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\begin{document}

\title{ANXIETY AND EATING DISORDERS DURING THE QUARANTINE OF COVID-19: AN
OBSERVATIONAL STUDY}



\author[1]{Dr. Idiberto Jose Zotarelli Filho, MSc, Ph.D}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 15, 2024}


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\textbf{Beatriz Colovati Saccardo}\textsuperscript{\textbf{1}}\selectlanguage{ngerman}\textbf{,
Camila Saggioro Paulucci¹,~ Pedro Saggioro Paulucci \textsuperscript{1},
Heloisa Dias Sanson¹, Otávio Carbone Ruy¹, Durval Ribas
Filho}\textsuperscript{\textbf{1,2}}\textbf{,}\textsuperscript{\textbf{~}}\textbf{Ana
Valéria Garcia Ramirez}\textsuperscript{\textbf{2,5}}\textbf{, Idiberto
José Zotarelli Filho}\textsuperscript{\textbf{2,3,4}}

~

1.~~~~~ FAMECA, Faculty of Medicine of Catanduva - Padre Albino
University Center, Catanduva/SP, Brazil.

2.~~~~~ Associação Brasileira de Nutrologia (ABRAN)/Brazilian
Association of Nutrology, Catanduva/SP, Brazil.

3.~~~~~ FACERES -- Faculdade de Medicina de São José do Rio Preto/SP,
Brazil.

4.~~~~~ Zotarelli-Filho Scientific Work, São José do Rio Preto/SP,
Brazil.

5.~~~~~ Ana Valeria Ramirez Clínica- Clinic of Nutrition and Health
Science, São José do Rio Preto SP, Brazil.

~ \textbf{Corresponding Author:} Dr. \textbf{} Idiberto José Zotarelli
Filho, MsC, Ph.D. FACERES- Medical School, São José do Rio Preto SP,
Brazil; email: dr.idibertozotarelli@faceres.com.br

~

\textbf{~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Abstract}

\textbf{~}During quarantine, imposed in a pandemic situation by
COVID-19, fears, and uncertainties, in addition to social isolation, are
characterized as risk factors for the mental health of the general
population and the effects can be felt through the manifestation of
conditions anxious, depressive or even binge eating. Binge eating can be
caused by anxiety, especially during quarantine, and the act of eating
is often linked to a way of relieving negative feelings. The research in
question was carried out using an online questionnaire, based on the
Hamilton Anxiety Scale and on the symptoms of binge eating defined by
the Brazilian Society of Neuropsychology. The questionnaire covered 944
people, who answered questions about the theme ``anxiety and binge
eating during quarantine'', 76.9\% were female and 23\% male. Of these
people, 80\% said they ate to escape from worries or relieve stress in
this period of the pandemic, when questioning how much the frequency of
meals per day and quantity changed, there were no significant changes,
however, approximately 50\% of people at least doubled their consumption
of industrialized foods, sweets, and fast foods. Most people (80\%) are
feeling a greater fear than normal, in addition to feeling that this
isolation is affecting mental health and routine and 78.6\% have already
experienced shortness of breath, palpitations, or restlessness during
this period. This group of people stated that this moment has negatively
affected their daily activities, on a scale of 1-10, 76.5\% placed it at
5-10. It was asked about the presence of mood swings, negative thoughts,
and discouragement, 73.8\% of people answered yes, in addition, on a
scale of 1-10, 50\% were between 5-10 when the question was the search
food as a way to feel better. Finally, 82.1\% of people said they were
more anxious in the quarantine period. Regarding the results, there was
a pattern indicating a correlation between anxiety and higher levels of
stress and behavior in which food has a compensatory role towards this
psychic imbalance possibly caused by quarantine. The first question in
the questionnaire is broad and serves as an overview of how much food is
a frequent thought for respondents. In it, 64\% ``said sometimes'' and
15\% ``always'' think about food during the day. As for the frequency
with which they eat, the results indicated that only 37\% of the
interviewees showed a significant increase. However, when it comes to
food quality, more than 20\% scored between 8 and 10 on a scale of 0 to
10, when it comes to increased consumption of processed foods. Showing
worsening in the nutritional quality of the interviewees. It is
concluded that the majority of people who answered the questionnaire
reported signs that indicate the occurrence of anxiety, based on the
Hamilton scale, such as fear and worry. Depending on these data, there
was an increase in the consumption of processed foods, sweets, and fast
foods, which are more accessible and palatable, leading to a feeling of
pleasure at specific times.

~

\textbf{Keywords:} Quarantine. Anxiety. Eating disorders.

\par\null

\textbf{INTRODUCTION}

Social isolation can affect people's routines and mental health. The
effects can be felt through the manifestation of anxiety, depression, or
even binge eating. Studies on impacts on mental health due to the
pandemic of the new coronavirus are still scarce, as it is a recent
phenomenon, but point to important negative repercussions {[}1{]}.

Gordilho (2020), explains that binge eating may have its cause in an
anxiety situation, especially during a quarantine. During this period,
some degree of anxiety may develop in the face of uncertainties, fear,
and distance from family and friends {[}1{]}.

A similar situation occurred in 2003, during the Severe Acute
Respiratory Syndrome Coronavirus --SARS epidemic, another type of
coronavirus, when the psychological impacts of the disease were greater
than the medical impacts, in terms of the number of people affected and
how long they were affected {[}3{]}.

The rapid spread of the new coronavirus throughout the world, the
uncertainties about how to control the disease, the seriousness of it,
as well as the unpredictability about the duration of the pandemic and
its consequences, are characterized as risk factors for the mental
health of the population. general population {[}4{]}. This scenario also
seems to be aggravated by the dissemination of video clips and alarming
messages about COVID-19 through smartphones and computers, often causing
panic {[}5{]}. Likewise, false news has been shared at times contrary to
the guidelines of health authorities and minimizing the effects of the
disease {[}6,7{]}.

In a literature review on quarantine, Brooks et al. (2020) {[}8{]}
identified that the negative effects of this measure include symptoms of
post-traumatic stress, confusion, and anger. Concerns about the scarcity
of supplies and financial losses also cause damage to psychological
well-being {[}9{]}. Symptoms of depression, anxiety, and stress in the
face of the pandemic have been identified in the general population
{[}10{]}.

During quarantine, the reduced possibility of exercising increases the
fear of weight gain, and the storage of non-perishable foods leads to
massive exposure to crackers, snacks, frozen dishes, soft drinks, and
the like. Still, the reduction of the relationship with other people or,
in the opposite direction, greater tension in the face of occasional
social encounters, are factors that cause some anxiety, being potential
triggers for episodes of binge eating {[}11{]}.

Compulsion is usually the result of a combination of factors, including
genetic, emotional characteristics related to life experiences. Binge
eating or Periodic Eating Compulsion Disorder (BED) is an eating
disorder characterized by recurrent episodes of binge eating, where
large amounts of food are eaten quickly until you feel discomfort, even
when not hungry, accompanied by a feeling of a total loss of control.
The person suffering from binge eating experiences shame, anguish, or
guilt after the binge episode {[}12{]}. Binge eating occurs, on average,
at least once a week for a minimum period of 3 months. Binge eating is
not related to the repetition of inappropriate compensatory behaviors
(eg, vomiting) as in the case of bulimia.

One of the most common reasons for binge eating is an attempt to manage
unpleasant emotions, such as stress, depression, loneliness, fear, and
anxiety. But the function of food is to nourish the organism and when
used to fill an emotional gap, it is effective only temporarily, as
emptiness always comes back together with the feeling of guilt since
food works as an immediate emotional reward mechanism {[}13{]}.

Thus, it is possible to see the relationship between anxiety and
Periodic Eating Compulsion Disorder, intensified during quarantine, in a
pandemic scenario, which requires social isolation. Therefore, the
present observational and cross-sectional study analyzed the
relationship between anxiety and binge eating during the quarantine of
COVID-19.

\textbf{METHODS}

The research in question is an observational, transversal, descriptive,
and quantitative study. Data collection was carried out in cities in the
interior of São Paulo using an online questionnaire, based on the
Hamilton Anxiety Scale and the main symptoms of binge eating defined by
the Brazilian Society of Neuropsychology, composed of 16 direct
questions for the people interviewed. about the theme of the
relationship between anxiety and binge eating during quarantine
{[}13{]}.

The questionnaire was developed specifically for this study by the
authors of this study, during the month of May 2020 and was available
for answers during the months of May, June, and July 2020. In addition,
the informed consent form was duly applied. Through it, an extensive and
direct observation was made on the subject, obtaining data from 944
people of different age groups, sex, occupations, and cities in the
interior of São Paulo.

\textbf{RESULTS}

The questionnaire covered 944 people, who answered questions about the
topic ``anxiety and binge eating during quarantine''. All of them
accepted the free and informed consent form. As for sex, 76.9\% were
female and 23\% male.

1. Do you think about food all the time (for example, do you have a meal
thinking about the next one?

- 64.5\% (609 people) posted sometimes, 20.6\% (194 people) never posted
and 14.6\% (141 people) always posted.

2. Do you eat to escape from worries, relieve stress, or to comfort
yourself?

- 73.2\% (691 people) did it at specific times, 19.2\% (181 people)
never did it and 7.6\% (72 people) did it at all meals.

3. Do you eat until you feel full (do you eat even after satiety)?

- 41.1\% (388 people) posted more than twice a week, 36.5\% (345 people)
posted once a week and 22.4\% (211 people) never posted.

4. Do you eat in secret / are you ashamed of how much you eat?

- 66.7\% (630 people) said no, 23.2\% (219 people) said the times and
10.1\% (95 people) said yes.

5. Do you feel guilty at times when you overeat?

- 45\% (425 people) said yes, 30.3\% (286 people) said the times and
24.7\% (233 people) said no.

6. How much has the frequency of eating per day increased at this time?

- It was analyzed on a scale of 1-10. 20.4\% (193 people) put 1; 13.8\%
(130 people) put 2; 15.5\% (146 people) put 3; 12\% (113 people) put 4;
15.8\% (149 people) put 5; 6.6\% (62 people) put 6; 6.4\% (60 people)
put 7; 6.5\% (61 people) put 8; 1.3\% (12 people) put 9 and 1.9\% (18
people) put 10 (Figure 1).

Figure 1. How often you eat each day.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}

1. How much has your food amount increased per meal?

It was analyzed on a scale of 1-10. 28\% (264 people) put 1; 19\% (179
people) put 2; 16.6\% (157 people) put 3; 8.8\% (83 people) put 4;
13.3\% (126 people) put 5; 3.6\% (34 people) put 6; 3.1\% (29 people)
put 7; 4.2\% (40 people) put 8; 0.6\% (6 people) put 9 and 2.8\% (26
people) put 10 (Figure 2).

Figure 2. Increase in the amount of food per meal.

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

1. How much has the consumption of processed foods, sweets, fast foods,
among others, increased?

It was analyzed on a scale of 1-10. 23.2\% (218 people) put 1; 11.4\%
(108 people) put 2; 9.4\% (89 people) put 3; 8.8\% (83 people) put 4;
12.8\% (121 people) put 5; 5.2\% (49 people) put 6; 7.4\% (70 people)
put 7; 9.3\% (88 people) put 8; 4.2\% (40 people) put 9 and 8.3\% (78
people) put 10 (Figure 3).

Figure 3. Increased consumption of processed foods, sweets, fast foods.

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}

1. Do you feel that at this moment you are feeling a greater fear and
concern than usual?

80.2\% (757 people) said yes and 19.8\% (187 people) said no.

2. If you answered yes to the previous question, do you feel that it has
hindered your mental health and routine?

- It was analyzed by a scale of 1-10. 8.3\% (67 people) put 1; 5.5\% (44
people) put 2; 5.5\% (44 people) put 3; 5\% (40 people) put 4; 14.1\%
(114 people) put 5; 8.2\% (66 people) put 6; 10.3\% (83 people) put 7;
17.4\% (140 people) put 8; 6.3\% (51 people) put 9 and 19.5\% (157
people) put 10 (Figure 4).

Figure 4. Has the increased consumption of processed foods, sweets, fast
foods hindered your mental health and routine?

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

\end{center}
\end{figure}



1. During quarantine, did you have feelings of shortness of breath,
palpitations, or restlessness?

- 52\% (491 people) answered sometimes, 31.4\% (296 people) answered
never and 16.6\% (157 people) answered always.

2. How much has it affected you negatively to stop doing things that you
were used to and now can't? (see the people you like, exercise, etc.)

- It was analyzed by a scale of 1-10. 3.7\% (35 people) put 1; 2\% (19
people) put 2; 4\% (38 people) put 3; 4.7\% (44 people) put 4; 9.1\% (86
people) put 5; 7.5\% (71 people) put 6; 14.1\% (133 people) put 7;
19.1\% (180 people) put 8; 10.9\% (103 people) put 9 and 24.9\% (235
people) put 10 (Figure 5).

Figure 5. The negative impact of not doing routine things.

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-5/Figure-5}

\end{center}
\end{figure}

1. Have you been experiencing a major change in mood, negative thoughts,
and discouragement at this time?

- 73.8\% (697 people) answered yes and 26.2\% (247 people) answered no.

2. Have you had more difficulty sleeping during this period?

- 58.3\% (550 people) answered yes and 41.7\% (394 people) answered no.

3. During periods like this, do you look for food in a way to feel
better?

- It was analyzed by a scale of 1-10. 21.5\% (203 people) put 1; 9.5\%
(90 people) put 2; 11.4\% (108 people) put 3; 7.7\% (73 people) put 4;
12.7\% (120 people) put 5; 8.4\% (79 people) put 6; 6.7\% (63 people)
put 7; 7.7\% (73 people) put 8; 3.1\% (29 people) put 9 and 11.2\% (106
people) put 10 (Figure 6).

Figure 6. Pleasure in the food?

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-6/Figure-6}

\end{center}
\end{figure}

1. Do you consider yourself more anxious in this quarantine period?

82.1\% (775 people) answered yes and 17.9\% (169 people) answered no.

\textbf{DISCUSSION}

Regarding the results, we could see a pattern indicative of a
correlation between anxiety and higher levels of stress and behavior in
which food has a compensatory role towards this psychic imbalance
possibly caused by quarantine. Here are the results:

The first question in the questionnaire is broad and serves as an
overview of how much food is a frequent thought for respondents. In it,
64\% ``stated sometimes'' and 15\% ``always'' think about food during
the day. We can thus associate it with two other questions that show us
that 73\% of respondents use food to relieve stress at specific times
and 7.6\% always; and that 41\% of respondents eat beyond satiety more
than twice a week and 36\% once a week, which are indications of
compulsive eating behavior, possibly triggered by increased anxiety in
the quarantine period.

About how they feel after eating, 75\% always or sometimes feel guilty,
but 67\% do not eat in secret nor are they ashamed of it, only 10\% do
so. As for the frequency with which they eat, the results indicated that
only 37\% of the interviewees showed a significant increase (a score of
5 to 10 on a scale of 0 to 10).

However, when it comes to food quality, more than 20\% scored between 8
and 10 on a scale of 0 to 10, when it comes to increasing consumption of
processed foods (sweets, fast foods, and the like). Showing worsening in
the nutritional quality of the interviewees. Henceforth, we proceeded to
questions of a psychological nature based on the Hamilton anxiety scale.

A total of 80.2\% of respondents reported an increase in fear/concern
since the beginning of the quarantine, among them, 75\% scored grades
between 5 and 10 on a scale of 0 to 10, with almost 20\% having a
maximum score for how much social isolation has hampered your mental
health. In addition, only 31.4\% had no feeling of shortness of breath,
palpitation, or restlessness during social isolation. Another result
that is in line with the previous one is that 85\% of the interviewees
scored 5 or more on a scale of 0 to 10 in which the lack of coexistence
with their family, friends, and loved ones has negatively affected their
psychological state, being that 25\% of respondents scored 10 in this
regard. In addition, 73.8\% reported mood swings, negative thoughts, and
discouragement and 58\% reported difficulty sleeping.

Finally, there was a scattered result on the question of eating to feel
better. 21\% had a minimum score for this aspect (grade 1), 11\% had a
maximum score (grade 10), and 50\% scored from 5 to 10, which may reveal
that people with compulsive eating behavior are not fully aware of this
behavior, since 80.2\% consider themselves more anxious due to the
pandemic and the feeding patterns of the previous questions reveal a
worsening in the quality of the respondents' food and an increase in the
amount of food per day; and anxiety patterns were confirmed by questions
based on the Hamilton anxiety scale.

In this scenario of the results of the present study, one should not
only help to care for those who suffer from contracting COVID-19, but
one must also address the psychological, financial, and social impact -
on those who do not. The peculiarities of COVID-19 and the reaction of
the public and governments to it are particularly relevant for people
living with an eating disorder and those who care for them.

Traumatic events affect people's mental health. The fear of contagion
and the death of family members created enormous uncertainty. Isolation
brings anxiety, sadness, anger, and loneliness. Social detachment and
''quarantine'' are against human nature. The negative emotional effects
of ``quarantine'' are likely to be accentuated for many individuals with
anorexia nervosa who are already emotionally and physically isolated
{[}14{]}.

In this sense, people with an eating disorder have a complex problematic
relationship with food, which will be intensified at this time of food
insecurity and panic buying {[}14{]}. Undoubtedly, there will be an
abundance of research in the coming months and years documenting the
impact that COVID-19 will have on the eating disorders community, both
from the perspective of the clinician and the patient. In addition,
there are similarities between previous outbreaks and the COVID-19
pandemic, as these outbreaks have resulted in an increasing sense of
foreboding and fear, as well as heightened feelings of anxiety and panic
and symptoms associated with post-traumatic stress disorder. {[}15{]}.

In addition, many people with bulimia nervosa and binge eating disorder
now stay at home 24 hours a day, seven days a week. There is no escape
from distancing yourself from food at home and the opportunities to go
out and buy food are limited. Overeating with family food when refueling
is problematic can lead to more family conflicts, increased emotional
arousal, depression, and anxiety, as well as the likelihood of increased
self-harm or even suicide {[}15{]}.

\textbf{CONCLUSION}

It is concluded that the majority of people who answered the
questionnaire reported signs that indicate the occurrence of anxiety,
based on the Hamilton scale, such as fear and worry. Also, they stated
that the COVID-19 pandemic period has negatively affected daily
activities, referring to mood swings, negative thoughts, and
discouragement. Depending on these data, there was an increase in the
consumption of processed foods, sweets, and fast foods, which are more
accessible and palatable, leading to a feeling of pleasure at specific
times. Therefore, anxious behaviors are triggered in restrictive
periods, such as quarantine, causing sporadic compulsive eating events
in search of momentary satisfaction.

\textbf{Declaration of Potential Conflict of Interest}

The authors declare no conflict of interest.

\textbf{Funding}

Not applicable

\textbf{Data sharing statement}

No additional data are available

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\end{enumerate}

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