Disordered eating among university students at pre- and post - COVID-19: a repeated cross-sectional study
DOI:
https://doi.org/10.13129/2282-1619/mjcp-5279Keywords:
Anxiety, COVID-19 pandemic, Disordered eating, Emotion regulation, University studentsAbstract
Background: Although the COVID-19 pandemic has passed, its impact on university students’ mental health remains evident, with lasting increases in anxiety, depression, and eating disorder symptoms. A repeated cross-sectional comparison was conducted to understand the role of weight concerns, emotion regulation, stress, anxiety and depression in the expression of eating disorders (ED) symptoms among two independent cross-sectional university samples collected in 2019, before COVID-19, and in 2022, after the pandemic.
Method: A total of 845 students completed the Depression, anxiety, stress questionnaire-21, the Difficulties in emotion regulation scale and the Weight concerns scale as part of a campus-wide campaign that aimed to raise awareness on psychological well-being among students, conducted before and after the pandemic. Multiple regression with interactions was run to test the effects of emotion regulation, stress, anxiety, depression and weight concerns on ED symptoms, controlling for participants’ age and sex.
Results: Results showed significant increases in students’ levels of stress, anxiety, depression as well as higher emotion regulation difficulties at post-pandemic. There were also, significant effects of anxiety and emotion regulation on ED symptoms across both years whereas students who experienced higher stress and weight concerns in 2022, towards the end of the pandemic, were more likely to report ED symptoms as compared to students at pre-pandemic.
Conclusion: These findings indicate that significant changes were noted in students’ emotional well-being while students with higher stress and weight concerns were more prone to disordered eating after the pandemic. Further evaluation of these factors is necessary to better understand the impact of COVID-19 on ED risk among university students and to inform universities efforts to revise and adapt prevention and screening programs to the post-COVID-19 era.
References
Alonso, J., Vilagut, G., Mortier, P., Auerbach, R. P., Bruffaerts, R., Cuijpers, P., Demyttenaere, K., Erbert, D. D., Ennis, E., Gutiérrez-García, R. A., Greif Green, J., Hasking, P., Lee, S., Bantjes, J., Nok, M. K., Pinder-Amaker, S., Sampson, N A., Zaslavsky, A. M., Kessler, R. C. & WHO WMH‐ICS Collaborators. (2019). The role impairment associated with mental disorder risk profiles in the WHO World Mental Health International College Student Initiative. International Journal of Methods in Psychiatric Research, 28(2), e1750. https://doi.org/10.1002/mpr.1750
Anthony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176–181. http://doi.org/10.1037/1040-3590.10.2.176
Arsandaux, J., Montagni, I., Macalli, M., Texier, N., Pouriel, M., Germain, R., Mebarki, A., Kinouani, S., Tournier, M., Schuck, S., & Tzourio, C. (2021). Mental health condition of college students compared to non-students during COVID-19 lockdown: the CONFINS study. BMJ Open, 11(8), e053231. https://doi.org/10.1136/bmjopen-2021-053231
Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G., Zaslavsky, A. M., Kessler, R. C., & WHO WMH-ICS Collaborators. (2018). WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623. https://dx.doi.org/10.1037/abn0000362
Baenas, I., Caravaca‐Sanz, E., Granero, R., Sánchez, I., Riesco, N., Testa, G., Vintró-Alcaraz, C., Treasure, J., Jiménez-Murcia, S., & Fernández‐Aranda, F. (2020). COVID‐19 and eating disorders during confinement: Analysis of factors associated with resilience and aggravation of symptoms. European Eating Disorders Review, 28(6), 855-863. https://doi.org/10.1002/erv.2771
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 912–920. https://doi.org/10.1016/S0140-6736(20)30460-8
Elmer, T., Mepham, K., & Stadtfeld, C. (2020). Students under lockdown: Comparisons of students’ social networks and mental health before and during the COVID-19 crisis in Switzerland. Plos one, 15(7), e0236337. https://doi.org/10.1371/journal.pone.0236337
Esposito, G., Passeggia, R., Pepicelli, G., Cannata, A., Di Natale, M. R., Parlato, F., & Freda, M. F. (2023). Supporting university students during the pandemic: A study on the efficacy of a mentalizing online group counselling. Mediterranean Journal of Clinical Psychology, 11(1). https://doi.org/10.13129/2282-1619/mjcp-3705
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41(5), 509-528. https://doi.org/10.1016/S0005-7967(02)00088-8
Flaudias, V., Iceta, S., Zerhouni, O., Rodgers, R. F., Billieux, J., Llorca, P. M., Boudesseul, J., de Chazeron, I., Romo, L., Maurage, P., Samalin, L., Bègue, L., Naassila, M., Brousse, G., & Guillaume, S. (2020). COVID-19 pandemic lockdown and problematic eating behaviors in a student population. Journal of Behavioral Addictions, 9(3), 826-835. https://doi.org/10.1556/2006.2020.00053
Galmiche, M., Dechelotte, P., Lambert, G., & Tavolacci, M. P. (2019). "Prevalence of eating disorders over the 2000-2018 period: A systematic literature review." American Journal of Clinical Nutrition, 109(5), 1402–1413. https://doi.org/10.1093/ajcn/nqy342
Gao, Y., Bagheri, N., & Furuya-Kanamori, L. (2022). Has the COVID-19 pandemic lockdown worsened eating disorders symptoms among patients with eating disorders? A systematic review. Journal of Public Health, 30(11), 2743-2752. Vol.:(0123456789)1 3. https://doi.org/10.1007/s10389-022-01704-4
Garfinkel, P. E., & Newman, A. (2001). The Eating Attitudes Test: Tenty-five Years Later. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 6. https://doi.org/https://doi.org/10.1007/BF03339747
Garner, D. M., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric Features and Clinical Correlates. Psychological Medicine, 12(4), 871–878. https://doi.org/10.1017/S0033291700049163
Gómez, J. F. P., & Grisales, A. M. (2023). Executive functioning in college students with anxiety and depression: a multivariate analysis. Mediterranean Journal of Clinical Psychology, 11(1). https://doi.org/10.13129/2282-1619/mjcp-3596
Gómez-Tabares, A. S., Restrepo, J. E., Aguirre, N. H., & González-Pérez, A. (2024). The Mediating role of purpose in life in the relationship between hopelessness, depression, and suicide risk. Mediterranean Journal of Clinical Psychology, 12(1). https://doi.org/10.13129/2282-1619/mjcp-4047
Graham, J. W., Olchowski, A. E., & Gilreath, T. D. (2007). How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prevention Science, 8(3), 206–213. https://doi.org/10.1007/s11121-007-0070-9
Gratz, K. L., & Roemer, L. (2004). Multidimensional Assessment of Emotion Regulation and Dysregulation: Development, Factor Structure, and Initial Validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94
Graupensperger, S., Cadigan, J. M., Einberger, C., & Lee, C. M. (2023). Multifaceted COVID-19-related stressors and associations with indices of mental health, well-being, and substance use among young adults. International Journal of Mental Health and Addiction, 21(1), 418-431. https://doi.org/10.1007/s11469-021-00636-6
Hair, J. F., Risher, Jeffrey J., Sarstedt, M., Ringle, C. M., Svensson, G., Svensson, G.. (2018). When to use and how to report the results of PLS-SEM. European Business Review, 31(1), 2–24. https://doi.org/10.1108/EBR-11-2018-0203
Harel, O. (2009). The estimation of R2 and adjusted R2 in incomplete data sets using multiple imputation. Journal of Applied Statistics, 36(10), 1109–1118. https://doi.org/10.1080/02664760802553000
Killen, J. D., Taylor, C. B., Hayward, C., Wilson, D. M., Haydel, K. F., Hammer, L. D., Simmonds, B., Robinson, T. N., Litt, I., Varady, A., & Kraemer, H. (1994). Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: A three‐year prospective analysis. International Journal of Eating Disorders, 16(3), 227–238. https://doi.org/10.1002/1098-108X(199411)16:3<227::AID-EAT2260160303>3.0.CO;2-L
Klanduchova, E., & Adamovska, L. (2025). Emotion and stress related eating and personality dimensions predict food addiction: Implications for personalized weight management and primary prevention. Mediterranean Journal of Clinical Psychology, 13(1). https://doi.org/10.13129/2282-1619/mjcp-4328
Koushiou, M., Nikolaou, P., & Karekla, M. (2020). Prevalence and correlates of eating disorders in greek-cypriot adolescents and young adults. The European Journal of Counselling Psychology, 8(1), 3-18. https://doi.org/10.5964/ejcop.v8i1.170
Leppanen, J., Brown, D., McLinden, H., Williams, S., & Tchanturia, K. (2022). The role of emotion regulation in eating disorders: a network meta-analysis approach. Frontiers in Psychiatry, 13, 793094. https://doi.org/10.3389/fpsyt.2022.793094
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343. https://doi.org/10.1007/BF02511245
Machado, P. P., Pinto-Bastos, A., Ramos, R., Rodrigues, T. F., Louro, E., Gonçalves, S., Brandão, I., & Vaz, A. (2020). Impact of COVID-19 lockdown measures on a cohort of eating disorders patients. Journal of Eating Disorders, 8, 1-8. https://doi.org/10.1186/s40337-020-00340-1
Marshall, A., Altman, D. G., Holder, R. L., & Royston, P. (2009). Combining estimates of interest in prognostic modelling studies after multiple imputation: Current practice and guidelines. BMC Medical Research Methodology, 9(1), 1–8. https://doi.org/10.1186/1471-2288-9-57
McEnery, F., Fitzgerald, A., McNicholas, F., & Dooley, B. (2016). Fit for Purpose, Psychometric Assessment of the Eating Attitudes Test-26 in an Irish Adolescent Sample. Eating Behaviors, 23, 52–57. https://doi.org/10.1016/j.eatbeh.2016.07.006
Meng, X.-L., & Rubin, D. B. (1992). Performing Likelihood Ratio Tests with Multiply-Imputed Data Sets Author. Biometrika, 79(1), 103–111. https://doi.org/10.1093/biomet/79.1.103
Merlyn, M. F., Moreta-Herrera, R., Díaz-Mosquera, E., Orbe, C., Rodas, J. A., Caycho-Rodríguez, T., & Torres-Gomez, B. (2025). Negative Body Image and Negative Eating Attitudes as Predictors of Depressive Symptoms in Women. Mediterranean Journal of Clinical Psychology, 13(3). https://doi.org/10.13129/2282-1619/mjcp-4989
Prefit, A. B., Candea, D. M., & Szentagotai-Tătar, A. (2019). Emotion regulation across eating pathology: A meta-analysis. Appetite, 143, 104438. https://doi.org/10.1016/j.appet.2019.104438
Quirama, T. C., Restrepo, J. E., & Alzate, R. C. (2025). Effects of Academic Stress on Psychological Distress and Suicidal Ideation in University Students: The Mediating Role of Coping Strategies. Mediterranean Journal of Clinical Psychology, 13(3). https://doi.org/10.13129/2282-1619/mjcp-5093
Raghunathan, T., Solenberger, P., Berglund, P., & van Hoewyk, J. (2022). IVEware: Imputation and Variance Estimation Software. https://smponline.isr.umich.edu/software/wp-content/uploads/iveware_manual_updated_19nov2022.pdf
Rodgers, R. F., Lombardo, C., Cerolini, S., Franko, D. L., Omori, M., Fuller‐Tyszkiewicz, M., Linardon, J., Courtet, P., & Guillaume, S. (2020). The impact of the COVID‐19 pandemic on eating disorder risk and symptoms. International Journal of Eating Disorders, 53(7), 1166-1170. https://doi.org/10.1002/eat.23318
Rodríguez, P. J., Restrepo, J. E., & Lara, R. M. M. (2024). Self-Care mediates the Effect of Psychological Distress on the Subjective Well-Being and Quality of Life among University Students. Mediterranean Journal of Clinical Psychology, 12(3). https://doi.org/10.13129/2282-1619/mjcp-4349
Salimi, N., Gere, B., Talley, W., & Irioogbe, B. (2023). College students mental health challenges: Concerns and considerations in the COVID-19 pandemic. Journal of College Student Psychotherapy, 37(1), 39-51. https://doi.org/10.1080/87568225.2021.1890298
Simone, M., Emery, R. L., Hazzard, V. M., Eisenberg, M. E., Larson, N., & Neumark‐Sztainer, D. (2021). Disordered eating in a population‐based sample of young adults during the COVID‐19 outbreak. International Journal of Eating Disorders, 54(7), 1189-1201. https://doi.org/10.1002/eat.23505
Smink, F. R., van Hoeken, D., Oldehinkel, A. J., Hoek, H. W. (2014). Prevalence and severity of DSM-5 eating disorders in a community cohort of adolescents. International Journal of Eating Disorders 47, 610–619. https://doi.org/10.1002/eat.22316
Son, C., Hegde, S., Smith, A., Wang, X., & Sasangohar, F. (2020). Effects of COVID-19 on college students’ mental health in the United States: Interview survey study. Journal of Medical Internet Research, 22(9), e21279. https://doi.org/10.2196/21279
Swinbourne, J. M., & Touyz, S. W. (2007). The co‐morbidity of eating disorders and anxiety disorders: A review. European Eating Disorders Review: The Professional Journal of the Eating Disorders Association, 15(4), 253-274.
https://doi.org/10.1002/erv.784
Tavolacci, M. P., Ladner, J., & Déchelotte, P. (2021). Sharp increase in eating disorders among university students since the COVID-19 pandemic. Nutrients, 13(10), 3415. https://doi.org/10.3390/nu13103415
Van Buuren, S. (2018). Flexible imputation of missing data (2nd ed.). CRC Press. https://stefvanbuuren.name/fimd/
Victor, S. E., & Klonsky, E. D. (2016). Validation of a Brief Version of the Difficulties in Emotion Regulation Scale (DERS-18) in Five Samples. Journal of Psychopathology and Behavioral Assessment, 38(4), 582–589. https://doi.org/10.1007/s10862-016-9547-9
Vuillier, L., May, L., Greville-Harris, M., Surman, R., & Moseley, R. L. (2021). The impact of the COVID-19 pandemic on individuals with eating disorders: the role of emotion regulation and exploration of online treatment experiences. Journal of eating disorders, 9, 1-18. https://doi.org/10.1186/s40337-020-00362-9
Wang, C., Wen, W., Zhang, H., Ni, J., Jiang, J., Cheng, Y., Zhou, M., Ye, L., Feng, Z., Ge, Z., Luo, H., Wang, M., Zhang, X., & Liu, W. (2021). Anxiety, depression, and stress prevalence among college students during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of American College Health, 71(7), 2123-2130. https://doi.org/10.1080/07448481.2021.1960849
Zipfel, S., Schmidt, U., & Giel, K. E. (2022). The hidden burden of eating disorders during the COVID-19 pandemic. The Lancet Psychiatry, 9(1), 9-11. https://doi.org/10.1016/S2215-0366(21)00435-1
Downloads
Published
Issue
Section
License
Articles and conference papers published in Mediterranean Journal of Clinical Psychology are distributed under the terms and conditions of a Creative Commons Attribution 4.0 Unported License. Correspondingly, authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
