Are Individuals with Eating Disorders at Greater Risk from COVID-19?

By Jennifer L. Gaudiani, MD, CEDS-S, FAED

I’ve been thinking about this question a lot lately, and many concerned patients and their families have asked me the same. The short and purely scientific answer is that we just don’t know, because we don’t have data.

However, these are my thoughts on the topic from a medical, whole-person, social justice-oriented perspective. On the whole, yes, I feel that individuals with eating disorders of all body shapes and sizes are at greater risk for a severe/dangerous version of COVID-19.

Anorexia nervosa in patients with low body weight: When someone in this category gets COVID, there are a couple significant risks:

· One, they may not have sufficient muscle strength to mount a strong cough. It turns out that coughing is remarkably important during a respiratory illness, and without the ability to cough and clear secretions from the lungs, patients may decompensate earlier and require hospitalization or even mechanical ventilation. Plus, starvation physiology may lead these patients not to be able to mount a typical fever, which could lead to missed assessment of severity or even leave them undiagnosed.

· Two, experiencing a life-threatening illness while malnourished and at a lower body weight is almost certain to result in even more inadequate nutrition intake which puts serious strain on all organs and can result in deadly complications like hypoglycemia.

· Three, there’s little chance that an overwhelmed hospital system will have the resources and knowledge base to care for critically ill patients with anorexia nervosa properly, from preventing skin breakdown to nourishing with the thousands of calories these individuals will need due to becoming hypermetabolic when a modality like tube feeding is started.

Anorexia nervosa in patients of “normal” or higher body weight: I’m just not going to call this atypical anorexia nervosa, its formal diagnosis in the DSM-5, because that’s such a stigmatizing and useless designation.

· These individuals have all the same body system dysfunction—bradycardia, low blood pressure, poor circulation, digestive slowing, poor skin and gut tissue quality—as the above category of patients. But lack of provider awareness runs the risk of key markers of systemic shut-down being missed. Someone who normally runs a pulse of 50 due to malnutrition for instance may present with a pulse of 85 at rest, which looks “normal” to a provider but in fact reflects a significantly heightened pulse.

· The above risks with lower-weight anorexia nervosa also apply.

Bulimia nervosa:

· Developing a serious infectious condition while dehydrated, with low potassium and possibly low magnesium and low phosphorus could increase risk for respiratory muscle failure and cardiac arrest.

· There’s no question that bodies are put under serious strain during COVID. We know that patients who are older and those with other medical conditions have substantially higher mortality rates. Someone who purges regularly (whether from anorexia nervosa or bulimia nervosa) starts out at a grave disadvantage due to electrolyte abnormalities and dehydration, just at a time when they need good circulating blood volume to keep heart rate and blood pressure stable.

· Serious rebound edema can develop when purging ceases—such as when hospitalized for COVID—and not only will medical providers NOT know how to diagnose and treat this, but it could further compromise respiratory function due to fluid overload.

Binge eating disorder in any body size:

· Restriction is a core element of binge eating disorder, and many patients with BED are not well nourished. Thus, some of the above concerns apply.

· BED can be associated with some of the comorbidities noted to be most risky for poor COVID outcomes, including hypertension and diabetes.

Above all, we have to think about limited intensive care resources in our medical system, and the overwhelmed, exhausted providers who are on the front lines facing an onslaught of seriously ill people with COVID. Perhaps what I fear most is that triaging—literally deciding in the moment who will live and who will die based on who gets that last ventilator—which has been required across the world already, is based on an individual provider’s spot-judgement about who is likeliest to survive. Anyone with an eating disorder and their family has experienced the profound error that medical providers mistakenly make in thinking they can look at someone’s body and determine how healthy they are. I worry profoundly that the population of individuals with eating disorders will be mis-triaged based on body appearance in the moment of truth, no matter where they fall on the weight spectrum.

Please: take this time to quarantine, care for yourself, focus on recovery work (rather than using this isolation as an opportunity to go deeper down the rabbit hole with your eating disorder), and reach out to your doctor immediately with any COVID symptoms.