key: cord-0987826-tte9s63s
authors: Matsungo, T. M.; Chopera, P.
title: The effect of the COVID-19 induced lockdown on nutrition, health and lifestyle patterns among adults in Zimbabwe
date: 2020-06-19
journal: nan
DOI: 10.1101/2020.06.16.20130278
sha: 3a298149348c6f0c3e0636d9e1f07da83a2e602c
doc_id: 987826
cord_uid: tte9s63s

Background: The 2019 coronavirus disease (COVID-19) is a global public health nightmare resulting in lockdowns, associated diet and lifestyle changes and constraint public health delivery. Objective: To investigate the impacts of the COVID-19 induced lockdown in Zimbabwe on nutrition, physical activity and lifestyle patterns among Zimbabwean population aged [≥]18years. Methods: A cross-sectional online survey was conducted using a structured questionnaire to collect information on demographics (age, gender, place of residence, current employment), food system dimensions, diet and physical activity patterns, stress and anxiety, body image perceptions, lifestyle behaviours like smoking, alcohol intake, screen time, and ease of access to health services. Electronic informed consent was obtained from all participants prior to completing the survey. Results: The majority of the participants were between the ages of 31-40 years, were female (63.0%) and had tertiary education (91.3%). The lockdown resulted in increase in food prices (94.8%) and decrease in availability of nutritious foods (64%). Most (62.5%) of the participants reported a reduction in their physical activity levels. The prevalence of Generalised Anxiety Disorder (GAD) was 40.4% and mostly affecting females [63.5%, P=0.909), 31-40 years age group (49.6%, P=0.886). Based on the BMI-based Silhouette Matching Test (BMI-SMT) 44.5% gained weight, 24.3% lost weight and 31.2% did not have weight change. The paired samples T test showed that there was a significant increase in perceived body weight (P<0.001). More than half (59.6%) reported having difficulties accessing drugs and medication and 37.8% growth monitoring services. Conclusions: The lockdown period was associated with increase in food prizes, decrease in dietary diversification, elevated stress, disrupted diet and consumption patterns. There was low levels of physical activity and perceived weight gained during the lockdown period. However, there are still lots on unknowns concerning the COVID-19 pandemic future studies with larger population are required.

The World Health Organization (WHO) on March 11, 2020 declared the outbreak of the novel 2019 coronavirus disease (COVID-19) a global pandemic 1 . The pandemic started in Wuhan, China, in late December 2019, and has spread globally 2 . The WHO situation report 113, reported that as of 12 May 2020 globally there were 4 088 848 cases and 283 153 deaths due to COVID-19 3 . The situation report also showed that the highest cases were in the Americas (1 743 717) and Europe (1 755 790), while Africa had the lowest (46 829).

In order to contain the spread of the virus, national lockdowns characterised by restricted movement and social distancing "Stay at Home" have been the order of the day in many countries 4, 5 . In Zimbabwe the government declared a state of national disaster in response to the COVID 19 pandemic on Friday 27 March 2020, this was followed by a nationwide lockdown on March 30 6 . Unfortunately this has also led to increased vulnerability to food insecurity especially among the urban poor and increased risk of overweight and obesity in the higher income classes 7 . This is worrying considering that obesity is a risk factor for severe COVID-19 infection complications 8 . Therefore, maintaining healthy body weight and consumption of diverse and nutritious diet is recommended to mitigate COVID-19 infection via the immune boosting mechanism 9, 10 .

Individuals who eat a well-balanced diet tend to be healthier with stronger immune systems and lower risk of chronic illnesses and infectious diseases including COVID-19 11,12 .

The COVID-19 induced lockdowns are normally characterised with restricted movements and disrupted food supply and accessibility in most settings. Specifically, the COVID-19 control measures and travel restrictions may compromise the ability to maintain physical activity and healthy lifestyles including reduced consumption of diverse and nutritious diets. Although not clearly understood, this can have implications on health and nutrition outcomes. Therefore, this study was designed to investigate the impacts of the COVID-19 induced lockdown in Zimbabwe on nutrition, physical activity and lifestyle patterns among adults in Zimbabwe.

The nationwide descriptive cross-sectional study was carried by a nutrition team from the University of Zimbabwe, using a web-survey (SurveyMonkey, California, USA), from 11-25

May 2020. A short online questionnaire was administered with mostly multiple choice questions and some open end questions to capture additional observations. This was a rapid appraisal of the perceptions on COVID-19 lockdown on nutrition, health and lifestyle indicators among adults (≥18 years) from the 10 provinces of Zimbabwe. The survey link was disseminated through institutional and private social networks (WhatsApp, Twitter, Facebook), and institutional mailing lists.

A self-administered online questionnaire was developed to collect data on demographics, socio-economic factors, and to explore the impact of COVID-19 induced lockdown restrictions on food system dimensions, diet and physical activity patterns, stress and anxiety, body image perceptions, lifestyle behaviours like smoking, alcohol intake, screen time (TV/ Tablet/Phone/ Laptop), and ease of access to health services.

Impact of lockdown on the consumption patterns for the following food groups was assessed; dark green leafy vegetables, other vitamin A rich fruits and vegetables, other vegetables, other fruits, meat and meat groups, cereal breads and tubers, pulses, legumes etc., nuts and seeds, dairy products, eggs 18 .

We used the validated Generalized Anxiety Disorder-7 (GAD-7) scale to assess respondent's anxiety symptoms 19 . Seven questions assessed the frequency of anxiety symptoms over the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20130278 doi: medRxiv preprint past two weeks on a 4-point Likert-scale ranging from 0 (never) to 3 (nearly every day) and the total score of GAD-7 ranged from 0 to 21, with increasing scores indicated a more severe functional impairments as a result of anxiety 19 . We adopted the cut-off (GAD total score of >9 points) previously used to define the presence of anxiety symptoms 20 .

The 9 figural BMI-based Silhouette Matching Test (BMI-SMT) was used determine perceived anthropometry before and after lockdown 21 . The silhouettes are ranked from the thinnest to the heaviest body size and responses are recorded on a scale from 1 (thinnest) to 9 (heaviest).

The Silhouette test was validated for use in populations of African descent 21, 22 . To assess respondents' perceived ideal body size, participants were asked to select a matching figure that best represents how they looked like before the lockdown and how they were looking like the time of the interview.

Data collected was entered and analysed using SPSS v 20 (IBM Inc. Armonk, NY). The Shapiro-Wilk test and data visualisations via Q-Q plots were used to test for normality of data.

Continuous data was presented as mean ± standard deviation (SD) while categorical data was presented as frequencies and percentages. Pearson's Chi-square was used to explore associations for categorical variables and continuous variables respectively. Paired samples T test was used to test for difference in means across continuous normally distributed variables.

Level of significance was set at P<0.05.

The study was conducted based on the ethical principles of respect, justice and confidentiality summarised in the 2013 Declaration of Helsinki 23 . The study obtained ethical clearance from the Medical Research Council of Zimbabwe (MRCZ/B/1920). Electronic informed consent was obtained from all participants prior to completing the survey.

On the 25 th of May 2020, the online-survey was stopped, and the collected data was analysed.

In total 505 participants took part in the survey after 2 declined to participate. The majority of the participants were between the ages of 31-40 years, were female (63.0%) and had tertiary education (91.3%). Most of the participants were employed in the formal sector (73.9%), and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20130278 doi: medRxiv preprint most were from Harare (60.5%). Almost all the participants (95.5%) said they did not receive government assistance during the lockdown period. Of those who did receive some form of assistance, 2.5% received food handouts and 2% received financial assistance (Table 1) . of most households appears to be compromised due to extortionate prices, availability of less . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20130278 doi: medRxiv preprint

Almost half (48%) thought they had gained weight, whilst 25.8% and 25.5% thought they had lost weight and weight did not change respectively. However, based on the 9 figural BMI-SMT to determine perceived anthropometry 44.5% gained weight, 24.3% lost weight and 31.2% did not have weight change. The average size before lockdown was 5.0±1.6 compared to 5.2±1.8 during lockdown. The paired samples T test showed that there was a significant increase in perceived body size when comparing pre and during lockdown body size (P<0.001). Based on the BMI-SMT we found that highest perceived weight gain during the lockdown was in the age group 31-40 years (48.9%, P=0.568), females (62.6%, P=0.062), participants with tertiary qualifications (92.5%, P=0.533), formal sector employees (75.3%, P=0.107), individuals who did not have GAD symptoms (60.1%, P=0.143).

Over half (59.9%) said drugs and medication were not easily available during lockdown compared to 19.8% who said the drugs and medication were still easily available. Over half (58.6%) said doctor's appointments and review visits were not easily available and 7.97% said appointments and review visits were still easily available. Concerning immunisation and growth monitoring 37.8% said this service was not easily available compared to 19% who mentioned that the services were still easily available. Concerning the same 59.9% this question did not apply to them (Figure 5) .

In the present study, we provided for the first time data on the effect of the COVID-19 lockdown on nutrition, anxiety, physical activity and lifestyle patterns in Zimbabwe. However, there are still lots of unknowns concerning the COVID-19 pandemic that is still ongoing, thus our data need to be confirmed and investigated in future population studies.

The lockdown period was associated with increases in food prizes and decrease in dietary diversification. The increases in food prizes is reflective of the negative impact of COVID-19 and lockdowns on agriculture and food supply systems 24 . This often results in artificial shortages and inflated prizes and compromising food security and access to healthy food options particularly on the vulnerable low income households. This is disturbing considering the importance of optimum nutrition for well-functioning immune system in these times of COVID-19 25 . Therefore, increases in food prizes reduces access to diverse and nutritious foods, which ultimately makes it difficult for individuals to maintain thriving immune systems.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06. 16.20130278 doi: medRxiv preprint Healthy diets help to avoid deficiencies of the nutrients that play an essential role in immune cell triggering, interaction, differentiation, or functional expression 26 . Considering that there is currently no known cure, the Hippocrates 400BC philosophy of, "let thy food be thy medicine" is vindicated as consumption of varied and nutritious foods will guarantee a healthy immune system 27 .

Unfortunately, the effect of COVID-19 pandemic on nutrition and dietary intake goes beyond the individual and the community to reach national and global levels 26 . Therefore, there are crucial policy implications for national governments centred around the need to stop the spread of COVID-19 using lockdowns and on the other side the glaring need to prevent and deal with the negative impacts of such policy decisions on food security and livelihoods. According to Siche (2020), the COVID-19 pandemic food demand and thus food security are greatly affected due to mobility restrictions, reduced purchasing power, and with a greater impact on the most vulnerable population groups. It remains the responsibility of the governments to create a supportive policy environment to enhance the physical and mental health of individuals in the context of COVID-19 pandemic, without also neglecting the potential risk of "lockdown associated obesity" during lockdowns. Naja and Hamadeh (2020) gave recommendations on how to provide nutrition demands in the context of COVID-19 utilising a multi-level framework for action adapted from the ecological model of health behaviour. There are economic arguments that prolonged lockdown are not sustainable in the long run, as this will lead to economic slump that ultimately creates negative health consequences "povertyinfection complex", which create more non-COVID-19-related deaths than confinement would save from this disease 28 . Governments are encouraged to make evidence and informed decisions to ensure responsible lockdown exit strategies.

The COVID-19 induced lockdown has resulted in and disruptions in consumption patterns (96.6%) and elevated anxiety levels (40.4%) Regarding the implications of lockdown on diet and consumption patterns there was a overall, trend of reduced intake of fruits and vegetables except for 'dark green leafy vegetables'. This decrease, is disturbing considering that WHO recommends an average consumption of 400 gr of fresh fruits and vegetables per day will boost the immune system. Therefore, the observed increase in consumption of dark leafy vegetables is commendable and reflects the utilisation of home or backyard nutrition gardens, that are common in most households in Zimbabwe 29 .

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . In this current study, the prevalence of GAD was 40.4% and mostly affecting females and the 31-40 years age group. Hence the finding that carbohydrate intake also decreased is surprising, considering that we expected this to increase due to the stress and sugar cravings in stressful lockdown conditions 16 . The current findings reveal that among participants with GAD symptoms, there was reduced physical activity and alcohol intake, while an increase in smoking and screen time (TV, laptop, and phone). In addition, continuously hearing or reading about the COVID-19 can be stressful and can lead towards overeating, mostly sugary foods "comfort foods" 30 .

With respect to physical activity we observed that most of the participants were less active and gained weight in the lockdown period, thus increasing the risk of overweight and obesity. The perceived weight gain by participants was higher in females (P=0.062), participants with tertiary qualifications (P=0.533), formal sector employees (P=0.107). These results paint a picture of the dangers of obesity associated severe COVID-19 complications in typical formally employed persons with a tertiary qualification. Considering that there is growing evidence showing that obesity is key risk factor in this crisis 8 , it is strongly recommended that individuals should reduce the consumption of energy dense "junk" food which predisposes to weight gain and susceptibility to COVID-19 31 . Thus, studies to investigate the impact of consumption of unhealthy diets and low physical activity and anxiety on the susceptibility to COVID-19 and recovery are warranted.

We reported reduction in access to medical doctors (58.6%) said, drugs (59.9%), immunisations and growth monitoring (37.8%) during the lockdown period. This has negative long-term implications as individuals will develop reluctance to access preventative health services. In addition, disruptions in drug supply chains is likely associated defaulters on immunisations schedules among children and this may lead to future fatal outbreaks of preventable diseases such as measles polio and diphtheria 32 .

The main limitation of the present study is that we utilised an online and self-reported questionnaire with completion rate of 76%, thus missing values on some variables. Although or survey had respondents from all the 10 provinces of Zimbabwe, online surveys tend to be restricted to individuals with access to internet with potential under representation of people from lower socio economic groups, rural settings. However, due to the lockdown restrictions on population based assessments the online survey remains useful avenue for a rapid . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20130278 doi: medRxiv preprint assessment. It's crucial that this rapid assessments went on at the most critical period of the epidemic in Zimbabwe, to inform program and policy decisions. Interestingly, evidence is gathering indicating that web based surveys are equivalent to conventional face to face interviews 33, 34 .

The lockdown period was associated with increases in food prizes and decrease in dietary diversification. In addition, the COVID-19 induced lockdown has resulted in disrupted consumption patterns and elevated anxiety levels. Participants indicated that their physical activity levels decreased and perceived weight gain in the lockdown period, thus increasing the risk of overweight and obesity. However, there is need for future larger population studies incorporating participants of different socio economic status for more definite conclusions.

Firstly we are very grateful to the respondents for accepting to join our rapid appraisal and for sharing their perspectives and insights into perceived effects of the COVID-19 in their communities. Great thank you to Ms Tavonga Muderedzwa for assistance in setting up the online poll.

Shi Y, Wang Y, Shao C, et al. COVID-19 infection: the perspectives on immune . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. 

Siche R. What is the impact of COVID-19 disease on agriculture? Sci Agropecu . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20130278 doi: medRxiv preprint

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