Baenas et al. Journal of Eating Disorders (2023) 11:39 Journal of Eating Disorders https://doi.org/10.1186/s40337-023-00762-7 RESEARCH Open Access Eating disorders during lockdown: the transcultural influence on eating and mood disturbances in Ibero‑Brazilian population Isabel Baenas1,2,3, Carmem Beatriz Neufeld4, Rita Ramos5, Lucero Munguía1,2,3, Rosane P. Pessa6, Tânia Rodrigues5, Susana Jiménez‑Murcia1,2,3,7, Sónia Gonçalves5, Marília C. Teodoro4, Ana Pinto‑Bastos5, Nazaré O. Almeida4, Roser Granero1,2,3,8, Mikel Etxandi1,9, Shauana R. S. Soares10, Fernando Fernández‑Aranda1,2,3,7* and Paulo P. P. Machado5* Abstract Background COVID-19 pandemic has implied exceptional restrictive measures to contain its widespread, with adverse consequences on mental health, especially for those people with a background of mental illness, such as eat‑ ing disorders (EDs). In this population, the influence of socio-cultural aspects on mental health has been still underex‑ plored. Then, the main aim of this study was to assess changes in eating and general psychopathology in people with EDs during lockdown regarding the ED subtype, age, and provenance, and considering socio-cultural aspects (e.g., socioeconomical factors such as work and financial losses, social support, restrictive measures, or health accessibility, among others). Methods The clinical sample was composed of 264 female participants with EDs (74 anorexia nervosa (AN), 44 bulimia nervosa (BN), 81 binge eating disorder (BED), and 65 other specified feeding and eating disorder (OSFED)), with a mean age of 33.49 years old (SD = 12.54), from specialized ED units in Brazil, Portugal, and Spain. The partici‑ pants were evaluated using the COVID-19 Isolation Eating Scale (CIES). Results A global impairment in mood symptoms and emotion regulation was reported in all the ED subtypes, groups of age, and countries. Spanish and Portuguese individuals seemed more resilient than Brazilian ones (p < .05), who reported a more adverse socio-cultural context (i.e., physical health, socio-familial, occupational, and economic status) (p < .001). A global trend to eating symptoms worsening during lockdown was observed, regardless of the ED subtype, group of age, and country, but without reaching statistical significance. However, the AN and BED groups described the highest worsening of the eating habits during lockdown. Moreover, individuals with BED significantly increased their weight and body mass index, similarly to BN, and in contrast to the AN and OSFED groups. Finally, we failed to find significant differences between groups of age although the younger group described a significant wors‑ ening of the eating symptoms during lockdown. *Correspondence: Fernando Fernández‑Aranda ffernandez@bellvitgehospital.cat Paulo P. P. Machado pmachado@psi.uminho.pt Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 2 of 11 Conclusions This study reports a psychopathological impairment in patients with EDs during lockdown, being socio-cultural aspects potential modulatory factors. Individualized approaches to detect special vulnerable groups and long-term follow-ups are still needed. Plain English Summary Adverse consequences on mental health derived from COVID-19 pandemic and lockdown particularly affected people with mental illness, including eating disorders (EDs), being the involvement of socio-cultural features poorly studied. We aimed to assess eating and mood changes in EDs during lockdown regarding ED subtypes, age, prov‑ enance, and considering socio-cultural aspects. 264 females with EDs linked to specialized ED units in Brazil, Portugal, and Spain were evaluated using the COVID-19 Isolation Eating Scale (CIES). A global impairment in mood symptoms and emotion regulation was reported regardless ED subtype, age, and country. Spanish and Portuguese individuals seemed more resilient than Brazilian ones, who reported a more adverse socio-cultural context. A global trend to eating symptoms worsening was observed, regardless of the ED subtype, age, and country, but without statistical significance. Patients with anorexia nervosa and binge eating disorder (BED) described eating style worsening. Moreo‑ ver, the BED group significantly increased weight and body mass index, similarly to bulimia nervosa, and in contrast to the other subtypes. In sum, a psychopathological impairment was observed in EDs during lockdown, suggesting that socio-cultural aspects could be considered as potential modulatory factors. Nevertheless, these are preliminary results, being longitudinal studies and long-term follow-ups still needed. This work also highlights the importance of more personalized therapeutic approaches. Keywords Eating disorders, Lockdown, COVID-19 isolation eating scale (CIES), Mood disturbances, Transcultural study Introduction influence the impact of the pandemic on the popula- From the end of 2019, the widespread of COVID-19 tion in each country, together with other idiosyncratic infection has categorized it as a pandemic [1]. The imple- aspects such as the amount and structure of the popu- mentation of different restrictive measures has limited lation, the economic situation of each country, the type mobility and favored social isolation at home, with a of health system, and accessibility to assistance, among global impact on individuals’ lifestyle on both physical others, contributing to perceived emotional distress [2]. and mental health [2]. In this line, different authors have Worldwide, people with a background of mental ill- reported a predominant negative impact of confinement ness were considered as an especially vulnerable group on eating patterns, physical activity, and emotional well- during the pandemic and lockdown [6], including indi- being in general population, including countries from viduals with eating disorders (EDs) [7]. Particularly the same geographic area (i.e., Spain and Portugal) or among them, changes in eating psychopathology and with shared socio-cultural aspects, such as speaking lan- psychological state have been reported [7, 8], being guage and historical background (i.e., Portugal and Bra- greater than in healthy controls [9], with a tendency to zil) [2–4]. worsen eating symptoms [10]. Lockdown in Portugal was instituted between 19th In Portuguese clinical population, Machado et al. March and 3rd May 2020 [5], similarly to Spain, where [11], evaluated the impact of the lockdown in 43 adult the state of alarm was decreed from 14th March to 21th individuals (95.3% females) with EDs through a self- June (https://​w ww.​boe.​es/​eli/​es/​rd/​2020/​03/​14/​463). reported survey: 20 with anorexia nervosa (AN), 14 Brazil did not establish neither an official lockdown nor with bulimia nervosa (BN), two with binge eating dis- national restrictive measures, which were unequally order (BED), and seven with other specified feeding applied by local governors. As a result, Brazil was con- and eating disorders (OSFED). Notably, 31% of the sidered in the top five countries with a high number of sample reported an increased weight during lockdown. contagious people (https://​w ww.​world​omete​rs.​info/​ Besides, a significant increase of body mass index coron​avirus/). Even to date, high differences are found (BMI) in the total sample was stated after lockdown. between the three countries. Brazil has 34,470,776 of Most participants, whether in treatment or not during total cases, and 684,369 deaths, while Spain has a total lockdown, described significant changes in their life- of 13,352,019 cases and 112,804 deaths, and Portugal style, including physical exercise and eating habits, as 5,429,340 cases and 24,886 deaths (https://​covid​19.​ well as stress linked to the pandemic situation. A higher who.​int/). Then, this differential lockdown context may impact of lockdown was significantly associated with Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 3 of 11 the presence of eating and general psychopathology, Other works found that again individuals with OSFED but also with impulsivity and difficulties in emotion reported the highest rates of anxiety and depressive regulation (ER). Indeed, the ER difficulties mediated the symptoms after lockdown [14], reinforcing the idea that impact of lockdown on the global clinical impairment a worse psychological state could influence eating symp- among these patients. In this vein, emotion dysregula- toms [14]. tion and a lack of adaptive coping strategies, together Considering that the heterogeneity of previous results with some personality traits (e.g., low self-directedness) may be influenced by the lack of homogenized psycho- have been considered as vulnerability factors leading to metric instruments to evaluate changes in eating and psychological distress during lockdown, which might mood psychopathology in the context of pandemic and also be associated with disturbed eating patterns not lockdown, the COVID Isolation Eating Scale (CIES) only in the general population [3], but also in individu- was developed by the Psychoneurobiology of Eating and als with EDs [12, 13]. Addictive Disorders Spanish research group [14]. The Previous literature in Spanish clinical population scale has been validated and translated into nineteen lan- has suggested that the effects of lockdown were differ- guages [14]. An international and multicentric group of ent depending on the ED subtypes [14], being individu- experts from different ED units used it to measure eating als with OSFED those who reported the highest global and general psychopathological changes during confine- impairment in eating psychopathology [14]. There are ment in individuals with EDs [21]. The authors pointed few Brazilian studies that evaluated eating patterns dur- out that while individuals with OSFED indeed were those ing lockdown, without referring to the clinical population who reported a worse psychological state during lock- with EDs. In the non-clinical population, we found some down, the highest impact on weight and eating symp- interesting results. For instance, an increase of the con- toms was associated with BED, in comparison with other sumption of bakery and processed foods was also accom- EDs. Interestingly, differences according to cultural con- panied by an inverted eating pattern, with a decrease text and age were also reported, concluding that Asian in food consumption in the morning and an increase at and younger individuals appeared to be more resilient night [15]. Another study that considered adults with than European and adults with EDs, respectively [21]. Diabetes Type I and II reported that 75.8% of the individ- However, no clinical groups from South America were uals had eating psychopathology in the context of lock- included in the study. down [16]. To the best of our knowledge, this is the first work Overall, these results were consistent with research aimed to explore eating and mood state during lockdown hypotheses that pointed out that the special circum- in a clinical sample with EDs from the Ibero-Brazilian stances of the lockdown may have favored not only an community regarding ED subtype, age, provenance, and eating style worsening, but also have contributed to exac- the socio-cultural context. On the one hand, we analyzed erbate unhealthy eating patterns among patients with whether there were intra-group pre-post changes in eat- EDs, such as overeating, or even precipitate an ED onset ing and general psychopathology within each ED sub- [17]. In this regard, younger age has been highlighted type, group of age, and country. On the other hand, we as a possible vulnerability factor related to the negative performed between-group comparisons, according to ED impact on mental health due to pandemic and lockdown subtypes, groups of age, and provenance. In this study, [18] although this aspect was underexplored among peo- we used a validated instrument such as CIES, which ple who already had an ED [19]. Moreover, the lockdown allowed us to assess eating symptoms and style, anxiety, and restrictive measures have involved changes in treat- and depressive symptoms, as well as ER strategies. More- ment approaches, including the closure of day hospitals over, we explored the socio-cultural context (e.g., work and outpatient facilities, or the adaptation to telehealth, status and financial losses, social support, restrictive which may also have contributed to a higher emotional measures, health accessibility, telehealth implementa- distress (e.g., anxiety, mood disturbances) [7] and, there- tion, among others), as some of these features have been fore, to a negative effect in eating symptoms [11]. recognized as potential contributing factors of emotional Early research in individuals with EDs has shown a distress and a worse psychological state [22–24]. Bear- worsening of their psychological state with anxiety, stress, ing in mind results from previous literature, we hypoth- and increased worries about the risk of being infected esized a global intra-group trend to worsening of eating with COVID-19 and other negative consequences of the and mood symptoms in the context of lockdown. Going lockdown (e.g., relatives’ infection, employment) [7, 12]. one step further, we suggested the presence of signifi- Curiously, mixed differences were found according to the cant differences in eating and mood changes in between- ED subtype. Some studies stated that patients with AN groups comparisons, with a particular influence of the had experienced the highest psychological distress [20]. Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 4 of 11 socio-cultural features in the contextualization of the dif- Factor 3 (F3), by the items assessing anxiety and depres- ferences between countries. sive symptoms (subscale III); Factor 4 (F4) was defined by the items related to ER (subscale III); and Factor 5 (F5), Materials and methods by those that evaluate telemedicine (subscale IV). In this Participants study, F5 (subscale IV) was not evaluated. This cross-sectional study was composed by a sample of Other socio-cultural and contextual information was N = 264 participants with a mean age of 33.49 years old also collected (e.g., age, work status, economic problems, (SD = 12.54) from private and public ED units in Bra- social support, and health state) (see Additional File 1). zil (n = 101), Portugal (n = 28) and Spain (n = 135). Age range in the study was between 14 and 70 years old. In Procedure the study, two groups of age were considered: adolescents All the participants were already involved in outpatient and young adulthood (younger than 25 years-old) versus treatment modality in specialized units of the differ- adulthood (25 years old and older). The choice of this cut ent countries. Data collection took place retrospectively off point is based in most psychological studies that con- between June 2020 and March 2021. The subjects were sider that adolescence now runs up until the age of 25 for asked by therapists from each centre to voluntarily par- the aims of analyzing and treating young people behav- ticipate, completing once the required information in ref- iors [25]. As inclusion criteria, all the participants were erence to the first/early lockdown: some subscales within females diagnosed with an ED, according to Diagnostic the CIES Scale, as well as additional data regarding socio- and Statistical Manual of Mental Disorders, fifth edition, cultural and contextual lockdown were asked regarding (DSM-5) criteria [26], by expert clinical psychologists two moments, before and after lockdown. and psychiatrists. All the participants included in this study fully completed the assessments. Statistical analysis Stata17 for Windows was used for the statistical analy- sis [27]. The post–pre differences/changes were gener- Contextual information ated for the weight (kg), the body mass index (BMI) (kg/ The Iberian countries are integrated by Spain and Portu- m2), and the CIES factor scores (the absence of changes gal. Lockdown in Portugal was instituted between 19th comparing the post- versus the pre-measures provided a March and 3rd May 2020 [5] and between 14th March difference equal to zero, positive differences indicated a and 11th May 2020 in Spain (although the state of alarm decreasing trend, and negative differences indicated an was extended until 21th June). In Brazil, around the 27th increasing trend). Repeated measures analysis of variance March 2020 some of the local state governors imposed (repeated-ANOVA) tested the significance relevance quarantine although more precise data on the duration of for the differences, and it was implemented through the this period is not available. manova command in Stata, which allows fitting mixed designs including controlled variables. The diagnostic subtype, age and, country were included as covariates Assessment in the study. Standardized Cohen’s-d coefficients meas- The COVID Isolation Eating Scale (CIES) is a self-report ured the effect size for the differences between the means questionnaire that evaluates the impact of confine- (null effect size was considered for |d|< 0.20, low-poor for ment on patients with EDs [14]. It is composed by four |d|> 0.20, moderate-medium for |d|> 0.50 and large-high subscales: I, referred to COVID-19 pandemic personal for |d|> 0.80) [28, 29]. The Finner’s method (family-wise circumstances (8 items); II, related to eating psychopa- error rate -FWER- algorithm more powerful than the thology during confinement (13 items), together with the classical Bonferroni’s correction) was employed for con- presence of other psychiatric comorbidities and diabetes trolling the increase in the Type-I error due the use of mellitus; III (34 items), regarding eating style, general multiple significance tests [30]. psychopathology, and ER; and IV (13 items), associated with the evaluation of telemedicine. The last three sub- Results scales are answered in a five-point Likert scale, and sub- Characteristics of the participants scales II and III are referred to two moments, before and Most participants in the study lived with other people after lockdown [14]. After a factorial analysis (CFA), five during the lockdown (only 29 individuals reported living factors were identified [14]. Factor 1 (F1) was defined alone, 11.0%), were not infected by COVID-19 (86%), did by the items measuring eating-related symptoms (sub- not have infected relatives or other close people (57.2%), scale II); Factor 2 (F2), by the items measuring the effects did not have the responsibility of caring for infected rela- of lockdown on the eating-related style (subscale III); tives (64.8%), were active at work (52.7%), and did not Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 5 of 11 report economic difficulties in the context of the confine- achieved similar mean increase, while a brief decrease ment (59.5%). Additional file 1 displays the distribution was reported for AN and BED. of the age and the contextual variables registered during the lockdown (see Additional file 1). Intra‑ and between‑group comparisons regarding groups of age The results of the repeated ANOVA exploring the Intra‑ and between‑group comparisons changes between the post- and pre-lockdown within regarding diagnostic subtypes each age group (young/adolescents and adults) are dis- Table 1 contains the post–pre changes in the weight (kg), played in Table 2. After the adjustment by the ED subtype the BMI (kg/m2) and CIES subscales scores within each and country, it was observed a significant increase in the diagnostic subtype. The repeated measures ANOVA CIES F1 eating-related symptoms and CIES F3 anxiety/ adjusted by age and country showed increase for the depression scales among the young/adolescents subsam- CIES F3 anxiety/depression and F4 emotion dysregula- ple. For the adult subsample, a significant increase was tion among all the ED subtypes. Additionally, patients observed in the weight, the BMI, the CIES F3 anxiety/ with BN also increased the CIES F1 eating-related symp- depression, and the CIES F4 emotional dysregulation. toms and F2 eating-related style; BED patients increased The results of the ANOVA procedures comparing the weight and BMI mean values. post–pre changes during the lockdown between the Figure 1 shows the mean scores for the post–pre groups of age (also adjusted by the ED subtype and the changes between groups (defined as the difference country) showed no differences (see Fig. 2 and Additional between the measures at the end of the lockdown ver- file 3). sus the measures prior to the lockdown) (see Additional file 2). After the adjustment by age and country, the mean Intra‑ and between‑group comparisons regarding country changes for weight and BMI were statistically equal com- The results of the repeated-ANOVA stratified by coun- paring AN versus OSFED (both groups decreased) and try and adjusted by the ED-subtype and age are shown comparing BN versus BED (both groups increased). in Table 3. For the three countries, a significant increase For the CIES F2 eating-related style, BN and OSFED was identified in the CIES F3 anxiety-depression scale. In addition, an increase in the CIES F4 emotion Table 1 Assessment of the post–pre changes stratified by ED-subtype Anorexia Nervosa (n = 74) Bulimia (n = 44) Pre Post Pre Post Mean SD Mean SD p |d| Mean SD Mean SD p |d| Weight (kg) 48.85 9.75 47.08 8.82 .061 0.19 62.96 12.10 63.94 13.03 .244 0.08 BMI (kg/m2) 18.84 3.26 18.28 3.99 .141 0.15 23.81 5.32 24.17 5.66 .252 0.07 CIES-F1 ED symptoms 15.07 6.06 15.81 5.90 .195 0.12 18.55 5.52 20.46 6.65 .041* 0.31 CIES-F2 Eating style 13.08 8.86 12.58 8.32 .398 0.06 20.64 9.67 23.68 11.19 .012* 0.29 CIES-F3 Anxiety-depress 19.66 8.95 24.77 9.13 < .001* 0.56† 19.39 10.07 24.64 11.63 < .001* 0.51† CIES-F4 Emotion dysreg 9.16 4.35 10.57 4.86 < .001* 0.30 9.52 4.95 11.02 5.57 .001* 0.28 BED (n = 81) OSFED (n = 65) Pre Post Pre Post Mean SD Mean SD p |d| Mean SD Mean SD p |d| Weight (kg) 85.59 19.58 89.29 21.36 < .001* 0.18 72.15 19.47 71.97 22.01 .868 0.01 BMI (kg/m2) 32.30 6.66 33.70 7.37 < .001* 0.20 27.04 7.40 26.95 8.17 .821 0.01 CIES-F1 ED symptoms 16.46 4.03 17.07 4.19 .209 0.15 15.66 5.40 15.89 5.39 .735 0.04 CIES-F2 Eating style 26.70 8.76 26.65 9.19 .960 0.01 17.62 9.00 19.06 9.63 .151 0.16 CIES-F3 Anxiety-depress 18.83 7.74 24.82 8.54 < .001* 0.73† 18.22 8.00 23.98 8.47 < .001* 0.70† CIES-F4 Emotional dysreg 8.44 4.30 9.67 4.41 < .001* 0.28 7.86 3.91 9.26 3.91 .008* 0.36 ED: eating disorder. BMI: body mass index. BED: binge eating disorder. OSFED: other specificized feeding and eating disorders. Emotion dysreg.: emotional dysregulation. SD: standard deviation. *Bold: significant comparison. †Bold: Effect size into the ranges moderate to large. Results adjusted by age and country Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 6 of 11 Fig. 1 Mean post–pre changes by country. Note. BMI: body mass index. AN: anorexia nervosa. BN: bulimia nervosa. BED: binge eating disorder. OSFED: other specified feeding eating disorder Table 2 Assessment of the post–pre changes by groups of age Young/adolescents (n = 78) Adults (n = 186) Pre Post Pre Post Mean SD Mean SD p |d| Mean SD Mean SD p |d| Weight (kg) 63.40 15.13 62.64 16.21 .451 0.05 67.72 22.20 69.08 24.39 .044* 0.06 BMI (kg/m2) 24.39 6.02 24.15 6.63 .513 0.04 25.71 7.95 26.27 8.81 .035* 0.07 CIES-F1 ED symptoms 15.60 5.51 17.45 6.46 .030* 0.31 16.98 5.20 17.44 5.29 .228 0.09 CIES-F2 Eating style 17.40 9.47 17.79 9.91 .679 0.04 20.59 10.17 21.51 10.67 .141 0.09 CIES-F3 Anxiety-depress 18.28 9.12 24.18 9.44 .001* 0.64† 19.72 8.28 24.52 9.15 .001* 0.55† CIES-F4 Emotional dysreg 9.19 4.68 10.26 4.90 .065 0.22 8.73 4.21 10.00 4.55 .001* 0.29 † ED: eating disorder. BMI: body mass index. Emotion dysreg.: emotional dysregulation. SD: standard deviation. *Bold: significant comparison. Bold: Effect size into the ranges moderate to large. Results adjusted by ED-subtype and country Fig. 2 Mean post–pre changes by age. Note: BMI, body mass index Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 7 of 11 Table 3 Assessment of the post–pre changes stratified by country Portugal (n = 28) Pre Post Mean SD Mean SD p |d| Weight (kg) 58.75 17.56 59.58 20.23 .410 0.04 BMI (kg/m2) 22.67 7.38 23.00 8.36 .398 0.04 CIES-F1 ED symptoms 16.69 5.37 17.41 7.91 .499 0.11 CIES-F2 Eating style 18.48 9.54 18.57 9.20 .939 0.01 CIES-F3 Anxiety-depression symptoms 21.84 7.75 24.01 8.32 .043* 0.27 CIES-F4 Emotional dysregulation 9.21 4.35 9.45 4.32 .527 0.06 Brazil (n = 101) Pre Post Mean SD Mean SD p |d| Weight (kg) 67.42 17.75 68.75 20.70 .316 0.07 BMI (kg/m2) 25.58 6.37 26.12 7.51 .273 0.08 CIES-F1 ED symptoms 17.40 4.59 18.54 4.77 .113 0.24 CIES-F2 Eating style 24.42 7.63 25.89 8.69 .226 0.18 CIES-F3 Anxiety-depression symptoms 19.27 7.29 27.08 8.26 < .001* 1.00† CIES-F4 Emotional dysregulation 8.76 3.80 10.64 4.19 < .001* 0.47 Spain (n = 135) Pre Post Mean SD Mean SD p |d| Weight (kg) 70.39 23.34 70.29 24.88 .879 0.00 BMI (kg/m2) 26.50 8.44 26.47 9.12 .921 0.00 CIES-F1 ED symptoms 15.93 5.83 16.61 5.72 .153 0.12 CIES-F2 Eating style 16.53 10.35 16.76 10.24 .701 0.02 CIES-F3 Anxiety-depression symptoms 18.95 9.50 23.88 10.01 < .001* 0.50† CIES-F4 Emotional dysregulation 8.88 4.75 10.20 5.05 < .001* 0.27 † ED: eating disorder. BMI: body mass index. SD: standard deviation. *Bold: significant comparison. Bold: Effect size into the ranges moderate to large. Results adjusted by ED-subtype and age. Fig. 3 Mean post–pre changes by country. Note: BMI, body mass index Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 8 of 11 dysregulation scale was observed for patients living in with a diagnostic of ED showed a psychopathological Brazil and Spain. impairment in the context of pandemic characterized The comparison of the post–pre changes between the by a higher difficulty in achieving goal weight, as well as countries (adjusted by the ED-subtype and age) is con- a higher hospitalization rate [33]. Lower food security, tained in Fig. 3 and Additional file 4. Patients living in changes in academic routines, and stress due to pandemic Brazil reported higher positive changes in the CIES scales with affective implications have been pointed as some of (except for the F1 eating-related symptom levels). the factors potentially involved [34]. However, we failed to find significant pre-post differences between adoles- Discussion cents/young individuals with EDs and adult patients nei- The main aim of this work was to evaluate the impact of ther in weight/BMI changes, eating symptoms, nor in COVID-19 lockdown in eating symptomatology and gen- psychological state. In the general population, younger eral psychopathology in patients with EDs from Ibero- age has been proposed as a contributing factor for suffer- Brazilian countries, considering the CIES Scale, as well ing from a more negative impact on mental health during as other socio-cultural and contextual factors. We also pandemic [18], including disordered eating [33, 34] and performed between-groups comparisons regarding ED the development of an ED [35]. On the other hand, our subtypes, age, and provenance. results also contrast with the hypothesis of a higher resil- A global trend towards the impairment of eating symp- ience among younger patients in comparison with adults toms pre to post lockdown was described in all ED sub- regarding people with EDs [21]. The global tendency to types [7, 11], reaching statistical significance in the BN an impairment of the eating and mood symptoms in both group. The last result contrasted with previous studies groups during lockdown could partially contribute to that described an absence of pre-post changes [14], or explain our findings, in line with Monteleone et al. [19]. even a decrease in eating symptoms, among individuals Indeed, an increased need for ED assistance has been with BN during lockdown [21]. In our study, surprisingly, described in the context of the pandemic in both adoles- these patients also reported a significant improvement in cents/young and adults individuals with EDs [36]. their eating style, similarly to the OSFED group. Likewise, While the younger group described a mild non-signif- changes in eating style were more alike between individu- icant loss of weight, the adult group experienced a sig- als with AN and BED, who reported eating style worsen- nificant increase of weight and BMI during lockdown. ing. This result partially agreed with previous literature Although our results have been adjusted by ED subtype, which referred to BED and BN as the ED subtypes with patients with younger age would presumably have a the highest negative impact on eating style [21]. In our higher prevalence of AN and OSFED diagnosis than BED, case, a higher trend to control food intake and restriction more frequent among adult individuals [37]. Moreover, in patients with AN [8, 9] whereas disordered eating such both groups showed an eating style worsening. In this as grazing eating behavior among individuals with BED regard, we hypothesize that the impaired eating pattern may support these findings [7]. in younger patients could be more linked to restrictive Remarkably, the AN and OSFED group had significant behaviors and exercise practice, in line with the observed differences in weight and BMI changes in comparison trend to control weight. On the other hand, changes in with the BED and BN groups, which also appeared to be eating style among adults might be closely associated more similar to each other. While a trend towards weight with increased food consumption (e.g., picking, binging), loss, with a consequent reduction in BMI, was observed which, consequently, could be more probably linked with in individuals with AN and OSFED, the opposite a weight increase. occurred in subjects with BED and BN [21, 31]. In fact, To the best of our knowledge, this is the first study intra-group comparisons showed that the BED group which includes European countries (Iberian countries, reported a significant increase in weight and BMI after Spain and Portugal) with South American ones (i.e., Bra- lockdown [21]. Restrictive measures, sedentarism, and zil). Previous studies analyzing eating and mood psy- food insecurity may be contributing factors [32]. How- chopathology between different continents are scarce ever, our results revealed that neither of the two weight without grouping European and South American coun- approaches were significantly superior to the other. Thus, tries [21]. Curiously, in the later work, authors reported a balanced weight change between ED subtypes may be that Asian patients seemed more resilient than European deduced in contrast with previous literature [21]. individuals with EDs, who reported worse eating symp- Despite both groups of age (i.e., adolescent/young tomatology during the lockdown [21]. Using the same and adults) reported worse eating symptoms after lock- instrument (i.e., CIES), the present study did not find down, in the case of younger patients this change was significant differences related to eating psychopathol- statistically significant. Works related to young people ogy, nor weight changes between European and South Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 9 of 11 American individuals, regardless of the ED subtype and both their own or their relatives’ health have been age. Indeed, we observed that the three groups of prove- reported as potential stressors with a negative impact nance reported a trend towards worsening of their eating on mental health during the COVID-19 pandemic [22], symptoms. Despite these results would be in line with the as well as in previous health crises [23]. On the other global impairment of eating symptoms described among hand, they also experienced higher financial losses dur- patients with EDs in the context of the lockdown [7, 8, ing lockdown, which might be associated with a higher 10, 11], it also highlights the need to design future stud- emotional distress. ies that include large international samples to contrast In Brazil, as in other South American countries, aspects whether the impact of the pandemic and lockdown on such as the lower social income of the population and a eating symptoms in individuals with EDs would be more lack of infrastructures related to the public health system similar between some continents, as well as which kind resulted in higher difficulties in access to treatment for of socio-cultural and contextual features could be modu- mental health, including EDs. Despite all the participants lating this fact. of the study were already linked to specific treatment Interestingly, after lockdown, the self-reported anxi- and aspects related to the evaluation of treatment dur- ety and depressive symptoms evaluated with the CIES ing lockdown were not reported in this study, we hypoth- scale were higher and statistically significant than in the esized whether being subject to different socio-cultural pre-lockdown in all the ED subtypes, age groups, and and contextual conditions may have had an influenced countries, and generally accompanied by an impaired ER in the adaptation and therapeutic adherence during this [11, 19]. Even that a concern for patients with EDs was period and, therefore, in the perceived emotional dis- expressed from the beginning of the COVID-19 pan- tress. In this line, during the pandemic, most of the stud- demic [7], current studies have supported that this popu- ies performed that reported the rapid implementation of lation has been highly impacted by this health crisis [38, telehealth care for EDs and other psychiatric conditions 39]. Going one step further, as a result of the between- have been carried out in European, Australian, Asiatic, groups comparisons, only the comparison between and North American countries so far [21, 40]. However, countries showed significant differences. Curiously, the there is still a lack of information on the health policies Brazilian group described a worse psychological state in of South American or African countries in this regard the context of the lockdown when compared with Iberian [24]. Then, both a regulation of the incomes and health countries. In this line, a previous study found higher anx- care policies may be considered and improved in order iety in the Brazilian population than in the Portuguese to ensure that health care will be provided in those vul- population [4], describing socio-cultural factors such as nerable populations despite the country of residence [24]. concern for health and finances as potential risk factors. This fact becomes especially relevant when considering Then, our results might also be considered in light of the that poorer adaptive coping strategies to deal with emo- existence of contextual differences during lockdown and tional distress related to the pandemic and lockdown has socio-cultural aspects. As mood disturbances have been been described as a factor of higher psychological vulner- associated with a negative impact on eating symptoms ability in patients with EDs [11–13]. Precisely, Brazilian among patients with ED [33], this study suggests whether participants showed lower resilience, which could also those individuals with more adverse contextual condi- mediate the significant differences observed regarding tions and a worse psychological state in the face of future greater emotional distress in this group. similar adverse circumstances might be at greater risk of This study has some limitations, such as a small sim- eating symptoms worsening in the middle and long term. ple size, an observational cross-sectional design, the The scenario related to early pandemic and the lack of a control group, and the focus on the female restrictive measures adopted by governments differed clinical population already linked to a specific treat- between countries and could have contributed to the ment unit, which could limit the generalization of the perceived emotional distress [2]. According to our results. Besides, a voluntary participation, the retro- results, the Brazilian individuals were those who had spective collection of the data through a self-report significantly higher percentages of people in charge, way, and differences in the recruitment period between infection by COVID-19 and close people infected, in units are other limiting aspects, which could be asso- contrast with the other countries. This could be related ciated with recall biases. On the other hand, some to the fact that Brazilian patients were those who strengths should also be highlighted. For instance, mostly kept working during the lockdown, with a pre- the study contemplated potential co-founder factors sumably higher exposure to the infection added to the in the analysis and the CIES is considered a validated fact that social measures in the face of the pandemic and homogeneous psychometric instrument. However, appeared to be laxer. In this line, concerns related to future research is still needed to further investigate the Baenas et al. Journal of Eating Disorders (2023) 11:39 Page 10 of 11 clinical implications of mood disturbances related to Writing–original draft, IB, LM; Writing–review & editing, CBN, RR, RPP, TR, SJM, SG, MCT, APB, NOA, ME, SRSS, PPPM, FFA. Fundings and Resources, SJM, pandemic situations on eating symptoms in the middle PPPM, FFA. All authors have read and agreed to the published version of the and long term, as well as potential meditational vari- manuscript. ables, such as sociodemographic and cultural factors. Funding In conclusion, the present study supports previous This manuscript and research were supported by grants from the Ministerio literature regarding the negative impact of the COVID- de Ciencia e Innovación (PDI2021-124887OB-I00), Delegación del Gobierno 19 pandemic and lockdown on patients with EDs, para el Plan Nacional sobre Drogas (2021I031), Instituto de Salud Carlos III (ISCIII) (FIS PI20/00132) and co-funded by FEDER funds/European Regional adding a transcultural perspective with the inclusion Development Fund (ERDF), a way to build Europe; European Union’s Horizon of European and South American countries, and pay- 2020 research and innovation programme under Grant agreement no. ing attention to the crucial role of mood disturbances 847879 (PRIME/H2020, Prevention and Remediation of Insulin Multimor‑ bidity in Europe CIBERObn is an initiative of ISCIII, which also supports this and the sociodemographic context of the participants. work through the grant CM21/00172 (co-funded by European Social Fund. Hence, more adverse contextual conditions, a worse ESF investing in your future). RG is supported by the Catalan Institution for psychological state, and poorer coping strategies may Research and Advanced Studies (ICREA-Academia, 2021-Programme). Addi‑ tional funding was received by AGAUR-Generalitat de Catalunya (2021-SGR- be potential contributing factors to the worsening of 00824). PM was supported, in part, by a Portuguese Foundation for Science the eating symptoms in similar adverse situations. and Technology grant (POCI-01–0145-FEDER-028145, and UIDB/01662/2020). This study was also partially conducted at the Psychology Research Centre (CIPsi), School of Psychology, University of Minho, supported by the Founda‑ Abbreviations tion for Science and Technology (FCT) through the Portuguese State Budget AN Anorexia nervosa (Ref.: UIDB/PSI/01662/2020).The funders had no role in the study design, data ANOVA Analysis of variance collection, and analysis, decision to publish, or preparation of the manuscript. BED Binge eating disorder BED BMI Body mass index Availability of data and materials BN Bulimia nervosa The datasets generated and/or analysed during the current study are not CFA Factorial Analysis publicly available to preserve participants’ privacy and due to there are ongo‑ CIES COVID-19 isolation eating scale ing studies using the data but are available from the corresponding author on CIES F1 CIES factor 1 reasonable request. CIES F2 CIES factor 2 CIES F3 CIES factor 3 CIES F4 CIES factor 4 Declarations CIES F5 CIES factor 5 Ethics approval and consent to participate DSM-5 Diagnostic and statistical manual of mental disorders, fifth edition The study was approved by all relevant committees, namely the Clinical EDs Eating disorders Research Ethics Committee of the leading University Hospital (Bellvitge ER Emotion regulation University Hospital, PR239/20), by the Ethics Committee of the University of Emotion dysreg Emotion dysregulation Minho (CEICSH 089/2020) and, the National Commission on Research Ethics in OSFED Other specified feeding and eating disorder Brazil (CAAE: 39338020.9.0000.5393). Written informed consent was obtained from all participants. Supplementary Information Consent for publication The online version contains supplementary material available at https://​doi.​ Not applicable. org/​10.​1186/​s40337-​023-​00762-7. Competing interests Additional file 1: Table S1. Descriptive for the age and the confinement Both Fernando Fernández-Aranda and Susana Jiménez-Murcia received context consultancy honoraria from Novo Nordisk and Fernando Fernández-Aranda Additional file 2: Table S2. Comparison of the post-pre differences by the received editorial honoraria as EIC from Wiley. The other authors have no ED-subtypes conflict of interest. Additional file 3: Table S3. Comparison of the post-pre differences by Author details groups of age (adjusted by ED-subtype and country) 1 Eating Disorders Unit, Department of Psychology, Bellvitge University Additional file 4: Table S4. Comparison of the post-pre differences by Hospital-IDIBELL, 08907 Barcelona, Spain. 2 CIBER Physiopathology of Obesity country (adjusted by ED-subtype and age) and Nutrition (CIBERobn), Instituto de Salud Carlos III, 28029 Barcelona, Spain. 3 Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), 08908 Bar‑ Acknowledgements celona, Spain. 4 Department of Psychology, Faculty of Philosophy, Sciences We thank CERCA Programme/Generalitat de Catalunya for institutional sup‑ and Languages of Ribeirão Preto, University of São Paulo, São Paulo, Brazil. 5 port. We also thank Instituto de Salud Carlos III (ISCIII), CIBERobn (an initiative Psychotherapy and Psychopathology Lab—Psychology Research Center, of ISCIII), FEDER funds/European Regional Development Fund (ERDF), a way School of Psychology, University of Minho, 4710‑057 Braga, Portugal. 6 Depart‑ to build Europe, and the Portuguese Foundation for Science and Technology ment of Maternal-Infant and Public Health Nursing, University of São Paulo (FCT). This work was also supported by ISCIII through the grant CM21/00172 at Ribeirão Preto College of Nursing, São Paulo, Brazil. 7 Department of Clinical (co-funded by European Social Fund. ESF, “Investing in your future”). RG is Sciences, School of Medicine and Health Sciences, University of Barcelona, supported by the Catalan Institution for Research and Advanced Studies 08907 Barcelona, Spain. 8 Department of Psychobiology and Methodology, (ICREA-Academia, 2021-Programme). 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