key: cord-0849920-mfj7wny5
authors: Robertson, MacKenzie; Duffy, Fiona; Newman, Emily; Bravo, Cecilia Prieto; Ates, Hasan Huseyin; Sharpe, Helen
title: Exploring changes in body image, eating and exercise during the COVID-19 lockdown: A UK survey
date: 2020-12-03
journal: Appetite
DOI: 10.1016/j.appet.2020.105062
sha: 7f01a70ca9c45015c46021287b41dba74994620f
doc_id: 849920
cord_uid: mfj7wny5

Early reports suggest that lockdown measures associated with the COVID-19 pandemic (e.g., social distancing) are having adverse consequences for people’s mental health, including increases in maladaptive eating habits and body dissatisfaction. Certain groups, such as those with pre-existing mental health difficulties, may be especially at risk. The current study explored perceived changes in eating, exercise, and body image during lockdown within the United Kingdom, using an online survey (n = 264). There were large individual differences in perceived changes in eating, exercise, and body image in this period. Women were more likely than men to report increasing struggles with regulating eating, preoccupation with food and worsening body image. Those with a current/past diagnosis of eating disorders reported significantly greater difficulties in regulating eating, increased preoccupation with food, exercise thoughts and behaviours and concern about appearance, even when compared to those with other mental health and developmental disorders. Ongoing research to explore individual differences in the trajectories of change in eating, exercise and body image as lockdown measures ease will be important for understanding the full psychological impact of this pandemic and improve service and public health planning going forward.

Early reports suggest that lockdown measures associated with the COVID-19 pandemic 23 (e.g., social distancing) are having adverse consequences for people's mental health, 24 including increases in maladaptive eating habits and body dissatisfaction. Certain 25 groups, such as those with pre-existing mental health difficulties, may be especially at 26 risk. The current study explored perceived changes in eating, exercise, and body image 27 during lockdown within the United Kingdom, using an online survey (n = 264). There 28 were large individual differences in perceived changes in eating, exercise, and body 29 image in this period. Women were more likely than men to report increasing struggles 30 with regulating eating, preoccupation with food and worsening body image. Those with 31 a current/past diagnosis of eating disorders reported significantly greater difficulties in 32 regulating eating, increased preoccupation with food, exercise thoughts and behaviours 33 and concern about appearance, even when compared to those with other mental health 34 and developmental disorders. Ongoing research to explore individual differences in the 35 trajectories of change in eating, exercise and body image as lockdown measures ease 36 will be important for understanding the full psychological impact of this pandemic and 37 improve service and public health planning going forward. 2020. This involved a "stay at home" directive where people were asked to only leave 49 their home for essential purposes (e.g., keyworker roles, medical needs, to care for 50 others, one form of exercise a day, and essential food purchases). This was accompanied 51 by advice on "social distancing", where people were required to maintain a distance 52 of two metres from each other, and "shielding" of physically vulnerable individuals by 53 minimising social interaction with them. While essential to prevent transmission of the 54 virus, evidence of a negative impact of these restrictions on mental health is emerging. 55

The Institute of Fiscal Studies analysed longitudinal data and found a substantial 56 deterioration in mental health during the period of COVD-19 lockdown in the UK, with 57 women, young people and those with pre-existing mental health difficulties particularly 58 Rodgers and colleagues (2020) outlined three potential pathways through which eating 77 disorder symptomatology might develop or be exacerbated in those with existing 78 difficulties during the pandemic. The first pathway suggests that disruptions to daily 79 routines and restrictions to activities (e.g., limited exercise, grocery shopping and food 80 insecurity, social distancing and/or isolation, reduced access to treatment or alternative 81 coping strategies, irregular sleep) might increase eating disorder psychopathology. In 82 the second pathway, increased consumption of media (particularly social media) due to 83 social distancing measures could contribute to increased eating disorder 84 psychopathology. This is through increased exposure to harmful eating and appearance-85 related content, as well as more general stressful or traumatic world events. The final 86 pathway proposes that the fear of contagion may increase levels of stress and 87 orthorexia-based cognitions, and subsequently increase the risk of disordered eating 88 behaviours. Other authors also highlight the potential impact of food insecurity 89 including financial ability to purchase binge foods (Touyz et al., 2020) reported a change in their hunger and satiety perception (17% reporting reduced 98 appetite, 34% increased appetite) and most participants reported a change in their 99 consumption of "healthy" foods during lockdown (37% reported eating more, and 36% 100 eating less). Despite this, 48% of the sample perceived that they had gained weight 101 during lockdown. There was no significant change in activity levels during lockdown for 102 participants who reported that they did not engage in any exercise before; however, for 103 participants who already engaged in exercise, the frequency of training increased 104 J o u r n a l P r e -p r o o f during lockdown. Notably, the percentage of participants that reported engaging in high 105 levels of exercise (at least five times per week) significantly increased from 6% before 106 lockdown to 16% during lockdown. A recent large-scale Australian survey (Phillipou et 107 al., 2020) saw variations in exercise behaviours, with 35% of the general population 108 sample (n = 5289) reporting more exercise than before the pandemic, but almost half 109 (43%) reporting less exercise. Therefore, there is clear evidence that lockdown has 110 impacted on perceived changes in eating and exercise behaviours internationally in the 111 general population. However, individual differences in response suggest a more 112 complex picture than that perceived and communicated by the media. 113

There is also preliminary evidence of an increase in disordered eating. In behaviours, relative to before COVID-19 (Phillipou et al., 2020) . Therefore, there is some 123 evidence to suggest that eating disorder psychopathology may worsen in people with 124 eating disorders, alongside the potential development of disordered eating behaviours 125 within the general population. Further evidence is required to determine who is at most 126 risk for these changes. 127

The aim of the current study was therefore to explore the perceived impact of the 128 COVID-19 related lockdown in the UK on people's eating, exercise and body image. Participants were asked several questions about mental health diagnoses. First, they 170 were asked if they had ever been diagnosed with an eating disorder, another mental 171 health disorder, or developmental disorder (yes, no, I'm not sure). Where participants 172 indicated that they had an eating disorder diagnosis, mental health or developmental 173 disorder diagnosis, they were also asked to specify the diagnosis. 174

As participants' eating attitudes and behaviour, exercise behaviours and body 176 image were unknown before the UK lockdown, we developed a measure to capture 177 perceived changes in behaviour specifically for this study. The measure consisted 178 of nine statements set in the timeframe of 'since the lockdown began'. Five of these 179 items are the focus of the current study: "I have found it more difficult to regulate or 180 control my eating"; "I have become more preoccupied with food/eating"; "I have been 181 exercising more", "I have been thinking about exercise more", and "I've been more 182 concerned about the way that I look". 1 All questions were answered using a 5-point 183 Likert scale, from strongly disagree (1) to strongly agree (5). Table 1 shows the frequencies with which people agreed with each statement regarding 240 changes in eating, exercise and body image during lockdown. There were clear 241 individual differences across each of the domains, with the sample endorsing the full 242 range of response options. Just over half of the sample reported that it was more 243 difficult to regulate or control their eating, with 60% reporting that they were more 244 preoccupied with food/eating. Half the sample reported exercising more during 245 lockdown, and over two thirds reported thinking more about exercise. Just under half 246 agreed that they had been more concerned about their appearance during lockdown. 247

and pre-existing mental health conditions? 249 Table 2 shows the results of the Kruskal-Wallis tests comparing perceived changes by 250 demographic characteristics. In general, women reported greater perceived changes 251 than men, specifically being more likely to report finding it more difficult to control or 252 J o u r n a l P r e -p r o o f regulate eating, being more preoccupied with food/eating, exercising more, and having 253 increasing concerns about their appearance. 254

Age was also associated with differential perceived changes, although across fewer 255 domains. Specifically, younger people (i.e. those aged <30 years) were more likely to 256 report thinking more about exercise and also having increasing concerns about their 257 appearance during lockdown. In contrast, there were no differences by age group in 258 perceived changes to eating. 259

Living alone versus living with other people was not associated with differences in rates 260 of perceived changes to eating, exercise or body image. 261

Finally, pre-existing diagnoses of mental health and developmental disorders were 262 associated with differential rates in perceived changes across all domains (illustrated in 263 Figure 1 ). Specifically, compared to those without a history of mental health problems 264 or developmental disorders, those with a current or past diagnosis of an ED were 265 significantly more likely to report increased difficulties in controlling/regulating eating, 266 increased preoccupation with food, increased exercise thoughts and behaviours, and 267 increased concerns about appearance. In all domains except regulation of eating, those 268 with ED also reported significant increases compared to those with other mental health 269 conditions or developmental disorders. 2019) and thus might be used as a coping strategy. Interestingly though, in the current 305 study distress was associated only with thinking about exercise more, and not a 306 perceived increase in exercise behaviour. This could signal that exercise-related 307 thoughts were driven more by appearance concerns than physical benefits, or simply 308 that during lockdown it was not possible for people to visit gyms or engage in their 309 usual levels of physical activity. distressed may be using eating as a new coping mechanism when constrained in other 346 coping skills. Given that overall levels of psychological distress in this study were in line 347 with norms reported prior to the pandemic (Löwe et al., 2010) , the latter may be more 348 probable. Future longitudinal work will be needed to explore this further, and this may 349 have significant implications for our understanding of the relationship between 350 significant psychosocial stressors and eating behaviours across the population. By 351 understanding underpinning mechanisms associated with these eating behaviours we 352 may begin to develop more targeted, and potentially more effective, public health 353 approaches to weight management. 354

There are some limitations of the current study that should be considered. First, our 355 recruitment strategy relied on people self-selecting to take part, which may mean that 356 our sample is biased towards those interested in health behaviours. Our participants 357 were recruited through social media platforms, and the survey was hosted online. 358 Therefore, our sample is likely to be biased towards individuals with internet access 359 and who actively use social media. For some analyses, we had small and unequal group 360 sample size, especially in the ED group, meaning it was not possible to differentially 361 explore current vs past diagnosis of an ED participants, nor between specific diagnoses 362 in the comparator group (e.g., depression, anxiety). Second, because of the lockdown 363 timing we were unable to obtain a baseline measures of body image, exercise and 364 eating, and therefore were reliant on self-reported changes using an unvalidated 365 measure; this limitation also affects other studies conducted during the lockdown 366 period (e.g. Di Renzo et al., 2020). Although we only required participants to report 367 change rather than actual eating or eating behaviour, we cannot objectively validate the 368 accuracy of these data. Third, the cross-sectional nature of the study means we can only 369 establish relationships between variables, rather than temporality or causality. As the 370 study will involve follow-up rounds, we can examine temporal relationships between 371 variables in more detail and the longer-term impact of changes within groups in later 372 survey sweeps. Finally, our findings do not address the nature of the mechanisms 373 underlying the perceived changes in eating and exercise behaviours. These mechanisms 374 need to be investigated further to identify why some individuals experienced greater 375 changes than others, to inform prevention and intervention strategies. 376

In conclusion, adults in the UK report a wide range of changes to their eating-and 377 exercise-related thoughts and behaviours, as well as their body image, during the 378 lockdown associated with this pandemic. Growing challenges with regulating food 379 consumption, being more preoccupied with food and worsening body image are all 380 linked with psychological distress. Importantly, some groups appear to be more 381 susceptible to these changes, with women, young people and those with pre-existing 382 mental health problems -especially eating disorders -being at heightened risk. 

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