Study sample
Our study sample (n = 89) was made up of a subset of adolescent and young adult participants enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who completed an additional COVID-19-specific survey. The RECOVERY study is a longitudinal registry of patients with EDs seeking care in the outpatient ED program at Boston Children’s Hospital (BCH). RECOVERY uses web-based surveys every 3 months in the first year of participation, followed by 6 months thereafter. Participants were recruited between June 2017 and August 2020. In light of the COVID-19 pandemic, during July 2020, the RECOVERY participants were asked to complete an additional COVID-19 related survey on their perceived impact of the pandemic on their social and economic lives, ED treatment, ED/MH related symptomology and behaviors, and overall general wellbeing. Fifty-six percent of RECOVERY participants responded to this survey that was sent off-cycle for scheduled RECOVERY questionnaires, and without the typical remuneration offered. Of the participants in our study, 4.5% reported living alone (n = 4) and 95.5% (n = 85) reported not living alone in a binary measure of living alone or not during the pandemic. The RECOVERY study and this survey were approved by the BCH Institutional Review Board.
Survey measures
Demographic patient characteristics were obtained from participants’ baseline RECOVERY survey responses. Measures of the COVID-19 survey were developed by researchers at the University Of North Carolina Centre Of Excellence for Eating Disorders (NCEED) [22].
Primary predictor variables
COVID-19 related familial economic disruption Participants self-reported on the COVID-19 related familial economic disruption, measured through a composite score of the following four markers:
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1)
Cut back hours at work: “A member of my family had to cut back hours at work.” (Answer Choices: Yes/No).
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2)
Temporary work stoppage: “A member of my family was required to stop working (expect to be called back).” (Answer Choices: Yes/No).
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3)
Permanent job loss: “A member of my family lost their job permanently.” (Answer Choices: Yes/No).
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4)
Health insurance/benefits loss: “My family lost health insurance/benefits.” (Answer Choices: Yes/No)
Responses (Yes = 1, No = 0) from the four questions were added to give a score between 0 and 4 and collapsed into any (\(\ge\) 1) vs. no (0) impact.
Primary outcomes
Participants were asked to rate, on a 5-point Likert scale from “increased significantly” to “decreased significantly”: “How has the COVID-19 pandemic affected each of the following:” “Feelings of anxiety,” “Feelings of depression,””Feelings of isolation,” “Intrusive ED thoughts,” and “Motivation to recover from an ED.” We then categorized the responses into increased (increased significantly, increased somewhat), no effect, and decreased (decrease somewhat, decreased significantly). These were further collapsed into dichotomous variables for worsening vs. no change/improving for adjusted analysis. An increase in feelings of depression, anxiety, isolation or intrusive thoughts, or a decrease in motivation to recover were considered “worsening.”
Additional variables
Age Participant age at the time of COVID-19 survey completion was calculated using the date of birth obtained from the RECOVERY study’s baseline survey and date of the COVID-19 survey.
ED Diagnosis Participants self-reported their ED diagnosis in the COVID-19 survey by answering the question: “Which of the following EDs do you currently have or have you had in the past? (Please check all that apply)” and were given a list of eight options: (1) anorexia nervosa (AN), (2) atypical anorexia nervosa (AAN), (3) avoidant restrictive food intake disorder (ARFID), (4) bulimia nervosa (BN), (5) binge-eating disorder (BED), (6) purging disorder, (7) other eating issue(s)/disorder(s), and (8) I don’t know/Unsure.
Race/ethnicity Our baseline survey included a question that asked participants to select all that applied from the following options: Hispanic/Non-Hispanic, American Indian or Alaska Native, Asian, Black or African American, Middle Eastern/North African, Native Hawaiian or other Pacific Islander, White/Caucasian or another race. We constructed a mutually exclusive race/ethnicity variable consisting of non-Hispanic white, Asian, Hispanic, Multiracial, non-Hispanic Black or African-American, and Other race.
Sex Participants self-reported their sex assigned at birth (female, male, or another sex) in the RECOVERY baseline survey.
Length of current treatment Length of time participant had engaged in current ED treatment was calculated from the date of the intake in the outpatient ED program from which the participants were recruited to the date of the COVID-19 survey completion.
Statistical analysis
We examined frequencies (percent) for categorical variables and means (standard deviations) for continuous variables. To examine potential response biases, RECOVERY participants who responded to the COVID-19 survey were compared to non-respondents on demographic factors (age, race/ethnicity, and sex) and ED diagnosis using t-tests for continuous variables and χ2 tests for categorical variables. We examined bivariate associations between reported pandemic-related familial economic impact and participant-reported changes in intrusive ED thoughts, feelings of depression, anxiety, isolation, and motivation to recover from ED using χ2 tests (or Fisher’s exact test where appropriate). Logistic regression models were used to examine the association between pandemic-related familial economic impact and self-reported worsening in ED/MH concerns (increase vs. no change/decrease) and motivation to recover (decrease vs. no change/increase), adjusting for age and ED diagnosis. All analyses were conducted using SAS (v9.4; Cary, NC) with p < 0.05 considered a statistically significant result.
