The COVID-19 pandemic has had major health, economic, financial, and social consequences worldwide. ¹ Not only because of the direct effects of this disease on the general health of people, but also because of the impact of infection prevention strategies that have led to unprecedented social restructuring. ² In spite of the implementation of mass lockdowns, cessation of mobility, social distancing and vaccination, the violent spread of the virus has not been fully controlled. ³ Therefore, the fear of contagion and the possible decease of infected family members were particularly challenging circumstances that produced uncertainty and severely affected the mental health of people without discrimination. ⁴ Especially because evidence indicates that social isolation brought with it manifestations of insomnia and other disorders such as anxiety disorders and depression. ⁵ It should be noted that an alteration of body image in people was also observed as a result of the limitation of physical activity in freely available spaces. ^{3 , 4} A study in a Chilean population indicated that people with less weekly physical activity time were more concerned about their body image, causing an increase in concern about weight and body shape, and in turn, negatively disturbing eating habits. ³ Besides, overweight, and obese Argentinian women, compared to women of healthy weight, have been reported to have a greater concern and negative perception of their body image, with an increased frequency of snacking between meals, binge eating, dieting behavior and the use of laxatives, diuretics, and diet pills. ⁶ Likewise, 5.2 million electronic health records of people under 30 years of age, mostly Americans, showed that the overall incidence of eating disorders increased by 15.3% with increased risk of suicidal behavior during 2020. ⁷

A recent systematic review found that university students may be more likely to be physically inactive during the COVID-19 pandemic since education and work became virtual, which forced them to spend more rest time. ⁸ According to an Ecuadorian study, 73.3% of their university students answered that they had a sedentary lifestyle and, as a consequence, 54.2% considered that they had gained weight. ⁹ For this reason, these sedentary behaviors are associated with a generally negative body image perception (fear of being overweight) exposing university students to the pressure to have a specific, athletic, and slim body appearance. ¹⁰ This results not only in negative thoughts, but also in distorted appraisals of their bodies, leading to high levels of body dissatisfaction. ¹¹ As seen in university students in Panama, 66% had distorted body image and 79% felt dissatisfied with their body image. In addition, 47% engaged in risky eating behaviors and there was a significant relationship between these behaviors and self-perceived body image. ¹²

As mentioned, the risk of having an eating disorder increased due to the psychological stress that occurred during the lockdown. This causes major public health challenges, as they often appear early in life and continue into adulthood. ¹³ For this reason, university students are even more vulnerable to eating disorders during their adult transition, as they have an academic burden and frequent financial difficulties when integrating independently into society. ¹⁴ A study in French university students showed that the prevalence of eating disorders is generally higher in females (51.6%) compared to males. ¹⁴ Similar results were found on the perception of body image dissatisfaction in two universities in Latin America, namely in Peru and Chile (69.7% and 47.7% respectively) affecting more females. ^{15 , 16} Considering the influence of body image, the risk of eating behaviors presents in the university population, and the long-term public health consequences of this type of disorder, it is key to understand the current scenario to carry out programs and interventions that promote self-esteem and the prevention of eating disorders.

The objective of this study is to determine the association between body image perception and the risk of eating disorders in university students during the COVID-19 pandemic. The study hypotheses were that i) there is a positive association between body image perception and risk of eating disorders, ii) there is a high frequency of body image perception in overweight and obese individuals, and iii) there is a high risk of eating disorders in Peruvian university students. Clearly this comprehensive approach to body image and eating practices is important to understand how the pandemic has affected these variables.

A total of 198 participants who met the inclusion criteria were initially obtained for the study. However, after conducting a quality check of the participants’ responses, 180 participants were considered for further analysis. The average age of the university students was 22.8±3.9 years (95% CI: 22.3 to 23.4), ranging from 18 to 35 years. The most common age group among the participants was 21 to 30 years, accounting for 65.6% (118/180), and the majority of the participants were women, constituting 67.8% (112/180). Among the participants, 46.1% (83/180) were employed, with the majority working on-site, accounting for 85.5% (71/180) of the employed participants. The full dataset can be found under Underlying data. ⁴⁴

Regarding Body Image perception, 51.1% (92/180) perceived themselves as overweight and 22.2% (40/180) as obese. Overweight and obesity were more frequent in women (47.5%, 58/122 and 18.9%, 23/122, respectively), and in the 21-30 age group (53.4%, 63/118 and 25.4%, 30/118, respectively). We found differences in body image perception between genders (p=0.009). According to employment status, the majority perceived themselves as overweight, regardless of whether they were working (57.8%, 48/83) or unemployed (42.7%, 44/97) ( Table 2).

46.1% (83/180) of the university students were at high risk for an eating disorder. The majority were female (47.5%, 58/122) and in the 21-30 age group (43.2%, 51/118). 49.5% (48/97) were unemployed and of the working group and had high risk of developing an eating disorder, and 43.7% (31/71) were in a classroom-based modality ( Table 3). Only gender was a predictor of body image (β=-0.342±0.129, 95%CI: -0.597 to -0.087) in university students during hybrid education (p=0.010).

Although most of the participants answered that they never vomit after eating (80%,144/180) or feel like vomiting afterwards (72.2%, 130/180). Always, and very often 2.2% (4/180) and 6.7% (12/180) of students answered that they like to feel an empty stomach, 5% (9/180) and 8.3% (15/180) feel very guilty after eating, and 2.8% (5/180) and 3.3% (6/180) feel that food controls their life, respectively. Only 1.7% (3/180) and 5.6% (10/180) of students always and frequently exercise a lot to burn calories, while only 3.3% (6/180) always take into account the calories in the food they eat. On the other hand, 31.7% (57/180) and 25% (45/180) of students never or rarely eat food with a lot of carbohydrates (i.e., bread, rice). 35% (63/180) never noticed that others would prefer them to eat more and for 30.6%, (55/180) others never perceived them as too thin. We found no association between body image and eating disorders (p=0.662).

Finally, we found that most of the participants who perceived themselves as underweight were at high risk of an eating disorder 58.9% (7/12). The same was true for 50% (20/40) of those who perceived themselves as obese ( Figure 2). We found no association between body image and eating disorders (p=0.661).

This study showed that just over half and almost a quarter of the university students perceived themselves to be overweight and obese, respectively. Also, about half were at high risk for an eating disorder, mainly affecting females aged 21-30 years. Likewise, most students who perceived themselves as underweight were at high risk of developing an eating disorder, as were half of those who perceived themselves as obese.

A strength of the study is it is the first association study of body image and eating disorders in university students who have undertaken remote education. Research in this area has been conducted in Peru ^{16 , 26} but none has included an analysis of the university population during the third year of the COVID-19 pandemic, a year when they were transitioning from fully digital education to a hybrid model. On the other hand, this study has used an instrument that has anatomical silhouettes specifically made and applied to an adult population within the average age range of university students. ^{19 , 20} The COVID-19 pandemic has posed challenges for on-site nutritional monitoring, leading to limited access to accurate BMI measurements among participants. ⁸ In virtual and remote education settings, the use of silhouettes has emerged as a valuable tool for estimating body image and gauging the health status of university students. Furthermore, this study benefits from the utilization of the EAT-26 questionnaire, which possesses robust psychometric properties for evaluating eating disorders within this specific population. ^{24 , 25} As the “new normal” has ushered in hybrid and remote education, disruptions in dietary habits during educational activities have become apparent. ^{14 , 27} Our findings present a fresh perspective on assessing both nutritional aspects and offer insights to guide interventions aimed at addressing the adverse effects on students’ well-being. This framework contributes to a better understanding of the situation and promotes proactive measures to mitigate the negative impacts experienced by students.

Our findings showed that females, participants aged 21-30 years and those perceived to be overweight or obese were at high risk of disordered eating. These results are consistent with the finding in French university students, ¹⁴ where women (51.6%) and first- and second-year students had the highest prevalence of disordered eating, although only 13.5% were overweight and 5.4% obese. Also, even though American university students did not show statistically significant changes in BMI, 60% had increased concerns about body weight and shape and their eating habits since the start of COVID-19. ²⁸ This pressure on body appearance was also experienced by 57-85% of students at nine large universities in Norway, finding that it is negatively related to body esteem, self-esteem, and life satisfaction. ¹⁰ Furthermore, they identified that this generates an unfavorable pattern in the mental health of university students related to their body image.

A study in Colombian university students ²⁹ that also used anatomical silhouettes for body image perception supports our results which estimated that ~51% self-perceive themselves as overweight. Similarly, another Peruvian study ³⁰ conducted among university students in the Municipality of Arequipa in 2020 showed that 27.8%, 16.7% and 8.7% had mild, moderate, and extreme body image concerns, respectively. Another study conducted in the same municipality in 2021 showed that 69.7% of students were dissatisfied with their body image, 82.4% were female and 67.9% engaged in moderate- to high-intensity physical activity. ¹⁶ Peruvian students have changed their body perception and satisfaction during the COVID-19 pandemic, and in the context of virtual education, this perception has been favored by study habits and remote activities. On the other hand, in both French and American university students, along with the prevalence or risk of eating disorders and body image concerns, a decrease in physical activity was observed in university students. ^{14 , 28} In contrast, no change in BMI or body image was reported in Lithuanian university students despite a significant decrease in physical activity levels. ³⁰

This change was most marked in women, who reported an increase in body image satisfaction, even though their BMI increased. Our results have identified that more than half of the women had eating disorders and an over-perception of their body image (i.e., overweight), and although we did not assess physical activity, it is possible that a large proportion of these students may have reduced their physical activity during the virtual classes because of COVID-19, as a recent study has shown. ⁸ It is important to develop a tripartite analysis of these variables since coping with bodily and nutritional changes may be optimal but also leads to a risk for the development of pathologies. As stated by the previously mentioned studies and reaffirmed by a systematic review, during the “new normal” the physical activity levels of university students tend to decrease or have negative changes as education and work become virtual, and they are forced to spend more time resting. ^{8 , 14 , 30 , 31}

Thus, there was an increase in sedentary behaviors, confirmed by two studies in American ²⁸ and Ecuadorian university students (73.3% led a sedentary lifestyle). ⁹ In view of this, physical activity levels during the pandemic are important. A study of Brazilian university students showed that physically active university students during lockdown had positive changes in appearance, and 50.7% reported negative changes when faced with the demands of meeting social standards of beauty. ³⁰ These negative thoughts and distorted appraisals of their bodies can lead to high levels of body dissatisfaction. ^{9 , 11} Similarly, there is a report of Chilean university students, who had dissatisfaction in their perception of their body image (47.7%), affecting women more frequently. ¹⁵ Likewise, 79% of university students in Panama also felt dissatisfied with their body image, 66% had body image distortion, 47% had risky eating behaviors, and a significant relationship was found between these behaviors and self-perceived body image. ¹² These results are consistent with our findings and together expose possible nutritional disturbances in university students during the “new normal” of the COVID-19 pandemic.

According to our results, no association was found between body image perception and risk of eating disorder. This is supported by another Peruvian study in the Municipality of Arequipa. ¹⁶ Moreover, our results showed that only women showed a predicted increased risk of body image disturbance, but not the risk of an eating disorder, in agreement with studies in Norway, Ecuador, Chile, Peru and Brazil. ^{9 , 10 , 11 , 15 , 16 , 32} Altogether, these studies show independent changes in the two variables, however, both may converge when there are risk factors (decreased physical activity, increased sedentary behaviors, psychological stress, insomnia) as previously reported. ^{3 , 5 , 8 , 9 , 13 , 27}

A recent review ³³ has shown a considerable increase in eating disorders during the pandemic and a worsening of its symptoms due to the lack of care and treatment, disruption of daily routine, negative influence of the media and the internet, ³⁴ and isolation due to security measures against COVID-19. The short-term effects of the pandemic on eating disorders have been reported. ^{14 , 35 , 36} These investigations and systematic reviews ³⁷ have not considered the university population of Latin American countries where the pandemic has hit differently. Even local or regional ^{1 – 13 , 15 , 16 , 32} studies have evaluated EDs but have not proven their link to body image. College students’ physical expectations during the pandemic may lead to dissatisfaction with how they are portrayed in the pandemic’s virtual environment. It has been seen ³⁸ that the impact of social networks on the perception of body image could lead to eating disorders. Although in this study, we did not find a relationship between both variables, it is possible that in rural or peri-urban populations, as well as in specific groups of university students (i.e., high-performance athletes or models), ³⁹ the links between eating disorder could be different. It is important to comprehensively study these phenomena, including the family core, ⁴⁰ the political position on the body (body positive or neutrally), ⁴¹ lifestyles, ⁸ and access to technology and income. ⁴²

This study had limitations. First, the physical activity (including physical activity in the gym) performed by university students was not taken into account. Physical activity is a key factor because lockdown led to changes in daily life and thus decreased physical activity. ⁸ Low levels of physical activity have been reported to be associated with increased body image concerns. ³ In addition, since we were in an optional and asynchronous hybrid environment, we could not measure the height, weight, and BMI of the participants in this research with surveys. Second, demographic and work factors were considered in the analysis, but other factors such as social media use (which increased during lockdown) may lead to a negative perception of body image and increased risk of eating disorders. ¹³ Third, the effects of remote education have not been evaluated as influential factors in changes in body image perception, the development of conduct and eating disorders, and reduced physical activity. Finally, we had a small sample of students from each university that could affect the results. However, this topic is important since several Peruvian universities continue to provide virtual, hybrid and asynchronous classes that place students in a “new” context and may support nutritional changes.

University students enrolled in virtual classes, aged 18 to 35, are commonly perceived as overweight and at a low risk of developing an eating disorder. This perception particularly affects women, with young students between 21 and 30 years old being more prone to being perceived as overweight or obese. Given the ongoing third year of the COVID-19 pandemic and the restrictions imposed by the Peruvian government, it is crucial to address the students’ situation and implement measures to enhance their nutritional well-being and promote healthy habits. Recognizing the significant impact that body image perception has on the lifestyle of university students, it becomes imperative to encourage the adoption of healthy eating practices and self-esteem enhancement strategies. By doing so, we can mitigate the risk of eating disorders stemming from dissatisfaction with one’s body, which is often influenced by societal beauty standards within the context of the “new normal.”

This study has complied with bioethical principles and the guidelines of the Helsinki declaration (WMA, 2013) ⁴³ and had the approval of the Ethics Committee of the Norbert Wiener University (Registration No. 01963-2022). Informed consent was obtained from all subjects involved in the study.

Conceptualization, J.M.-S. and E.A.G.-P.; methodology, J.M.-S., H.C.-P., and E.A.G.-P.; software, V.R.-Z.; validation, J.M.S., M.J.S.M.-S. and E.A.G.-P.; formal analysis, J.M.-S. and E.A.G.-P.; investigation, H.C.-P.; resources, V.R.-Z.; data curation, M.J.S.M.-S. and E.A.G.-P.; writing—original draft preparation, J.M.-S. and E.A.G.-P.; writing—review and editing, J.M.-S., V.R.-Z., H.C.-P, and M.J.S.M.-S.; visualization, J.M.-S.; supervision, H.C.-P.; project administration, E.A.G.-P. All authors have read and agreed to the published version of the manuscript.