key: cord-0863843-rus7mutj authors: Schneider, Jekaterina; Pegram, Georgina; Gibson, Benjamin; Talamonti, Deborah; Tinoco, Aline; Craddock, Nadia; Matheson, Emily; Forshaw, Mark title: A mixed‐studies systematic review of the experiences of body image, disordered eating, and eating disorders during the COVID‐19 pandemic date: 2022-03-23 journal: Int J Eat Disord DOI: 10.1002/eat.23706 sha: d83febaaa8921e20e3528b0e8ba2e5cc5c70923f doc_id: 863843 cord_uid: rus7mutj OBJECTIVES: This systematic review assessed the influence of the COVID‐19 pandemic and associated restrictions on body image, disordered eating (DE), and eating disorder outcomes. METHODS: After registration on PROSPERO, a search was conducted for papers published between December 1, 2019 and August 1, 2021, using the databases PsycINFO, PsycARTICLES, CINAHL Plus, AMED, MEDLINE, ERIC, EMBASE, Wiley, and ProQuest (dissertations and theses). RESULTS: Data from 75 qualitative, quantitative, and mixed‐methods studies were synthesized using a convergent integrated approach and presented narratively within four themes: (1) disruptions due to the COVID‐19 pandemic; (2) variability in the improvement or exacerbation of symptoms; (3) factors associated with body image and DE outcomes; (4) unique challenges for marginalized and underrepresented groups. Disruptions due to the pandemic included social and functional restrictions. Although most studies reported a worsening of concerns, some participants also reported symptom improvement or no change as a result of the pandemic. Factors associated with worse outcomes included psychological, individual, social, and eating disorder‐related variables. Individuals identifying as LGBTQ+ reported unique concerns during COVID‐19. DISCUSSION: There is large variability in individuals' responses to COVID‐19 and limited research exploring the effect of the pandemic on body image, DE, and eating disorder outcomes using longitudinal and experimental study designs. In addition, further research is required to investigate the effect of the COVID‐19 pandemic on body image and eating concerns among minoritized, racialized, underrepresented, or otherwise marginalized participants. Based on the findings of this review, we make recommendations for individuals, researchers, clinicians, and public health messaging. PUBLIC SIGNIFICANCE: This review of 75 studies highlights the widespread negative impacts that the COVID‐19 pandemic and associated restrictions have had on body image and disordered eating outcomes. It also identifies considerable variations in both the improvement and exacerbation of said outcomes that individuals, researchers, clinicians, and other public health professionals should be mindful of if we are to ensure that vulnerable people get the tailored support they require. image and disordered eating outcomes. It also identifies considerable variations in both the improvement and exacerbation of said outcomes that individuals, researchers, clinicians, and other public health professionals should be mindful of if we are to ensure that vulnerable people get the tailored support they require. Objetivos: Esta revisi on sistemática evalu o la influencia de la pandemia de COVID-19 y las restricciones asociadas en los resultados en imagen corporal, la alimentaci on disfuncional y los trastornos alimentarios. Método: Después del registro en PROSPERO, se realiz o una búsqueda de artículos publicados entre el 1 de diciembre de 2019 y el 1 de agosto de 2021, utilizando las bases de datos PsycINFO, PsycARTICLES, CINAHL Plus, AMED, MEDLINE, ERIC, EMBASE, Wiley y ProQuest (disertaciones y tesis). Resultados: Los datos de 75 estudios cualitativos, cuantitativos y de métodos mixtos se sintetizaron utilizando un enfoque integrado convergente y se presentaron narrativamente dentro de cuatro temas: (1) interrupciones debidas a la pandemia de (2) variabilidad en la mejoría o exacerbaci on de los síntomas; (3) factores asociados con resultados de la imagen corporal y alimentarios disfuncional; (4) desafíos únicos para los grupos marginados y subrepresentados. Las interrupciones debidas a la pandemia incluyeron restricciones sociales y funcionales. Aunque la mayoría de los estudios informaron un empeoramiento de las preocupaciones, algunos participantes también informaron una mejoría de los síntomas o ningún cambio como resultado de la pandemia. Los factores asociados con peores resultados incluyeron variables psicol ogicas, individuales, sociales y relacionadas con el trastorno alimentario. Las personas que se identificaron como LGBTQ + informaron preocupaciones únicas durante COVID-19. Discusi on: Existe una gran variabilidad en las respuestas de los individuos a COVID-19 y una investigaci on limitada que explora el efecto de la pandemia en los resultados de la imagen corporal, la alimentaci on disfuncional y los trastornos de la conducta alimentaria utilizando diseños de estudios longitudinales y experimentales. Además, se requiere más investigaci on para investigar el efecto de la pandemia de COVID-19 en la imagen corporal y las preocupaciones alimentarias entre los participantes minoritarios, racializados, subrepresentados o marginados. Basados en los hallazgos de esta revisi on, se hacen recomendaciones para individuos, investigadores, médicos y mensajes de salud pública. body image, coronavirus, COVID-19, disordered eating, eating and feeding disorders, health inequality, isolation, lockdown, narrative synthesis, pandemic The novel coronavirus disease is an infectious respiratory illness that has claimed millions of lives globally (World Health Organization, 2021) and has had significant psychological ramifications. Individuals with disordered eating (DE) and eating disorders (EDs) may be particularly vulnerable due to the impact of distancing measures on social support and access to mental health services (Christensen, Hagan, et al., 2021; Touyz et al., 2020) , as well as their problematic relationships with food in a time of food insecurity (Islam et al., 2021) . Emerging evidence suggests that public health messaging associated with COVID-19 and increased reliance on videoconferencing technologies have had a negative impact on body image (BI; Pearl & Schulte, 2021; Pikoos et al., 2021) , which is closely associated with DE and ED symptoms (Smolak & Levine, 2015) . A systematic investigation is therefore warranted to explore the ways in which the ongoing pandemic might impact BI, DE, and ED outcomes. Previous reviews have documented the negative impact of social restrictions (e.g., "lockdowns" and related physical distancing measures) associated with the COVID-19 pandemic on psychological wellbeing Rajkumar, 2020; Schneider et al., 2021) . Early commentary has indicated that social restrictions may be particularly challenging for individuals living with, and vulnerable to, EDs due to changes in daily routine and increased psychological distress . Furthermore, there have been notable disruptions to treatment and access to professional support (Weissman et al., 2020) , though some studies have highlighted a potential benefit of increased online service provision for those not already connected with care (Simpson et al., 2021) . In addition, studies have found that changes to meal patterns, food planning and buying, and physical activity have negatively impacted cognitions and behaviors across the spectrum of ED diagnoses (Hansen & Menkes, 2021; Hayes & Smith, 2021) . Individuals with higher levels of psychological distress related to COVID-19 restrictions are more likely to report increased BI concerns and DE (Flaudias et al., 2020; Swami, Horne, et al., 2021) , as well as worsened ED symptomatology Chan & Chiu, 2021) . This may be exacerbated by increased social media use due to limits on in-person interactions (Pikoos et al., 2021) and increased exposure to content related to eating and appearance (Holland & Tiggemann, 2016) . Research has also highlighted harmful messaging around weight gain during the COVID-19 pandemic. Terms such as "covibesity" (Khan & Smith, 2020) , "COVID-15" (Pearl, 2020) , and "Quarantine-15" (Pearl & Schulte, 2021) are considered new risk factors for ED cognitions and behaviors, as well as increased BI concerns. Although considerable research has been conducted on the prevalence of weight gain during COVID-19, less research has considered the exposure effects associated with this messaging (Pearl & Schulte, 2021) . Previous literature shows a negative impact of weight stigmatizing public health messages on multiple physical and mental health outcomes, including reduced physical activity, increased binge eating, greater psychological distress, and an increase in body dissatisfaction (Bristow et al., 2020; Emmer et al., 2020; Mensinger et al., 2021) . As such, media coverage of COVID-19 related to weight gain is likely to exacerbate weight stigma and psychological distress in individuals with EDs, as well as DE behaviors and BI concerns in the general population (Lessard & Puhl, 2021 ). Food insecurity (i.e., concern about, or actual changes in, food availability) has been associated with binge eating and binge eating disorder (BED), bulimia nervosa (BN), as well as general ED pathology and symptomatology (Becker et al., 2017; Hazzard et al., 2020; Rasmusson et al., 2019; Zickgraf et al., 2022) . Food insecurity may be exacerbated during COVID-19 due to increased financial stress and economic limitations, as well as the "panic buying" behaviors and shortage of staple foods that characterized the initial phases of the pandemic (Khosravi, 2020; Weissman et al., 2020) . These effects may be further strengthened by the pervasive media coverage about threats of food shortages (Rasmusson et al., 2019) . Early research has shown increased food insecurity across multiple countries as a result of the pandemic (Mishra & Rampal, 2020; Niles et al., 2020; Zidouemba et al., 2020) , but fewer studies have explored the influence of food insecurity on eating outcomes Coulthard et al., 2021) . To date, most BI and ED research has been conducted with predominantly White, cisgender, and heterosexual participants, with the vast majority of studies taking place in Western, educated, industrialized, rich, and democratic (WEIRD) countries (Mikhail & Klump, 2021) . ED research is often conducted with female samples, thus underrepresenting men and nonbinary or genderqueer participants (Burke et al., 2020) . This is despite evidence showing that participants who identify as Black, Indigenous, or other People of Color (BIPOC) and participants from non-WEIRD countries experience equivalent, if not higher, rates of EDs (Acle et al., 2021; Alfalahi et al., 2021) . In addition, recent studies have found higher prevalence of BI and DE concerns in lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ+) participants (Nowaskie et al., 2021) . Such effects are compounded among individuals who experience multiple intersecting inequalities (e.g., Black, LGBTQ+ women; Crenshaw, 2017) , and are thus likely to show the highest prevalence of BI concerns and DE (Beccia et al., 2021) . A recent review on the impact of inequality factors on mental health outcomes during COVID-19 found that certain individual characteristics, such as female gender, existing psychological health conditions, and being subjected to stigma because of one's identity as a member of an ethnic or sexual minority group predicted worse mental health outcomes . However, to date, no reviews have looked specifically at BI and eating outcomes during COVID-19 among marginalized and underrepresented populations. The current mixed-studies systematic review aimed to assess the influence of COVID-19 on BI, DE behaviors, and ED outcomes. Several reviews have investigated the effect of COVID-19 on EDs (Miniati et al., 2021; Monteleone, Cascino, Barone, et al., 2021; Sideli et al., 2021) , reporting worsening of symptoms, increased levels of anxiety, and difficulties in treatment compliance during lockdown. However, little is still known about the adverse effects of the pandemic on ED outcomes and no systematic review has hitherto considered the influence of COVID-19 on BI and DE behaviors in the general population. Furthermore, no previous reviews have adopted a mixed-studies approach to assess the influence of COVID-19 on BI and eating concerns. Mixed-studies reviews maximize the findings of traditional systematic reviews (i.e., reviews summarizing qualitative or quantitative studies), and thus the ability of those findings to inform policy and practice (Harden, 2010; Stern et al., 2020) . As such, the current mixedstudies review will provide a more comprehensive depiction of the influence of COVID-19 on BI and eating outcomes, and enhance the utility and impact of findings (Harden & Thomas, 2010; Noyes et al., 2019) . Specifically, we aimed to: (1) identify studies that assess the influence of the COVID-19 pandemic and related variables (e.g., experience of quarantine, social distancing measures, "stay at home" orders, lockdown) on BI, DE, and EDs; (2) evaluate the influence of the COVID-19 pandemic on ED-specific and general psychopathology in individuals with EDs; (3) explore possible differences in the experiences of, and responses to, the pandemic among participants from marginalized and underrepresented populations; and (4) provide evidence-based recommendations for individuals, researchers, clinicians, and public health messaging. Reviews and Meta-Analyses statement (PRISMA; Page et al., 2021) and was preregistered on PROSPERO (ref no. CRD42021247921) prior to commencement (May 10, 2021). Searches were conducted for papers published between December 1, 2019 and August 1, 2021, using the databases PsycINFO, Psy-cARTICLES, CINAHL Plus, AMED, MEDLINE, ERIC (all accessed via EBSCO), EMBASE, Wiley, and ProQuest (dissertations and theses). We did not limit searches by language or country of publication. Boolean combinations of the following search terms and their abbreviations were used: anorexia; appearance anxiety; appearance comparison; appearance concern; atypical anorexia; atypical bulimia; atypical eating disorder; binge; binge eating; body anxiety; body checking; body dissatisfaction; body dysmorphia; body dysmorphic disorder; body image; body image concern; bulimia; compulsive exercise; dietary restriction; disordered eating; eating disorder; eating pathology; eating disorders not otherwise specified; excessive exercise; feeding disorder; food intake disorder; food restriction; laxative; obsessive exercise; orthorexia; other specified feeding and eating disorders; over exercising; pica; purging; restrictive diet; rumination disorder; shape concern; vomit; weight concern; coronavirus; COVID; COVID-19; lockdown; pandemic; quarantine; SARS-CoV-2; social distancing. The full search strategy can be found on the project's Open Science Framework page (https://osf.io/pz48w/). Reference sections of the included articles were scanned to identify additional studies that met inclusion criteria. We also searched for We included papers that examined the influence of the COVID-19 pandemic or variables directly related to the pandemic (e.g., experience of quarantine, social distancing measures, "stay at home" orders, lockdown, COVID-19-related anxiety or stress) on BI, DE, and ED outcomes. BI outcomes included, for example, experiences of weight stigma, appearance concerns, and body anxiety. DE and ED outcomes included onset of, exacerbation of, or change in specific symptoms (e.g., binge eating, purging, compulsive exercise, food restriction), mental health and well-being in individuals with diagnosed or undiagnosed EDs (e.g., anxiety, stress, depression, psychological distress, negative affect), and treatment outcomes (e.g., adherence to treatment, treatment efficacy). This was a mixed-studies review; as such, we included controlled trials, cohort studies, cross-sectional studies, case reports, and qualitative studies that examined the influence of the COVID-19 pandemic on target outcomes. We excluded: (1) review papers, commentaries, opinion pieces, and editorials; (2) studies that did not assess the direct relationship between the COVID-19 pandemic and target outcomes (e.g., studies that were conducted during the pandemic, but did not examine the influence of COVID-19 or related predictors on target outcomes, or studies that did not compare current levels of BI concerns or ED symptoms with prepandemic levels); and (3) studies related to eating habits, dieting, or exercise unrelated to BI or ED symptomatology (e.g., adherence to a Mediterranean diet, changes in physical activity in the general population). Two authors (J.S. and G.P.) screened titles and abstracts of retrieved papers against the inclusion and exclusion criteria outlined above. Duplicates and irrelevant papers were removed. J.S. and A.T., and G.P. and B.G. independently screened 50% of the full texts that were identified as potentially eligible. The authors held regular meetings to discuss uncertainties and clarify eligibility criteria. Any discrepancies in selecting the final papers for inclusion were resolved through discussion and consultation with the full review team. Data extraction was completed by four researchers who crosschecked each other's data extraction (J.S., A.T., G.P., and B.G.). In line with Harden (2010) , we used two separate protocols for quantitative and qualitative data. Data extracted for quantitative and qualitative studies are presented in Tables 1 and 2, respectively. For studies that described statistically significant outcomes, a p < .05 was considered significant. Due to the inclusion of mixed-methods studies and the heterogeneity of existing evidence, we adopted a narrative synthesis approach informed by the guidance by Popay et al. (2006) : (1) developing a theory; (2) developing a preliminary synthesis; (3) exploring relationships in the data; and (4) assessing robustness of the synthesis. This stage was performed early on in the review process and helped shape the review aims. Through an initial review of the literature and discussion among the research team, we identified several possible mechanisms whereby the COVID-19 pandemic and related factors may influence BI, DE, and EDs, such as psychological distress due to the ongoing pandemic, disruption of access to support and treatment, food shortage and insecurity, and increased loneliness and social isolation. Key findings from the literature review are outlined in the introduction section of this manuscript. This process also highlighted a lack of studies focusing on individuals from marginalized and underrepresented populations, which we included as a key aim of our review. The second stage involved organizing and describing the included papers to explore patterns across studies. We followed Stern et al.'s (2020) guidance on conducting mixed-studies systematic reviews, as outlined in the Joanna Briggs Institute (JBI) manual for evidence synthesis. Accordingly, we conducted the current review using the convergent integrated approach (Hong et al., 2017) , whereby findings from the qualitative, quantitative, and mixed-methods studies were integrated in the narrative synthesis. Quantitative data were transformed (or qualitized) into "textual descriptions" and presented in conjunction with qualitative data. This approach is recommended over its counterpart where qualitative data are assigned numerical values (quantitized), as codifying quantitative data is less error-prone than attributing numerical values to qualitative data. One of the distinguishing features of mixed-studies systematic reviews is the inclusion of primary mixed-methods studies, from which data are extracted so they can be classified as quantitative or qualitative (Stern et al., 2020) . Therefore, quantitative data from mixed-methods studies were also transformed and synthesized with quantitative data from quantitative studies and nontransformed qualitative data from qualitative and mixed-methods studies. Due to the variability in the emerging literature and the need to comprehensively capture all relevant findings, the themes and resulting narrative synthesis were based on a comprehensive examination of all included papers, regardless of study quality. In this stage, four main themes (and two subthemes) were generated from the integrated qualitative and transformed quantitative data to answer the key research aims. The themes were generated using deductive, or theory-driven approaches (i.e., considering data relevant to answering the review questions) and inductive, or data-driven approaches (i.e., being open to the data that are present across studies and unexpected findings; Clarke & Braun, 2014) . All themes were informed by both qualitative and quantitative research. For clarity, a selection of references is provided in the narrative synthesis; please see Tables 1 and 2 for a detailed breakdown of study findings and associated citations. Illustrative quotes for each theme are presented in Table 3. 2.5.4 | Stage 4: Evaluating the robustness of the synthesis In the final stage, the methodological quality of the included studies and of the review process was examined to assess the strength of the evidence presented within the review. We provide considerations and implications of the review's findings in the discussion section of this manuscript. Due to the novelty of COVID-19 and the need to gain a comprehensive understanding of its impact on BI and DE, no studies were excluded as a result of the quality assessments. Rather, quality scores of the included studies are provided in Tables 1 and 2 and considered in the results and discussion sections of this manuscript. Participants assessed post-COVID showed a greater increase in weight concern scores (ƞ 2 p = 0.094) and repetitive eating (ƞ 2 p = 0.076) compared with participants assessed pre-COVID; no difference between groups in shape concern, food concerns, or restraint eating Cross-sectional Perceived stress; concern about weight gain; ED examination; emotional eating Disordered eating associated with concern about weight gain before (β=.18) and during (β=.32) COVID; stress and concern about weight gain during COVID predicted variance in eating pathology among caregivers (r 2 = 0.48). worsening of their ED due to a "triggering environment"; 74% reported an increase in ED thoughts, 77% reported anxiety, 73% reported depression, and 80% reported isolation they perceived to be related to COVID; 29% reported decrease in motivation to recover they perceived to be related to COVID; participants who reported concern for worsening of their ED due to a triggering environment expressed 3 T A B L E 1 (Continued) Author ( The majority of included studies did not specify whether they assessed sex assigned at birth, gender, or gender identity; where this information is available, sex assigned at birth, gender, and gender identity are reported separately. b Signifies a multimethods paper. Information detailed here concerns the quantitative methods, analysis, and findings. See Table 2 (1) disruption to living situation; (2) increased social isolation and reduced access to usual support networks; (3) changes to physical activity rates; (4) reduced access to healthcare services; (5) disruption to routine and perceived control; (6) increased exposure to triggering messages; (2) helping others versus helping oneself; (3) challenges of reduced professional support; (4) Note: Study quality was assessed using an adapted version of the critical appraisal skills program (CASP) tool (Long et al., 2020) . Abbreviations: AAN, atypical anorexia; AN, anorexia nervosa; AN-BP, binging/purging anorexia subtype; AN-R, restrictive anorexia subtype; ARFID, avoidant restrictive food intake disorder; BED, binge eating disorder; BI, body image; BN, bulimia nervosa; DE, disordered eating; ED, eating disorder; OSFED, other specified feeding or eating disorder; UFED, unspecified feeding or eating disorder. a The majority of included studies did not specify whether they assessed sex assigned at birth, gender, or gender identity; where this information is available, sex assigned at birth, gender, and gender identity are reported separately. b Signifies a multimethods paper. Information detailed here concerns the qualitative methods, analysis, and findings. See Table 1 for the quantitative characteristics of this study. Theme Quote Author 1. Disruptions due to COVID-19 "Feeling frustrated because I've been learning how to control the bulimic symptoms and normally able to manage them. Yet the change in routine (or lack of) and general stress/anxiety is unsettling it and I noticed my thoughts and behaviors changing" (participant details not provided) (2020) "Without structure and focus (and meaning) of uni [university] and friends and having a life that feels worth living, now it's just old habits and misery" (participant details not provided) "My routine has gotten lost, which tampers with my sleep, which in turn tampers with my ability to follow my meal plan" (30, female participant, anorexia nervosa) Hunter and Gibson (2021 "The pandemic has increased my self-harm, as I've felt so restricted by the government in terms of what I can do to deal with my feelings (i.e., initially -only exercise once a day, not able to exercise with anyone else). Using healthy means to deal with difficult feelings (i.e., go for a walk, meet a friend for coffee) have been more limited and so it is really easy to go back to unhelpful ways of coping such as self-harm" (female participant, anorexia nervosa) "But I very quickly was able to turn it around and make it an opportunity for healing and like, I've dedicated so much time to eating disorder recovery during quarantine that I felt like that's what it was for. […] And so, I literally like am living in this renaissance of intuitive eating and of like, anti-diet-culture activism, because I found so much space for it during quarantine" (female participant) Stoddard et al. (2021) "Having the space to do that [reflect on recovery] is really good but I definitely did think that I was further along in my recovery than I am, but I guess that is a good thing because it means yeah I guess it is a good thing because it means I am aware of it as well which is helpful" (29, female participant, anorexia nervosa) Hunter and Gibson (2021) 3. Factors associated with body image and disordered eating outcomes "My mom had always joked about my body/weight (since I used to be overweight, she would joke about me not being able to fit through my door). She does not mean any harm, but I get really devastated when she mentioned that I've gained weight during quarantine. I started to restrict even more" (participant details not provided) "I'm trapped at home with people who do not know I have anorexia. I am hiding and lying constantly" (participant details not provided) (2020) It has meant that I have no one around to keep an eye on me so I can binge when I want to and then make myself sick to make myself feel better and I do not have to explain it to anyone because there is no one there to hear me" (male participant, bulimia nervosa) "It's a very secretive disorder and if I'm face to face with someone [for treatment] I cannot lie, I cannot hide the fact that I've lost weight or hide the fact that I'm drained energy-wise, whereas on the phone I can cover up" (29, female participant, anorexia nervosa) Hunter and Gibson (2021) 4. Unique challenges for marginalized and underrepresented groups "I was always concerned about how I look externally but ever since the pandemic the focus has been so much more because the way I justify it is I have more time to work on my body" (South Asian, gay, cisgender man) Quathamer and Joy (2021) "I found myself snacking more than usual. Some days I would overeat, other days I would barely eat anything. The major concern has always been my weight. So that's something I'm looking forward to, like getting back on track with the whole, exercising, and trying not to snack as much as before" (Latina, pansexual, cisgender woman) Thomas et al., 2004) . The EPHPP provides an overall methodological quality rating of "strong" (no weak component ratings), "moderate" (one weak component rating), or "weak" (two or more weak component ratings). The ratings are based on the following components: selection bias, study design, confounders, blinding, data collection method, and withdrawals and dropouts. The EPHPP is suitable for evaluating the methodological quality of various study designs (Jackson & Waters, 2005) . In addition, the EPHPP has excellent interrater reliability for overall scores when compared to the Cochrane Collaboration Risk of Bias Tool (Armijo-Olivo et al., 2012) and established construct and content validity (Jackson & Waters, 2005) . Two authors (B.G. and D.T.) independently assessed all studies. Cohen's kappa (Cohen, 1960) was calculated to determine interrater reliability, showing good agreement (92%) between total scores (κ = 0.866, p < .001). Discrepancies were resolved by a third author (J.S.), who rated all papers in line with either BG or DT, and the majority score was assigned. Quality of qualitative studies was assessed using a modified version of the 10-item Critical Appraisal Skills Program (CASP) qualitative checklist, as detailed by Long et al. (2020) . The CASP checklist is the most commonly used checklist-based tool for quality appraisal in healthrelated qualitative evidence syntheses, and is endorsed by the Cochrane Qualitative and Implementation Methods Group (Long et al., 2020) . Each of the 10 items focus on a different methodological aspect of a qualitative study. To improve the tool's sensitivity to theoretical validity, the following question was added by Long et al. (2020) : "Are the study's theoretical underpinnings (e.g., ontological and epistemological assumptions; guiding theoretical framework(s)) clear, consistent and conceptually coherent?" The CASP checklist questions were scored independently as "yes" (1), "no" (0), "somewhat" (0.5), or "cannot tell" (0) by two authors (N.C. and G.P.), and assigned a total score (out of 10). Cohen's κ was calculated to determine interrater reliability, showing moderate agreement (76%) between total scores (κ = 0.712, p < .001). Four studies with differences of one point were independently scored by a third author (A.T.), who rated all in line with either GP or NC, and the majority score was assigned. As of August 1, 2021, the search protocol yielded 3230 papers (see Quathamer and Joy (2021) of which one report could not be retrieved. In total, 154 articles were assessed for eligibility. Thirteen papers were excluded because they did not describe an empirical study, 31 studies were excluded because they did not assess target outcomes, and 36 studies were excluded because they did not assess the influence of COVID-19 on target outcomes. A final sample of 74 reports, describing 75 studies (quantitative n = 58, mixed-methods n = 7, qualitative n = 10), was included in this review. Characteristics of quantitative studies (including quantitative data from mixed-methods studies) are described in Table 1 and characteristics of qualitative studies (including qualitative data from mixed-methods studies) are described in Table 2 . Of the 65 studies that reported quantitative findings, 46 were cross-sectional (of which 13 were retrospective), 16 were longitudinal, and 3 were cohort studies. Of the 17 studies that reported qualitative findings, six used online surveys for data collection, six used semi-structured interviews, one used focus groups, one used a combination of semi-structured interviews and autoethnography, one used a combination of online surveys and semi-structured interviews, one used textual analysis of chat transcripts, and one analyzed individual posts from the social media platform Reddit. The majority of qualitative studies analyzed the data using thematic analysis (n = 14), two used content analysis, and one used Foucauldian discourse analysis. The studies were conducted in more than 20 countries, predominantly in Europe and North America, including the United States (n = 23), the United Kingdom (n = 12), Spain (n = 7), Italy (n = 6); Germany (n = 4), Portugal (n = 4), Australia (n = 3), Canada (n = 3), France (n = 2), Lebanon (n = 2), Turkey (n = 2), Austria (n = 1), Belgium (n = 1), Greece (n = 1), Hong Kong (n = 1), Ireland (n = 1), Lithuania (n = 1), Netherlands (n = 1), Poland (n = 1), and multiple countries (n = 2). Participants were mostly adults, with nine studies being conducted with children and/or adolescents. Of the studies evaluated using the EPHPP, 28 were rated as "weak," 32 were rated as "moderate," and 5 were rated as "strong." Most F I G U R E 1 PRISMA flowchart of study selection studies lacked quality in study design (e.g., bias due to allocation process) and selection bias (e.g., how representative the sample is of the target population). Of the studies assessed using the CASP, 1 was rated as "weak," 10 were rated as "moderate," and 6 were rated as Findings were mixed regarding the impact of COVID-19 on BI, DE behaviors, and EDs. Studies reported inconsistent rates of symptom deterioration and improvement during COVID-19. For example, studies found that between 33% and 70% of participants reported worse BI during COVID-19, 10%-26% reported improved BI, and 4%-51% reported no change in BI as a result of the pandemic. In terms of EDs, 16%-87% of participants reported worsened ED symptoms or reactivation of ED symptoms during COVID-19, 2%-51% reported improved ED symptoms, and 8%-66% reported no change in ED symptoms as compared to prepandemic levels. In addition, there was great variation in which symptoms were most affected by the COVID-19 pandemic, with some studies showing no differences in target outcomes from pre-to postlockdown (e.g., Koenig et al., 2021; Martínezde-Quel et al., 2021) . As such, two subthemes were generated: (1) negative outcomes of the COVID-19 pandemic and (2) positive outcomes of the COVID-19 pandemic. Of note, multiple participants reported experiencing both positive and negative outcomes simultaneously; however, for simplicity, negative and positive outcomes are presented separately. Overall, most studies reported some negative outcomes of the COVID-19 pandemic for individuals living with EDs and the general population. Multiple studies reported deterioration in participants' BI outcomes, such as body esteem, body dissatisfaction, weight and shape concerns, and drive for thinness (e.g., Keel et al., 2020; Larkin, 2021; Nutley et al., 2021; White, 2021) , as well as DE behaviors, such as dietary restriction, emotional eating, binging and purging, and compulsive exercise (e.g., Giel et al., 2021; Phelan et al., 2021; Philippe et al., 2021; Zhou & Wade, 2021) . Moreover, studies showed a higher prevalence of EDs during the pandemic compared to previous years (e.g., Spettigue et al., 2021; Taquet et al., 2021) . Patients with EDs reported reduced psychological wellbeing (e.g., H. Kim, Rackoff, et al., 2021; Leenaerts et al., 2021) ; feeling out of control (e.g., Branley-Bell & Talbot, 2021; Richardson et al., 2020) ; increased suicide ideation, suicidal thoughts, and self-harm (e.g., Monteleone et al., 2021) ; higher levels of loneliness (e.g., S. Kim, Wang, et al., 2021; Schlegl, Maier, et al., 2020) ; increased posttraumatic stress (e.g., Nisticò et al., 2021) ; and changes in ED-specific and general psychopathology (e.g., Castellini et al., 2020; Simone et al., 2021; Trott et al., 2021; Vitagliano et al., 2021) . Positive outcomes of the pandemic relating to BI, DE, and ED experiences included making time for self-care (e.g., McCombie et al., 2020; Termorshuizen et al., 2020) ; having space away from in-person appearance comparisons and reduced weight monitoring (e.g., Graell et al., 2020; Quathamer & Joy, 2021) ; and connecting virtually with friends, family, and the community (e.g., Termorshuizen et al., 2020; Zeiler et al., 2021) . Patients with EDs specifically reported a reduction in ED symptomatology (e.g., Schlegl, Maier, et al., 2020) ; increased attempts at self-management in recovery (e.g., Schlegl, Maier, et al., 2020) ; greater motivation to recover (e.g., Clark Bryan et al., 2020; Termorshuizen et al., 2020); and more time for reflection on recovery (e.g., Hunter & Gibson, 2021) . 3.6 | Theme 3: Factors associated with BI and DE outcomes As described above, social implications of the COVID-19 pandemic and changes in participants' physical environment were associated with both symptom deterioration and improvement. As such, several associated factors were identified to explain these discrepancies. Factors that were associated with worse BI and eating outcomes during the pandemic included psychological, individual, social, and ED-related characteristics. Psychological variables associated with worse outcomes included higher levels of worry, rumination, loneliness, anxiety, depression, stress, psychological distress, and fear of COVID-19 (e.g., Akgül et al., 2021; Chan & Chiu, 2021; Frayn et al., 2021; Swami, Horne, et al., 2021) ; comorbidity of mental health concerns and childhood trauma (e.g., Castellini et al., 2020; Chan & Chiu, 2021 ); insecure attachment, lower self-directedness, and poor coping strategies (e.g., Haddad et al., 2020) ; poor emotion regulation (e.g., Flaudias et al., 2020; Machado et al., 2020) ; higher levels of uncertainty intolerance (e.g., Scharmer et al., 2020) ; and greater food insecurity (e.g., Christensen, Forbush, et al., 2021) . Individual variables associated with worse outcomes included identifying as a woman (e.g., Baceviciene & Jankauskiene, 2021; Buckley et al., 2021; Serin & Koç, 2020) ; increased time spent online or on social media (e.g., Bellapigna et al., 2021; Vall-Roqué et al., 2021) ; identifying as an ethnic minority participant (e.g., Christensen, Forbush, et al., 2021; S. Kim, Wang, et al., 2021) ; pre-COVID-19 experiences of weight stigma (e.g., Puhl et al., 2020) ; and higher body mass index or body weight, or reporting changes in weight during COVID-19 (e.g., Lessard & Puhl, 2021; Stoddard, 2021) . Findings were inconclusive regarding the effect of age, with some studies showing younger age to be a risk factor and older age to be a protective factor (e.g., Pikoos et al., 2020; , one study showing that adolescents reported higher reactivation of ED symptoms than children (Graell et al., 2020) , and one study showing no influence of age on target outcomes (Monteleone, Marciello, et al., 2021) . Contrary to expectations, increased videoconferencing as a result of confinement did not predict BI or binge eating postlockdown (Gullo & Walker, 2021; Pfund et al., 2020) . Social variables associated with worse outcomes included household arguments or family conflicts (e.g., Castellini et al., 2020) ; change in living situation and access to usual support networks (e.g., Branley-Bell & Talbot, 2020; Monteleone, Cascino, Marciello, et al., 2021) ; fear for the safety of loved ones (e.g., Castellini et al., 2020); longer social isolation and confinement (e.g., Coulthard et al., 2021; Haddad et al., 2021) ; perceived low quality of personal and therapeutic relationships (e.g., Cecchetto et al., 2021; Monteleone, Cascino, Marciello, et al., 2021) ; and exposure to COVID-19-related media and triggering messages regarding quarantine weight gain and exercise (e.g., Nutley et al., 2021; Vuillier et al., 2021) . Evidence was mixed regarding participants' living situation, with some studies showing that living alone or living with fewer people was associated with less favorable outcomes Pikoos et al., 2020) , and other studies showing the detrimental effects of living with a higher number of adults in confinement (Haddad et al., 2020; Zeiler et al., 2021) . Finally, ED-related variables associated with worse outcomes included a prior or current ED diagnosis (e.g., Breiner et al., 2021; Meda et al., 2021; Phillipou et al., 2020; Robertson et al., 2021) and higher levels of BI and/or eating concerns at baseline (e.g., Jordan et al., 2021; Pfund et al., 2020) . Results were inconclusive regarding ED subtype. Two studies found that patients with anorexia nervosa (AN; Monteleone, Marciello, et al., 2021) and other specified feeding or eating disorders (OSFED; were more likely to report symptom deterioration and worse mental health outcomes during confinement. In addition, patients with AN reported the greatest dissatisfaction and accommodation difficulty with remote therapy (Fernández-Aranda, Munguía, et al., 2020) . However, another study found that patients with BN reported more severe COVID-19-related posttraumatic symptomatology than patients with AN and healthy controls (Castellini et al., 2020) . Similarly, patients with AN reported a positive response to treatment during confinement, while no changes were found in patients with BN, and patients with OSFED reported an increase in eating symptomatology and psychopathology (Fernández-Aranda, Munguía, et al., 2020) . In terms of prevalence, one study found that increased diagnostic incidence of EDs in 2020 was primarily related to AN (Taquet et al., 2021) , while another study showed increased prevalence of BN and BED during the pandemic, with no differences found in prevalence of AN from pre-to during COVID-19 (H. Kim, Rackoff, et al., 2021) . However, it should be noted that Taquet et al.'s study included health records of more than 5 million people to compare ED incidence risk in 2020 with previous years, while H. Kim, Rackoff, et al. (2021) longitudinally examined change in frequencies of psychological health conditions in a sample of 4970 participants from pre-to during COVID-19, making comparison between studies difficult. Finally, several studies showed no effect of ED diagnosis on target outcomes (e.g., Monteleone, Cascino, Marciello, et al., 2021; Vuillier et al., 2021) . Multiple factors were also identified that were associated with more positive and less negative BI and eating outcomes during the pandemic, including personal characteristics, such as adaptive coping mechanisms (e.g., , self-compassion (e.g., Swami, Todd, et al., 2021), emotion regulation (e.g., reappraisal; Giel et al., 2021) , sense of coherence (e.g., Giel et al., 2021) , and higher perceived control (e.g., Branley-Bell & Talbot, 2020) ; social characteristics, such as emotional and social support from others (e.g., Tabler et al., 2021) , virtual social contact with friends and family (e.g., , and more time spent with family and improved family relationships (e.g., Vuillier et al., 2021) ; and individual behaviors, such as mild physical activity (e.g., , taking part in enjoyable activities (e.g., Schlegl, Maier, et al., 2020; , maintaining daily routines (e.g., Schlegl, Maier, et al., 2020) , and day planning (e.g., Schlegl, Maier, et al., 2020) . Notably, findings were inconsistent regarding the influence of physical activity on BI and eating outcomes. Some studies have suggested that change in an individuals' physical activity routine as a result of restrictions may be associated with worse outcomes, regardless of their current level of physical activity. For example, Martínez- de-Quel et al. (2021) found that the lockdown period due to COVID-19 negatively influenced physical activity levels, sleep quality, and well-being in participants who had a physically active lifestyle before the COVID-19 pandemic, but not in participants who were classed as physically inactive prepandemic. However, they did not assess the relationship between changes in physical activity levels and ED risk. Two studies found that change in physical activity was associated with worsened ED symptoms (Branley-Bell & Talbot, 2020; Vuillier et al., 2021) . Specifically, for some people, reduced physical activity as a result of restrictions was associated with increased ED cognitions or compensatory disordered behaviors (e.g., food restriction), while others engaged in more excessive exercise at home to cope with the loss of their usual physical activity routine. Indeed, several studies found that physical activity was positively associated with adverse outcomes in participants with EDs and in the general population, such as dietary restraint, eating concerns, shape and weight concerns, and eating symptomatology (Haddad et al., 2020; Monteleone, Marciello, et al., 2021) . In line with the aim to highlight the impact of the COVID-19 pandemic on BI and DE outcomes in marginalized and underrepresented populations, the final theme relates to findings from studies that have included such participant samples. Specifically, we considered the influences of sexuality, gender identity, belonging to a racialized group, and ethnicity. As the majority of studies were conducted in Europe or North America, we were not able to explore differences in the effect of COVID-19 on target outcomes in countries that are typically less represented in psychological research (i.e., non-WEIRD countries). Among studies that reported race or ethnicity data (n = 32; 43%), a majority of participants were White, with few studies comparing outcomes between participants who identified with different ethnicities or racialized groups. S. Kim, Wang, et al. (2021) found that identifying as Black was associated with lower psychological distress, stress, and loneliness, while identifying as Asian was associated with higher psychological distress, stress, and loneliness in participants with confirmed or suspected EDs. Moreover, Christensen, Forbush, et al. (2021) found that participants who identified as Black were significantly more likely to report individual food insecurity relative to other racialized groups, but found no differences in food insecurity from before to during the beginning of the COVID-19 pandemic. Overall, participants who identified as BIPOC reported similar BI and eating concerns as outlined in previous themes. Only nine studies (12%) reported participants' sexual orientation and 19 studies (25%) included participants with nonbinary or transgender identities. Of note, the majority of the included studies did not specify whether they assessed sex assigned at birth, gender, or gender identity, and many used "sex" and "gender" interchangeably. In addition, most studies included predominantly cisgender and heterosexual participants, apart from Quathamer and Joy (2021) four studies conducted analyses based on gender, of which two excluded these participants due to small group size (<6%), instead focusing on differences in target outcomes within the male-female gender binary. In addition, one study grouped all participants who identified as LGBTQ+ in their analyses. Indeed, even in studies that specifically targeted LGBTQ+ samples (Quathamer & Joy, 2021; Tabler et al., 2021) , the majority of participants identified as cisgender. As such, findings across all participants who identified as LGBTQ+ are presented together in this review, while we acknowledge the possible differences in experiences across various identities. Overall, findings indicate that pandemic-related stress was associated with ED symptoms and perceived weight gain, and this association was stronger in women and individuals who identified as LGBTQ + compared to cisgender and heterosexual men (Tabler et al., 2021) . Although findings regarding the impact of the COVID-19 pandemic on BI and eating outcomes generally mirrored those discussed above, individuals who identified as LGBTQ+ discussed challenges of COVID-19 through a lens of gender identity and sexuality. For example, some participants reported unique challenges directly related to restrictions imposed as a result of the COVID-19 pandemic, such as being confined with family members who were not aware of, or did not approve of, their gender identity or sexuality (Quathamer & Joy, 2021) . In addition, participants reported gender dysphoria-related body issues due to the fear of gaining weight during quarantine (Quathamer & Joy, 2021) . On the other hand, several participants reported that the restrictions associated with the pandemic gave them a break from the pressure to present their body and gender in a socially acceptable way (Quathamer & Joy, 2021) . Some participants further reported that the removal of distractions and a break from engaging with a heteronormative society allowed them to be present more fully in their body and explore their gender identity in greater depth (Quathamer & Joy, 2021) . Of note, several studies reported no effect of gender (e.g., H. Kim, Rackoff, et al., 2021; Puhl et al., 2020) , ethnicity/racialized group belonging (e.g., Coulthard et al., 2021; Czepczor-Bernat et al., 2021; H. Kim, Rackoff, et al., 2021) , or sexual orientation (e.g., Czepczor-Bernat et al., 2021; H. Kim, Rackoff, et al., 2021) on BI or eating outcomes during COVID-19. The current review is the first to investigate the influence of the COVID-19 pandemic and related restrictions on BI, DE behaviors, and ED outcomes. The findings of this review complement and extend findings from previous reviews conducted on the impact of COVID-19 on EDs (Miniati et al., 2021; Monteleone, Cascino, Barone, et al., 2021; Sideli et al., 2021) . First, previous reviews evaluate earlier research on COVID-19 (spanning the time period from January 2020 to January 2021). Our review extends this time period until August 2021, which includes the easing of restrictions in many countries. Second, previous reviews have included between 21 and 26 papers, most of which were quantitative, and have predominantly focused on ED outcomes. We include 75 studies (including 16 longitudinal studies and 17 studies that report qualitative findings) and adopt a mixedstudies approach to explore both quantitative and qualitative outcomes. Moreover, the current review contributes novel findings on the impact of COVID-19 on BI and DE behaviors in the general population. As such, we also extend existing recommendations beyond clinical practice and treatment (see Table 4 ). Four themes were generated across qualitative, quantitative, and mixed-methods studies, including: (1) disruptions due to the COVID-19 pandemic; (2) variability in the improvement or exacerbation of symptoms; (3) factors associated with BI and DE outcomes; and (4) unique challenges for marginalized and underrepresented groups. Overall, qualitative and quantitative data complemented each other and showed a negative influence of the COVID-19 pandemic on BI and DE. Specifically, with respect to BI, studies showed increased shape and weight concerns (Schlegl, Maier, et al., 2020) , drive for thinness/muscularity (Swami, Horne, et al., 2021) , body and appearance dissatisfaction (Vall-Roqué et al., 2021) , and decreased self-esteem (White, 2021 Kim, Rackoff, et al., 2021) . The majority of participants also reported perceived disruptions of the pandemic to their daily routine (Nutley et al., 2021) , social support networks (Vuillier et al., 2021) , and access to treatment and professional support (Hunter & Gibson, 2021) . Conversely, many studies also reported positive outcomes of the COVID-19 pandemic, including reduction in ED symptomatology, more time to reflect on recovery and engage in self-care, greater motivation to recover, and more time to connect with family in person or online (e.g., McCombie et al., 2020; Schlegl, Maier, et al., 2020; Termorshuizen et al., 2020; Zeiler et al., 2021) . Collectively, the included studies identified several factors that may contribute to an individual's risk and/or protection from adverse outcomes during the pandemic. The most commonly reported factors associated with worse outcomes during the pandemic included psychological distress, comorbidity, poor coping and emotion regulation strategies, female gender, increased time spent online, longer periods of social isolation and confinement, and higher levels of BI and eating concerns at baseline (e.g., Castellini et al., 2020; Coulthard et al., 2021; Haddad et al., 2020) . Notably, body mass index was also reported as a correlate of adverse BI and DE/ED outcomes; however, this is likely due to the effect of societal stigma (i.e., through weight-centric healthcare and public health messaging) and internalized weight stigma (Lessard & Puhl, 2021; Pearl & Schulte, 2021) . Unsurprisingly, the most commonly reported factors associated with better outcomes were contradictory of the abovementioned factors, and included adaptive coping mechanisms and emotion regulation strategies, social support, taking part in enjoyable activities, and maintaining daily routines (e.g., Branley-Bell & Talbot, 2020; Giel et al., 2021; Schlegl, Maier, et al., 2020; . Findings were inconsistent regarding the role of ED subtype as a risk factor for more adverse outcomes. Weight stigma/stigmatizing messaging: • COVID-19-related media and triggering messages regarding quarantine weight gain and exercise were found to negatively influence body image and eating outcomes (e.g., Nutley et al., 2021; Vuillier et al., 2021) . • Pre-COVID-19 experiences of weight stigma were associated with more negative outcomes (e.g., Puhl et al., 2020) . • Reduce time spent online, particularly if the media content makes you feel worse about your body. • Be critical about media reporting worse health outcomes in individuals with higher weight in recognition of widespread societal anti-fat weight bias and an overreliance on correlational data to imply causation. • Qualitative and quantitative research is required to assess the potentially harmful effects of "antiobesity" messaging on individuals' mental health and well-being during the pandemic and beyond. This research should take into account a variety of media promoting such messages, including formal (e.g., news outlets, articles) and informal media (e.g., social media posts, memes). • This research should consequently be used to inform public health messaging guidelines to avoid stigmatizing language and promote size-and weight-inclusive health messaging. • Explore client's social media use (e.g., frequency, duration, accounts followed). Work together to identify helpful and unhelpful content, the costs/ benefits of (dis)engaging with this content and how to cultivate a helpful social media environment (e.g., unfollowing accounts, reporting harmful content). • Due to the high proportion of individuals reporting increased exposure to weight stigmatizing social media content during COVID-19, and the negative impact of weight stigmatizing public health campaigns on mental and physical health, clinicians should adopt a weightneutral approach, such as Health at Every Size. • Use nonstigmatizing and weight-inclusive alternatives to health messaging around COVID-19. When designing a health message, image choice (i.e., weight-inclusive rather than weight-stigmatizing) and wording (i.e., non-forceful) should be considered. • Health messaging should focus on specific, realistically achievable behaviors, rather than weight or appearance (e.g., engaging in physical activity, keeping a safe distance, handwashing) and encourage activities for mental health and well-being as well (e.g., spending time with family and friends, taking breaks, trying new hobbies). Disruptions/changes to treatment: • Most patients reported a disruption in treatment or professional support during the pandemic (e.g., Fernández-Aranda, Casas, et al., 2020; Fernández-Aranda, Munguía, et al., 2020) . • Different patients respond differently to online treatment (e.g., Hunter & Gibson, 2021) . • The inability to fully access professional services was highlighted as a major concern for those participants receiving professional support prior to the pandemic/confinement period (e.g., Hunter & Gibson, 2021 • Research is required to investigate for whom online treatment works best and how to adapt online treatment to enhance effectiveness and patient acceptability. • This research should consequently be used to inform treatment and support adaptations, and feed into novel telehealth approaches to ensure treatment is both accessible and effective, including for individuals who have difficulties accessing in-person support due to the pandemic or other reasons. • When adapting or moving treatment programs to online platforms, consider participant preferences and living conditions (e.g., privacy, access to safe spaces). • Offer patients time to share their thoughts and concerns about changes in treatment routine/ methods. This should be at the start of the session and not derail the treatment plan and goals. • If treatment is modified for existing patients, clear and timely communication about when and how their regular treatment will be modified is required. • For patients with more advanced symptoms that include secretive disordered behaviors, in-person therapy is preferred to enhance accountability and transparency. • Messaging should be clear and timely regarding available treatment providers and alternative support options, such as telehealth or online therapy. • Messaging should also be accessible for everyone (e.g., not dependent on access to the internet) and easy to follow. Important findings this is particularly important as flexible or remote working is likely to continue in the future. • Assist your patients in building online and in-person social support networks if these have been disrupted during the pandemic; for example, by building connections with local communities (e.g., schools, community centers) to facilitate patient connectedness. This may be most applicable for patients transitioning from in-patient/daypatient treatment. Physical activity/daily routines: • Engaging in some physical activity may protect against negative outcomes during the COVID-19 pandemic (e.g., . • Taking part in enjoyable activities and maintaining daily routines were associated with more positive and less negative outcomes during COVID-19 (e.g., Schlegl, Maier et al., 2020; . • Additionally, some individuals reported improved eating disorder symptoms due to having more time to engage in self-care activities (e.g., McCombie et al., 2020; Termorshuizen et al., 2020) . • Mild physical activity may be beneficial, but monitor your thoughts and motivations for exercise if this has previously been triggering for you; this can include dance, stretching, yoga, walking, or other types of exercise that you enjoy. • Try to maintain or create new daily routines by planning your day or week in advance, and make sure to incorporate some enjoyable activities into your day. • Moreover, take time for self-care, whether it is spending time alone, reading a book, meditating, painting, listening to music, or learning something new. • More research is required on the protective benefits of physical activity during lockdown, depending on physical activity type (e.g., vigorous versus mild) and specific population (e.g., patients with eating disorders versus healthy participants). • More research is required to understand individual differences in experiences of, and responses to, COVID-19 restrictions, as well as to identify risk and protective factors or mechanisms that can be targeted in future interventions and treatment approaches. • Such research should (1) employ longitudinal or cohort study designs and (2) investigate risk and protective factors at multiple levels (i.e., individual, social, societal). • Tailor physical activity advice to individual patients' needs and discuss any changes in exercise routine caused by the pandemic. • Discuss coping strategies with your patients and identify what strategies are most beneficial to help them in their recovery. For example, help your patients create and maintain a daily routine if it has been disrupted by the pandemic. • Encourage your patients to spend some time on self-care activities, or activities that they enjoy and that make them feel good. Impact on marginalized groups: (e.g., Christensen, Forbush, et al., 2021; S. Kim, Wang, et al., 2021; Tabler et al., 2021; Quathamer & Joy, 2021) . • Limited research has been conducted on the impact of the COVID-19 pandemic on participants from historically marginalized or underrepresented groups. • More research is required on minoritized, racialized, underrepresented, or otherwise marginalized participants during COVID-19, considering the effects of intersectionality (i.e., the connectedness and interaction between multiple identities) and inequality (e.g., biases, discrimination, stigma) on body image and eating concerns. • Additionally, more research is required on groups previously underrepresented in eating disorder research (e.g., people of color, men) and individuals who may have unique body image and eating concerns (e.g., individuals who identify as LGBTQ+, adolescents). • Researchers should consider targeted recruitment strategies to reach underresearched populations and distinguish participants based on more than one identity factor when presenting study results (e.g., Black men, Black women, White men, White women). • When working with patients from marginalized backgrounds, clinicians need to consider additional concerns and unique challenges that these participants may face (e.g., experience of discrimination), which may impact both symptomatology and treatment outcomes. • Additionally, clinicians need to consider their own implicit biases and explicit behaviors when working with all patients. • Strive for inclusivity and diversity by engaging marginalized and underrepresented communities in designing public health messaging. • Collaborate with researchers, clinicians, and community leaders to ensure messaging is accurate, timely, and relevant. status, the majority of participants were White, cisgender, heterosexual, highly educated, and of a higher socioeconomic status. There is some evidence showing that participants who identify as LGBTQ+ and/or BIPOC are more at risk of reporting adverse mental health, BI, and eating outcomes during COVID-19 S. Kim, Wang, et al., 2021; Quathamer & Joy, 2021; Tabler et al., 2021) . Contrary to expectations, several studies reported no effect of gender (e.g., H. Kim, Rackoff, et al., 2021; Puhl et al., 2020) , ethnicity/racialized group belonging (e.g., Coulthard et al., 2021; Czepczor-Bernat et al., 2021; H. Kim, Rackoff, et al., 2021) , or sexuality (e.g., Czepczor-Bernat et al., 2021; H. Kim, Rackoff, et al., 2021) on BI or DE. However, such studies included predominantly White, female, and heterosexual participants, which could have obscured unique effects. Future research should explicitly take into account participants' experiences of discrimination and racism as a possible mechanism of effects. In addition, when conducting comparisons across participants, some studies combined multiple sexualities (e.g., heterosexual compared to lesbian, bisexual, queer, questioning, or other sexualities) and ethnicities (e.g., Hispanic compared to non-Hispanic); thus, ignoring important differences between specific participant subgroups. In fact, in the majority of studies, gender, sexual orientation, and ethnicity were not reported, or were assessed as dichotomous variables (e.g., male, female; heterosexual, nonheterosexual; White, non-White). Finally, in longitudinal studies, the proportion of LGBTQ+ and/or BIPOC participants tended to decrease over time, indicating higher attrition rates for these populations. Future studies should therefore consider employing novel strategies to ensure equitable recruitment and analysis of participant subgroups, while considering intersecting identities and the impact of experiencing multiple inequalities on mental health outcomes during COVID-19 . Furthermore, clinicians, researchers, and other practitioners should be aware of their own implicit and explicit biases, and consider how inequalities might affect their patients and/or participants with regards to symptomatology, treatment/research experiences, and outcomes (Crisp, 2021). Strengths of this review include the preregistration of the protocol with PROSPERO, the rigorous dual screening process for inclusion and quality assessment, and the use of validated and rigorous tools (EPHPP and CASP) specifically targeted for evaluation of quantitative and qualitative studies. The inclusion of qualitative, quantitative, and mixed-methods studies allowed for a more comprehensive and global understanding of the impact of COVID-19 on target outcomes, not limited to quantifiable measures. Finally, the insights generated from this review led to a practical recommendation guide for individuals living and/or working with EDs and those responsible for public health messaging (see Table 4 ). The findings of the present review should also be considered in light of some limitations. Overall, given the range of divergent findings of studies, it is at present challenging to understand and synthesize these studies in more depth. Although presenting multiple advantages above traditional systematic reviews, mixed-studies reviews may compound the methodological challenges of selecting, appraising, and synthesizing quantitative and qualitative research with the added difficulty of integrating the data in a meaningful way. Although we followed predetermined inclusion and exclusion criteria and multiple authors were engaged in the study selection and data extraction processes, we did not assess interrater reliability. As such, a limitation is that the accuracy of the study selection and data extraction procedures in the current review were not evaluated. Furthermore, no consensus currently exists regarding at which point and in which manner quantitative and qualitative components should be integrated, although existing guidelines were used to minimize this limitation. In addition, mixed-studies reviews present theoretical and methodological challenges of bringing together differently structured studies, addressing different, yet related, questions, and studies conducted within different paradigms (Grant & Booth, 2009 ). For the current review, we adopted the convergent integrated approach (Hong et al., 2017) to ensure that the data from qualitative and quantitative studies were combined and evaluated using an established methodology to increase the richness and robustness of the synthesis (Grant & Booth, 2009; Stern et al., 2020) . The findings of this review show both negative and positive influences of the COVID-19 pandemic and related restrictions on individuals' BI, DE outcomes, ED symptomatology, and overall mental health and well-being. There is currently high variability in study designs, measures used, and findings across different studies and participant samples, precluding firm conclusions regarding the impact of COVID-19 on target outcomes, particularly in the long term. However, the combined findings of this review highlight multiple important considerations for future research, including the need to identify risk and protective factors to enhance BI and eating outcomes, as well as overall mental health during the ongoing pandemic and beyond. 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A mixed-studies systematic review of the experiences of body image, disordered eating, and eating disorders during the COVID-19 pandemic The authors declare no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.