key: cord-0838854-v3z340td
authors: Al-Domi, Hayder; AL-Dalaeen, Anfal; AL-Rosan, Sara; Batarseh, Nour; Nawaiseh, Hala
title: Healthy Nutritional Behavior during COVID-19 Lockdown: A Cross-Sectional Study
date: 2021-02-23
journal: Clin Nutr ESPEN
DOI: 10.1016/j.clnesp.2021.02.003
sha: 39b4efd783be877ad071caeb5b8b394585b29cb3
doc_id: 838854
cord_uid: v3z340td

Background Ongoing outbreak of the novel coronavirus infectious disease 2019 (COVID- 19) constitutes a major global pandemic health care system challenge. Shortly following the disease outbreak, like SARS-CoV virus, all affected countries are implementing various preventive and control measures to mitigate the spread of the disease. Optimizing public health system during COVID-19 pandemic requires not only advanced medical and biological sciences knowledge, but also all human sciences related to social, as well as nutritional behavior, and lifestyle practices. Aim To investigate the effect of COVID-19- quarantine on healthy nutritional behavior and lifestyle practices among Jordanian population. Methods A cross-sectional study among Jordanian population was conducted using an online questionnaire between March and April 2020. Participants were kindly requested to answer a standardized and validated structured questionnaire. Demographic information (age, gender, place of residence, and occupation), anthropometric data (reported weight and height); dietary habits information (number of meals per day, snakes, water intake), and physical activity behavior were requested. Results A total of 4473 respondents were included in the study; obese (n=1135), normal body weight (n=1561), and underweight (n=116). During COVID-19 quarantine, a significant increase in body weight (12.9% underweight, 28.5% normal body weight, 36.4 % overweight’ and 41.1% of obese, (p<.001) was reported. Moreover, the number of snacks between meals (p<.001), number of main meals (p<.001), and the smoking rate was also increased significantly; however, there was no significant difference regarding physical activity among various weight status groups (p<0.05). Conclusions In this study, we have provided evidence, for the first time, that there were significant negative changes in healthy nutritional behavior among Jordanians during COVID-19 quarantine who encountered significantly increased body weight, appetite, and smoking. Future larger cross-sectional studies are warranted.

The world is currently experiencing an unprecedented pandemic of the novel acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Globally, more the 96.2 million individuals were diagnosed with coronavirus disease 2019 (COVID- 19) , which continues to spread rapidly across the world. In December 2019, COVID-19 infection began in Wuhan, Hubei, China [2] , which started with an animal-to-human infection. The direct cause of death is generally due to ensuing severe atypical pneumonia [2] . As such, COVID-19 has been declared a pandemic by the World Health Organization (WHO) in February 2020 [3] .

To prevent or at least ameliorate the sweeping spread of COVID-19, populations throughout the world have been under extended quarantine as a strategy to prevent the spread of the disease, which then also reduces the impact on medical resources [4] . Since the quarantine is associated with the interruption of the life and work routine [5] , it could result in boredom [6] , which could be associated with increased intake of higher quantities of macronutrients; fats, carbohydrates, and proteins; each of which has a distinctive set of properties that impact health, but all are a source of energy. Surplus intake of macronutrients are regarded as potentially problematic that could contribute to disordered eating [7] . Continuous television watching or reading about the pandemic without a break during the extended quarantine could be also stressful [8] . As such, stress drives people toward hedonic overeating, mostly consuming more sugary and salty food "comfort foods" [9] . This desire to consume higher amounts of specific foods, defined as food craving, is a multidimensional concept including emotional eating (intense desire to eat), behavioral (seeking food), cognitive (thoughts about food), and physiological (salivation) processes [10] . Healthy nutrition is crucial for good health, whereas unhealthy nutritional behavior and sedentary behavior are associated with a significant risk of developing overweight or obesity [11] . The pro-subclinical pro-inflammatory state caused by obesity is often complicated by serious comorbidities, including, but not limited to diabesity, cardiovascular diseases, and pulmonary diseases [12] that have been demonstrated to increase the risk of serious complications of COVID-19 [13] .

J o u r n a l P r e -p r o o f Increased intake of macronutrients during quarantine could also be accompanied by micronutrient deficiency associated with increased body weight [14] , which is associated with an impaired immune response; this could be responsible for heightened susceptibility to infections [15] . Thus, during this time of quarantine, it is pivotal to maintain healthy nutrition behavior and undertake adequate physical activity [8] .

The Jordanian government announced a lockdown on 17 March 2020, which was later turned into a strictly-enforced curfew that was described as one of the world's strictest measures Jordan Ministry of Health (2021). As of January 24, 2021, the accumulative positive cases were 319, 519, the incidence rate was 5.8 per 100,000 population, and the daily death rate was 1.6 per 100,000 population. It is conceived that due to the quarantine-related situational stress-eating, healthy nutrition should become a national priority.

This study, therefore, aimed to establish national base-line data on the effect of quarantine on nutritional behavior, physical activity among Jordanian residents using a formulated online survey. A comparison of lifestyle and nutritional behavior during the lockdown was also undertaken to allow a better understanding of the impact of COVID-19induced confinement policies on lifestyle practices among the Jordanians as well as to examine the potential risks of nutritional inadequacies.

A population-based cross-sectional study was conducted between March and April 2020. The study was conducted using an online self-administered questionnaire distributed through social networking sites (SNS), mainly Facebook. The decision was made because it is the most used SNS in Jordan. As of January 2020, a minimum of 6.78 million Jordanians have internet access, which accounted for 67% of the entire ten million Jordanian population [16] ; of the more than six million Jordanians have a Facebook account (57.3% men, and 42.7% women) [17] . Worth noting that two of the largest mobile service providers in Jordan offer free access to Facebook, especially during the COVID-19 quarantine. According to the Inclusive Internet Index of 2019, a slight gender gap exists in internet and mobile phone access in Jordan [16] .

The target population was Jordanian adults aged more than 18 years. Participants were invited to participate in this online survey using snowball sampling methods to guarantee a largescale distribution and recruitment of participants [18] .

To assess the content validity, the questionnaire was revised by a Panel of Academics of Nutrition, and Nutrition Epidemiologist and Arabic literature, and their respected comments were taken into consideration. Then, the questionnaire was formatted into Google forms, an internet-based software commonly used for data collection. Google forms were preferred for their convenience, efficiency, and high popularity especially in the current scenario where people in Jordan were under quarantine. After adding the questionnaire into Google forms, a link was generated and randomly distributed using social media networking sites such as Facebook and by phone on WhatsApp groups.

Before distribution, the initial version was further reviewed by experts and was piloted on 30 participants for clarity and language. All the feedback about the survey was positive and no changes were suggested and, subsequently, all piloted cases were included in the data analysis. J o u r n a l P r e -p r o o f *Data are presented as frequency (%)and is considered statistically significant at p<0.05 *Data are presented as frequency (%)and is considered statistically significant at p< 0.05

This study was undertaken to assess the effect of the COVID-19 quarantine on healthy habits related to nutritional behavior, dietary patterns, and sedentary behavior among the Jordanian population during the COVID-19 pandemic. To the best of our knowledge, this study could be among the first in Jordan to investigate the impact of COVID-19 on ceratin nutritional behavior aspects. Our findings revealed a significant variation of eating patterns and lifestyle factors that were affected by the quarantine.

This online survey was conducted in March 2020, and the data was collected from all 12 governorates of Jordan, which are in one of three regions: the North, Central, and Southern region. The majority of the study participants were females, which could be attributed to the fact that females who participate are more involved in online surveys, mostly whenever related to their interests. Generally, they have a positive attitude toward online operations, and they provide more accurate and consistent responses [18, 19] .

Our findings showed that the 26 to 40 years age of the participants was the dominant age group; provided that according to the Jordan statistical book (2016), 62% of the Jordanian population aged between 15 and 64 years old. As such, it is highly anticipated that this age group is more familiar with technology and online surveys compared to older individuals [20] ..;

Furthermore, this survey was conducted during the second academic semester (2020) where the majority of the college students were highly engaged in online learning during COVID-19

quarantine and therefore, this could explain the limited participation (26.7%) of the young adults (18-26 years old).

As mentioned before, our findings showed that participants who are employed and hold a bachelor degree or a higher were either overweight or obese with the highest percentage J o u r n a l P r e -p r o o f reported among females, provided that 70% of the participants were females); similarly, the highest percentage of overweight (39.2%) and obese (44.5%; p< 0.05 was among participants in the Northern region. This is consistent with an earlier report which found that the percentage of obese women in Northern Jordan constituted 53.1% of the population sample compared to men (28.1%) who were obese and their. Furthermore, we found that there were significant differences between obesity and its comorbidities, particularly type 2 diabetes, hypertension, and other cardiovascular diseases (p≤0.001), which is consistent with a report indicating that there was a strong association with obesity in chronic morbidities, especially diabetes, hypertension, and other cardiovascular diseases, p≤ 0.001) [19] More than 45% of the participants had a low monthly income between (200-500 JD); of them, about a half were either overweight or obese. The income issue plays an essential role in the nutritional behavior of Jordanians; it affects directly the economic access to foods [20] .

Quarantine has imposed more stress on Jordanian families as many of them lost their income. It has been reported that while Mafraq, Karak, and Tafileh governorates are the highest incidence of poverty, Amman, Madaba, and Irbid governorates are the lowest [21] . Jordanians who have higher income adopt better healthy nutritional behaviors, whereas individuals living in rural areas and have low income are less likely to adopt healthy promotion behavior [21] .

During the COVID-19 locked down, our findings showed a significant change in the Jordanian nutritional behavior as well as and lifestyle practices. It has been known that Jordan is one of the highest counties globally in the smoking rate. According to the world health organization, 66% of Jordanian men and more than 17% of women are smokers [5] , and the smoking rate is the highest among poor individuals ( monthly income 100-250 JD) followed by individuals with a monthly income up to 500 JD [22] . Nutritional behavior is likely to change due to reduced availability of goods, limited access to food caused by restricted store opening hours, and a switch to unhealthy food [23] .

In 2020, findings on the quarantine in Italy found that COVID-19 generates intense stress and challenge on individuals who smoke [22] . Dual users of cigarette, e-cigarette, and exclusive cigarette smokers reported that their daily consumption has slightly decreased while exclusive cigarette smokers and exclusive e-cigarette users changed purchasing products. This result is generally is consistent with our findings; a minimum of 46% of the participating smokers J o u r n a l P r e -p r o o f reported an increase in tobacco smoking. On the other hand, it has been demonstrated individuals who smoke more than ten cigarettes per day have decreased by 0.5% cigarettes per day.

Findings of this study revealed that lunch was the main meal during the quarantine, increased appetite, and the intake of foods or supplements containing antioxidants has increased during the quarantine. Home-cooked meals, eating five portions of fruits and vegetables, whole grains, drinking enough water, avoiding added sugar and salt is recommended, and taking multivitamins for short periods during this epidemic could be beneficial [11] . Nonetheless, the sense of hunger and satiety changed for more than half of the population participants during COVID-19 causing weight gain [8] .

Physical activity is one of the most critical determinants of health, specifically for Jordanian patients with common cardiovascular diseases [23] . However, there was a significant weakness in applying this concept to Jordanian patients, especially by health sector workers [24] .

In 2018, Hayder et al discussed the importance of physical activity in reducing overweight and obesity issues from early stages. Their research showed that Jordanian girls who have normal body weight were more physically active and maintain regular excises than boys(49%, 26.5%;

respectively, p<0.01), and school children who spent around 30 min/day exercising have a decreased risk of overweight by 0.5-fold [25] .

The decrease in physical activity is associated with a lower metabolic rate and energy expenditure that poses health issues and an economic burden [26] , while regular physical activity has positive effects on the immune system and prevents low-grade inflammatory response [27] .

During the COVID-19 lockdown, negative impacts on psychological health and exercise motivation were globally noticed [28] . Like other countries, sedentary behavior was dominant in Jordan during the lockdown, and this significantly affected the physical activity as almost 70 % of Jordanian who reported changes in their physical activity, and 39% of overweight and obese reported inactive state.

Adequate water intake is essential, reflects good nutritional behavior, and suboptimal hydration before weeks of infection with COVID-19 rises angiotensin-converting enzyme 2 receptors lung, which causes epithelial cells injury, leakage of fluid into the airway space and therefore, it could increase the risk of COVID-19-related mortality [29] . Daily total water intakes less than 1.8 L/day (7.2cups) may start a neuroendocrine defense for water in the body that influence the risk of dysfunctional metabolism [30] . Generally, 69% of Jordanians reported J o u r n a l P r e -p r o o f drinking less than eight cups of water per day during the lockdown, precisely 64% of obese people who are considered a high-risk group for metabolic disorders.

Due to the COVID-19 quarantine-related stress-eating, changes in the nutritional behavior should constitute a priority at this time. Many people probably encountered an increase in their appetite, and many breakfasts and dinner meals were consumed. Water intake was reported below the recommended in all weight groups, and inactive physical behavior was dominant, specifically among overweight and obese during the quarantine. Strategies to promote healthy nutritional behavior, positive lifestyle practices, and enhancing physical activity should be developed and implemented. Further large-scale population-based studies are warranted to investigate the long-term effect of this pandemic on various aspects of nutritional behavior.

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The authors would like to thank all participants for their participation.

The authors declare no conflict of interest.[