¹The Nutrition Project, India
²Mind Heal(th), India

*Address for Correspondence: Bhatia IN, The Nutrition Project, 7, Embassy Center, Ground Floor, Nariman Point, Mumbai - 400 021, India Tel:+918657991198; E-mail: ishitaa.bhatia@gmail.com

Article Information: Submission: 18/02/2021; Accepted: 10/03/2021; Published: 13/03/2021

Copyright: © 2021 Bhatia IN, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The purpose of the study was to investigate whether there was a significant positive correlation between disordered eating behaviours and mental health concerns (depression, anxiety and stress).

A master survey was electronically circulated to young males and females (age 15-30 years) residing in the city of Mumbai, India during the national lockdown in the month of May 2020. The survey included the DASS-21 questionnaire (depression, anxiety and stress score) and the EDE-Q (Eating Disorder Examination Questionnaire). Subscale and global scores were processed. One-tailed Pearson’s correlation was conducted to investigate the relation between EDE-Q global score and DASS-21 subscale scores. One hundred and eighteen (n=118) respondents took the survey. The mean scores for the depression, anxiety and stress subscales were 15.25 (moderate), 9.94 (moderate) and 16.28 (mild) respectively. Out of the four EDE-Q subscales, the mean score of shape concern appeared to be the highest (2.39 ± 1.6), followed by weight concern (1.96 ± 1.59), restriction (1.31 ± 1.37) and eating concerns (0.92 ± 1.19). The mean global EDE-Q score was 1.65 ± 1.22. A positive correlation was found between EDE-Q global scores and DASS-21 subscale scores i.e. depression (r=0.49; p<0.01) anxiety (r=0.31; p<0.01) and stress (r=0.41; p<0.01). The present study gives insight into mental health conditions and eating behaviours present within an Indian sample during the national lockdown. It opens avenues for discussion for the need of multidisciplinary healthcare teams to provide holistic eating disorder care.

Survey; Depression; Anxiety; Stress; Disordered eating; Lockdown; Correlation; Eating behaviour; Mental health; Pandemic

The widespread COVID-19 outbreak in December of 2019 in China identified that the Chinese public was at a high risk of displaying a myriad of psychological distress and mental health issues. The overall prevalence of mental health conditions - Generalized Anxiety Disorder (GAD) and depressive symptoms were significantly high and the Chinese population indicated higher risk for poorer sleep quality [1]. Current literature suggests that self-reported stress, depression and anxiety symptoms are common psychological responses to the pandemic [2]. In addition, the restricted outdoor mobility and disruptions in daily routines have indicated changes in eating behaviours in individuals as observed by a preliminary health survey [3]. The changes include snacking frequency, eating out of control frequency and hunger/satiety perception, sweet intake frequency etc. [3].

Eating disorders are psychological disorders characterised by abnormal or disturbed eating behaviours with or without compensatory behaviours as diagnosed by DSM-5 [4]. Behaviours include binge-eating, purging, laxative usage, food restrictions and excessive exercise. Disordered eating is a condition described by similar characteristics of a lower level of severity and frequency as that of an eating disorder [4]. Indicators of low self-esteem such as body shape, weight, perception and preoccupation/anxiety towards certain food groups are also found to be related to disturbed eating patterns. It is essential to highlight that populations with depressive symptoms also often experience increased body image dissatisfaction, binge eating and disordered eating behaviors [5]. Conversely, low self esteem, poor body image issues and lack of social support systems are also indicative as potential risk factors for depression [6]. The bidirectional influential nature of these constructs along with the observed high levels of comorbidity between depressive and disordered eating symptomatology warrants a further investigation to explore the relationship between the two.

Furthermore, it is essential to highlight that there is a paucity of research in India to determine the prevalence of eating disorders and disordered eating behaviors due to under-reporting concerns [7]. Although, there have been small and isolated studies in the recent past that indicate the prevalence of disordered eating in India between 16.9% to 29.2% (Table 1).

Majority of the studies conducted in India have predominantly employed the Eating Attitudes Test- 26 item (EAT- 26) measure as the chosen screening tool [7]. However, the EAT-26 aims to assess eating attitudes by calculating scores on only three subscales: 1) Dieting, 2) Bulimia and Food preoccupation and 3) Oral Control. Alternatively, the Eating Disorder Examination Questionnaire (EDE-Q) is considered to be the clinical gold standard screening tool to evaluate the presence of key behavioural and cognitive features present in disordered eating, as well as eating disorders [4]. The EDE-Q has shown to have good internal consistency, high validity and sensitivity [8]. The Depression Anxiety Stress Score (DASS‐21) questionnaire is a well‐established instrument for measuring depression, anxiety, and stress with good reliability and validity reported across cultures [9].

The dearth of Indian research on disordered eating behaviors coupled with the above stated bidirectional influence calls for further empirical inquiry. This lends an opportunity to conduct a study examining the relationship between mental health concerns and disordered eating in the context of COVID-19. The research proposes that a significant positive Pearson’s correlation will be observed between mental health concerns (depression, stress and anxiety scores) and disordered eating scores during the country-wide lockdown.

A 60 item master survey was developed by compiling the 33 item EDE-Q and the 21 item DASS-21 questionnaires, in addition to six demographic questions. Previously validated questionnaires were chosen as they have been extensively tested in the past and thus correctly calibrated to their target [10-12]. A voluntary response sampling method was employed. A web-based survey approach was selected in light of the national lockdown. Compared to manual entry, web-based surveys are time and cost effective. Further, they improve data collection quality and response rate compared with alternative survey forms [13]. The web-based nature facilitated the survey to reach various regions of the city of Mumbai, India. The survey platform employed was Google Forms.

Participants: The 15 minute master survey was electronically distributed to young males and females (age 15-30) residing in the city of Mumbai, India during the national lockdown in the month of May 2020.

Survey: The survey was divided into two main parts, DASS-21 questions and EDE-Q questions. The DASS- depression subscale focuses on reports of low mood, motivation, and self-esteem. The DASS-anxiety on physiological arousal, perceived panic, and fear. Lastly, the DASSstress subscale on tension and irritability [14].

The EDE-Q is a 33 item questionnaire developed by Fairburn and colleagues addressing cognitive features of eating disorders over the past 28 days [15]. It includes subscales like Eating Concerns, Shape concerns, Weight Concerns and Dietary Restraint. The mean of the subscales was employed to calculate the overall EDE-Q global score [15]. This global score was then correlated with the DASS-21 subscales.

Statistics: The responses were maintained on Microsoft Office Excel. Subscale scores and global scores of the respective validated questionnaires were calculated in accordance to the questionnaire guides. One-tailed Pearson’s correlation was conducted using the Statistical Package for the Social Science (SPSS) Statistics software [16,17].

One hundred and eighteen (n=118) complete responses of youth aged 15-30 years from Mumbai, India- were received electronically. Out of the total number of responses 53 (44.9%) were male and 65 (55.1%) were female. More than half of the participants (76; 64.4%) were between 21-25 years of age. Most of the participants were unmarried (114; 96.6%). The mean weight, height and BMI of the participants were 63.57 kgs, 116.3 cm, 22.78 kg/m2 respectively (Table 2).

DASS-21 scores: As per the DASS-21 questionnaire, the mean scores during the national lockdown for the depression and anxiety scales were 15.25 and 9.94 respectively - which is observed as moderate levels of severity. The mean score for the stress scale was 16.28; indicating mild levels of stress (Table 3).

EDE- Q scores: The mean scores of the EDEQ subscales i.e., dietary restraint, eating concerns, shape concerns and weight concern were computed. Out of the four subscales, the mean score of shape concern appeared to be the highest (2.39 ± 1.61), followed by weight concern (1.94 ± 1.59), dietary restraint (1.31 ± 1.37) and eating concerns (0.92 ± 1.19). The mean global EDE-Q score was 1.65 ± 1.22 (Table 4).

Correlation: DASS-21 depression, anxiety and stress subscales, individually showed a significant positive correlation with the EDE-Q global disordered eating scores i.e. r=0.49, p<0.01; r=0.31, p<0.01; r=0.42, p<0.01 respectively (Table 5).

This study is one of the preliminary studies that compares disordered eating behaviours with depression, anxiety and stress in a South Asian sample population. Validated questionnaires have been used to assess the said variables. The present study showed that amongst the DASS-21 subscales - the scores for depression and anxiety subscales were of moderate severity at 15.25 and 9.94 respectively, while the mean score for the stress subscale was of mild severity at 16.28. For the EDEQ subscales, the mean score of shape concern appeared to be the highest (2.39 ± 1.6), followed by weight concern (1.94 ± 1.59), dietary restraint (1.31 ± 1.37) and eating concerns (0.92 ± 1.19). The mean global EDE-Q score was 1.65 ± 1.22. The present study also showed that there are significant positive correlations between disordered eating with depression (r=0.49; p<0.01), anxiety (r=0.31; p<0.01) and stress (r=0.42; p<0.01) respectively.

In the past, studies have explored correlations between disordered eating with mental health concerns [19-21]. Most recently a correlation between stress and disordered eating in first year college women was found [22]. Gan and colleagues have also found positive correlations between stress, anxiety, depression and disordered eating [21]. The current study was set up to re-examine these variables in a South Asian sample population in the backdrop of the COVID-19 lockdown. The results show to be in line with the outcome of previous studies.

Furthermore, examining the observed EDEQ individual subscale scores could facilitate researchers to explore potential reasons for weight and shape concerns to be relatively higher than eating concerns during the national lockdown. This period, marked with isolation and social distancing, seemed to have left individuals and communities excessively using mass media as a coping tool. Social media platforms have seen a 61% increase in consumption as people employ the platforms to stay connected with family, friends, and colleagues [23]. The excessive usage of platforms such as instagram does serve as a potential explanatory force to better comprehend why shape concern is relatively high in the light of lockdown. A recent qualitative study exploring instagram use and body image suggests how participants were inclined to adhering to a variety of beauty standards by responding to beauty ideals such as comparing self with others, and displaying of self. Participants reported significant appearance dissatisfaction when trying to achieve these ideals and frequently compared their photos to the number of likes with others using the platform [24]. One could also draw light on the nature of the content displayed on these platforms during the lockdown. A British study examining the impact on COVID-19 on those with eating disorders states that there was an increase in posts about physical activity (eg. sharing daily exercise routines) and “fear of gaining weight” during the lockdown [25]. There is also some evidence highlighting higher anxiety being significantly associated with higher weight change perception during COVID-19 [26]. Thus, the influx of such content on social media may be a potential contributor to a relatively higher shape and weight concern in the present study participants.

On the other hand, interestingly-participants scored the lowest on the eating concern subscale. The speculated reasons for this may be twofold. Firstly, the lack of availability of a variety of foods, with access to only staples may have made individuals more open to consuming foods that are available even if it is uncharacteristic of their regular food choices. Secondly, social influences of eating may have reduced with the confinement - leading to higher degrees of food freedom. The effect of social comparison on eating behaviours has been discussed in the past. Polivy outlines how people tend to alter not just the amount of food eaten (e.g. women may tend to eat lesser when they want to make a positive impression on someone) but also the kind of food eaten (eg. men avoid eating quiche and other “lady foods,” and choose more hearty meals) in a social setting [27].

It could also be inferred that the uncertainty and lack of control individuals experience during a lockdown causes significant anxiety that they wish to diminish by regaining control in other life spheres. Taking control of their diets, food intake, body shape, size and form could potentially be a sphere that individuals employ to channelize their distress and reclaim their control and power. There is adequate evidence through time, indicating the impact of emotions on eating behaviours across cultures [28-30]. Similarly, in such trying times, one can speculate how food can be used as a coping mechanism, and provide comfort - thus reiterating the influence of mental health concerns on eating behaviours.

There are certain limitations in the present study. The participating sample size (young males and females in Mumbai, India) limits generalizability to other groups and contexts. Moreover, web-surveys can make it difficult to assess the degree of functionality of the sample population. It is essential to note that the data collection measures employed are self-report and are subject to self-report biases. The limited cultural sensitivity of the screening tools employed is crucial to highlight, since they have been used on an Indian sample. Lastly, it is important to highlight that correlation research does not imply causation and hence there could be several other mediating variables that could explain the relations observed which cannot be overlooked.

Looking forward, there are significant, widespread and impactful implications for the findings of the study. It creates awareness about the relation between depression, anxiety, stress and disordered eating. Moreover, it also opens avenues for further discussions for creating an interdisciplinary approach amongst mental health professionals and dietitians to be able to provide appropriate collaborative care, as well as early interventions to prevent clinical eating disorders. The study also contributes to disordered eating and mental health disorders literature within a South Asian cohort, especially during the unconventional COVID-19 era. Larger, temporal and causal studies are required to further investigate and confirm the relation between disordered eating behaviours with mental health concerns.