key: cord-0805130-yfjwh2s0
authors: Yücel, Ümüş Özbey; Yücel, Murat
title: Changes in Diet, Lifestyle, and Orthorexia Nervosa Tendency During the COVID-19 Pandemic: A Web-Based Study
date: 2022-04-15
journal: Clin Nutr ESPEN
DOI: 10.1016/j.clnesp.2022.04.011
sha: 987abd28347f3ed4969a12ea3fc80d6d6f5f7bf8
doc_id: 805130
cord_uid: yfjwh2s0

Objective During the COVID-19 pandemic, our diet and lifestyle have changed significantly. In this study, it was aimed to determine the changes in diet, body weight and Orthorexia Nervosa (ON) tendency in the pandemic. Method This cross-sectional study was carried out among adults (n=945). An online questionnaire was used to determine nutrition, lifestyle factors and ON tendency (via Google Docs). The questionnaire was also shared on social media groups and pages (instagram, twitter and facebook) managed by registered dietitians. Results During the COVID-19 pandemic individuals' body weight and total food consumption increased by 51.0% and 57.2%, respectively. Increased screen time (OR:1.912, 95%CI:1.374-2.661 p<0.001), sleeping time (OR:3.630, 95%CI:2.551-5.166 p<0.001) and decreased physical activity (OR:2.051, 95%CI: 1.198-3.509 p<0.01) were associated with weight gain. The ON tendency increased in all groups according to the change in food consumption status (p<0.05). Conclusions Considering the ongoing pandemic, individuals should be provided with adequate nutritional support. It is very important to get that support from nutritionists in order to monitor and control body weight and ON tendency.

COVID-19 (Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)), which first appeared in late 2019, continues as a life-threatening danger all over the world. COVID-19, which was declared a pandemic by the world health organization (WHO) due to its high spread and death rate (2-3%), mostly affects the respiratory system [1] . Coughing, high fever, muscle pain and fatigue are the most common symptoms [2] .

Despite the strict isolation measures taken since March 11, 2020 , when the first case emerged in Turkey, 20.881 people died by the end of 2020 due to COVID-19, according to the data of the Turkish Ministry of Health [3] . Since there was no specific and effective treatment method in the initial phase of the pandemic, social distancing, mask and personal hygiene practices were recommended and/or enforced to prevent infection. Due to all these social distance and isolation rules, our lifestyle has inevitably changed [1] .

General dietary habits and physical activity are also among the lifestyle factors that have changed in the COVID-19 pandemic [4, 5] . In particular, the fact that individuals spend more time at home with media and social media tools has led to an increase in sedentary time [6] . In addition to these, the change in the diet of individuals due to the fear and stress caused by the pandemic has led to an increase in healthy eating obsession, which is defined as Orthorexia Nervosa (ON) [7, 8] . In the study of Zeynep et al. (2022) , it was found that the fear of COVID-19 was related to an increase in the tendency toward ON [7] . Another study also reported that the time spent on social media to follow the COVID-19 and nutrition news were associated with higher ON symptoms [8] . Due to all these health concerns many individuals have consumed more organic/fresh food than they would usually require, assuming that it will boost immune against COVID-19 [9] . As a result of these new habits and trends, the risk of obesity and some eating behavior disorders have increased even more [6] .

Consequently, this study was conducted to determine the changes in diet, body weight and Orthorexia Nervosa (ON) tendency during the pandemic J o u r n a l P r e -p r o o f

This cross-sectional study was conducted between September and November 2020, when the number of cases with COVID-19 was quite high in Turkey. Volunteers between the ages of 20-65 were included in the study. Registered dietitians were contacted to reach individuals, and a questionnaire including sections about informed consent, demographic characteristics, diet, lifestyle, and healthy eating obsession was sent online (via Google Docs). On the first page of the questionnaire, there were statements that the participation was on a voluntary basis. The research questionnaire was shared in social media groups (instagram, twitter and facebook) managed by registered dietitians.

During the research period, individuals who followed any diet or physical activity program, were pregnant/lactating, or were previously diagnosed with COVID-19 (due to its effects on food consumption and appetite) were excluded from the study. According to the preliminary data, 1043 people participated in the study. However, as a result of excluding questionnaires that did not meet the criteria (n=98), the study was completed with 945 people. The research was conducted in accordance with the principles of the Declaration of Helsinki and received approval from the Ankara University Ethics Committee (number: 12/034).

In the demographic information section age, gender, marital status, level of education and working status were collected. Dietary and lifestyle changes of individuals during the COVID-19 pandemic were compared with pre-pandemic through increased', 'decreased' and 'unchanged' options. Changes in diet were questioned through the headings of "total food consumption", "organic food consumption", "fruit consumption", "fast food consumption", junk food consumption", "frozen food consumption", "number of main meals", "number of snacks", "food restriction status" and "night eating status". In order to determine the lifestyle changes of individuals, the parameters of 'physical activity duration', 'screen time', 'sleeping time' and 'body weight', 'use of vitamin-mineral supplements' and 'nutrition label reading habit' were also questioned.

The Turkish validated Orthorexia Nervosa (ON)-15 scale was used to evaluate the obsession with healthy eating [10] . The decrease in the score obtained from the scale indicates an increase in the ON tendency. Each question was asked twice to assess its impact before and during the COVID-19

pandemic.

For sample size calculation G Power program was used. Number of predictor and total sample size of the similar study were taken as a reference and the study was completed with 95% power. 15 The Descriptive statistics were shown as number and percentage (n (%)). Multinomial logistic regression analysis was used to evaluate the body weight change of individuals in the pandemic. In dependent and independent variables, the category 'unchanged' was taken as a reference. To adjust for potential confounding, age and gender were included into the regression model. Paired t-test was used to compare ON scores before and during COVID-19 pandemic. All statistical analyses were performed within a confidence interval of 95.0%, and p values of <0.05 were considered significant.

The study population consisted of 945 people and the majority of whom were between the ages of 20-29 years (82.1%), women (75.8%) and single (91.6%). In total, 74.4% of individuals were university graduates and 62.1% were unemployed (Table 1) .

During the COVID-19 pandemic, individuals' body weight (51.0%), total food consumption (57.2%), organic food consumption (56.6%), fruit consumption (52.6%), number of snacks (49.2%) and night eating status increased, while their fast-food consumption (53.0%) decreased (Table 2) . According J o u r n a l P r e -p r o o f to the regression model given in Table 3 (Table 3 and Figure 1 ). When the factors affecting decreased body weight were examined, it was observed that only increased vitamin-mineral use (OR:3.313, 95%CI:1.262-4.807 p<0.05) had a significant effect (Table 3) .

According to the change in total food consumption, ON scores decreased in all groups compared to the pre-pandemic period. The most significant change was observed in the group with increased food consumption (p<0.05) ( Table 4 

Since the advent of COVID-19 and consequent quarantine and isolation measures, our lifestyle has gone through many changes. Prolonged restrictions and our survival instincts have driven us largely away from our social life to maintain our health [11] . One of the most obvious changes in this regard has been seen in our diet. During the pandemic, when we mostly spend time at home, has not only changed the amount of food we consume but also the choice of our food [12] . People started to consume more fresh/organic food by assuming that it would improve their immune system. In our study, the total food consumption (57.2%), organic food consumption (56.6%), fruit consumption (52.6%) and the number of snacks (49.2%) increased compared to the pre-pandemic period. In the study of Ruis-Roso et al. (2020), it was found that fruit/vegetable consumption and the number of snacks increased during the COVID-19 lockdown [13] . Another cross-sectional study conducted J o u r n a l P r e -p r o o f with young adults also found that participants' fruit and vegetable consumption increased during the COVID-19 lockdown [14] . Similarly, in other studies, total food consumption, organic-fresh food consumption and the number of snacks increased in the COVID-19 pandemic [15] [16] [17] . During the pandemic, fast food consumption tended to decrease due to the increase in home cooking practices and the fear of COVID-19 contamination from packaged products [18] . In this study fast food consumption decreased (53.0%) compared to the pre-pandemic period. In other studies, in parallel with our study, it was found that fast food consumption decreased during the pandemic [19] [20] [21] .

The increase in body weight is expected to be a possible outcome of increased food consumption coupled with the decreased or unchanged physical activity [12] . According to the results of our study, one of the important factors affecting increased body weight during the pandemic was found to be reported that the increase in food consumption in the COVID-19 pandemic affected weight gain (p<0.05). Physical activity was also found to be negatively associated with weight gain (r=−0.155, p=0.034) [11] . Similarly, Allabadi et al. (2020) , found that the increase in food consumption during the pandemic was associated with weight gain (p<0.01) [12] . In the study of Tan et al. (2021) , it was found that almost half (47.7%) of Indonesian students and more than half (57.8%) of Malaysian students gained weight during the COVID-19 pandemic [22] . In another cross-sectional study, conducted with 1101 students, it was found that approximately half of the students (46.9%) gained weight and the majority (56.7%) did not exercise regularly [23] .

The changing sleep pattern during the pandemic has also been associated with diet. Less exposure to daylight, changing sleep/wake times and online work have affected individuals' circadian rhythm and diet [24] . Our results suggest, increased sleep duration significantly affected individuals' total food intake (OR:1. Increased screen time can delay mealtimes and change the amount of food consumed. Spending a long time with the media and social media in the COVID-19 pandemic has also affected food intake [25] . In this study, increased screen time was one of the factors affecting body weight (OR:1.912, 95%CI:1.374-2.661 p<0.001) and increased food intake (OR:2.047, 95%CI:0.980-3.112 p<0.01).

Parallel to our study, other studies found that an increase in screen time increases body weight and food intake [6, 25] . However, in the study of Tan et al. (2021) , no relationship was found between body weight change and screen time [26] .

Since adequate and balanced nutrition have positive effects on health, as mentioned above, people tried to eat healthier during COVID-19 than before the pandemic. However, the fact that this situation turned into an obsession, resulting in increase of some eating behavior disorders [9] . According to the data we obtained, ON tendency, which evaluates individuals' obsession with healthy eating, This study has some limitation. The results cannot be generalized to the whole population, since the research was conducted on the internet and a certain number of people were reached. Due to pandemic conditions, detailed anthropometric measurements of individuals could not be taken. In addition, the results of the study were not compared with the physical activity record and macromicronutrient intake. Despite all these limitations, the comparison of diet, lifestyle factors and ON tendency with each other and with the pre-pandemic period has added strength to the research.

It was found that the total food consumption, body weight, and ON tendency of individuals increased in the COVID-19 pandemic. Increased sleep time, screen time, and decreased physical activity were J o u r n a l P r e -p r o o f the main factors affecting weight gain and increase in total food consumption. The ON score also showed a positive relationship with increased total food consumption. According to the results, considering the ongoing pandemic process, individuals should be provided with adequate nutritional support. It is very important to get support from nutritionists during the pandemic process in order to monitor and control both body weight and physical activity. For this purpose, correct information should be conveyed by experts in the media and on social media platforms as well. J o u r n a l P r e -p r o o f

Nutrition, immunity and COVID-19

The impact of nutrition on COVID-19 susceptibility and long-term consequences

COVID-19 outbreak control, example of ministry of health of Turkey

Eating Behaviors among Online Learning Undergraduates during the COVID-19 Pandemic

Eating behavior among remote working adults during the COVID-19 pandemic

Physical activity: Benefits and challenges during the COVID-19 pandemic

Evaluation of orthorexia nervosa tendency and fear of COVID-19 in university students receiving health education

The COVID-19 Pandemic Drives People to Orthorexia and Anxiety with the Influence of Social Media: A Cross-Sectional Study of 525 Adults in Semi-Quarantine

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Orthorexia Nervosa and Adaptation of ORTO-11 into Turkish

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Impact of COVID-19 lockdown on dietary and lifestyle behaviours among adolescents in Palestine

COVID-19 lockdown and changes of the dietary pattern and physical activity habits in a cohort of patients with type 2 diabetes mellitus

Changes in Dietary Intake Patterns and Weight Status during the COVID-19 Lockdown: A Cross-Sectional Study Focusing on Young Adults in Malaysia. Nutrient

Consumer behaviour in online shopping organic food during the COVID-19 pandemic in Serbia

The Effects of COVID-19 on the Eating Habits of Children and Adolescents in Italy: A Pilot Survey Study

Weight gain in a sample of patients affected by overweight/obesity with and without a psychiatric diagnosis during the covid-19 lockdown

The impact of COVID-19 lockdown on snacking habits, fast-food and alcohol consumption: A systematic review of the evidence

Hamu łka J. Dietary and lifestyle changes during covid-19 and the subsequent lockdowns among polish adults: a cross-sectional online survey plifecovid-19 study

Does COVID-19 change dietary habits and lifestyle behaviours in Kuwait: a community-based cross-sectional study

Associations between changes in health behaviours and body weight during the covid-19 quarantine in Lithuania: the Lithuanian covidiet study

Physical activity, sedentary behavior, and weight status of university students during the covid-19 lockdown: A cross-national comparative study

The Effect of Social Isolation during COVID-19 Pandemic on Nutrition and Exercise Behaviors of Nursing Students

The impact of COVID-19 stay-at-home orders on health behaviors in adults

Longitudinal weight gain and related risk behaviors during the COVID-19 pandemic in adults in the US

Screen time-based sedentary behaviour, eating regulation and weight status of university students during the COVID-19 lockdown

Figure 1. Factors associated with increased total food consumption in the COVID-19 pandemic. Multinomial logistic regression analysis was used. The category 'unchanged' was taken as a reference. Age and gender were included into the regression model

The authors would like to thank Jawad Ahmed Nizamani for his support at every stage of the study.

The authors declared no potential conflict of interests with respect to the research.

None.

UOY: Study design, data interpretation, drafting and revising the article. MY: Study design, data analysis-interpretation, revising the article and final approval.J o u r n a l P r e -p r o o f