Disordered eating behaviors, food insecurity and the COVID-19 pandemic among undergraduate students in the United States: a systematic review

Abstract

Background

Eating disorders are highly prevalent among undergraduate students at colleges and universities in the United States (US). These behaviors may be associated with food insecurity and the COVID-19 pandemic, as both represent stressors that may be difficult for young adults to independently manage and cope with, turning to maladaptive coping strategies that are characteristic of disordered eating. The aim of this systematic review was to understand the relationship between eating disorders, defined by DSM-5 criteria, and food insecurity among undergraduate college students in the US, with additional consideration for the effects of the COVID-19 pandemic.

Methods

PubMed, Cochrane Library, Scopus, Global Health (Ovid), PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Psychology Database were searched from 2014 to 2024 to capture eating disorders as defined by the DSM-5 criteria, searching terms representing eating disorders, food insecurity, and COVID-19. Articles were screened independently by 2 researchers using inclusion criteria agreed upon by all authors.

Results

Disordered eating was associated with food insecurity and changes in behavior due to the COVID-19 pandemic. All studies were cross sectional with the number of participants ranging from 98 to 1996. Due to heterogeneity in assessment tools used in studies pooling of data and direct comparison of findings was limited. While no study measured eating disorders, food insecurity, and COVID-19 together, studies did reveal that food insecurity and COVID-19 were both associated with emotional eating that may indicate a greater risk for binge eating disorder.

Conclusions

While the overall data is limited, studies examining the effect of food insecurity or COVID-19 on undergraduate eating behaviors found that students experienced a significant increase in depressive and anxious symptoms contributing to disordered eating patterns. This may have a long-term impact on academic and health outcomes for young adults.

Systematic Review Registration: PROSPERO registration number CRD42024577588.

Plain language summary

This systematic review of peer-reviewed manuscripts published between 2013 (the year the DSM-5 was updated) and 2024 that examine disordered eating, food insecurity, and COVID-19 among undergraduate students in the United States found that food insecurity and COVID-19 were associated with higher emotional eating, particularly binge eating disorder, among undergraduate students. Although no studies examined the effect of disordered eating, food insecurity, and COVID-19 together, the relationship between major life stressors (e.g., food insecurity and COVID-19) and disordered eating behaviors highlight greater need for institution-level supports for these groups of emerging adults, as the behaviors can have long-term impacts on health and wellness.

Introduction

The transition from high school to undergraduate college can be a particularly challenging period for adolescents. This period of emerging adulthood involves a deeper development of one’s identity including sense of self, solidification of values, and clarification of goals. Additionally, many young adults experience a change in access to and availability of the support networks previously sustaining their health and wellbeing [1]. Undergraduate students become increasingly responsible for independently meeting their nutritional requirements, which can worsen existing food insecurity [2] and exacerbate patterns of disordered eating. [3–5]. As with any transition, this change requires responsive adaptation, however, achieving this end can be particularly challenging for those students who rely on disordered eating behaviors to regulate their emotions [6]. The psychological impact of the COVID-19 pandemic resulted in an increase in the number of adolescents relying upon maladaptive coping strategies to manage stress, therefore it is imperative to examine food insecurity and disordered eating patterns on college campuses.

Food insecurity is an established risk factor for poor overall physical and mental health [7–10], increased financial stress [11, 12], decreased academic achievement [13], and higher levels of eating disordered pathology [14] among college students. The 2020–2025 Dietary Guidelines emphasize that food insecurity prevents individuals and families from following a healthy dietary pattern. [15] College students are particularly vulnerable to shifts in food security status due to changes in living conditions, variable sources of income and financial support, and mounting financial pressures requiring additional jobs to supplement income while living on or around campus [16]. The estimated national prevalence of food insecurity among college students varies drastically from 10 to 82% [17, 18], which is markedly higher than the estimated national average of approximately 10.2% among United States (US) households in 2021 [19]. The National College Health Assessment (NCHA), which surveyed 23,866 undergraduates across the US in Fall 2022, found that 43.7% of respondents reported any food insecurity, based on responses to the US Household Food Security Survey Module [20], and 77.8% of respondents reported a moderate or high level of stress within the last 30 days [21].

Disordered eating patterns are similarly pervasive on college campuses. While the 12-month prevalence of eating disorders was estimated to be less than 1% of the adult population worldwide [22], estimates vary widely for students, ranging from 14% to 32% among female students [23, 24], and 4 to 13% for male students [23, 24]. The COVID-19 pandemic impacted the prevalence of eating disorders, with one study reporting an increase to 52% among female students and 31% among male students. [24]. Despite these rising numbers of eating disorders among college students, the Fall 2022 National College Health Association found that only 6.9% of respondents self-reported ever being formally diagnosed with an eating disorder [21], which corresponds to fewer students receiving treatment [5]. Prevalence estimates may not accurately capture the full scope of disordered eating thoughts and behaviors among students who may engage with these beliefs, yet not meet formal diagnostic criteria guidelines. Formal diagnosis with an eating disorder is based on meeting criteria established by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [25].

The impact of the COVID-19 pandemic on both food insecurity and eating disorders on campus is not yet fully understood, particularly as campuses are reconciling the long-term impacts of the pandemic on students who may have missed critical developmental milestones due to the timing of the pandemic. The purpose of this systematic review was to examine the relationship between food insecurity and disordered eating under the DSM-5 definitions [25], with additional consideration of the effects of COVID-19, among undergraduate students attending colleges and universities in the US. Our goal is to identify interventions and policies that will support student health and optimize academic outcomes.

Methods

The protocol was pre-registered in PROSPERO (CRD42024577588) and search strategy was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to trace and report progress on the systematic search for studies [26]. Fig. 1 depicts the PRISMA flowchart of the search strategy. The study also utilized a Population, Intervention, Context, and Outcomes (PICO) framework, defined in Fig. 2.

Fig. 1.

PRISMA flowchart of the literature search and review process

Fig. 2.

PICO framework to define systematic review

Search strategy

A comprehensive search of seven databases (PubMed, Cochrane Library, Scopus, Global Health (Ovid), PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Psychology Database) was conducted for English-language articles published between 2013 and 2024. This time frame was selected to ensure that articles were reflective of current practices and behaviors among college students, and disordered eating was defined in accordance with DSM-5 criteria (published 2013) [25]. Search terms included (disordered eating OR eating disorder OR “anorexia nervosa” OR bulimia OR binge eating disorder) AND (undergraduate students OR college students OR university students) AND (food insecurity OR food security OR COVID-19). Following the completion of searches, duplicates were removed.

Eligibility criteria

Original research articles were included if they were observational (cross-sectional and cohort studies); reported disordered eating with measurement using validated instruments; assessed student food insecurity or impact of the COVID-19 pandemic; and examined undergraduate students studying at colleges and universities in the United States. Non-English language manuscripts, editorials, reviews, meta-analyses, randomized intervention studies, and case studies were excluded. Studies reporting pooled results of undergraduate and graduate students were excluded. As undergraduate students differ significantly from graduate students by their full-time enrollment status, living on campus, work experience, family status, and age [27], which all influence the development of their relationship to disordered eating, food insecurity, and experience during the COVID-19 pandemic, studies examining graduate students were excluded from the analysis.

Data extraction

Eligible articles were exported to Zotero and managed using Covidence. The titles and abstracts, and subsequently the full-text articles, were independently screened and reviewed against the inclusion criteria by B.M.H. and M.H. Where there was disagreement, the full text manuscript was consulted with input from all co-authors to reach agreement for a final decision. A data-extraction tables was completed following the selection of studies, which was divided based on study measurements (Tables 1 and 2). Due to heterogeneity of methodological approaches between the studies examined, this review followed the Synthesis without Meta-analysis (SWiM) guideline recommendations [28]. The Risk of Bias for Nutrition Observational Studies (RoB-NObs) Tool was used to assess risk of bias due to confounding, selection bias, bias in classification of exposures, bias due to departures from intended exposures, bias due to missing data, bias in the measurement of outcomes and bias in the selection of reported results [29].

Table 1.

Characteristics and results of included studies, COVID-19 and eating disorders (n = 6)

Reference	Sample	Measures	Results
Bronfman et al. (2023) [1]	n = 202; 42.9% female; mean age 20.7 ± 1.6 years (range 18–23)	COVID-19: Epidemic-Pandemic Impacts Inventory (EPII) [2] Food Insecurity: None Eating Disorder: Eating Disorder Examination Questionnaire (EDE-Q) 28-item questionnaire [3]	Eating disorder psychopathology was associated with social isolation, physical and mental health impacts of COVID-19, depressive, and anxiety symptoms. COVID-19 infection exposures were associated with BN (aOR:1.14 (1.06,1.22)) Increased social media use was associated with BED (aOR: 1.13 (1.01, 1.25))
Coakley & Gonzalez-Pacheco (2020) [4]	n = 526; 92.8% female; mean age 24.2 ± 6.0 years; dietetics undergraduate students	COVID-19: no validated tool used; asked questions that were categorized on a likert scale Food Insecurity: None Eating Disorder: no validated tool used; participants were asked if they experienced an eating disorder during the fall 2020 semester	31.9% of respondents reported experiencing an eating disorder during the fall of 2020
Harris et al. (2023) [5]	n = 1996; 71.6% female; mean age 20.1 ± 3.5 years	COVID-19: conducted in context of COVID-19, but did not specifically query effects of pandemic Food Insecurity: None Eating Disorder: Eating Competence (ecSI 2.0™) [6]; Weight-and-body shame and/or guilt (WEB-SG) [7]; Weight satisfaction single question [8]; Current weight loss effort single question [9]; Sick-Control-One stone-Fat-Food (SCOFF) 5-item survey [10]	Women reported lower body weight satisfaction compared to men (p < 0.001). Nearly half (47.93%) of respondents were trying to lose weight. Based on the SCOFF survey, 41.2% of participants were at risk for an eating disorder, with women demonstrating the highest prevalence of risk (45.0%)
Sanzari et al. (2023) [11]	2 cross-sectional surveys: 2015 Sample: n = 359; 54.9% female; mean age 19.4 ± 2.9 years 2022 Sample: n = 267; 54.3% female; mean age 19.1 ± 1.5 years	COVID-19: sample 2 were asked about the perceived impact of the COVID-19 pandemic on their social media use, changes to use, and whether they sought out specific social media content related to weight loss and/or body positivity. Food Insecurity: None Eating Disorder: Eating Disorder Examination Questionnaire (EDE-Q) 38-item questionnaire [12]	Higher social media use was associated with lower body satisfaction scores, higher BMI, more frequent binge eating and vomiting (p < 0.05). Respondents with higher social media use and exposure to weight loss content reported higher binge frequency. Participants reported higher social media use post-COVID-19, including greater consumption of weight loss social media content, which was associated with higher body image disturbances and disordered eating behaviors when compared to sample 1.
Scharmer et al. (2020) [13]	n = 295; 65.1% female; mean age 19.7 ± 2.0 years	COVID-19: Fear of Illness and Virus Evaluation (FIVE) 35-item measure assessing fear and anxiety associated with infectious disease modified to reference the “coronavirus public health emergency.” Unpublished instrument. [14]; Intolerance of COVID-19 uncertainty scale 12-item scale, tailored by authors to relate to the coronavirus pandemic [15, 16]. Food Insecurity: None Eating Disorder: Eating Disorder Examination Questionnaire (EDE-Q) 38-item questionnaire [12]	Bivariate analysis found that COVID-19 anxiety and intolerance of uncertainty was correlated with higher EDE-Q scores (p < 0.001)
Wojtaszek & Saules (2024) [17]	2 cross-sectional surveys: Wave 1 (8/2020-12/2020) n = 230; 73% female; mean age 20.8 ± 4.9 years Wave 2 (3/2021-4/2021) n = 179; 66% female; mean age 21.4 ± 5.6 years	COVID-19: asked about impacts from COVID-19 including job status, living situation, health status, uncertainty related to contracting COVID-19 or losing a job, vaccination status; Intolerance of Uncertainty Scale (IUS-12) [16] Food Insecurity: None Eating Disorder: Recognizing Addictive Disorders scale (RAD) assessed binge eating [18]; Composite Measure of Problem Behaviors (CMPR) measured restrictive eating [19]; Exercise and Eating Disorders questionnaire (EED) [20]	Bivariate analysis found that binge eating behaviors were higher during COVID-19 in both waves of data collection (p < 0.01 for both). There was no significant effect of COVID-19 on restrictive eating.

Table 2.

Characteristics and results of included studies, food insecurity and eating disorders (n = 5)

Reference	Sample	Measures	Results
Darling et al. (2017) [21]	n = 98; 75% female; mean age 18.23 ± 0.74 years; freshmen college students	COVID-19: study conducted prior to COVID-19 Food Insecurity: Core Food Security Screener [22] Eating Disorder: Eating Disorder Examination Questionnaire (EDE-Q) 38-item questionnaire [12]	28% of sample endorsed experiencing food insecurity at least once. Those with a history of food insecurity had a higher BMI (mean 27.25 ± 6.39 kg/m2 versus 24.18 ± 5.3 kg/m2; p < 0.05) and higher waist-to-height ration (mean 0.532 ± 0.09 versus 0.48 ± 0.07; p < 0.05). Respondents with history of food insecurity were more likely to have disordered eating patterns (mean score 1.27 ± 1.06 versus 0.69 ± 0.73; p < 0.01)
El Zein et al. (2019) [23]	n = 855; 68.8% female; 34.6% students age 18 years; first year undergraduate students	COVID-19: study conducted prior to COVID-19 Food Insecurity: US Department of Agriculture Adult Food Security Survey Module, 10-item [24]; Participants asked about food pantry knowledge and use. Eating Disorder: Eating Attitudes Test-26 (EAT-26) [25]	Students with food insecurity were more likely to have a higher score indicating problematic eating behaviors (9.5 ± 9.1 versus 7.0 ± 6.9; p = 0.001).
Poll et al. (2020) [26]	n = 111; male athletes; mean age 21 ± 2 years (range 19–23 years); male NCAA division I athletes	COVID-19: study conducted prior to COVID-19 Food Insecurity: US Adult Food Security Survey Model [27]; two-item food security measure was included to measure the history of childhood food insecurity (authors cited “personal communication” for the item measure) Eating Disorder: Hoarding, sneaking food, binge eating behaviors [28]	High school food insecurity was associated with preoccupation with food in college (p < 0.001), but not with food hoarding or bingeing behaviors (e.g., keeping food in lockers). Food insecurity in college was associated with preoccupation with food (p < 0.001) and food hoarding behavior (p < 0.001). A small proportion of respondents met criteria for low/very low food security in high school (n = 15; 13.5%) or college (n = 11; 9.9%), limiting the interpretation of the findings.
Richards & Specker (2019) [29]	n = 153; 76.1% female; mean age 20.7 ± 4.8 years (range 18–52)	COVID-19: study conducted prior to COVID-19 Food Insecurity: USDA 6-item short form of the household food security scale [30] Eating Disorder: Three Factor Eating Questionnaire Revised (TFEQ-R18V2) [31, 32]	Food security status was correlated with uncontrolled eating behavior (p < 0.01), but not associated in adjusted models. Emotional eating was associated with higher perceived stress (p < 0.001) and females had higher emotional eating scores compared to men p = 021 in linear regression models.
Royer et al. (2021) [33]	n = 533; 77.7% female; mean age 20.4 ± 1.7 years	COVID-19: study conducted prior to COVID-19 Food Insecurity: US Department of Agriculture Adult Food Security Survey Module, 10-item [24] Eating Disorder: Eating Disorder Examination Questionnaire (EDE-Q) 28-item questionnaire [3]	Participants experiencing food insecurity were more likely to report global disordered eating behaviors, eating concerns, shape concerns, and weight concerns (p < 0.001 for all). Disordered eating behaviors were most severe among respondents meeting criteria for very low food security.

Results

Characteristics of studies

Out of 748 records that were identified, 676 studies were screened for eligibility by title and abstract, 26 were assessed during the full-text review, and 11 met inclusion criteria for this review (Fig. 1). Articles were excluded due to setting (not conducted in the US), population (inclusion of graduate students within the sample), and if they lacked evaluation of disordered eating.

Included studies were published after 2013 in order to capture eating disorders defined by DSM-5 diagnostic criteria [25]. All studies described results from cross-sectional surveys. While two studies included results from repeated cross-sectional surveys [30, 31], none included sample follow up data. Six studies examined disordered eating in the context of COVID-19 [30–35]. Five studies evaluated the relationship between food security status and disordered eating [36–39]. No studies evaluated COVID-19, food insecurity, and disordered eating. Study samples ranged from 98 to 1996 participants (median 267). The average age of student participants was 20.5 years, and most studies had a sample that was predominantly female, though one study looked exclusively at males [38].

Study instrument use

COVID-19 Three studies used validated instruments to measure respondent impacts from the pandemic [32, 40] and intolerance of uncertainty [31, 35, 41], tailoring questions to the COVID-19 pandemic. Two studies did not use validated tools, but queried student experience of COVID-19, including questions categorized on a Likert scale [33] and perceived impact of the pandemic on behaviors [30]. One study was conducted in the context of COVID-19, but did not specifically measure the effects of the pandemic [34].

Food insecurity Four studies administered the USDA’s US Adult Food Security Survey [37–39, 42]. Two studies used the 10-item form [37, 42, 43], one used the 6-item short form [20, 39], and one used an older form pre-dating the 6- and 10-item forms [38, 44]. One study used a two-item screener developed to identify families at risk for food insecurity [36, 45]. All screening tools used were developed for adult or household food insecurity assessment.

Eating disorder Five studies utilized Fairburn’s 28- [46] or 38-item [47] Eating Disorder Examination Questionnaire (EDE-Q) [30, 32, 35, 36, 42], both of which were developed to assess eating disorders prior to the DSM-5 manual updates. [25]. Two studies utilized a compilation of validated tools and questions to assess eating, weight and body satisfaction, binge eating behaviors, restrictive eating, and exercise and eating. [31, 34]. One assessed hoarding and sneaking food [38, 48], one queried eating attitudes [37, 49], and one measured the cognitive and behavioral components of eating [39, 50]. One study did not use a validated instrument to measure disordered eating, but asked respondents whether they experienced an eating disorder during the fall 2020 semester [33].

Study findings

COVID-19 and eating disorders Table 1 provides a summary of the findings from studies examining eating disorders during COVID-19. Studies found that COVID-19, particularly the uncertainty caused by with the pandemic, was associated with binge eating behaviors [30, 32] and higher eating disorder scores overall [31, 34]. COVID-19 was also associated with greater social media use, resulting in higher body image dissatisfaction and disordered eating behaviors. [30, 32].

Food insecurity and eating disorders Table 2 provides an overview of the findings from studies examining the relationship between food insecurity and eating disorders among undergraduate students over the last decade. Studies found that respondents with history of food insecurity were more likely to have disordered eating patterns, regardless of current food security status. [36–38, 42]. One study described a dose-response relationship between food insecurity and disordered eating behaviors, finding that higher food insecurity (students with low or very low food insecurity) displayed more severe disordered eating behaviors [42].

Quality of included studies

All studies included a relatively small sample size in relationship to their student body sample, indicating that the studies were likely unable to represent the student population, limiting external validity and exchangeability of the findings. In general, studies described bivariate associations between variables and were unable to assess models adjusted for potential confounding factors. Half the studies examining the effect of COVID-19 on disordered eating utilized validated tools to assess the exposure and outcomes of interest [31, 32, 35]. All five studies evaluating the relationship between food insecurity and disordered eating used validated tools [36–39, 42]. None of the studies utilized tools that were designed and specifically validated for undergraduate students living on college campuses.

Discussion

This systematic review provides valuable insight into the relationship between disordered eating and food insecurity, and eating disorders among undergraduate college students during the COVID-19 pandemic. The impact of the stress, uncertainty, and social isolation from the global pandemic cannot be understated. Undergraduate students experienced a significant increase in depressive and anxious symptoms contributing to more frequent social media engagement and a corresponding decrease in overall body satisfaction with an increase in consumption of weight loss associated online content and restrictive eating patterns. Additionally, students who experienced food insecurity were overall more preoccupied with food and more likely to overeat and engage in binge eating behavior. This review did not capture the interrelationship of these variables due to a lack of available literature indicating that further research is necessary to understand the role and interaction of these variables. Even after the COVID-19 pandemic, current college students experienced the pandemic at vulnerable ages and the effects from their experience may play out as they emerge into young adulthood. Although no studies in our review examined the effects of food insecurity, COVID-19, and disordered eating together, overlapping findings about food insecurity, COVID-19, and disordered eating should be considered. For example, students with food insecurity were more likely to have a higher disordered eating score [37], food hoarding and bingeing [38], and uncontrolled eating [39]. Similarly, impacts of COVID-19, such as social isolation [32], higher social media use [30], and anxiety related to the pandemic [35] were all associated with higher eating disorder scale scores, specifically more binge eating behaviors. This intersection of findings supports the need for interventions that specifically target stressors associated with food insecurity and the stress, especially considering the typical chronicity of both of which persist beyond an individual’s experience of each event.

There was heterogeneity regarding how studies evaluated effects of COVID-19, food insecurity, and disordered eating behaviors among undergraduate students. This is due in part to a lack of validated tools that are specifically intended for undergraduate students. For example, the USDA’s Adult Food Security Survey Module is widely used to assess food insecurity among adults in the US [51]. The tool, however, has not been validated for use amongst college students and may not fully capture the nuances of food insecurity among undergraduates living on-campus and among their peers [52, 53]. This challenge to assessing undergraduate students is also present for disordered eating questionnaires, despite the high prevalence of eating disorders among college-aged adults [3, 4]. Further, to our knowledge, there are no validated tools specifically used for assessing the effects of the COVID-19 pandemic on student behavior, though studies did use alternative tools and methods to measure the impact of the pandemic.

Findings from this systematic review should be interpreted in the context of similar studies. A 2022 systematic review assessing the influence of COVID-19 on disordered eating and related outcomes among all adults similarly found disruptions to normative social and psychological functioning, with particular vulnerability reported among underrepresented population groups [54]. In much of the literature, student mental health during COVID-19 was consistently characterized by depression and anxiety, which was also associated with disordered eating behaviors [55–57]. The preponderance of evidence linking effects of COVID-19 to disordered eating among college students underscores the importance of addressing long-term health vulnerabilities experienced by individuals who were in college during the pandemic. Although a cohort effect may normalize the social, emotional, and physical consequences experienced during 2020, it is paramount to consider the reverberating effects of this worldwide event.

Similarly, food insecurity has long-term consequences for a disordered relationship with food amongst children, adolescents, and adults. A 2023 systematic review of literature found that binge eating and loss of control while eating were described amongst children and adolescents who also experienced food insecurity [58], which is consistent with the findings from a 2020 review examining adults with food insecurity [14]. Evidence from the Healthy Minds Study, a survey of more than 350,000 undergraduate and graduate students across 373 college campuses collected from 2013 to present [59, 60], demonstrates that food insecurity may be associated with disordered eating patterns, independent from symptoms of depression and anxiety [61], suggesting binge eating patterns are more strongly associated with food insecurity [62] itself rather than mediated by levels of anxiety or depression.

Agreements and disagreements with other studies or reviews

Our review of the literature aligns with recently published information. While these previous reviews examine related exposures and outcomes, none look specifically at the relationship between disordered eating, food insecurity, and the COVID-19 pandemic among undergraduate students in the US. For example, a 2025 systematic review and meta-analysis examining the prevalence of food insecurity among college students in high income countries found a high proportion of students experiencing food insecurity that was associated with poorer academic performance and one or more poor health outcomes [63]. The review details that five of the 65 studies that reported health outcomes (7.7%) provided information on the relationship between food insecurity and disordered eating behavior, with lower quality diet observed [63]. This finding is consistent with the information reported herein, underscoring that there is a relationship between food insecurity and disordered eating patterns, regardless of school-wide income trends. This finding strengthens the call for more deliberate study around the relationship between food insecurity and disordered eating patterns, regardless of socioeconomic status. A 2018 systematic review found that the prevalence of food insecurity was estimated to be three times higher than the national household food security estimates, with an estimated 43.5% of college students in the US reporting food insecurity [64]. While the review did not specifically examine disordered eating or health outcomes, the findings support the need for deeper research around the impact of food insecurity on college students due to its high prevalence in the US during such a formative period in an individual’s development. Similarly, there is developing literature examining the prevalence of eating disorders on college campuses and call for prevention strategies to support students [65, 66]. A 2022 global review of eating disorders among university students estimated 19.7% of university students exhibited behaviors consistent with disordered eating and that more robust preventative measures were necessary on college campuses around the world [65] Eating disorder hospital admissions were also associated with the COVID-19 pandemic, with one review documenting increases in eating disorder symptoms that were consistent with increased admissions during COVID-19 among all patients with eating disorders [67]. To our knowledge, no previous systematic review examined the relationship between disordered eating and COVID-19 among college students. Taken together, these previous literatures support the findings in this review. While none directly examine the nuanced relationship between disordered eating, food insecurity, and the COVID-19 pandemic in undergraduate students in the US, the results are consistent and support a need for deeper examination of the relationship between factors, particularly as prevention and intervention strategies are developed to support student health.

Limitations

While this literature review sought to examine the relationship between food insecurity and disordered eating patterns in the context of the COVID-19 pandemic among undergraduate students in the US, we did not identify research that captured this relationship within the target population. One study that surveyed students at a large Midwestern university confirmed that food insecurity was associated with disordered eating symptoms such as binge eating and compensatory fasting, and that there was no difference in reported food insecurity status before or during COVID-19 [68]. The study included students with greater than six years of post-high school education, as well as continuing education students, so the population demographic could not be confirmed. This overall lack of research demonstrates a greater gap in the literature that may have prolonged consequences to the depth of long-term pandemic-related consequences on social and structural access to food (e.g., food insecurity) and health outcomes (e.g., disordered eating behaviors and habits) that may persist among this vulnerable population group.

Another limitation of this review is the study design and sample size. The existing literature largely gathered cross-sectional data among relatively small, geographically isolated, populations of students. As the data were gathered at individual universities and colleges, the external validity may be limited to how comparable student groups and institutions are to the groups surveyed. While the Healthy Minds Study [59] seeks to rectify this limitation with data gathered from across institutions in the US, reported data combine responses from undergraduate and graduate students. It is important to examine student experiences based on their standing, as an on-campus living and learning environments largely tailored to young adults that characterizes the undergraduate experience is distinct from graduate students, who often vary by age, living and working arrangements, and family obligations [69]. A future review examining the topic and context among graduate students may provide additional context to the role university settings play in supporting food security and mitigating disordered eating among all students.

Finally, given the heterogeneity of survey tools used to measure food insecurity, effects of COVID-19, and disordered eating thoughts and behaviors, studies were not easily compared. This may be due, in large part, to the unique timeframe and setting that defines undergraduate students. While many tools assess household food insecurity, or food insecurity among adults, undergraduate students living on campus with access to a meal plan that varies by institution may have a difficult time accurately reporting food insecurity experiences in a standard, quantitative tool. Similarly, many tools evaluating disordered eating are validated for adolescent populations or adult populations, but not necessarily young adult populations aged 18–22. This may also bias results to the null when trying to consider and assess experiences of undergraduate students through a variety of not-quite-right quantitative tools. The creation and validation of tools tailored to this population should be considered in the future.

Conclusion

This systematic review of the literature provides additional evidence for the relationship between disordered eating patterns, particularly binge eating behaviors, and food insecurity and COVID-19. While no studies examined the effect of all three variables together, the field of eating disorder research should consider the impact of these major life stressors (food insecurity, global pandemic) on the development stress response and eating behaviors among undergraduate students. Consideration of how emerging adults respond to outside stressors, impacting long-term morbidity and mortality, should be prioritized by institutions seeking to support healthy student life. Colleges and universities should consider broad interventions and supports for students who may underreport food insecurity, stressors persisting in the wake of the pandemic, and disordered eating behaviors.

Author contributions

BMH, MH, DC, MG, AH, and AB conceptualized the project. BMH, MH, and AB were responsible for analysis and interpretation of outcomes. BMH wrote the manuscript with support from DC. BMH, MH, DC, MG, AH, and AB edited and finalized the submitted manuscript.

Funding

There was no funding provided for this project.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Institutional Review Board and oversight, as well as consent to participate does not apply to this systematic review of published articles.

Competing interests

The authors declare no competing interests.