Eating disorders (EDs) are serious mental-health conditions that are prevalent worldwide, with the average point prevalence of 4.6% in the United States (US), 2.2% in Europe, and 3.5% in Asia (Galmiche et al., 2019). Unfortunately, ED symptoms have increased in Western and non-Western societies following the onset of the SARS-CoV-2 or “COVID-19” pandemic (Kurisu et al., 2021; Schafer et al., 2022). In fact, ED-related hospitalizations have increased by a staggering 48% since the onset of the COVID-19 in Western societies (Devoe et al., 2022). Although many factors are likely contributing to the increase in ED symptoms since the COVID-19 pandemic began, studies conducted in Western contexts have reported that COVID-related fears and insomnia (Ramos-Padilla et al., 2021) have worsened ED symptoms (Castellini et al., 2020; Devoe et al., 2022; Hart et al., 2022; Mannino et al., 2021; Mehak et al., 2022). Recent studies have noted that in the past three decades, research centered on ethnic and racial minority individuals and samples outside of Europe and the US have been lacking, and it is unclear which risk factors may be shared and which factors may be distinct between White Euro-US samples and other samples (Egbert et al., 2022; Mikhail & Klump, 2021). While 70% of studies in the ED field comprise of White samples, less than half of all studies include any ethnic or racial minorities (Egbert et al., 2022). Hence, conducting studies using understudied samples will advance diversity and equity within the field of EDs. The current study aims to examine how fear of COVID-19 and insomnia may relate to ED symptoms in one such understudied sample comprising of Iranian adults.Like Western societies (i.e., Schafer et al., 2022), the prevalence of ED symptoms has increased during COVID-19 pandemic in Iran (Faramarzi et al., 2021; Firoozjah et al., 2022), with a recent study demonstrating increased point prevalence of binge eating (25.30%), purging (2.9-3.5%) and clinically1 significant levels of ED symptoms (25.50%; Sahlan et al., under review).
Dear Visitors,
Please find below a study that was published in Science Direct, ‘Fear of COVID-19, insomnia, and eating disorder symptoms among Iranian college students’. We share this study for research and the information purposes only.
Fear of COVID-19 insomnia and eating
disorder
symptoms among Iranian college students
Highlights
- •
We found that fear of COVID-19 had a significant positive main effect on eating disorder (ED) symptoms.
- •
Insomnia had a significant positive main effect on ED symptoms, except for purging.
- •
Insomnia did not moderate associations between fear of COVID-19 and ED symptoms.
Abstract
Objective
Eating disorders (EDs), fear of COVID-19, and insomnia have all increased during the COVID-19 pandemic in Western societies. Additionally, fear of COVID-19 and sleep disturbances relate to ED symptoms in Western societies. However, it is unknown whether fear of COVID-19 and insomnia relate to ED symptoms in non-Western countries, such as Iran. Thus, this study examined the relation between fear of COVID-19, insomnia, and ED symptoms among Iranian college students. Specifically, we hypothesized that insomnia and fear of COVID-19 would each uniquely relate to ED symptoms and the interaction between insomnia and fear of COVID-19 would also associate with increased ED symptoms.
Method
College students (N =1,043) filled out measures assessing fear of COVID-19, insomnia, and ED symptoms. We ran moderation analyses using linear regression for global ED symptoms and negative binomial regressions for binge eating and purging.
Results
Fear of COVID-19 and insomnia had unique effects on global ED symptoms and binge eating. Insomnia, but not fear of COVID-19, had a unique effect on purging. No significant interaction effect was found.
Discussion
This study was the first to examine the association between fear of COVID-19 and insomnia on ED symptoms in Iran. Fear of COVID-19 and insomnia should be incorporated into novel assessments and treatments for EDs.
Keywords
Fear of COVID-19
Insomnia
Global eating disorder symptoms
Binge eating
Purging
College students
1. Introduction
Eating disorders (EDs) are serious mental-health conditions that are prevalent worldwide, with the average point prevalence of 4.6% in the United States (US), 2.2% in Europe, and 3.5% in Asia (Galmiche et al., 2019). Unfortunately, ED symptoms have increased in Western and non-Western societies following the onset of the SARS-CoV-2 or “COVID-19” pandemic (Kurisu et al., 2021; Schafer et al., 2022). In fact, ED-related hospitalizations have increased by a staggering 48% since the onset of the COVID-19 in Western societies (Devoe et al., 2022). Although many factors are likely contributing to the increase in ED symptoms since the COVID-19 pandemic began, studies conducted in Western contexts have reported that COVID-related fears and insomnia (Ramos-Padilla et al., 2021) have worsened ED symptoms (Castellini et al., 2020; Devoe et al., 2022; Hart et al., 2022; Mannino et al., 2021; Mehak et al., 2022). Recent studies have noted that in the past three decades, research centered on ethnic and racial minority individuals and samples outside of Europe and the US have been lacking, and it is unclear which risk factors may be shared and which factors may be distinct between White Euro-US samples and other samples (Egbert et al., 2022; Mikhail & Klump, 2021). While 70% of studies in the ED field comprise of White samples, less than half of all studies include any ethnic or racial minorities (Egbert et al., 2022). Hence, conducting studies using understudied samples will advance diversity and equity within the field of EDs. The current study aims to examine how fear of COVID-19 and insomnia may relate to ED symptoms in one such understudied sample comprising of Iranian adults.
Like Western societies (i.e., Schafer et al., 2022), the prevalence of ED symptoms has increased during COVID-19 pandemic in Iran (Faramarzi et al., 2021; Firoozjah et al., 2022), with a recent study demonstrating increased point prevalence of binge eating (25.30%), purging (2.9-3.5%) and clinically1 significant levels of ED symptoms (25.50%; Sahlan et al., under review). However, it is unclear what specific attributes of COVID-19 pandemic lead to elevated ED symptoms. Importantly, as has been found in the US (i.e., Schafer et al., 2022), the COVID-19 pandemic has led to high mortality rates in Iran (Khalagi et al., 2021; Tadbiri et al., 2020) which has resulted in high rates of fear of COVID-19 (i.e., COVID-19-related symptoms, catching virus, etc; Ahorsu et al., 2020) among Iranian individuals. It is possible that individuals with COVID-related fear and anxiety may engage in ED behaviors in order to manage these distressing emotions (Mehak et al., 2022; Vuillier et al., 2021), thereby exacerbating their ED symptoms. Thus, fear of COVID-19 may contribute to EDs in Iran. Hence, examining the relation between fear of COVID-19 and ED symptoms in an Iranian context would add to the nascent literature on how the COVID-19 pandemic has affected ED symptoms in a global context.
Another factor that contributes towards increased ED symptoms is insomnia. Individuals with EDs are more likely to experience insomnia than the general population, and insomnia in turn exacerbates ED symptoms (Asaad Abdou et al., 2018; Cooper et al., 2020). Insomnia has been shown to be common among college students with ED symptoms in Western (Bos et al., 2013; Soares et al., 2011) and non-Western (i.e., Iran; Golmohammadi et al., 2019) societies showing associations between insomnia and more severe ED symptoms. ED symptoms and insomnia also co-occur among college samples (25-30%; Aspen et al., 2014), and insomnia has direct (Kauffman et al., 2018) and indirect (through depression and anxiety; Goel et al., 2021) effects on ED symptoms.
Additionally, fear of COVID has shown associations with insomnia (Voitsidis et al., 2020) and this finding has also been replicated across cultural contexts. Specifically, fear of COVID-19 has been linked to insomnia among adults in Bangladesh (Hasan et al., 2021), Pakistan (De Clercq et al., 2021), Turkey (Yilmaz et al., 2021), and Iran (Akbarpour et al., 2022; Lin et al., 2020). A recent study indicated that 55.2% of Iranian adults reported insomnia during COVID-19 (Akbarpour et al., 2022), which is higher than Western societies (37.6%; Voitsidis et al., 2020). Thus, examining the relation between insomnia in addition to fear of COVID-19 symptoms, would allow us to test two novel risk factors for ED symptoms within an Iranian context. Taken together, we posit that insomnia and fear of COVID-19 may uniquely and conjointly relate to ED symptoms in an Iranian context. In other words, we hypothesized that insomnia would heighten the relation between fear of COVID-19 and ED symptoms.
The present study examined fear of COVID-19, insomnia, and ED symptoms among a sample of Iranian college students. In line with previous studies (H1; Hart et al., 2022; Mannino et al., 2021; Mehak et al., 2022), we first hypothesized that fear of COVID-19 would independently have an effect on increased ED symptoms. Second, in accordance with previous research (H2; Bos et al., 2013; Kauffman et al., 2018), we postulated that insomnia would independently have an effect on ED symptoms. Third, we hypothesized (H3; Castellini et al., 2020; Devoe et al., 2022; Schafer et al., 2022) that insomnia would moderate the association between fear of COVID-19 and ED symptoms. Specifically, we predicted that the relation between fear of COVID-19 and ED symptoms would be stronger at high (vs low) levels of insomnia.
2. Methods
2.1. Participants and procedure
We recruited college students (n = 1,043; 88.1% women) from four Iranian cities with diverse geographic zones, and most participants (92.9%) were vaccinated against COVID-19 (see Table 1 for demographic information). From August 2021 to March 2022, we collected data via online links in university groups (i.e., social media [WhatsApp, Telegram, Instagram]), and participants were directed to a battery of questionnaires after providing informed consent. Due to COVID-19 related precautions, the current study was conducted remotely and participants completed study surveys on their personal electronic devices from locations of their choosing. In line with research norms in Iran (e.g., Sahlan, Williams et al., 2021), participants were not provided any remuneration for participation. The study was approved by the institutional review board from a large Iranian university.
Table 1. Participant Demographic Information and Mean Différences across Groups.
| Empty Cell | Range | Mean (SD) | |||||
| Age (years) | 18-27 | 20.77±2.08 | |||||
|---|---|---|---|---|---|---|---|
| BMI (kg/m2) | 14.34-42.45 | 23.70±4.27 | |||||
| Empty Cell | Men (n = 124) | Women (n = 919) | ANOVA | ||||
| Empty Cell | M±SD | M±SD | F | p | Eta | ||
| Global ED symptoms | 1.22±1.11 | 1.71±1.38 | 14.53 | .001 | .014 | ||
| Binge eating | 2.44±4.62 | 3.20±6.03 | 1.84 | .175 | .002 | ||
| Purging | .27±2.31 | .53±2.76 | .96 | .328 | .001 | ||
| Insomnia | 10.69±5.71 | 11.97±5.86 | 5.26 | .022 | .005 | ||
| Fear of COVID-19 | 14.25±5.85 | 16.15±5.82 | 11.65 | .001 | .011 | ||
| No past covid diagnosis | Yes past covid diagnosis | ||||||
| (n = 508, 48.7%) | (n = 535, 51.3%) | ||||||
| Global ED symptoms | 1.48±1.27 | 1.82±1.41 | 16.67 | .001 | .016 | ||
| Binge eating | 2.54±5.08 | 3.64±6.51 | 9.19 | .002 | .009 | ||
| Purging | .36±1.93 | .63±3.27 | 2.63 | .105 | .003 | ||
| Insomnia | 11.02±5.71 | 12.57±5.90 | 18.58 | .001 | .018 | ||
| Fear of COVID-19 | 16.20±6.02 | 15.66±5.69 | 2.24 | .134 | .002 | ||
| No current covid diagnosis | Yes current covid diagnosis | ||||||
| (n = 1018, 97.6%) | (n = 25, 2.4%) | ||||||
| Global ED symptoms | 1.66±1.35 | 1.47±1.49 | .46 | .498 | .00 | ||
| Binge eating | 3.16±5.93 | 1.16±2.87 | 2.82 | .094 | .003 | ||
| Purging | .49±2.72 | .88±2.33 | .51 | .475 | .000 | ||
| Insomnia | 11.86±5.86 | 9.92±5.52 | 2.69 | .101 | .003 | ||
| Fear of COVID-19 | 15.91±5.88 | 16.64±5.03 | .38 | .538 | .13 | ||
| No received covid vaccine | Yes received covid vaccine | ||||||
| (n = 74, 7.1%) | (n = 969, 92.9%) | ||||||
| Global ED symptoms | 1.64±1.37 | 1.66±1.36 | .01 | .929 | .000 | ||
| Binge eating | 3.46±6.50 | 3.08±5.83 | .29 | .593 | .000 | ||
| Purging | .73±3.99 | .48±2.59 | .59 | .444 | .001 | ||
| Insomnia | 11.64±6.76 | 11.83±5.78 | .08 | .784 | .000 | ||
| Fear of COVID-19 | 15.97±7.22 | 15.92±5.74 | .01 | .943 | .000 | ||
| ED symptoms group | Binge eating group | Purging group | |||||
| (n = 268, 25.7%) | (n = 265, 25.4%) | (n = 40, 3.8%) | |||||
| Subthreshold insomnia % | 39.6 | 43.0 | 32.5 | ||||
| Moderate insomnia % | 30.6 | 29.4 | 35.0 | ||||
| Severe insomnia % | 12.7 | 9.1 | 20.0 | ||||
| Fear of COVID-19 M±SD | 17.43±6.0 | 16.77±5.99 | 15.43±6.17 | ||||
| Subthreshold insomnia group | Moderate insomnia group | Severe insomnia group | |||||
| (n = 437, 41.9%) | (n = 248, 23.8%) | (n = 75, 7.2%) | |||||
| Global ED symptoms % | 24.3 | 33.1 | 45.3 | ||||
| Binge eating % | 26.1 | 31.5 | 32.0 | ||||
| Purging % | 3.0 | 5.6 | 10.7 | ||||
| Fear of COVID-19 M±SD | 16.56±5.95 | 17.27±6.12 | 17.69±6.49 | ||||
2.2. Measures
Demographic Collection. Participants reported on demographic variables including age, gender, height, and weight, and answered three COVID-related questions (i.e., are you currently suffering from COVID-19?, did you get COVID-19 in the past?, did you get vaccinated against COVID-19?). Height and weight information was used to calculate participant BMI.
Farsi-Fear of COVID-19 Scale. We used a Farsi version of this scale to examine COVID-related fears (e.g., it makes me uncomfortable to think about coronavirus-19, I cannot sleep because I’m worrying about getting coronavirus-19; Ahorsu et al., 2020). The scale includes 7 items which are rated on a five-point Likert scale ranging from 1 (Strongly disagree) to 5 (Strongly agree). A total score is calculated by adding up each item score (ranging from 7 to 35) and a higher score is indicative of a greater fear of COVID-19. This scale has demonstrated appropriate validity and reliability in Iranian adults (Ahorsu et al., 2020), and Cronbach’s α was .87 in this sample.
Farsi-Insomnia Severity Index (F-ISI). We used the F-ISI (Yazdi et al., 2012) to assess severity of insomnia (e.g., problems waking up too early, difficulty falling asleep). This scale includes 7 items which are rated on a five-point Likert scale ranging from 0 (Not at all) to 4 (Extremely). A total score is calculated by adding up each item score (ranging from 0 to 28), and a higher score is indicative of greater severity of insomnia. Participants were either categorized as being nonclinical (scores of 0–7, 27.1%), or as having subthreshold (8–14, 41.9%), moderately severe (15–21, 23.8%), or severe clinical insomnia (22–28, 7.2%). The F-ISI has demonstrated appropriate validity and reliability in Iranian adults (Yazdi et al., 2012). Cronbach’s α was .87 in this sample.
Farsi-Eating Disorder Examination Questionnaire – 6th Edition (F-EDE-Q). We used the combined original four subscales of the F-EDE-Q (i.e., dietary restraint, shape concern, weight concern, eating concern; Sahlan et al., 2020; Sahlan, Saunders et al., 2021) to examine global ED symptoms over the past 28 days. The global ED symptoms items (e.g., have you had a definite fear that you might gain weight?, how dissatisfied have you been with your weight?) are rated on a seven-point Likert scale ranging from 0 (No days) to 6 (Every day). In addition, a single item was used to examine binge eating (i.e., having loss of control over eating and consuming a large amount of food). Self-induced vomiting and laxative misuse alone were not common behaviors among our sample. Thus, we merged both self-induced vomiting and laxative misuse-related items to assess purging as they are both similar disordered eating-related compensatory behaviors. Thus, in line with a previous study in Iran (Sahlan et al., 2021), we also summed self-induced vomiting and laxative misuse items to provide one purging frequency index. The F-EDE-Q has demonstrated appropriate validity and reliability in Iranian adults and adolescents (Sahlan et al., 2020; Sahlan, Saunders et al., 2021). In the current study, 25.7% of participants reported clinical levels of ED symptoms (i.e., ≥2.5; EDE-Q, global score; Rø et al., 2015) based on a threshold determined in clinical samples. Additionally, the distribution of recurrent behavioral ED symptoms (≥4 episodes in the past 28 days) was as follows: binge eating (25.4%) and purging (i.e., 1.3-3.1% [self-induced vomiting, laxative misuse]). In this study, we evaluated global ED symptoms, binge eating, and purging. Cronbach’s α was .94 for a global score of the F-EDE-Q in this sample.
2.3. Data analytic plan
There were no missing data on any of the scales administered. We used one-way analysis of variance (ANOVA) to examine where mean differences in disordered eating-related variables existed across gender and COVID-19-related groups (i.e., past COVID, current COVID, and COVID vaccination). Regarding main results, we conducted moderation analyses using linear and binomial regression to examine if the interaction between fear of COVID-19 and insomnia were associated with global ED symptoms, binge eating, and purging, respectively. Negative binominal regression was used for the binge eating and purge moderation analyses as the outcome variables consisted of count data and the standard deviation exceeded the mean for both binge eating (M = 3.11, SD = 5.88) and purging (M = .50, SD = 2.71). All models were run on SPSS version 26.
3. Results
Analyses of variances (ANOVA)2 were used to examine gender and group differences on the variables. Participants who had a past diagnosis of COVID-19 reported higher global ED symptoms (M = 1.82, SD = 1.41, F = 16.67, p<.001), binge eating (M = 3.64, SD = 6.51, F = 9.19, p<.002), and insomnia (M = 12.57, SD = 5.90, F = 18.58, p<.001) than those who had not had COVID-19. Notably, college women reported significantly higher scores than men on fear of COVID-19 (M = 16.15, SD = 5.82, F = 11.65, p<.001), global ED symptoms (M = 1.71, SD =1.38, F = 14.53, p<.001), and insomnia (M = 11.97, SD = 5.86, F = 5.26, p<.021). Of note, there were no gender differences for binge eating and purging. Also, a prior diagnosis of COVID-19 did not influence purging and fear of COVID-19. There were no differences in global ED symptoms, binge eating, purging, insomnia, and fear of COVID-19 when comparing individuals who currently had been diagnosed with COVID-19 to those that were currently vaccinated against COVID-19 (see Table 1 for more information). Overall, college students with ED symptoms (i.e., global ED symptoms, binge eating, purging) endorsed varying severity (subthreshold, moderate, and severe) of insomnia and fear of COVID-19, and the distribution of insomnia severity also varied across ED symptoms and fear of COVID-19 (see Table 1 for more information). Pearson correlations were examined among study variables and are reported in Table 2. All variables were significantly positively associated with one another, except for relation between fear of COVID-19 and purging.
Table 2. Pearson Correlations between Study Variables.
| Empty Cell | Fear of COVID-19 | Insomnia | Global ED symptoms | Binge eating |
| Fear of COVID-19 | – | |||
|---|---|---|---|---|
| Insomnia | .20* | – | ||
| Global ED symptoms | .16* | .24* | – | |
| Binge eating | .10* | .15* | .45* | – |
| Purging | .02a | .14* | .27* | .20* |
Note: * = p < .001. a. Non-significant
After accounting for covariates, results from the linear regression showed significant independent effects of fear of COVID-19 (b = .03, SE =.01, p = <.001, 95% CI = [.01, .04]) and insomnia (b=.05, SE = .01, p = <.001, 95% CI = [.04, .06]) on global ED. Specifically, a .03 unit increase in global ED symptoms was expected with every unit increase in fear of COVID-19, and a .05 unit increase in global ED symptoms was expected with every unit increase of insomnia. There was no interaction between fear of COVID-19 and insomnia on global ED symptoms (b = .00, SE = .008, p = .74, 95% CI = [-.002, .002]). These findings suggest that insomnia and fear of COVID-19 independently, but not conjointly, relate to global ED symptoms (See Table 3).
Table 3. Regressions of independent variables and covariates on global ED symptoms.
| Empty Cell | B | SE | β | t | Sig. | 95%CI [Lower, Upper] |
| (constant) | -3.32 | .33 | -10.12 | .00 | [-3.97, -2.68] | |
|---|---|---|---|---|---|---|
| Gender | .61 | .11 | .15 | 5.56 | .00 | [.39, .82] |
| BMI | .16 | .01 | .49 | 18.76 | .00 | [.14, .17] |
| Current COVID-19 | -.11 | .23 | -.01 | -.50 | .62 | [-.56, .33] |
| Past COVID-19 | .13 | .07 | .05 | 1.89 | .06 | [-.01, .27] |
| Vaccination | .11 | .14 | .02 | .79 | .43 | [-.16, .37] |
| Fear of COVID-19 | .03 | .01 | .11 | 4.10 | .00 | [.01, .04] |
| Insomnia | .05 | .01 | .22 | 8.12 | .00 | [.04, .06] |
| Int (Fear of COVID-19*Insomnia) | .00 | .00 | .01 | .33 | .74 | [-.00, .00] |
Note: Global ED symptoms is the dependent variable in each regression. Int. = Interaction.
Results from a negative binomial regression analysis revealed that fear of COVID-19 and insomnia accounted for a significant amount of variance in binge eating, likelihood ratio X2 (2) = 374.36, p < 0.001. After accounting for covariates, the interaction between fear of COVID-19 and insomnia did not have unique effect on binge eating (p = 0.054). Fear of COVID-19 (B = .02, p < 0.001, 95% CI [.02, .08]) and insomnia (B = .08, p < 0.001, 95% CI [.04, .12]) had significant unique effects on binge eating. Specifically, with each one-unit increase in fear of COVID-19, the expected log count of binge eating increases by .02, and with each one-unit increase in insomnia, the expected log count of binge episodes increases by .08. Similar to the findings with global ED symptoms, these findings suggest that insomnia and fear of COVID-19 independently relate to binge eating, but the interaction of insomnia and fear of COVID-19 was not significant.
Results from a negative binomial regression analysis revealed that fear of COVID-19 and insomnia accounted for a significant amount of variance in purging, likelihood ratio X2 (2) = 167.90, p < 0.001. After accounting for covariates, the interaction between fear of COVID-19 and insomnia did not have a unique effect on purging (p > 0.05). Fear of COVID-19 was not a significant unique effect on purging. However, insomnia (B = .11, p < 0.001, 95% CI [.06, .17]) had a unique effect on purging. Specifically, with each one-unit increase in insomnia, the expected log count of purging increases by .11. Hence, insomnia, but not fear of COVID-19, uniquely related to purging symptoms.
4. Discussion
The purpose of the current study was to examine the relation between fear of COVID-19, insomnia, global ED symptoms, binge eating, and purging in a sample of Iranian college students. Consistent with our first hypothesis and previous research (Hart et al., 2022; Mannino et al., 2021; Mehak et al., 2022), fear of COVID-19 uniquely related to global ED symptoms, binge eating, and purging. Given that fear of COVID-19 is common in Iran (i.e., Ahorsu et al., 2020), global ED symptoms may be strategies by which college samples cope with fear of COVID-19 during pandemic (Kurisu et al., 2021; Schafer et al., 2022). Further, our results were also consistent with our second hypothesis and previous literature (i.e., Bos et al., 2013; Kauffman et al., 2018), albeit with some mixed findings; insomnia during COVID-19 uniquely related to global ED symptoms, binge eating, and purging. Finally, we did not find evidence to support our third hypothesis, as the interaction between fear of COVID-19 and insomnia did not relate to ED symptoms.
Our findings add to the literature by noting that fear of COVID-19 and insomnia independently relate to ED symptoms but may not have a synergistic effect on ED symptoms in this sample. In particular, our findings support growing literature that the chronic stress and psychological distress exerted by anxiety and fear around the COVID-19 pandemic has deleterious effects on ED symptoms (Mehak et al., 2022; Schafer et al., 2022). In line with previous findings (Bos et al., 2013; Tanahashi et al., 2017), we found insomnia related to purging in our study.
Lastly, we did not find support for our last hypothesis that fear of COVID-19 symptoms’ association with ED symptoms would vary by insomnia. There are several potential explanations for these patterns of results. For example, approximately 41.9% of our sample demonstrated subthreshold insomnia. Despite this high rate, we ultimately did not utilize a sample with clinical levels of insomnia and this may have influenced the differential associations between our constructs. It is also possible that insomnia and fear of COVID-19 simply do not interact with one another when predicting ED symptoms. Taken together, further research is needed to validate this pattern of results in populations with more clinical levels of insomnia.
4.1. Clinical implications
Our results have some clinical implications. Given that ED symptoms and insomnia are common among Iranian college students (Akbarpour et al., 2022; Sahlan et al., 2020; Sahlan, Williams et al., 2021), clinicians should consider assessing for ED symptoms among individuals presenting with comorbid fear of COVID-19 and insomnia. In addition, given that our results were consistent with previous studies findings that sleep problems are elevated among patients with EDs (Kinkel-Ram et al., 2021; Padez-Vieira & Afonso, 2016), novel assessments and screening protocols for EDs may consider including questions about insomnia severity. Additionally, screening for fear of COVID-19 and insomnia among students may help colleges to identify at-risk students who may also be in need of psychological interventions for ED symptoms. Since sleep disturbances appear to be qualitatively less stigmatizing than ED symptoms (i.e., Griffiths et al., 2015; He et al., 2022), individuals could potentially more accurately report on these this than ED related constructs. Also, given that evidence-based treatments incorporating cognitive-behavioral therapy (CBT) are already widely used to treat EDs, such as enhanced cognitive behavior therapy for EDs (CBT-E; Fairburn, 2008), CBT interventions incorporating interventions for insomnia, such as cognitive behavioral therapy for insomnia (CBT-I), and CBT interventions incorporating interventions for fear of COVID-19 (CBT-C) may be beneficial in conjunction with CBT-E to target fear of COVID-19, insomnia symptoms alongside ED symptoms (Hertenstein et al., 2022; Samantaray et al., 2022; Smith et al., 2005).
4.2. Strengths, limitations, and future directions
This was the first study to examine the associations among fear of COVID-19, insomnia, and ED symptoms. A strength of the present study was the use of an understudied sample (i.e., Iranian college students) within the context of ED research. Bearing these strengths in mind, the results of the present study should be interpreted with consideration of some limitations. As we sought to find preliminary evidence of the relation between our study variables, we used a non-clinical sample, and the data is cross-sectional that cannot examine temporal relationships among the variables. Hence, there may be limited generalizability to clinical ED samples, and predictive inferences cannot be made. Future studies should continue to examine how fear of COVID-19 and insomnia relate to ED symptoms longitudinally and within clinical samples (e.g., Nagata et al., 2021). Furthermore, researchers should use other more comprehensive and multi-faceted ED symptoms questionnaires (i.e., Farsi-Eating Pathology Symptoms Inventory [F-EPSI]; Sahlan et al., 2022, 2023) that assess both women (i.e., drive for thinness) and men’s (i.e., muscularity) ED symptoms. Additionally, as has been done in a previous study (Sahlan et al., 2021), our purging variable included both self-induced vomiting and laxative misuse, however, it may be important to examine these behaviors, separately.
5. Conclusions
The current study found that fear of COVID-19 and insomnia uniquely related to global ED symptoms, binge eating, and purging among Iranian college students, but the interaction between these variables did not significantly relate to ED symptoms. This study bridges a gap in the literature and was the first to examine the relations between these constructs and within an understudied sample. Thus, our findings suggest that ED symptoms should be assessed for among college students presenting with insomnia and fear of COVID-19, and also points to the potential of incorporating both insomnia and COVID-19 fears in ED treatments.
Contributions
Reza N. Sahlan: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Software; Writing – original draft; Writing – review & editing. Shruti S., Kinkel-Ram: Conceptualization; Formal analysis; Methodology; Project administration; Writing – original draft; Writing – review & editing. Kelechi Uzoegwu: Formal analysis; Methodology; Writing – original draft; Writing – review & editing. April Smith: Project administration; Supervision; Writing – review & editing. All authors have reviewed and approved the final version of the manuscript.
Funding
This research received no specific grant.
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
Acknowledgment
We would like to thank the college students who made this research possible.
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(≥2.5; Eating Disorder Examination-Questionnaire [EDE-Q], a global score; Rø et al., 2015).
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. We ran both controlled (ANCOVA, controlling for gender, COVID-related items) and uncontrolled analyses (ANOVA), and given that they did not differ, we report only uncontrolled analyses for clarity.
