key: cord-0761332-h2gubzqz
authors: Garcia-Esquinas, E.; Ortol, R.; Gine-Vazquez, I.; Carnicero, J. A.; Manas, A.; Lara, E.; Alvarez-Bustos, A.; Vicente-Rodriguez, G.; Sotos-Prieto, M.; Olaya, B.; Garcia-Garcia, F. J.; Gusi, N.; Banegas, J. R.; Rodriguez-Gomez, I.; Struijk, E. A.; Martinez-Gomez, D.; Lana, A.; Haro, J. M.; Ayuso-Mateos, J. L.; Rodriguez-Manas, L.; Ara, I.; Miret, M.; Rodriguez-Artalejo, F.
title: Changes in health behaviors, mental and physical health among older adults under severe lockdown restrictions during the COVID-19 pandemic in Spain
date: 2021-02-16
journal: nan
DOI: 10.1101/2021.02.15.21251738
sha: c86fc2ac86b3df4edc1a3383037b7fc2e70a217a
doc_id: 761332
cord_uid: h2gubzqz

Background: We aimed to examine main changes in health behaviors, mental and physical health among older adults under severe lockdown restrictions during the COVID-19. Methods: We used prospective data from 3041 participants in four cohorts of community-dwelling individuals aged [≥]65 years in Spain. Data were obtained using validated questionnaires through a pre-pandemic face-to-face interview and a telephone interview conducted between weeks 7 to 15 after the beginning the COVID-19 lockdown. Lineal or multinomial, as appropriate, regression models with adjustment for the main confounders were used to assess changes in the outcome variables from the pre-pandemic to the confinement period, and to identify their associated factors. Results: On average, the confinement was not associated with a deterioration in lifestyle risk factors (smoking, alcohol intake, diet or weight), except for a decreased physical activity and increased sedentary time, which reversed with the end of confinement. However, chronic pain worsened, and moderate declines in mental health, that did not seem to reverse after restrictions were lifted, were observed. Several subgroups of individuals were at increased risk of developing unhealthier lifestyles or mental health decline with confinement: (i)-males (for physical activity and sedentariness), (ii)-those with greater social isolation (for diet, physical activity, mental health), (iii)-feelings of loneliness (for diet, sleep quality, mental health), (iv)-poor housing conditions (for diet, physical activity, TV viewing time), (v)-unhealthy sleep duration (for physical activity and sedentariness), and (vi-worse overall health or chronic morbidities (for physical activity, screen time, mental health). On the other hand, previously having a greater adherence to the Mediterranean diet and doing more physical activity protected older adults from developing unhealthier lifestyles with confinement. Conclusions: The lockdown during the first wave of the COVID-19 in Spain, which was one of the most restrictive in Europe, only led to minor average changes in health behaviors among older adults. However, mental health was moderately affected. If another lockdown were imposed on this or future pandemics, public health programs should specially address the needs of older individuals with male sex, greater social isolation, poor housing conditions and chronic morbidities, because of their greater vulnerability to the enacted movement restrictions

The COVID-19 pandemic has rocked our society to its core. Until a safe and effective vaccines are globally distributed, social distancing interventions to reduce the transmission of SARS-CoV-2 are essential (1), but themselves are not extent from health and economic challenges (2-5).

The State of Alarm imposed by the Spanish Government to curb the spread of the SARS-CoV-2 infection, entailed a national lockdown starting on March 15 th , and the imposition of distancing measures like the cancelation of mass events or the closure of non-essential customer-facing business and educational institutions (6) .Two weeks later, on March 29 th , the Government strengthened these measures to avoid the saturation of intensive care units (7) . A period of five weeks started in which citizens were only allowed to leave their homes for essential work, buying of staple products or emergencies. On May 4 th , citizens were first authorized to leave their homes to exercise or walk, for a maximum of 1 hour a day, following timetables according to age, and only being accompanied by people they had been living together during the lockdown. From May 10 th to June 21 st , a progressive de-escalation of confinement measures lead to the so-called "New Normality" in which Spaniards were allowed to attend their jobs, gather in small groups, and move between provinces as long as they complied with safe distancing and face covering requirements.

All around the world, countries dealt with the first wave of the pandemic with different degree of movement restrictions, but the Spanish lockdown, especially during those five weeks between March 30 th and May 4 th , was one of the most restrictive in Europe.

A few studies have investigated the health consequences of the lockdown during the first wave of the pandemic in the Spanish adult population. Using convenience sample surveys conducted between March and June 2020, in which participants reported their perceived changes in lifestyle and health-related factors since the start of the pandemic, these studies have shown a general worsening in psychological and mental health (8) (9) (10) , as well as in sleep quality (11) (12) (13) , mild or no changes in tobacco and alcohol consumption (11, 14) , slight or no changes in weight (14) (15) (16) , conflicting results for diet quality (17, 18) , important reductions in physical activity and increases in sedentary time (11, (19) (20) (21) .

Interestingly, one survey found that the percentage of interviewees meeting the guidelines regarding screen time became lower between March 22 nd and April 5 th , while unhealthy . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted February 16, 2021. ;  alcohol consumption and insufficient physical activity decreased during this three-week period (22) .

Unfortunately, none of these studies described the determinants of the observed changes in health behaviors, most were at high risk of information bias (i.e. people not accurately reporting their past exposures or symptoms, especially at a time of emotional distress), and, although a few provided stratified information by age groups, most presented aggregated information for young, middle-aged and older adults. Moreover, most of these studies were based on convenience samples, which increase the risk of selection bias. As the COVID-19 epidemic evolves and new social distancing measures may be needed (23) , and being aware of the risk of future infectious pandemics, it is critical that we identify population subgroups that are at increased risk of health deterioration with social isolation and confinement. This is especially important for older adults, because they represent around 10% of the worldwide population (up to 20% in Spain), frequently live alone, and are most vulnerable to the development and progression of diseases including COVID- 19 .

In this context, this study describes the main changes in health behaviors, mental and physical health between a pre-pandemic period and weeks 7 to 15 after the beginning the COVID-19 lockdown, among participants in four cohorts of community-dwelling older adults in Spain.

Seniors-ENRICA-2 (ENRICA): Longitudinal study of older adults selected between 2015-2017 through sex-and district-stratified random sampling of all community-dwelling individuals aged ≥65 years holding a national healthcare card and living in the Madrid Region (24) . In 2019 (baseline wave for the present study), participants were reinterviewed face-to-face at their homes using Computer-Assisted Personal Interviews (CAPI), and underwent a physical exam and blood tests (24) . Participants gave informed written consent, and the Clinical Research Ethics Committee of the La Paz University Hospital in Madrid approved the study (Protocol #HULP-PI 1793). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint [baseline wave for the present study]) participants responded to a face-to-face questionnaire and underwent a physical exam (27) . Participants gave informed written consent, and the Clinical Research Ethics Committee of Aragón approved the study (#18/2008).

A total of 4936 participants from the cohorts with at least one pre-pandemic follow-up visit were eligible to participate in the study. From these, 753 individuals could not be contacted, and 717 did not agree to participate. After excluding 120 individuals infected with COVID-19, 97 living with a COVID-19 infected patient, as well as 208 participants . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint with no information on important confounders, a total of 1323 individuals from ENRICA, 464 from ES, 829 from TSHA, and 425 from EXERNET comprised the analytical sample (n=3041).

At baseline and at follow-up, we collected data on health behaviors, mental and physical health, and their potential determinants including demographic and social variables, housing conditions, and aging experiences.

In all cohorts, baseline information was collected on sociodemographic factors (sex, age, education, civil status); social isolation (cohabitation, frequency of contacts with family and friends); tobacco consumption; diet quality (14-point Mediterranean diet adherence screener questionnaire-MEDAS) (28) ; physical activity, as per the EPIC-cohort questionnaire (29) in ENRICA and the EEPAQ questionnaire (30) in EXERNET, with results expressed as Metabolic Equivalent Tasks (METs), the Global Physical Activity Questionnaire in ES (31) , and the Physical Activity Scale for the Elderly (PASE) in the TSHA) (32) ; measured weight and height, with the body mass index (BMI) being calculated as the weight in kg divided by squared height in m; hours of night-time sleep (short sleep defined as ≤6 hours, and long sleep as ≥9 hours); quality of life (the 12-item Short Form (SF) in ENRICA (33), the WHO Disability Assessment Schedule 2.0 (WHODAS) in ES (34) , and the EuroQol-5D (35) in TSHA and EXERNET; and history of physician-diagnosed chronic conditions (i.e. hypertension, diabetes, osteoarthritis, and depression). Definition of hypertension was based on a self-reported physician diagnosis, current use of anti-hypertensive medication, or a clinical blood pressure reading ≥140/90 mmHg. Type 2 diabetes mellitus was defined as a self-reported physician diagnosis, current use of anti-diabetic medication, or fasting glucose ≥126 mg/d.

Additionally, in some cohorts, information was collected on feelings of loneliness (the 3item UCLA loneliness scale in ES, and a 0 to 5 scale in ENRICA) (36) ; exposure to second-hand smoke (SHS) (ENRICA) (37) ; alcohol intake (all cohorts but EXERNET); frequency of snack consumption and use of food to calm anxiety (ENRICA); time on sedentary activities (the Nurses' Health Study questionnaire in ENRICA) (38) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint overall sleep quality (in all cohorts but TSHA); other indicators of poor night-time sleep quality (i.e. "difficulty falling asleep", "awakening during night-time", "early awakening with difficulty getting back to sleep" and "use of sleeping pills") and drowsiness (i.e. "being so sleepy at daytime as to need a nap", "not feeling rested in the morning", and the Epworth Sleepiness Scale) in ENRICA (39) ; prevalence and characteristics of pain (ENRICA) (40) ; history of physician-diagnosed coronary heart disease, congestive heart failure, angina or cancer at any site (all cohorts but EXERNET), mobility limitations, in Information on overall sleep quality was harmonized into a variable with the following categories: "very good", "good", "fair", "poor/very poor." Moreover, in ENRICA a 0 to 7 score with the number of poor sleep quality indicators was constructed as follows: those who answered "sometimes" or "almost always" to the items "difficulty falling asleep", "awakening during night-time", "early awakening with difficulty getting back to sleep", "use of sleeping pills", "being so sleepy at daytime as to need a nap" or "not feeling rested in the morning", as well as those with an Epworth Sleepiness Scale score >10, received 1 point; their counterparts received 0 points. Also, in ENRICA, a pain scale ranging from 0 (no pain) to 7 (worse pain) was created based on pain frequency, intensity (assessed according to its impact on habitual activities), and number of pain sites. Sporadic (<2 times/week) and frequent (≥2 times/week) pain were assigned scores of 1 and 2, respectively; light, moderate and high intensity pain, scores of 1, 2, and 3, respectively; and 1-2 and ≥3 pain sites scores of 1 and 2, respectively (40) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ; a terrace/balcony or a private garden/yard to go out during confinement); tobacco consumption; passive tobacco smoke; alcohol drinking; diet quality; grocery modality during confinement (on-line, in-store) and person in charge; eating at a regular time (all cohorts but ES); eating more ultra-processed food than usual; eating snacks or food to calm anxiety (ENRICA); time spent in physical activities like walking (i.e. to the supermarket, the pharmacy or to walk the dog), exercising at home (i.e. with a stationary bike, a treadmill, fitness devices…), engaging in do-it yourself activities, or doing housework (ENRICA and EXERNET); the PASE questionnaire (TSHA and EXERNET); 

We first evaluated the longitudinal changes in the frequency of smoking, SHS, alcohol intake, diet, physical activity, measured weight, sedentary time, night-time and day-time sleep, sleep quality, overall health and pain between the pre-confinement and confinement periods, by using mixed models with robust standard errors accounting for within-participant correlations induced by repeated measures. These mixed models were fitted with adjustment for sociodemographic, lifestyle and health-related risk factors, including fixed effects for sex, educational level (primary or less, secondary, or university), baseline marital status (married, widowed, single, divorced), and study cohort (model 1); as well as fixed effects for baseline BMI and chronic morbidities, and changes over time in cohabitation status (living alone or not), smoking status (never, former or current), adherence to the Mediterranean diet score (0 to 14 points), physical activity (cohort-specific quartiles), night-time sleep, and overall health (cohort-specific quartiles) (model 2). To reduce the influence of increasing age during follow-up, we also conducted sensitivity analyses by excluding participants whose baseline measures were obtained earlier than 1.5 years before confinement.

In order to identify potential determinants of lifestyle changes or health declines during confinement, we then evaluated the relationship between baseline variables and changes in lifestyles and health outcomes. With this purpose, we used either linear or multinomial is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  regression models that adjusted for baseline socio-demographic factors, housing conditions, smoking status, adherence to the Mediterranean diet, BMI, recreational activity and household activity, night-time sleep, chronic morbidities, time since last follow-up visit, cohort of study, and week of confinement. Although results from these models are given for each predictor and study outcome in tables, we tried to simplify the presentation of results by conducting additional backward stepwise linear and multinomial regression models with the studied baseline predictors (inclusion set at p<0.1). These models were forced to adjust for age and sex, and their results are reported in figures, with red or blue colors identifying subjects with unhealthier and healthier changes, respectively. Categories "a" and "b" from multinomial regression models (defined in the paragraph below) represent these unhealthier (red) and healthier (blue) categories. 1-Changes in alcohol consumption. Participants in ENRICA, ES and TSHA cohorts were classified into the following categories: a) drinkers who increased their frequency of consumption (i.e. changed from not daily to daily drinkers); b) drinkers who decreased their frequency of intake (i.e. changed from daily to not daily or to not consumption at all); c) drinkers who did not change their frequency of consumption (reference); and d) not-drinkers who maintained their non-drinking status during confinement.

2-Changes in diet quality. A "worsening" (a) and an "improvement" (b) categories were created including individuals who had either decreased or increased, respectively, their MEDAS score ≥1 point over follow-up; while a "reference" (c) category classified those who experienced no changes or slight increases/decreases (below 1 point) on this score.

3-Changes in weight. Individuals who gained or lost >1 kg were classified into an "increased weight" (a) or "decreased weight" (b) category, respectively, while those . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted February 16, 2021. ;  who experienced no or small (<1 kg) changes in weight were classified into a "maintained weight" or "reference" (c) category.

EXERNET cohorts were classified as experiencing: a) "Unhealthier changes", if they decreased physical activity or increased sedentary time more than the observed 75 th percentile in each cohort; b) "Healthier changes", if they decreased activity or increased sedentary time less than the 25 th percentile, or if they had increased activity or decreased sedentary time with confinement; and c); "Average" or "reference" changes if they changed between the 25 th and 75 th percentile. 5-Changes in night-time sleep. The following categories were defined: a) "Worsening", those who at baseline had normal sleep and developed short or long sleep with confinement; b) "Improvement", those who at baseline had short or long sleep and developed normal sleep during confinement; and c) "Reference", those who stayed in the same normal/non-normal sleep category.

6-Changes in sleep quality. Finally, older adults in ENRICA, ES and EXERNET cohorts were classified into: a) "Worsening", if they had suffered an increase in the "poor sleep quality" score during confinement; b) "Improvement", if they decreased in that score, and c) "Reference", if that had no changes.

Statistical analyses were performed with Stata version 14.1 (StataCorp LP, College Station, TX). Table 1 shows the prevalence and mean (SD) estimates for the main sociodemographic, lifestyle and health characteristics of participants in the four cohorts at the pre-confinement period (baseline) and the confinement follow-up period. At baseline, the mean age was 74.5 years and the proportion of men 42.3%, although this latter figure varied widely across cohorts (from 21.2% in EXERNET to 50.5% in ENRICA). The prevalence of university studies also differed across cohorts and ranged from >15% in the ENRICA and ES to 8% in TSHAA and EXERNET. Similarly, participants in ENRICA and ES showed a higher prevalence of Internet access. Overall, 65% of participants were married, 4 to 10% lived in houses with no outdoor views, and 24 to 37% lacked an outdoor terrace or balcony to go outside during confinement.

Regarding social factors, the proportion of participants who lived alone was similar at . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted February 16, 2021. ;  baseline and during confinement (around 20-25% in all cohorts except for EXERNET, were the frequency was 35%). However, the percentage of participants without daily contact with family or friends halved during the pandemic. Moreover, in ENRICA, the single cohort where this information was available, no increases in lonely feelings during the study period were observed.

Changes in tobacco exposure, alcohol intake, diet quality and weight Table 1 shows results for changes in the prevalence of smoking, SHS, alcohol intake and diet quality between the pre-confinement and confinement periods. While the prevalence of active smoking remained stable, the likelihood of quitting smoking increased during follow-up. About half of the active smokers at confinement reported no changes in the frequency of tobacco consumption, while 22% reported an increase, and 27% a decrease, in the frequency of smoking since the start of the pandemic. The risk of increased consumption was higher among smokers with bad sleep quality at baseline and was lower among those lacking a terrace or balcony to smoke (Supplementary Table 2 ).

In ENRICA, the prevalence of SHS increased during follow-up, although this association was lost when excluding participants who had been followed-up for more than 1.5 years.

The prevalence of current alcohol drinking was very similar in both periods, whereas a decreased risk of not daily alcohol consumption, and a non-significant increased risk of daily intake, were observed. Despite this change in the frequency of consumption, data from ENRICA showed that the prevalence of binge drinking (defined as having >5 units of alcohol in a session in men, or >4 in women) was lower during confinement (1.8%) than before (2.7%) (data not shown in tables). Among drinkers, only a few baseline factors were associated with the odds of changing the frequency of alcohol consumption;

notably participants who lacked a terrace or balcony and former smokers showed a lower odds of increasing their frequency of alcohol intake during follow-up (Figure 1 and

Most study participants reported eating at a regular time during confinement, and a very low proportion declared eating more ultra-processed food than before (Supplementary Table 1 ). During confinement, 51.5% of study participants shopped face-to-face, 41.7% asked someone to shop for them, and 6.8% shopped online (data not shown in tables). In ENRICA, the odds of snacks consumption and that of use of food to calm anxiety was . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint although the association with snacks consumption was lost when excluding participants whose follow-up was longer than 1.5 years. Data from all cohorts combined showed a mean reduction of 0.5 points (95%CI: -0.60; -0.45) in the MEDAS score during followup ( Table 1 ). The items that were most negatively affected by the State of Alarm were fruits and vegetables, fish, wine, olive oil and sofrito (a sauced made of olive oil and garlic); while the preference for olive oil and red meat, consumption of legumes and consuming less sweets and cakes, improved. Predictors of increased odds of worsening diet quality with confinement included having better MEDAS scores at baseline, being older, lacking outdoor views, and sleeping > 9 hours/night (Figure 1 and Supplementary   table 3) . A lower odd of worsening diet quality was observed for daily moderate drinkers and for individuals who performed more physical activity, while those with better general health and non-hypertensives were more likely to experience improvements in the MEDAS. No differences in changes in the MEDAS score were observed by grocery modality (data not shown).

Although 29% and 19% of participants reported "feeling they were getting fatter or thinner" with confinement, respectively, no changes in weight between study periods were observed in those with objective information (mean change: -0.57 kgs; 95%CI: -1.29; 0.15). Still, self-reported and objective information showed some correlation: on average, those who self-reported "feeling they were getting fatter" had gained 1.3 kg since the pre-confinement measure was taken, while those who self-reported "feeling they were losing weight" had lost, on average, -2.3 kg. Women, those with university studies, short night-time sleepers and those who took longer naps at baseline, experienced greater weight loss during follow-up than their counterparts (Supplementary table 4) .

Physical activity and sedentary time were the lifestyle behaviors that changed the most with confinement ( Table 1 and Supplementary table 1 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  13.73). Alleged reasons for not doing any physical activity during confinement among those who used to engage in some type of recreational activity before confinement included not being able to go outside (52.4%), not knowing how to perform physical activity at home (11.4%), not having the resources to do physical activity at home (13.3%), or not having enough time (3.4%). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;

In multivariate models adjusted for changes in other potential confounders, data from all cohorts combined showed no changes in night-time sleep duration with confinement (-0.00 hours/night; 95%CI: 0.06; 0.05). However, slight decreases were observed in daytime sleep duration (-12.08 minutes/day; 95%CI -13.73, -10.42), as well as in the "poor sleep quality" scale (0.12 points; 95%CI: 0.09; 0.15) ( Table 1) . Baseline predictors of unhealthier changes in sleep quality included being a married woman, living alone, feeling lonelier, doing more physical activity, a lower adherence to the Mediterranean diet, having worse overall health and greater pain (Supplementary Table 7 and Figure   3 ). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  3.65; -1.35) and pain (mean changes in pain score: 0.28; 95%CI:0.03; 0.51), while participants with higher education in the ES study showed healthier changes in the WHODAS-12 (mean change -4.12; 95%CI: -7.70; -0.53), than their counterparts.

Other predictors of unhealthier changes in the PCS were lacking a garden/yard, poorer sleep quality, hypertension, cardiovascular disease, cancer, depression, mobility limitations, and lower general life-satisfaction. Predictors of unhealthier changes in MCS were living alone, feeling lonelier, having too much noise at home, doing less physical activity, taking very long naps, having mobility limitations, a negative ageing experience, and low MMSE scores. Finally, unhealthier changes in pain were observed in participants who lived in homes with more noise, as well as in those who suffered from baseline short sleep, worse overall health, osteo-muscular disease, depression, mobility limitations or lower general life-satisfaction.

When analyses were restricted to the 857 participants whose baseline measurements had been taken as far apart as 1.5 years before the State of Alarm, consistent findings were observed for most variables except for SHS, snacks consumption, and household physical activity, which no longer showed significant changes. The relationship with changes in some MEDAS items (i.e. vegetables, red meat, wine, sweets and cakes) also disappeared, and a slight decrease in night-time sleep was now observed (mean change -0.16 hours/day; 95%CI: -0.27; -0.06).

This study, conducted with older adults from four Spanish population-based cohorts, showed that, on average, strict confinement was not associated with a deterioration in lifestyle risk factors, except for physical activity and sedentary time, whose effects seemed to reverse with the end of the State of Alarm. Despite this, results from the ENRICA suggested moderate declines in mental health that did not seem to reverse after restrictions were lifted. On the other hand, the apparent improvements in physical health in participants from this last cohort did reverse with the end of the State of Alarm and may have been related to a better self-perceived performance at a less physically demanding time. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  This study identified subgroups of individuals at increased risk of developing unhealthier lifestyles with confinement, including males (for physical activity and sedentariness), those without daily contact with family and friends (for diet and physical activity), shown that current smokers were similarly likely (around 20-25%) to increase or decrease their tobacco consumption with the pandemic. In the Dutch survey, authors found that this apparently contradictory relationship was driven both by a negative effect of stress, boredom and restriction on smoking, and by a positive effect of motivation to quit smoking from fearing to contract COVID-19 and become severely ill. Consistently, in a Chinese survey, participants with higher epidemiologic concern were more often willing to improve their diets (48) . In the UK study, on the other hand, symptoms of mental distress (i.e. anxiety, low mood, sleeping problems) during quarantine were more frequently associated with increasing than decreasing tobacco smoke. Although in secondary analysis we did not find a relationship between symptoms of psychological distress and depression (measured at follow-up with the General Health Questionnaire-12 (49) and the Geriatric Depression Scale (50)) and changes in smoking frequency, we did observe that smoking older adults who spent more time listening or reading news related to the COVID-19 outbreak were more likely to increase their tobacco consumption (data not shown in tables). Our study provides evidence that smokers with poor sleep quality may be at higher risk of increasing smoking frequency in stressful situations than those who have good sleep quality. Also, it shows that while "lacking a terrace or balcony" was positively associated with unhealthier changes in physical activity and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ; sedentary time with confinement, it reduced the risk of smokers and drinkers to increase their frequency of tobacco and alcohol intake, respectively.

In our study, the frequency of alcohol drinkers who increased and that of those who decreased alcohol intake with lockdown was very similar, around 15%. Compared to other surveys, the frequency of increased alcohol consumption was much lower in our population than in adults in Germany (34.7%) (51), Australia (20.0% (52) to 30.8% (53)) or the USA (29%) (54) , and more similar to that reported in other Spanish (14, 22) , French (45, 55) , and Italian surveys (56) . In fact, in these studies, declining alcohol consumption during quarantine was more common than increasing it. Although some of the observed differences across countries may be accounted by discrepancies in study designs (prepost comparisons vs online surveys) and age of participants, they may also be influenced by the more social nature of drinking in Southern-Europe countries than in other cultures.

In any case, to our knowledge, ours are the first results that are entirely based on an elderly population.

Results for changes in diet quality are difficult to compare because of differences in diet assessment across studies, with some showing the proportion of those who increased or decreased the consumption of certain products (11, 15, 56, 57) , others asking participants to report their self-perceived changes in quality (55, 58) , and only a few studies providing validated diet quality scores (17, 18, 59) . Even for the latter, comparisons are limited due to the use of different scales; for instance, in a Spanish study, confinement was associated with a mean increase of 0.8 points in the MEDAS score (17) , in one French study it was associated with a mean reduction of 0.32 points in the simplified PNNS-GS2 index (18) , while in another study it was associated with equivalent increases or decreases in the Alternative Healthy Eating Index (59) . Other factors compounding this comparison are the retrospective collection of pre-confinement information, and the lack of focus on older adults.

Our results were somewhat expected because, during the State of Alarm, both older adults (the segment of the population that is more used to daily shopping for foodstuffs in Spain(60)) and the whole the population, inevitably had to decrease the frequency of shopping of foods that are typically consumed fresh (i.e. fruits, vegetables or fish). In line with our results, two Spanish surveys indicated a reduction in the consumption of these fresh foods in younger adults during confinement (17, 22) . Despite this, we observed some is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ; compensations in diet quality in older adults thanks to a decrease in the intake of nontypical Mediterranean Diet foods (i.e. red meat, sweets and cakes), or an increase in the consumption of legumes, which are typically prepared at home.

Previous surveys described mental health during confinement as an important predictor of reductions in diet quality, a fact confirmed in our study, where those with higher follow-up GDS-10 scores showed a higher risk of diet quality decline (Relative Risk Ratio (RRR) per 1 point increase in the GDS-10: 1.25; 95%CI: 1.13-1.39). We also identified a number of baseline predictors of diet decline with confinement: social isolation (which may reflect not having someone to buy fresh foods for them), a lack of outdoor views (which is associated with lower income), the insufficiency of physical activity, or the suffering poor general health or hypertension.

Changes in weight occurring in short periods of time may be important if, as the literature on obesity suggests, they remain over time (61) . Fortunately, though, most surveys either showed none or small changes in weight with confinement (14) (15) (16) . In our study, despite mean declines in diet quality and physical activity, only specific subgroups of older adults (mainly hypertensives and those with a negative ageing experience) presented significant weight gains. Moreover, we observed that women, those with university studies, and those with short sleep and very long naps presented significant weight loss. The fact that weight loss was not associated with either baseline or follow-up (secondary analysis) overall health, psychological distress or depression symptoms, reduces the probability that it was involuntary and, thus, indicative of an increased risk of frailty (62) . In any case, underlying changes in body composition (i.e. reduction in muscle mass and increase in fat mass) associated with the COVID-9 lockdown deserve further studies in the older population.

Surveys on non-institutionalized adults have uniformly shown declines in physical activity and increases in sedentary time after confinement (11, 19, 20, (63) (64) (65) , with unhealthier changes observed among those with higher activity and lower sedentariness at baseline (19, 63, 65) , and among those who had follow-up symptoms of loneliness and worse mental health (12, 19, 63, 65) . In our study, we corroborated the association between previous levels of activity and sedentariness and changes in these behaviors with is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  confinement, probably reflecting the regression to the mean phenomenon. Additionally, we first identified subpopulations of older adults who may be at increased risk of decreasing PA or increasing ST during quarantine. This information can help prioritize subgroups for health promotion or for being allowed to go outside, may future home confinements take place (i.e. the oldest old, those with worse housing conditions, or individuals with diabetes).

Worse sleep quality with confinement has been reported among the adult general population in different countries (11) (12) (13) 65) , and partly attributed to inactivity (12) and higher anxiety and mental distress during isolation (21) . In our study, the association with mental health during quarantine was confirmed, with an increased risk of reducing sleep quality in individuals with higher GDS-10 scores (RRR: 1.25; 95%CI: 1.13-1.39; data not shown in tables). Moreover, our study identified for the first time predictors of these changes, showing that older women who live alone and feel lonely, those with worse diet quality, as well as those with worse overall health and higher pain are at increased risk of developing sleep problems with confinement.

A mount of evidence supports a link between confinement and declines in mental health, both in middle-aged and older adults, and provides evidence that female gender (9) and being younger (66) are risk factors of these declines. However, we have only found one study evaluating the effect of confinement on chronic pain, this showing a mild improvement of migraine features during quarantine (67) . Now we have identified subgroups of older adults who are more vulnerable to mental health declines with confinement, including those who feel lonelier, perform less physical activity, have mobility limitations, low MMSE scores or a negative ageing experience. Also, we found that individuals who lacked a garden/yard, with poor sleep quality, hypertension, cardiovascular disease, cancer, depression or mobility limitations were at increased risk of deteriorating physical function during confinement. Finally, we observed that women with short sleep, worse overall health and lower overall life satisfaction, osteomuscular is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  disease and depression, as well as those who suffered from mobility limitations were at increased risk of pain worsening.

Among the limitations of the present study is that not all cohorts had information in all the studied variables and a lack of data on the longer-term (July-December) effects of isolation measures. Moreover, the study cohort did not include institutionalized older adults, so results may not be generalizable to them. However, ours is one of the very few studies that have evaluated the effects of the pandemic in non-COVID-19-infected older adults. Also, unlike most of the reviewed web-based surveys, it relied on telephone interviews and used pre-pandemic in-home collected information on participants´ health behaviors and health status, reducing the risk of information bias (i.e. people not accurately reporting their past exposures or symptoms).

The lockdown during the first wave of the COVID-19 in Spain, which was one of the most restrictive in Europe, only led to minor average changes in health behaviors among older adults. However, mental health was affected, particularly in those living alone, is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ; Table 1 : Longitudinal changes in the prevalence of smoking, second-hand smoke, alcohol intake, diet quality, physical activity, weight, sedentary time, sleep characteristics, overall health and pain between the COVID-19 pre-confinement (t0) and the confinement (t1) periods. Prospective association between participant characteristics and changes in the mental component (MCS) and physical component (PCS) scores of the SF-12 (n=1243 from Seniors-ENRICA-2), the WHODAS-12 (n=460 from Edad con Salud), and the pain score (n=983 from Seniors-ENRICA-2) during the COVID-19 confinement. Increases in MCS or PCS components reflect improvements in health, while increases in the WHODAS-12 or pain scores reflect worsening in health or pain, respectively. † The pain scale ranged 0 (no pain) to 7 (worst pain) and was created based on pain frequency, pain intensity (assessed according to its impact on habitual activities), and number of pain sites. Sporadic (<2 times/week) and frequent (≥ 2 times/week) pain were assigned a score of 1 and 2, respectively; light, moderate and high intensity, a score of 1, 2, and 3, respectively; and 1-2 and ≥3 sites a score of 1 and 2, respectively. ‡ Information only available in the Seniors ENRICA-2 cohort * p-value for trend <0.05 All models were adjusted for baseline age, sex (men or women), educational level (primary or less, secondary, or university), civil status (married, widowed, single, divorced), housing conditions (lack of outdoor views, terrace/balcony, private garden/yard, lack of internet and noise), smoking status (never, former, or current), adherence to the Mediterranean diet (MEDAS score), body mass index (normoweight, overweight, or obese), physical activity (cohort-specific quartiles), hours of night-time sleep (normal, short sleep, long sleep), chronic comorbidities (hypertension, diabetes, osteo-muscular disease and depression), time since last follow-up visit, cohort of study and week of the State of Alarm. Models for MCS and PCS components of the SF-12 adjusted for baseline values of the PCS and the MCS, respectively. Worsening was defined by increasing alcohol frequency from not daily to daily, or by decreasing the MEDAS score in one or more points during follow-up. Improvement was defined by decreasing alcohol frequency from daily to not daily, or by increasing the MEDAS scores in one or more points during follow-up. Variables were selected with a backward stepwise regression from the list of candidate variables shown in Supplementary Tables 2-3. Worsening was defined by decreasing physical activity or increasing sedentary time more than the observed 75 th percentile change. Improvement was defined by decreasing or increasing sedentary time less than observed 25 th percentile change Variables were selected with a backward stepwise regression from the list of candidate variables shown in Supplementary Tables 5-6. Worsening was defined as an increase in the poor sleep quality score, and improvement as a decrease in the same score. Variables were selected with a backward stepwise regression from the list of candidate variables shown in Supplementary Table 7 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;  III and co-funded by the European Union (FEDER/FSE, "Investing in your future"). BO was supported by the Miguel Servet programme (reference CP20/00040), funded by is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 16, 2021. ;

Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan

A Long and Difficult Ascent

Mental health and health behaviours before and during the initial phase of the COVID-19 lockdown: longitudinal analyses of the UK Household Longitudinal Study

Effects of the lockdown on the mental health of the general population during the COVID-19 pandemic in Italy: Results from the COMET collaborative network

Covid-19 health crisis and lockdown associated with high level of sleep complaints and hypnotic uptake at the population level

Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el COVID-19

por el que se regula un permiso retribuido recuperable para las personas trabajadoras por cuenta ajena que no presten servicios esenciales, con el fin de reducir la movilidad de la población en el contexto de la lucha contra el COVID-19

How did Different Generations Cope with the COVID-19 Pandemic? Early Stages of the Pandemic in Spain

Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain

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Profiles of sleep changes during the COVID-19 pandemic: Demographic, behavioural and psychological factors

Physical and Psychological Effects Related to Food Habits and Lifestyle Changes Derived from COVID-19 Home Confinement in the Spanish Population

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Physical Activity Change during COVID-19 Confinement

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por el que se declara el estado de alarma para responder ante situaciones de especial riesgo por transmisión no controlada de infecciones causadas por el SARS-CoV-2

Selenium and impaired physical function in US and Spanish older adults

Fruit and Vegetable Consumption and Potential Moderators Associated with All-Cause Mortality in a Representative Sample of Spanish Older Adults

The prevalence of frailty syndrome in an older population from Spain. The Toledo study for healthy aging

The effects of Age, Organized Physical Activity and Sedentarism on Fitness in Older Adults: An 8-Year Longitudinal Study

A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women

Estimation of reproducibility and relative validity of the questions included in the EPIC Physical Activity Questionnaire

Validation of the self-report EXERNET questionnaire for measuring physical activity and sedentary behavior in elderly

International physical activity questionnaire: 12-country reliability and validity

The Physical Activity Scale for the Elderly (PASE) Questionnaire; Does It Predict Physical Health?

How to ScoreVersion 2 of the Sf-12 Health Survey (with a Supplement Documenting

Quality Metric Inc. Health Assessment Lab

Developing the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ

Validity of the EQ-5D-5L and reference norms for the Spanish population

A Short Scale for Measuring Loneliness in Large Surveys: Results From Two Population-Based Studies

Exposure to secondhand tobacco smoke is associated with reduced muscle strength in US adults

Validation of the Spanish version of the physical activity questionnaire used in the Nurses' Health Study and the Health Professionals' Follow-up Study

Social network and risk of poor sleep outcomes in older adults. Social network and risk of poor sleep outcomes in older adults: results from a Spanish prospective cohort study

Gender Differences in Pain Risk in Old Age: Magnitude and Contributors

Television viewing time as a risk factor for frailty and functional limitations in older adults: results from 2 European prospective cohorts

Cantril Self-Anchoring Striving Scale. Encyclopedia of Quality of Life and Well-Being Research

Brief Report: Increased Addictive Internet and Substance Use Behavior During the COVID-19 Pandemic in China

Alcool : quel impact du confinement sur la consommation des Français? Available at

The double-edged relationship between COVID-19 stress and smoking: Implications for smoking cessation

The psychosocial impact of the COVID-19 pandemic on changes in smoking behavior: Evidence from a nationwide survey in the UK

The association between subjective impact and the willingness to adopt healthy dietary habits after experiencing the outbreak of the 2019 novel coronavirus disease (COVID-19): a cross-sectional study in China

The 12-Item General Health Questionnaire (GHQ-12): reliability, external validity and factor structure in the Spanish population

Development and validation of a geriatric depression screening scale: A preliminary report

Did the General Population in Germany Drink More Alcohol during the COVID-19 Pandemic Lockdown?

Alcohol use and mental health status during the first months of COVID-19 pandemic in Australia

Alcohol use in Australia during the early days of the COVID-19 pandemic: Initial results from the COLLATE project

Alcohol Consumption in Response to the COVID-19 Pandemic in the United States

Behavioral Changes During COVID-19 Confinement in France: A Web-Based Study

Covid-19 and the Subsequent Lockdown Modified Dietary Habits of Almost Half the Population in an Italian Sample

Eating Habits and Lifestyle during COVID-19 Lockdown in the United Arab Emirates: A Cross-Sectional Study

Determinants of the Lifestyle Changes during COVID-19 Pandemic in the Residents of Northern Italy

Diet and physical activity during the COVID-19 lockdown period

Present Food Shopping Habits in the Spanish Adult Population: A Cross-Sectional Study

COVID-19-Related Home Confinement in Adults: Weight Gain Risks and Opportunities. Obesity (Silver Spring)

Frailty in Older Adults Evidence for a Phenotype

Changes in Physical Activity and Sedentary Behavior in Response to COVID-19 and Their Associations with Mental Health in 3052 US Adults

Socio-Cognitive Factors Associated With Lifestyle Changes in Response to the COVID-19 Epidemic in the General Population: Results From a Cross-Sectional Study in France

Physical activity, dietary habits and sleep quality before and during COVID-19 lockdown: A longitudinal study

Older Adults and the Mental Health Effects of COVID-19

Investigating the Effects of COVID-19 Quarantine in Migraine: An Observational Cross-Sectional Study From the Italian National Headache Registry (RICe). Front Neuro