In March, as Covid-19 swept across the United States and Americans sheltered in place, Stephanie Parker noticed something wasn’t right. She was spending a lot of money on food, but not eating it. The 34-year-old would clean, and check in with herself to see if she “deserved” to eat—an internal negotiation that sometimes ended with her starving. She became fixated on cleanliness and became anxious and tired. The eating disorders she’d kept at bay for most of her life—anorexia and binge eating—became uncontrollable. “And that’s when I realized, if I do not get help, I’m going to die from this,” Parker says.

She is not alone. Scientists have found that since the start of the pandemic many people with anorexia have become more restricted, and many with binge eating disorder or bulimia, have had more binging episodes. Researchers from the United States, Sweden and the Netherlands published a study in July in the International Journal of Eating Disorders that links Covid-19 to exacerbated eating disorders . The study’s findings line up with an increase in calls to the helpline of the National Eating Disorders Association. The nonprofit reported 69 percent more calls in June and July of 2020 than in June and July of 2019.

Lauren Smolar, senior director of programs for the National Association of Eating Disorders, says the incidence is on the rise for a number of reasons, including a crumbling sense of structure, an inability to find social support and a difficulty finding foods that fit into a meal plan. “Your risk of eating disorders are going to increase whenever there's higher levels of stress,” Smolar says.

Doctors and psychologists consider eating disorders to be mental and physical illnesses. Experts say 20 million women and 10 million men living in the United States will have an eating disorder at some point in their lives. Eating disorders often go hand in hand with other mental health conditions. A 2014 study in Eating Disorders: The Journal of Treatment and Prevention found that 97 percent of 2400 people hospitalized for an eating disorder had other mental health conditions, including depression and anxiety.

For the July study, Cynthia Bulik, founding director of the University of North Carolina at Chapel Hill’s Center of Excellence for Eating Disorders, and colleagues surveyed more than 1,000 people in the United States and the Netherlands with self-reported eating disorders about the impacts of the pandemic. At the time the study started, nearly all respondents had been practicing social distancing. Eighty percent of participants said their overall anxiety levels had increased during the pandemic. Seventy-nine percent of Americans and 66 percent of Netherlanders said they were concerned a lack of structure would worsen their eating disorder. More than half of all participants said they were worried about being in a home environment that might trigger an eating disorder.

Bulik says that more participants were worried about the pandemic’s affect on their mental health than their physical health. “My gut sense [was] that they would be more concerned about their physical health because that's what everybody is talking about,” she says. “But I think these folks were really clear that the pandemic, and the measures that were being taken to take control the pandemic, had a real direct effect on your mental well-being.”

Bulik says she was surprised about Americans’ anxiety surrounding exercise—57 percent of Americans said they were concerned they wouldn’t be able to exercise.

Ryan Sheldon, 32, says social media posts about diets or ways to lose weight have dredged up obsessive thoughts that once contributed to his binge eating and body dysmorphia—a fixation with physical appearance, typically not grounded in reality. On Instagram, he’s seen humans vow to leave quarantine in better shape than they started, or to beat back the “Covid 19”—a play on the weight gain in college known as the “Freshman 15.”

“I think people think that we're getting graded,” says Sheldon. “They think that we're going to get a report card by the time we leave this and we're all going to fail because we're not eating healthy or we're not working out.”

The way American mainstream media has talked about quarantine, says Bulik, is a factor. “It’s all about how to exercise when your gym’s closed, or not going back at the gym,” she says.

Bulik’s team did find some positives. Forty nine percent of American participants said staying at home and a slower pace of life helped them work toward recovery. “As we were sort of initially hunkering down and spending time at home, sometimes that gave people the ability to kind of take a pause,” says Christine Peat, director of the National Center of Excellence for Eating Disorders at the University of North Carolina at Chapel Hill and one of the authors of the study.

Patients are also seeking help via telehealth—a method that could make recovery accessible to those who’ve traditionally been excluded because of geography or cost.

“Traditionally eating disorders are underreported and we know that this was a high stress situation,” Smolar says. “And so that's been a positive somewhat from the outlook,is that it has moved many treatment options online or virtually in some capacity.”

Bulik and colleagues made recommendations to accompany their study. Healthcare workers should be aware of the increase in eating disorders and anxiety. Families or roommates can foster a safe environment for recovery by having regular meal times and scheduling time for connection. Patients recovering from an eating disorder are encouraged to stay connected with a treatment team or reach out to a resource such as the National Eating Disorder’s helpline.

“It's something really special," Sheldon says about the helpline, which is staffed by trained volunteers. “Because you finally can feel like you relate to somebody and you aren't ashamed of talking about it because they've been through it.”

Nowadays, Parker, is in individual and group therapy, all on Zoom. It’s allowed her to connect with others of color all around the country, who are often left out of the conversation about eating disorders. For anyone who thinks they might struggle with eating, she recommends reaching out. “There’s so many people out there silently struggling with an eating disorder and either they don’t realize it or they do and they don’t know what to call it because they don’t have language or support,” she says. “It makes a huge difference.”

If you or someone you know is struggling with an eating disorder, you can call the National Eating Disorders Association Helpline at 1-800-931-2237, text "NEDA" to 741-741 or click to chat .