1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Received: 27 June 2022 Revised: 25 October 2022 Accepted: 25 October 2022 DOI: 10.1002/eat.23848 ORIGINAL ARTICLE Impact of the COVID-19 pandemic on eating disorders diagnoses among adolescents and young adults in Catalonia: A population-based cohort study  s MSc 1,2 Berta Ravento | Alicia Abellan PhD 2 | Andrea Pistillo MSc 2 | Carlen Reyes PhD 2 | Edward Burn PhD 2,3 | Talita Duarte-Salles PhD 2 1 Universitat Autònoma de Barcelona, Barcelona, Spain Abstract 2 Fundacio Institut Universitari per a la recerca Objective: To describe the impact of the COVID-19 pandemic on trends in incidence  Primària de Salut Jordi Gol i Gurina a l'Atencio (IDIAPJGol), Barcelona, Spain rates (IR) of diagnoses of eating disorders (ED) among adolescents and young adults. 3 Centre for Statistics in Medicine (CSM), Methods: Population-based cohort study using primary care records of people aged Nuffield Department of Orthopaedics, 10–24 years between January, 2016 and December, 2021 in Catalonia, Spain. IRs were Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK calculated monthly and grouped by the different stages of the COVID-19 pandemic in Catalonia: (1) the pre-lockdown (January, 2016–February, 2020), (2) lockdown (March– Correspondence Berta Ravento s, Fundacio Institut Universitari June, 2020) and, (3) post-lockdown (July, 2020–December, 2021) periods. Incidence  Primària de Salut per a la recerca a l'Atencio rate ratios (IRR) relative to the corresponding periods in 2018–2019 were calculated. Jordi Gol i Gurina (IDIAPJGol) Gran Via Corts Catalanes, 587 àtic 08007 Barcelona, Spain. Results: A total of 1,179,009 individuals were included. The IR was 9.2 per 100,000 Email: braventos@idiapjgol.info person-months (95% confidence intervals [CI]: 8.9–9.5) during the pre-lockdown Action Editor: Ruth Striegel Weissman period. It decreased during the lockdown period (6.3 per 100,000 person-months [5.5–7.3]), but substantially increased during the following period (19.4. per 100,000 person-months [18.7–20.1]). While large reductions in IRs were observed for both sexes during the lockdown period (IRR 95% CI: 0.65 [0.54–0.78] in females and 0.46 [0.29–0.71] in males), substantial increases during the post-lockdown period were limited to females, and were particularly pronounced among those aged 10–14 and 15–19 years (2.50 [2.23–2.80] and 2.29 [2.07–2.54], respectively). Discussion: The COVID-19 pandemic has resulted in a substantial increase in ED diagnoses, primarily driven by higher rates among adolescent females. Public Significance: This population-based cohort study demonstrated a substantial increase in incidence rates of eating disorders in primary care following the end of lockdown in Catalonia, Spain, with adolescent girls seen to be most affected. KEYWORDS COVID-19, eating disorders, epidemiology Edward Burn and Talita Duarte-Salles are Joint senior authorship. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2022 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC. Int J Eat Disord. 2023;56:225–234. wileyonlinelibrary.com/journal/eat 225 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 226 RAVENTÓS ET AL. 1 | I N T RO DU CT I O N de Catalunya, 2022a), measures were progressively eased as the pan- demic continued. However, some restrictions persisted throughout The COVID-19 pandemic presented a public health emergency world- the end of the year (e.g., mask use, limitations in social gatherings and wide. Unprecedented restrictions were adopted to reduce the com- events, closure of indoor nightlife venues). munity spread of the virus, causing major disruptions in socialization To date, few longitudinal studies have studied the potential effect and daily routines. This holds true especially for adolescents and of the COVID-19 pandemic on ED diagnoses (Asch et al., 2021; Bilu young adults, whose lives have been dramatically restricted by the et al., 2022; Haripersad et al., 2021; Lin et al., 2021; Taquet pandemic (Kazi & Mushtaq, 2021; Lee, 2020). Prolonged school clo- et al., 2021). However, most of these were focused on the short- or sures and reduced interactions with peers, along with family stressors mid-term effects of the pandemic, and none included incidence rates and missed or delayed social and educational milestones, are likely to stratified by socioeconomic status or in European countries (Asch have negatively impacted their physical and mental well-being. et al., 2021; Haripersad et al., 2021; Lin et al., 2021; Taquet Indeed, the rapidly accumulating evidence on the negative impact of et al., 2021). Understanding the long-term consequences of COVID- the COVID-19 on youth mental health suggests that psychological 19 on EDs among adolescents and young adults and how they differ distress increased considerably during the pandemic (Racine by sociodemographic characteristics could provide valuable informa- et al., 2021; von Soest et al., 2022). tion to plan interventions and prevention strategies to better support The impact of the pandemic on eating disorders (ED) among ado- those particularly affected by the pandemic. In the present study, we lescents and young adults has not gone unnoticed (Zipfel et al., 2022). aim to describe the impact of the COVID-19 pandemic on incidence An increase in incidence rates of EDs has been reported in different trends of EDs among adolescents and young adults through the end countries, often occurring with more severe symptomatology and of 2021 in a large primary care longitudinal dataset representative of increased rates of in-patient care (Agostino et al., 2021; Asch the population living in Catalonia, Spain. et al., 2021; Gilsbach et al., 2022; Haripersad et al., 2021; Lin et al., 2021; Spettigue et al., 2021; Taquet et al., 2021). Several factors related to the COVID-19 pandemic have been identified as potentially 2 | METHODS detrimental to ED risk and recovery. Some of those are food insecu- rity (e.g., reduced access to “safe” foods or increased urge to binge), 2.1 | Study design exercise limitations (e.g., increased weight concerns), increased media consumption (e.g., exposure to fatphobic messages or stressful media We conducted an open cohort study based on electronic health coverage), and fear of contagion from COVID-19 (e.g., restrictive diets records (EHR) from January 1, 2016 to December 31, 2021 in focused on increased immunity) (Cooper et al., 2022; Rodgers Catalonia, Spain. We described the first wave of the pandemic in et al., 2020). Furthermore, the COVID-19 pandemic and its associated Spain as the lockdown period given that it was the only wave where a control measures have negatively affected protective factors against stay-at-home order was issued. The study periods were defined as: EDs, such as structured routines, social support and healthy coping (1) the pre-lockdown period, from January 1, 2016 to February mechanisms, and have hampered access to healthcare services 29, 2020; (2) the lockdown period, from March 1, 2020 to June (Rodgers et al., 2020). 30, 2020; (3) the post-lockdown period, from July 1, 2020 to In Spain, a national lockdown was implemented on March December 31, 2021. 14, 2020 following the declaration of the State of Alarm (Real Decreto 436/2020, 2020). The freedom of movement was limited to a few exceptions, such as grocery shopping, health emergencies or essential 2.2 | Setting, data source, and study participants work. Moreover, it forced the suspension of all non-necessary com- mercial and recreational activities. Educational activities were pro- The Catalan healthcare system is publicly financed and provides uni- vided when possible by on-line platforms, and educational institutions versal health coverage to people living in Catalonia. Primary care is remained closed until the following academic year, which started in the main entry point for accessing public nonemergency health- September 2021 (Viguria & Casamitjana, 2021). Population-wide related services, and provides continuous care throughout the life restrictions, such as mandatory mask use, limitations in social gather- span. Pediatric services in primary care are provided up until age ings and in the capacity of commercial establishments and events con- 15, when adolescents are transferred to adult-oriented services. tinued once lockdown measures were lifted on June 21, 2020 (Real Data were obtained from the Information System for Research in Decreto 555/2020, 2020). Strict nationwide measures were imple- Primary Care (SIDIAP; www.sidiap.org), a primary care database that mented from October 25, 2020 to May 9, 2021 due to a resurgence contains pseudo-anonymized EHR from approximately 75% of the of COVID-19 cases, including mobility restrictions and curfew hours population in Catalonia, Spain. SIDIAP has been shown to be repre- (Real Decreto 926/2020, 2020). The timeline of the restrictions imple- sentative of the Catalan population in terms of age, sex, and geo- mented during this period in Catalonia, Spain, has been described in graphic distribution (Recalde et al., 2022). SIDIAP has been linked to further detail elsewhere (Perramon et al., 2021). While successive COVID-19 RT-PCR test results, hospital records, and regional mortal- COVID-19 waves occurred during the following months (Generalitat ity data, and it has been mapped to the Observational Medical 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License RAVENTÓS ET AL. 227 Outcomes Partnership (OMOP) Common Data Model (CDM) (Burn T A B L E 1 Population characteristics of adolescents and young et al., 2021). adults included in the study, 2016–2021 All individuals aged 10–24 years old during the study period with Total at least 1 year of prior history at the index date (i.e., the day they (n = 1 179 009) entered the cohort) and with no diagnosis of ED prior to the index Age at index date, median (IQR), years 13.0 (10.0,19.0) date were included. Individuals were followed from the start of the Females, n (%) 569 261 (48.3) study (January 1, 2016), the start of the observation period (the day in Sex: females which they were registered on the database) or the day after they Age group at entry (years), n (%) turned 10 years, whichever came last. Participants were followed to 10–14 314 823 (55.3) the earliest of the following: first incident ED diagnosis, end of data 15–19 125 953 (22.1) availability (December 31, 2021), the day on which participants turned 20–24 128 485 (22.6) 25 years, or until they were transferred out of the database or died. Sex: males Age group at entry (years), n (%) 2.3 | Variables 10–14 334 485 (54.9) 15–19 137 313 (22.5) We considered the first incident ED diagnosis as the outcome of inter- 20–24 137 950 (22.6) est. Diagnosis of EDs was made at primary care facilities based on stan- MEDEA deprivation index, n (%) (a) dard practice, and were registered by general practitioners or First, least deprived 168 451 (14.3) pediatricians during their daily practice. EDs were identified on the basis Second 168 044 (14.3) of the International Statistical Classification of Diseases and Related Third 167 388 (14.2) Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) Fourth 1 68 473 (14.3) codification system. All descendants of the F50 code were considered, Fifth, most deprived 177 897 (15.1) including anorexia nervosa (F50.1), bulimia nervosa (F50.2), other speci- Rural 200 793 (17.0) fied EDs including binge-eating disorder and avoidant restrictive food Missing 127 963 (10.9) intake disorder (F50.8), and unspecified EDs (F50.9). Years of prior history at index date, median 10.0 (10.0,10.0) We also extracted information on sex (female, male) and age. The (IQR) age range included in this study was defined according to the World Years contributed to the cohort, median (IQR) 4.9 (2.4, 6.0) Health Organization definition of adolescents and young adults (10–19 and 15–24 years, respectively) (World Health Organization, 2022), Abbreviations: IQR, Interquartile range; MEDEA, Mortalidad en áreas pequeñas Españolas y Desigualdades Socioecono  micas y Ambientales. and was further divided into three age groups (10–14, 15–19, and a Rural was included as a category since the index cannot be calculated for 20–24 years). people living in rural areas. We assessed socioeconomic status using the Mortalidad en áreas micas y Ambientales pequeñas Españolas y Desigualdades Socioecono (MEDEA) deprivation index, which is calculated at the census tract level during the lockdown and post-lockdown periods compared to the and it is categorized into quintiles, with the first and fifth quintiles same periods from March, 2018 to December, 2019. We stratified IRs n representing the least and most deprived areas (Domínguez-Berjo and IRRs by sex (males and females), age groups (10–14, 15–19, and et al., 2008). We included a rural category, as the MEDEA deprivation 20–24 years; calculated monthly) and the MEDEA deprivation index. index is only available for individuals living in urban areas of Catalonia. We used 95% CI to interpret differences between study periods. When the 95% CIs did not overlap, we understood the differences between time periods to be significant (p < 0.05). 2.4 | Statistical methods To test the robustness of our findings, we re-calculated IRRs using data from March, 2016 to December, 2017 as the comparison We summarized the characteristics of participants at their index date, period. with categorical variables presented as number and percentage and Following governance requirements, results with less than 5 indi- numerical variables presented as median and interquartile range (IQR). viduals were blinded and reported as <5. This analysis was descriptive in nature, with the explicit intention of All analyses were performed in R v 4.1. exploring new-onset ED trajectories among adolescents and young adults in Catalonia, Spain. Incidence rates (IR) with 95% confidence intervals (CI) were calculated for each month and study period by 3 | RE SU LT S dividing the number of new cases of EDs by 100,000 person-months at risk. Incidence rate ratios (IRR) with 95% CI were calculated to esti- We identified 1,367,785 individuals aged 10–24 years during the mate differences in the incidence of each strata of the population study period. We excluded 11,017 individuals with an ED 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 228 RAVENTÓS ET AL. TABLE 2 Population characteristics of adolescents and young adults diagnosed with eating disorders according to disorder type, 2016–2021 Eating Other eating Unspecified eating disorders (any) Anorexia Bulimia disorders disorders Cases, n (row %) (a) 6994 (100) 1494 (21.5) 783 (11.3) 170 (2.5) 4591 (66.1) Age at diagnosis, median (IQR), 15.0 (14.0, 18.0) 15.0 (14.0, 17.0) 17.0 (15.0, 20.0) 15.0 (13.0, 18.0) 15.0 (13.0, 17.0) years Females, n (%) 6085 (87.0) 1362 (91.2) 688 (87.9) 126 (74.1) 3949 (86.0) Sex: females Age group at diagnosis (years), n (%) 10–14 2276 (37.4) 503 (36.9) 101 (14.7) 59 (46.8) 1627 (41.2) 15–19 2838 (46.6) 685 (50.3) 374 (54.4) 48 (38.1) 1754 (44.4) 20–24 971 (16.0) 174 (12.8) 213 (31.0) 19 (15.1) 568 (14.4) Sex: males Age group at diagnosis (years), n (%) 10–14 469 (51.6) 62 (47.0) 20 (21.1) 22 (50) 367 (57.2) 15–19 325 (35.8) 60 (45.5) 47 (49.5) 15 (34.1) 204 (31.4) 20–24 115 (12.7) 10 (7.6) 28 (29.5) 7 (15.9) 71 (11.1) b MEDEA deprivation index, n (%) ( ) First, least deprived 990 (14.2) 250 (16.7) 110 (14.0) 18 (10.6) 616 (13.4) Second 1116 (16.0) 257 (17.2) 133 (17.0) 19 (11.2) 713 (15.5) Third 1074 (15.4) 199 (13.3) 105 (13.4) 29 (17.1) 748 (16.3) Fourth 957 (13.7) 168 (11.2) 107 (13.7) 26 (15.3) 661 (14.4) Fifth, most deprived 944 (13.5) 163 (10.9) 115 (14.7) 33 (19.4) 642 (14.0) Rural 1194 (17.1) 285 (19.1) 126 (16.1) 29 (17.1) 762 (16.6) Missing 719 (10.3) 172 (11.5) 87 (11.1) 16 (9.4) 449 (9.8) a Study period, cases, n (row %) ( ) Pre-COVID 3832 (100) 856 (22.3) 506 (13.2) 89 (2.3) 2405 (63.3) Lockdown 218 (100) 49 (22.5) 15 (6.9) <5 151 (69.3) Post-lockdown 2944 (100) 589 (20.0) 262 (8.9) 77 (2.6) 2035 (69.1) Abbreviations: IQR, interquartile range; MEDEA, Mortalidad en áreas pequeñas Españolas y Desigualdades Socioecono  micas y Ambientales. a Not mutually exclusive. Counts are limited to diagnoses performed at the first day of a recorded diagnosis of an eating disorder (i.e., more than one diagnosis can be recorded at the same day). ICD-10-CM codes were used to identify forms of EDs. The F50.1 and F50.2 codes were used to define anorexia nervosa and bulimia nervosa, respectively. Conditions classified under the F50.8 diagnostic code were considered as other eating disorders, and included binge eating disorder and avoidant restrictive food intake disorder, among others. Conditions classified under the F50.9 diagnostic code were considered as unspecified eating disorders. b Rural was included as a category since theindex cannot be calculated for people living in rural areas. diagnosis before the index date, and 177,759 with less than a similar for all disorder types except for bulimia (17.0 [IQR: 15.0– year of prior history (Figure S1). The final study population 20.0]). For socioeconomic status, we found a gradient in the number included 1,179,009 people, who contributed 58,506,600 person- of cases of anorexia, with the highest reported among the second months of data. Among all participants, 48.3% were female, and least deprived quintile (17.2%), and the lowest among the most the median age at inclusion was 13.0 (IQR: 10.0–19.0) years deprived (10.9%). This gradient was reversed when analyzing other (Table 1). specified EDs (10.6% and 19.4% among the least and most deprived, We identified 6994 individuals with a first diagnosis of an ED dur- respectively) (Table 2). ing the study period. The unspecified form of EDs was the most com- mon recorded diagnosis (66.1%), and was followed by anorexia (21.5%) and bulimia (11.3%) (Table 2). Other specified disorders only 3.1 | Incidence rates represented 2.5% of the recorded diagnoses. More than 85% of the cases diagnosed were females with the exception of other specified The IR of EDs was 9.2 per 100,000 person-months (95% CI 8.9–9.5) EDs, in which they accounted for 74.1% of the diagnoses (Table 2). during the pre-lockdown period. Monthly IRs exhibited pronounced The median age at diagnosis was 15.0 (IQR: 14.0–18.0), and was fluctuations, but remained stable between 2016 and 2019 when using 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License RAVENTÓS ET AL. 229 F I G U R E 1 Monthly incidence rates stratified by sex. Points indicate monthly incidence rates of eating disorders from January, 2016 to December, 2021. Shaded areas represent 95% confidence intervals. The lockdown period is delimited by two vertical lines, which indicate March, 2020 and June, 2020. F I G U R E 2 Monthly incidence rates stratified by age groups in females. Points indicate monthly incidence rates of eating disorders from January, 2016 to December, 2021. Shaded areas represent 95% confidence intervals. The lockdown period is delimited by two vertical lines, which indicate March, 2020 and June, 2020. yearly aggregated data (Table S1; Figure S2). The IR decreased during The impact of the COVID-19 pandemic on incidence trends of the lockdown period (6.3 per 100,000 person-months [5.5–7.3]), but EDs was particularly pronounced among females (Figure 1). Rates was double the figures observed before the pandemic during the during the pre-pandemic period were 15.9 per 100,000 person- post-lockdown period (19.4 per 100,000 person-months [18.7–20.1]) months (15.4–16.5) among females and 2.9 per 100,000 person- (Tables S3 and S4). months (2.6–3.1) among males (Table S2). Among females, the IR was 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 230 RAVENTÓS ET AL. F I G U R E 3 Incidence rate ratios (IRRs) with 95 % confidence intervaks (CI) of first recorded cases of eating disorders overall and stratified by sex, age group and deprivation index. IRRs were calculated by dividing the incidence rate obtained for each strata during the COVID-19 periods by the incidence rate obtained for the same strata during the same periods in 2018 and 2019. IRR corresponding to events with less than five occurrences have been omitted for privacy reasons. MEDEA: Mortalidad en áreas pequeñas Españolas y Desigualdades Socioecono micas y Ambientales; R, rural; U, urban. substantially reduced in March, 2020, and reached its minimum value (Table S5). The initial decrease in IR during lockdown occurred in in April, 2020 (5.2 per 100,000 person-months [3.2–8.0]). Conversely, both sexes, but was particularly pronounced among males (0.46 the IR steadily increased from May, 2020 to March, 2021 despite a [0.29–0.71] in males versus 0.65 [0.54–0.78] in females). The IR sub- few minor fluctuations. This increase was particularly profound from stantially increased among females during the post-lockdown period September, 2020 onwards (54.4 per 100,000 person-months (2.28 [2.12–2.44]), but suggested a lower difference in incidence [47.4–62.1] in March, 2021). The IR decreased during the following among males (1.20 [1.00–1.45]) (Figure 3; Table S5). months, and substantially dropped in August, 2021 (23.9 [19.4–29.3]). During the lockdown period, reductions were found across age The IR increased during the following months, reaching its second groups, with the biggest drops observed among females aged 10–14 peak in November, 2021 (57.1 [49.8–65.2]). Females up to 19 years and 20–24 years (0.55 [0.40–0.76] and 0.51[0.31–0.81], respectively), old showed higher IR compared to those aged 20–24 years across and males aged 10–14 years (0.41 [0.22–0.72]). Males aged 20– study periods, and showed abrupt changes in monthly IRs following 24 years obtained less than five occurrences and were blinded the lockdown announcement in March, 2020 (Figure 2). following the requirement of information governance (Table S5). The IR of EDs among males slightly fluctuated over the study Compared to the corresponding period in 2018–2019, IRs substan- period, ranging from 1.0 per 100,000 person-months (0.3–2.5) in tially increased during the post-lockdown period and more than March, 2020 to 5.1 per 100,000 person-months (3.1–7.7) in April, doubled among females aged 10–14 and 15–19 years (2.50 [2.23–2.80] 2021 (Figure 1). Although we observed some similarities between and 2.29 [2.07–2.54], respectively). Among males, this increase was trends in both sexes (i.e., IR decreased in March, 2020 but increased much less pronounced for all age groups (Figure 3; Table S5). in the following months), increases in the IR among males were less For socioeconomic status, we observed a drop in IRs during the pronounced than those observed in females (Figure 1). lockdown period across deprivation quintiles and rural areas A similar trend in IRs was also observed across MEDEA depriva- (Figure 3). Compared to the corresponding period in 2018 and 2019, tion quintiles although fluctuations over time differed across sub- IRs across deprivation quintiles increased during the post-lockdown groups (Figure S3). Information on the number of events, person-time period and doubled among most subgroups (Figure 3). The most at risk, and incidence rates over study periods by sex, age, and socio- deprived quintile of the population obtained the highest increase in IR economic status is described in Appendix S1 (Tables S2–S4). during the post-lockdown period (2.54 [2.11–3.08]) compared to the corresponding period in 2018–2019. Rural areas exhibited a similar pattern, with a substantial increase in IR during the post-lockdown 3.2 | Incidence rate ratios period (2.17 [1.86–2.54]) (Table S5). We found similar results in sensitivity analysis when computing Compared to the corresponding period in 2018–2019, the overall IR IRRs stratified by age and sex groups using data from 2016 to 2017 as of EDs decreased during the lockdown period (IRR: 0.61 [0.51–0.73]), the comparison period (Table S6). However, IRRs differed when strati- and increased during the following period (2.11 [1.98–2.25]) fying results by deprivation quintiles. For instance, while absolute 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License RAVENTÓS ET AL. 231 figures did not account for large differences, the most deprived quin- future will continue to reflect similar patterns to those observed dur- tile of the population obtained the highest increase in IRRs during the ing the pre-pandemic period. post-lockdown period in the main analysis, but the lowest increase Our results align with other EHR-based studies reporting when comparing IRs to 2016–2017 data (Table S6). Notwithstanding increased IRs of EDs during the COVID-19 pandemic (Asch these variations, the overall pattern was consistent across deprivation et al., 2021; Taquet et al., 2021). A large cohort study including more quintiles in both analyses (i.e., decreased IR during lockdown and sub- than 5 million patients mainly from the United States, found that IRs stantial increases afterwards) (Table S6). of EDs steadily increased from May, 2020 to January, 2021, after a brief initial decline in diagnoses in the early months of the pandemic. Similar to our study, they found that the increased risk of EDs during 4 | DISCUSSION the pandemic was limited to females and was greatest for adoles- cents aged 10–19 years old (Taquet et al., 2021). Another US study In this population-based cohort study of more than one million ado- including more than 3 million commercially insured individuals exam- lescents and young adults living in Catalonia, we observed a sustained ined trends in health care for ED from 2018 to 2020, and found an and pronounced increase in the incidence of EDs diagnosed in primary increase in the number of individuals receiving outpatient care dur- care following the end of lockdown, which was preceded by a brief ing the pandemic. Furthermore, they found a strong increase in the decrease in diagnoses in the early months of the lockdown measures number and length of inpatient stays related to these conditions in Catalonia. This increase was unequal across the study population, (Asch et al., 2021). Increases in the number of ED-related medical with females, particularly those aged 10–19 years, more affected than hospitalizations have also been reported in other studies (Agostino others. et al., 2021; Gilsbach et al., 2022; Haripersad et al., 2021; Lin The increase in incidence of EDs observed in this study is consis- et al., 2021; Spettigue et al., 2021). None of these studies stratified tent with growing literature describing worsening EDs symptoms dur- their results by socioeconomic status. Emerging evidence based on ing the pandemic (Devoe et al., 2022). The temporary reduction in EHR data from Israel also suggests a significant rise in EDs diagnoses diagnoses of EDs in March–April, 2020 observed in this study is in line among adolescents aged 12–17 years old, with higher increases with the substantial drop in all-cause diagnoses observed during the among those with medium and high socioeconomic status (Bilu first months of the pandemic in Catalonia (Pifarré I Arolas et al., 2022). In the present study, the most deprived quintile of the et al., 2021). We observed a sustained increase in the incidence rates population obtained the highest increase in incidence rates during of EDs from May, 2020 to March, 2021. Given that health care sys- the post-lockdown period compared to those obtained in 2018– tems were heavily disrupted at the onset of the pandemic, we hypoth- 2019. However, these results must be interpreted with caution, as esize that the steep upward trend in incidence rates after September, our study failed to identify consistent socioeconomic differences in 2020 is partially to be explained by the late reporting of prevalent risk when using different study years as the comparison period to cases developed during the first wave of the pandemic. This increase calculate IRRs. might likely reflect the accumulated effect of the COVID-19 pandemic on EDs, and the increasing number of people who presented to care once the immediate effects of the pandemic were lessened. The fluc- 4.1 | Strengths and limitations tuations in incidence rates observed throughout the second half of 2021 must be interpreted with caution. Incidence rates peaked in The main strength of this study is the large sample size of the SIDIAP March and November, 2021, with substantial drops in August and database, which is representative of the population living in Catalonia, December of the same year. We hypothesize that these fluctuations and the availability of longitudinal data. In addition, our study investi- could be partially explained by seasonal effects (i.e., low utilization of gates the COVID-19-related effects up to December, 2021, providing services during the holidays), as other diagnoses recorded in SIDIAP detailed data across sociodemographic strata up to 22 months after  s et al., 2022). While seasonal have exhibited similar patterns (Ravento the onset of the COVID-19 pandemic in Catalonia. However, we patterns were also observed during the pre-pandemic period, these acknowledge some limitations. First, our results might likely represent variations seemed to be more pronounced during the post-lockdown an underestimation of the true burden of newly diagnosed EDs. Our period, which could respond to an accentuated effect of seasonality data is limited to diagnoses recorded in primary care, and therefore it due to higher incidence rates (Moltchanova et al., 2009). The after- does not capture cases diagnosed in mental health services, emer- wards increase in incidence rates, such as the one observed from gency care or in-patient care. Although primary care is the first-point September to November 2021, could be due to the accumulation of of care within the healthcare system, some people might have experi- cases and late reporting rather than to the detection of new cases. enced barriers to access outpatient care during the pandemic. Accord- Nevertheless, the overall higher IRs of ED diagnoses in the post- ingly, delayed care might have eventually led to an increased use of lockdown period suggest that the COVID-19 pandemic and its associ- emergency services or in-patient care. Therefore, we might have ated control measures are still affecting ED diagnoses in our setting. missed cases among patients who directly accessed those services. In In this line, the recovery to pre-pandemic levels is far from complete. terms of mental health services, referrals must be indicated by a gen- Further evidence is required to assess whether trends in the near eral practitioner or a pediatrician in primary care. Although referrals 1098108x, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23848 by Universitat Autonoma de Barcelona, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 232 RAVENTÓS ET AL. from primary care must include a recorded diagnosis, some individuals ACKNOWLEDG MENTS might have been referred to mental health services through other This study was carried out as part of the Doctoral Program in Biomed- resources, such as psycho-pedagogical services in educational settings ical Research Methodology and Public Health at the Autonomous Uni- or social services. Moreover, individuals already using mental health versity of Barcelona. The authors would like to acknowledge the services due to other mental health problems might directly access efforts of all public healthcare workers in Catalonia who daily register care without requiring a new referral from their primary care physi- information in the populations' electronic health records. cian. Given that EDs are associated with both prior and later psychiat- ric disorders (Momen et al., 2022; Plana-Ripoll et al., 2019), we might FUNDING INF ORMATI ON have missed cases among patients already receiving care in specialized This research received no specific grant from any funding agency in mental health services. In addition, 28.7% of people in Catalonia in the public, commercial or not-for-profit sectors. TDS acknowledges 2021 were estimated to have double health coverage, which trans- receiving financial support from the Instituto de Salud Carlos III (ISCIII; lates into access to both public and private healthcare services (Gen- Miguel Servet 2021: CP21/00023). eralitat de Catalunya, 2022b). Thus, we might have missed cases who accessed private healthcare services or other forms of help without CONFLIC T OF INT ER E ST interacting with the public healthcare system. Third, our study was The authors declare that there is no conflict of interest. underpinned by EHR of routinely collected primary care data, and therefore, there is a potential risk of misclassification of ED diagnoses. DATA AVAILABILITY STAT EMEN T However, this risk is minimized in our analysis as the IRs depicted is In accordance with current European and national law, the data used for all forms of EDs and, more importantly, we do not expect the in this study is only available for the researchers participating in this degree of misclassification to have changed during the study period. study. Thus, we are not allowed to distribute or make publicly avail- Our data do not accurately capture information on symptomatol- able the data to other parties. However, researchers from public insti- ogy or severity of illness at presentation, which was beyond the tutions can request data from SIDIAP if they comply with certain scope of our study. Additional data might allow a more detailed requirements. Further information is available online (https://www. study to determine whether the acuity of EDs and its disorder sub- sidiap.org/index.php/menu-solicitudesen/application-proccedure) or types have changed during the pandemic in our setting. Lastly, we by contacting SIDIAP (sidiap@idiapjgol.org). found inconsistencies in ED risk across deprivation quintiles using different time periods to compare incidence rates over the COVID- ET HICS S TAT E MENT 19 periods. Given that the MEDEA deprivation index was only This project was approved by the Clinical Research Ethics Committee available for individuals living in urban areas, socioeconomic differ- of the IDIAPJGol (project code: 21/052-PCV). ences in rural areas were not explored. Further evidence is required to disentangle potential socioeconomic or geographic differences OR CID in the impact of the COVID-19 pandemic on EDs. s Berta Ravento https://orcid.org/0000-0002-4668-2970 Alicia Abellan https://orcid.org/0000-0001-6552-6060 Andrea Pistillo https://orcid.org/0000-0002-4467-0220 5 | C O N CL U S I O N Edward Burn https://orcid.org/0000-0002-9286-1128 Talita Duarte-Salles https://orcid.org/0000-0002-8274-0357 We found a substantial increase in incidence rates of EDs in primary care after the initial phase of the COVID-19 pandemic, which was par- RE FE RE NCE S ticularly pronounced in adolescent females. Our results are of impor- Agostino, H., Burstein, B., Moubayed, D., Taddeo, D., Grady, R., Vyver, E., tance to better understand the effect of the COVID-19 pandemic on Dimitropoulos, G., Dominic, A., & Coelho, J. S. (2021). Trends in the incidence trends of EDs among adolescents and young adults in incidence of new-onset anorexia nervosa and atypical anorexia ner- vosa among youth during the COVID-19 pandemic in Canada. JAMA Catalonia and to identify groups that are most in need of attention. Network Open, 4(12), e2137395. https://doi.org/10.1001/ jamanetworkopen.2021.37395 AUTHOR CONTRIBUTIONS Asch, D. A., Buresh, J., Allison, K. C., Islam, N., Sheils, N. E., Doshi, J. A., &  s: Conceptualization; data curation; formal analysis; Berta Ravento Werner, R. M. (2021). Trends in US patients receiving care for eating disorders and Other common behavioral health conditions before and investigation; methodology; visualization; writing – original draft. during the COVID-19 pandemic. JAMA Network Open, 4(11), Alicia Abellan: Writing – review and editing. Andrea Pistillo: Writing – e2134913. https://doi.org/10.1001/jamanetworkopen.2021.34913 review and editing. Carlen Reyes: Investigation; writing – review and Bilu, Y., Flaks-Manov, N., Bivas-Benita, M., Akiva, P., Kalkstein, N., editing. Edward Burn: Conceptualization; formal analysis; investiga- Yehezkelli, Y., Mizrahi-Reuveni, M., Ekka-Zohar, A., Shapiro Ben David, S., Lerner, U., Bodenheimer, G., & Greenfeld, S. (2022). Data-driven tion; methodology; software; supervision; writing – review and edit- assessment of adolescents' mental health during the COVID-19 pan- ing. 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