more frequently and following appearance-focused Instagram accounts indicate the desire for thinness [23]. These findings highlighted the harmful influences of SNS deterioration during the pandemic, and it is likely that COVID-19 is associated with risk for ED behaviors related to media effects and a growing desire for thinness [23]. Especially for those who have a history of body image disturbances and have accessed SNS more frequently during the COVID-19 period, Vall-Roqué [23] suggested the possibility of a mutual association between body image disturbance and self-esteem linked to SNS.

Next, due to the decreased availability of social support, healthcare, and effective coping mechanisms, the pandemic may have reduced the protective ability and accessibility to care [3]. In terms of social support, 86.4% of participants in Branley-Bell [15] have experienced more social isolation because they could not connect with supportive support networks, such as friends and family. Individuals who have an ED experience cannot cope with their symptoms successfully since quarantine has hindered them from eating in secure places outside of the home [15]. Further, a lack of social support obstructed individuals from ED recovery because of strengthened ED during long periods of quarantine [15]. The lost connection with close others intensified the social isolation and feelings of loneliness, which diminished the drive for recovery in adolescents with ED [8]. While some participants felt less social pressure about losing weight without social pressure, some participants felt worried about being more flexible about food choices and returning to social eating [15].

Moreover, the quarantine has brought profound changes in people with EDs’ daily routines. According to Branley-Bell [15], 65% of participants reported the pandemic altered their common coping mechanisms. If individuals with EDs have a low level of sense of control over their social activities, study, or work, they may use behaviors of ED to retain control with food.

Finally, both Goode [24] and Spigel [25] have shown that the COVID-19 pandemic has brought serious challenges to the recovery process of EDs because of access to healthcare resources. Admittedly, Spigel [25] did not demonstrate a statistically significant relationship between access to healthcare and more symptoms of ED in adolescents. Some adolescents in EDs reported the availability of online treatments as high quality, and telehealth provided some opportunities to continue some of their treatments in the age of COVID-19 [25]. Online treatments also increase the safety and convenience of treatments, especially for those people who are unable or averse to meeting health professionals face-to-face [24]. However, individuals with EDs still reported challenges related to treatment during the first half of the COVID-19 pandemic [24]. Although some individuals were able to accommodate online treatments, the decreased accessibility of ED-related treatments in the age of the COVID-19 pandemic still brought uninterrupted difficulties to people with EDs [24]. These challenges include treatment disruption, as evidenced by individuals who have experienced EDs being discharged from inpatient treatments prematurely and receiving restricted post-discharge support [15]. Similar to this finding, Goode [24] showed that 47% of participants suspended some of their treatments in a research consisting of young adults and adolescents with EDs. Individuals with EDs did not regard online treatments as a substitute for in-person support, and they still prioritized face-to-face treatment [15]. Some participants reported virtual treatment challenges because they were unable to find available treatment providers and/or adapt to the new requirements of telehealth [24]. In addition, telehealth is not without its limitations, which include losing connections with in-person healthcare professionals and the inability to assess weight, important signs, and physiological evaluations [24]. In Branley-Bell [15], some participants reported online treatments brought fatal influences on their EDs. For example, some participants became more self-aware and self-critical of their appearance in video calls and even described the effects of not being physically monitored as detrimental [15]. Telehealth has not generalized globally. According to Schlegl [10], only 20% of their German participants with BN utilized video-conferenced treatment, which is 22–25% lower than the amount of BN patients who used it in the United States and the Netherlands. In other words, the rate of practicality and acceptance of telehealth appears to be low in Germany [10].

3.1.2 Personal causes

Biological factors, personality characteristics, and the synthetic effect of family all contributed to the increasing risks of developing EDs and aggravated ED symptoms in the year of the COVID-19 pandemic.

In the first place, from the medical perspective, medical history and comorbidity of ED and other mental disorders account for the exacerbation of ED behaviors during the COVID-19 pandemic. According to Jones [26], adolescent females with type 1 diabetes (T1D) are twice as likely to develop eating disorders compared to those without T1D. Agreeing with this finding, Erthal [27], an 18-month longitudinal study during the COVID-19 pandemic, demonstrated that people with both T1D and type 2 diabetes had a significant risk of developing eating disorders; especially those people who have been diagnosed with diabetes over 15 years and experienced emotional effects on their food selections had a greater possibility of their eating habits deteriorating. While the quarantine, change in sleeping patterns, and the growing stress and anxiety due to media exposure are variables that impact disordered eating behaviors, worsened ED behavior in adolescents with T1D during the pandemic primarily resulted from the desire to be thin and the alternation of eating patterns [28]. Twenty-five percent of adolescents in Gillon-Kere [28] reported weight gains during the pandemic. Increasing consumption of daily energy consumption and unhealthy processed foods during the pandemic resulted in low nutritional quality in people with diabetes [27]. To protect their children from the disease, parents were more concerned about the diet of adolescents with T1D, resulting in their children’s increasing pressure and preference to eat alone [28].

A history of mental health disorders also predisposes adolescents to the development of EDs and worsens ED symptoms. Sander [29], a study focused on female adolescents and female adults, found a significant correlation between anxiety/depression and ED symptoms. There was also a positive relationship between severe anxiety/depression and severe symptoms in these female participants [29]. Aligning with this finding, the elevated risk of suicide attempts in adolescent girls with AN and BN was associated with depression [30].

Secondly, along with medical history, those who have a comorbidity of ED and other mental disorders have faced environmental challenges, such as inaccessibility to outdoor activities, interruption of daily routines, fear of contagion, and growing exposure to anxiety-provoking and ED-related media in the age of the COVID-19 pandemic [3]. During quarantine, in comparison to those aged between 25 and 35 years, individuals aged between 14 and 25 years old experienced substantially higher levels of depression, anxiety, and stress. Those women who were uncertain about whether they had contracted COVID-19 scored much higher on depression and stress and more disordered eating, such as bulimia and food preoccupation, than those who had not been infected with COVID-19 [31]. In addition, Garell [11] showed a higher prevalence of mental disorder comorbidity and suicide risk for hospitalized adolescent patients with EDs during the COVID-19 pandemic compared to those admitted patients the year before may have resulted from the COVID-19 pandemic. Suicide risk may be related to growing familial conflicts [11]. The alteration in family life leads to parents becoming more conscious of the changes in symptoms of adolescent parents with EDs and progressively governing their behavior, which may have an adverse effect on unpleasant emotions for adolescents with EDs [8].

Additionally, as evidenced by Warne [32], in the age of COVID-19, disordered eating, self-harm, and comorbid disordered eating were associated with worse mental health, higher anxiety, and depression symptoms [32]. In other words, the comorbidity of ED and mood disorders, such as anxiety and depression, is a risk factor that exacerbated ED symptoms during the COVID-19 pandemic [21]. Vall-Roqué [31] showed grief may impact mental health and consequently result in eating disturbances. Emotional eating refers to eating in reaction to emotional signals, regarded as a defensive mechanism for negative emotions [31]. In responding to the sadness of losing loved ones during COVID-19, women scored higher on emotional distress and experienced more eating disturbances [31]. EDs are also a coping mechanism for problems of identity and personal control [21]. People with BN reported reduced anxiety and depression after binging, and people with AN gained emotional gratification by restricting food intake [21]. Recognizing slimness as a coping mechanism for adolescents’ problems, the family may be an immediate cause of identity and/or self-control problems [21]. BN’s increased body dissatisfaction and body-size perception are caused by negative affect, which can result in ED symptoms regardless of its fundamental cause [21].

The second aspect of personal causes of EDs is concerned with personal characteristics. One of the predisposing factors of EDs is perfectionism, as evidenced by perfectionism being an early indication of AN [21]. However, perfectionism is not a fundamental cause of EDs. There have to be other variables that trigger this predisposition. One of the factors is anxiety. According to Egan [33], anxiety partially mediates self-oriented perfectionism, where people have high standards of themselves, and EDs, which means there are other essential factors influencing this association. As mentioned above, the challenges during the COVID-19 pandemic have been a potential environmental trigger of the mediating effect of anxiety between perfectionism and EDs. When individuals with binge eating disorders feel overweight, perfectionism is a predisposing factor for binge eating [33]. Individuals use binge eating as a coping mechanism for a strong negative effect and undesirable self-awareness [33]. A study showed that women with high levels of perfectionism also had the most severe symptoms of binge eating [33].

Furthermore, family factors play a crucial role in the relationship between perfectionism and EDs [33]. Adolescents with eating disorders reported a critical family environment without frequent communication and a high level of warmth [21]. Not being able to acquire empathy from their caregivers, adolescents engage in perfectionism, such as strict management of their eating, weight, and shape to obtain self-recognition [21]. One of the characteristics of perfectionism is to cover mistakes [33]. Limited interactions within a critical family environment and parents’ distraction from dealing with their own psychological burdens during the COVID-19 pandemic decreased individuals’ opportunities to learn from families’ feedback [33]. Individuals’ difficulty in correcting their mistakes toward perfectionism may increase their vulnerability to developing EDs.

In addition to perfectionism, low self-esteem predicated an increase in ED-related behaviors in adolescents worldwide [34]. Consistent with this finding, girls with low self-esteem have a higher risk of developing EDs later in their lives [21]. Frieiro [34] also showed low positive self-esteem is positively associated with ED behaviors, food preoccupation, and bulimia, and negative self-esteem is associated with diet and bulimia [33]. Self-esteem is a representation of others’ reactions toward an individual, and therefore, it is possible that a lower self-esteem and maladaptive behaviors, such as EDs, may result from perceived rejection [21]. Among adolescents between 12 and 18 years old, the use of social networks (SN) is positively associated with EDs, which means that socialization via SNs results in exacerbated ED risk behaviors, especially among those who experience violence or rejection from SNs [33]. Considering increasing SN use in adolescents during the pandemic, it is possible that COVID-19 may have worsened the risk of developing EDs. Against the COVID-19 quarantine background, compared to those women who perceived themselves as living in relaxing family environments, women who were not living in a relaxing family environment scored significantly higher on eating disturbances, such as dieting, bulimia, and food preoccupation, and lower on self-esteem [31].

Moreover, another predisposing factor for developing EDs is body dissatisfaction through media effects and family pressure [21]. Salci [35] referred to body image as a multidimensional psychological experience of representation not limited to individuals’ physical appearance, revealing people’s views, emotions, judgments, and assessments of their bodies. Negative emotions and negative perceptions about oneself can translate into body dissatisfaction [21]. Body image disorders impact individuals’ behaviors related to body weight or shape and are found to be correlated with AN and BN [36]. To lessen the above-mentioned body image disturbances brought by social media and increasing SNS use, adolescents with EDs engage in harmful ED behaviors. In Branley-Bell [15], some of the participants have reported more physical activities to alleviate their anxieties about gaining weight or compensating for restricted opportunities of binging and purging in the monitoring of others. Align with these qualitative data, a study focused on French undergraduate students showed a significant positive correlation between media exposure related to COVID-19 and a tendency to binge eat [37]. A study focused on adolescents showed adolescents who were diagnosed with AN at the age pandemic had a lower weight and spent more time on compulsive exercise compared to other activities to avoid “quarantine-15,” which highlighted the increased compulsive exercise as a trigger for adolescents with AN [38].

Except for media effects, there is a reciprocal relationship between family pressure and children’s ED symptoms. The weight loss behavior, weight dissatisfaction, and body shape dissatisfaction of caregivers may impact how their offspring view their own bodies, which may become a risk factor for ED [18]. Among parents who lived with their offspring with EDs during the COVID-19 pandemic, 25% and 35% of them experienced body shape dissatisfaction and weight dissatisfaction, respectively [18]. These parents scored higher on depression than those without body shape dissatisfaction or weight dissatisfaction [18]. Especially the caregivers of offspring with AN reported the highest depression because it is possible that offspring with AN frequently experience serious malnutrition and a significant risk of mortality, which requires multidisciplinary treatments [18], due to a higher relapse rate and suicide risks for adolescents with EDs who need day-hospital treatment and because they need significant more in-person and telehealth treatments during quarantine [11]. Nevertheless, they were prevented from receiving inpatient and outpatient professional help because of the lockdown policy [18]. More symptoms of ED were reported when the offspring felt more pressure from their mother [18].

Finally, restricted engagement in physical activity regularly during quarantine can result in shape and weight concerns and problematic eating behaviors [37]. The COVID-19 pandemic had led to the suspension of schools and the closure of recreational and sports facilities. According to the World Health Organization (WHO) [39], lots of individuals engaged in less physical activities and increased screen time and had irregular sleeping habits and eating patterns, which may cause weight gain. The unavailability of regular physical activity intensified anxiety about weight gain in adolescents with AN, exacerbating food restriction and thinness [40]. Research on AN patients supported that individuals claimed deliberate and unintended weight loss, psychological involvement with body weight and food, acute worries of gaining weight, and distorted body image [40]. Flaudias [37] provided a possible explanation, which is that deteriorated body dissatisfaction mediates the correlation between pressure related to quarantine and spatial distancing and disordered eating behaviors.

4. Conclusion

In conclusion, adolescents with EDs were a high-susceptibility group for exacerbation and relapse of ED symptoms during the COVID-19 pandemic, and thus, it is urgent to provide a comprehensive overview of the causes of EDs to facilitate thorough research in this area and inform the highest standard of clinical support.

From a social perspective, the quarantine has enormously disrupted the normal routine of adolescents with EDs and insulated their connections with supportive others. Both Branley-Bell [15] and Özemete [41] have identified that social support has had a protective role against anxiety during the pandemic. According to Özemete [41], perception influences individuals’ anxiety levels. Especially during the COVID-19 pandemic, a time of high uncertainty and decreased social interactions, perceived social support has had a larger impact on individuals’ anxiety levels compared to received social support [41]. Özemete [41] emphasized the negative association between perceived family support, perceived friend support, and perceived social support and anxiety during the pandemic. Aiming to boost the coping capacity of individuals with EDs, a group of people with high risk and vulnerability during the pandemic, workers can buttress the perceived social support of individuals with ED [41].

Secondly, adolescents with EDs report feelings of stress in the monitoring of their parents and aggravated social isolation in a high-pressure family environment. Instead of emphasizing excessively the necessity for recovery, parents may aim to establish mutual trust with children. They should not only accept and tolerate their children’s struggles for recovery but also boost their self-esteem by discovering their children’s merits other than slimness, which plays a preventive role against EDs. Parents should also spend more time observing their children’s psychological changes and provide psychological guidance accordingly.

Thirdly, preoccupied media exposure to body shape, weight, and exercise has damaged the body image, increased the desire for thinness, and worsened compulsive exercise in adolescents with EDs. Medical institutions and administration must recognize these messages are disturbing or stressful for adolescents with EDs and endeavor to develop principles to solve the over-reported issue [15]. Future research is needed to investigate the measures to avoid excessive media exposure and deal with the effects of watching triggering information [15]. The current review identifies the necessity for governments to build constructive regulations on media reports and social media practices to deal with psychological distress [15].

Next, adolescents with EDs need special medical attention during the COVID-19 pandemic. Given the severe malnutrition status of adolescents with EDs, they are vulnerable to other medical complications. For example, people with AN have higher risks of being infected by respiratory symptoms, especially those who have weakened immune systems and other medical comorbidities. The peripheral circulatory problems and vasculitis in individuals with AN are considered late manifestations of COVID-19 [42].

In Branley-Bell [15], some participants reported the benefits of the updated technology. Some participants used social media to establish effective support networks as evidenced by the reduced frequency of binge eating. Some participants reported diminished anxiety because of less social interaction and consequent reduced social comparisons. Although these positive effects are not representative and not a healthy panacea, these qualitative data still provide treatment designers some inspiration to adjust traditional treatment methods tailored to individuals with EDs’ personal needs and constantly evolving epidemic situations [15].

Considering the experiences of adolescents with EDs in COVID-19, this review emphasizes the significance of discussing the prevention strategies of EDs in adolescents. Some universal prevention strategies may include educating adolescents about healthy weight management and the harmful effects of malnutrition in schools. However, given the complexity of the causes of EDs in COVID-19, it is difficult to target multiple causes of EDs in one adolescent [14]. Therefore, universal prevention strategies may be challenging and ineffective in decreasing the prevalence of EDs in adolescents [14]. The second-level prevention refers to preventing populations with high risks of EDs and those who have developed some symptoms of EDs [14]. It is helpful to design some programs to help high school and college students, especially those who increasingly focus on their bodies and have a strong desire for thinness, to resist societal pressure to become thin. For example, the programs may focus on helping adolescents to redevelop more regular, balanced, and flexible eating habits and improve their body image. While the goal of third-level prevention is to decrease the long-term influence of EDs, Walsh [14] argued it is better to incorporate third-level prevention into the treatment plan. Nevertheless, there is no perfect strategy to eliminate the possibility of developing EDs in adolescents. Regardless, adolescents benefit from the programs that concentrate on changing their unhealthy perceptions of body and weight and unhealthy eating habits [14].

From the clinical point of view, apart from the well-acknowledged multidisciplinary treatment team, which includes psychologists, dietitians, and psychiatrists, for adolescents with EDs, the treatment of EDs may be modified to accommodate for infection and quarantine policy. During the assessment phase, therapists should pay more attention to the psychological changes of individuals with EDs before and after the pandemic. To best explore the etiology of adolescents with EDs, therapists should use the biopsychosocial model to explore the etiology of adolescents with EDs: (1) personal factors, such as medical history, the comorbidity of EDs, and personal characteristics; (2) family factors, such as caregivers’ history of EDs; (3) medical and nutritional evaluations; and (4) environmental factors, such as the effects of social isolation [42].

The absence of connections to supporting resources and exacerbation of mental health have discouraged adolescents with EDs from recovery [8, 42]. Therefore, the rationale behind the treatment of adolescents with EDs in the year of the COVID-19 pandemic is to boost adolescents’ motivations for recovery, take advantage of the strengths and modify the weaknesses of internet-based treatment, and encourage cooperation between parents and medical professionals. Outpatient treatment is the most optimal in the setting of COVID-19 quarantine, with a focus on families and the professional assistance of medical staff [42]. To effectively regulate the relapse of ED symptoms and mental health of adolescents with ED in the age of COVID-19, Graell [11] suggested a combined treatment of telehealth, outpatient treatment, and partial day care hospital. First, it is important to prioritize motivation for recovery and goal setting [8]. To alleviate adolescents’ discomforts about telehealth and anxieties about the suspension of traditional treatment options, therapists can utilize video calls to promote communication between adolescents with EDs and primary caregivers [8]. The goals are to acquaint caregivers and adolescents with new treatments and discuss their concerns [8]. Second, to best ease parents’ pressure on taking care of their children with EDs and extra burdens, therapists should not only inform their duties in the comprehensive treatments but also provide them with self-care methods [8]. Third, to monitor the indications of change in symptoms in adolescents with EDs, therapists may ask caregivers to help them report their weight weekly and record calories of food intake and energy consumption [42]. In sum, the ultimate goal of the treatment of EDs during the COVID-19 pandemic is to minimize in-person visits to decrease the risks of infection and reduce the stress of caregivers while still maintaining the highest quality of clinical therapy [42]. Since the pandemic has caused widespread anxiety, the current review suggests it is worth investigating the specific impacts of the psychological status of primary caregivers and medical professionals on adolescents with EDs.

In summary, this paper discussed the possible causes of EDs in adolescents in the age of the COVID-19 pandemic. The current literature suggests, under the context of the COVID-19 pandemic, EDs are a complicated and severe mental disorder because they influence adolescents with EDs’ biological functioning, nutritional status, as well as mental health. The causes of EDs in the COVID-19 pandemic have been a combination of social and personal variables. However, either of these factors can bring powerful effects to increase the risks or exacerbate the symptoms of EDs independently, and the interaction between them maximizes the negative influences of the COVID-19 pandemic on adolescents with EDs.