Covid19 has affected the balance of already fragile patients. The lack of routine referrals and the constant, incessant flow of news have contributed to destabilizing patients who are already fragile or who have become fragile.

Covid19 has affected the balance of already fragile patients. The lack of routine referrals and the constant, incessant flow of news have contributed to destabilizing patients who are already fragile or who have become fragile.

greeneatchef insicurezza alimentare loveyourself 1
Love yourself

The coronavirus disease of 2019 (COVID-19) became a global pandemic only a few months after emerging in China. Moreover, this pandemic has imposed negative consequences on public health, particularly on the mental health status of people with severe mental illness. However, the adverse effects of pandemic COVID-19 on patients with eating and feeding disorders (EDDs) are unclear at this stage. In this letter, the author seeks to acknowledge the risks of worsening FED during this uncertain period.

A public health emergency can affect both individuals and communities. Individual health, well-being, and safety can be affected by feelings of confusion, emotional isolation, insecurity, and stigma. In addition, communities are affected by the inevitable closure of schools and workplaces, economic loss, as well as increased demand for medical equipment. These effects can be reflected in a variety of emotional reactions, e.g., distress or psychiatric disorders, as well as unhealthy behaviors, e.g., maladaptive eating behaviors, in both health care providers and the general population. Research has found that emotional distress is ubiquitous in affected populations. Indeed, this finding will be echoed in populations affected by the 2019 coronavirus disease pandemic (COVID-19) [ 1]. Despite the lack of definitive studies to assess the impact of pandemic COVID-19 on mental health, research conducted in China has suggested moderate to severe adverse mental health effects in more than half of the participants [ 2 ].
Furthermore, considering the effects of previous severe global health disasters, this pandemic is expected to increase the stress level of individuals and lead to increased rates of depression and anxiety [ 3 ]. In addition, individuals who have a previous mental disorder are at greater risk of experiencing worsening mental health status due to the current pandemics [ 2 , 4 ]. Therefore, this pandemic is expected to worsen the severity of eating disorder (ED) symptomatology due to several reasons, some of which are discussed below:
Food Insecurity at the Time of COVID-19
Food insecurity is defined as the disruption of food intake or altered eating patterns caused by a shortage of money or other resources. Several factors, such as employment, income, ethnicity/race, and disability, influence food insecurity. The risk of food insecurity is exacerbated by a lack of money or lack of money [ 5 ]. Pandemic COVID-19 has the potential to exacerbate FED and associated mental health symptoms due to intensified economic constraints that result in food insecurity (i.e., limited access to food caused by economic problems). Many studies have suggested an association between food insecurity and uncontrolled eating, bulimia nervosa, and obesity [ 6 , 7 , 8]. This may be due to the fact that people do not have sufficient funds to purchase enough food. These episodes of restriction will increase the risk of binge eating through food cravings and the biological effects of hunger. Another, perhaps complementary, explanation is that stress caused by economic stresses may, in turn, promote binge eating.
In addition, it can be argued that the cost of binge eating or the negative effects of the FED experience on educational outcomes or employment visions cause economic disadvantage and food insecurity. In addition, it is established that in families with food scarcity, family members may feel a sense of shame about their appetite or guilt about eating without worrying about taking food from others in the family. These feelings of guilt may worsen in underweight patients who are encouraged to eat more than their family members to support weight restoration [ 9 ].
Stressful effects of daily news
FEDs may be initiated because of psychosocial stress. Studies have suggested that some people use disturbed eating behaviors, including binge eating and purging, to cope with their negative emotions. According to previous studies of clinical populations, an association has been found between stressful events and worsening of disturbed eating behaviors [ 10 ]. These exacerbations can be caused by several reasons, such as the stress-triggering impacts of daily reports of new cases and the mortality rate of the disease (some mental health professionals call this “major stress disorder” [ 11 ]; worrying about infections and death of their family members [ 12 ];

unavoidable media coverage of grocery shopping, food security, threats of food shortages, and “how to control emotional eating”; or the focus of some online content regarding the pandemic on “how to look perfect on a webcam”) as well as at-home workout challenges may unintentionally reinforce eating disorder behaviors and cognitions [ 9 ].
Concerns about health and fitness during quarantine
Concerns regarding health and fitness during quarantine may contribute to the development of FED in prone individuals. In addition, additional risk factors may increase the risk of developing FED. These risk factors include spending more time on social media and the destructive impact of thin ideal objectification. Loneliness and isolation are common causes of anorexia nervosa, which can be intensified due to imposed quarantine. Emotional imbalance can cause symptoms of FED (i.e., episodes of uncontrolled eating followed by elimination behaviors) [ 13 ], whereas increased external control can reduce food intake [ 14 ]. Maladaptive emotional reactions of family members caused by quarantine stress can result in aggression and/or splitting and fragmentation [ 15 ]. In addition, orders to stay home and limited food selection choices in stores may make it seem rational for some individuals to skip meals or limit their caloric intake, which will subsequently worsen pre-existing restrictive tendencies [ 9 ].
Disruption of access to professional support
Obeying physical distances as well as the global mantra of staying at home has challenged face-to-face hospital programs [ 16 ]. The current disruption of access to reliable care may draw FED patients to unreliable sources, e.g., social media (e.g., Whatsapp, Instagram, Telegram, etc.) [ 17 ]. In addition, the time limitation of professionals to prepare FED patients and their families for treatment change has been associated with intensified fear and feelings of loss of control, already felt with the dissemination of COVID-19. Online therapy is available for some patients, although experts agree that in the case of absent face-to-face accountability (i.e., absence of weights), increased self-management is vital for FED patients [ 15]. To summarize, the COVID-19 pandemic likely leads to an exacerbation of mental health in FED patients due to logistical challenges caused by the safety protocols developed for COVID-19 [ 9 ].
In conclusion, taking into account the confinement and distress caused by uncertainty in FED patients who are at greater physical risk (including frailty caused by anorexia nervosa, electrolyte imbalance due to bulimia nervosa, and cardiovascular risk caused by binge eating) as reduced access to usual treatments [ 15 ], it is critical to develop evidence-based practice. This is in order to reduce the negative consequences of COVID-19 and learn from this unpredictable crisis for future benefits.