key: cord-0988605-izuy4lrs authors: Mazzolani, B. C.; Smaira, F. I.; Astley, C.; Iraha, A. Y.; Pinto, A. J.; Marques, I. G.; Amarante, M. C.; Rezende, N. S.; Sieczkowska, S. M.; Franco, T. C.; Miranda, L. C. d. A.; Lindoso, L.; Helito, A. C.; Oba, J.; Queiroz, L. B.; Pereira, R. M. R.; Roschel, H.; Silva, C. A.; Gualano, B. title: Changes in eating habits and sedentary behavior during the COVID-19 pandemic in adolescents with chronic conditions date: 2021-04-16 journal: nan DOI: 10.1101/2021.04.16.21255582 sha: d84c215859c17abeb3722385628a537738ff9a71 doc_id: 988605 cord_uid: izuy4lrs Purpose: To report on the impact of the COVID-19 outbreak on eating habits and sedentary behavior among adolescents with multiple chronic conditions (n=347) from a tertiary, referral hospital vs. healthy peers. Methods: This observational study was conducted in Sao Paulo (Brazil) between July and October 2020, period in which a set of social distancing measures to contain the pandemic. Results: The main findings of this study were that adolescents with chronic conditions showed important changes in eating habits (e.g., less often consumption of convenience foods and more often eating in front of television than before quarantine). Also, 86.8% of adolescents with chronic conditions reported increasing screen time during pandemic. No major differences were observed between patients and controls. Conclusions: Adolescents with chronic conditions exposed to pandemic showed substantial changes in lifestyle, stressing the need for specific care to mitigate poor eating habits and excessive sedentary behavior in this group. Despite growing evidence showing that pediatric population is less susceptible to severe Coronavirus Disease 2019 (COVID-19) (Kabeerdoss, et al., 2021) , adolescents have been refrained from school, sports and social activities. Among healthy adolescents, school closures and home confinement were shown to increase unhealthier eating habits, such as increases in snacking, eating while watching television, and consumption of sweets and fried foods. (Ruiz-Roso, et al., 2020) Social distancing measures also scaled up sedentary behavior in teenagers. (Pecanha, Goessler, Roschel, & Gualano, 2020) More strict social distancing measures have been specifically implemented among pediatric groups with chronic conditions (e.g., autoimmune diseases, gastrointestinal, kidney and hepatic conditions), since they are deemed to be at risk for more severe COVID-19. (Evliyaoglu, 2020; Wang, et al., 2020) Because of the pressure in the health system caused by the pandemic, some of these patients were also deprived of in-person medical assistance, resulting in sub-optimal health care delivery and limited recommendations regarding healthy lifestyle during the pandemic. However, it remains unknown to which extent the pandemic has impacted the lifestyle of adolescents with chronic conditions, among whom poorer eating habits and higher sedentariness could lead to even further overall health deterioration (Bar-Or & Rowland, 2004; Dohrn, Welmer, & Hagströmer, 2019) . This study reports on the impact of the COVID-19 pandemic on eating habits and sedentary behavior in a large cohort of adolescents with multiple chronic conditions vs. healthy peers. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. included in this study. Additionally, healthy adolescents (n=95), frequency-matched for age and sex, were recruited to serve as controls. All participants completed an online survey on Research Electronic Data Capture ® (REDCap ® ) platform, which included questions about: i) demographic characteristics (i.e., age, sex, ethnicity, and educational level); ii) changes in eating habits during the pandemic (i.e., consumption of convenience foods and home-made meals, eating with others, eating in front of television/tablet/cellphone, mindful eating, and cooking); iii) changes in sedentary behavior during the pandemic, as assessed by screen time. The study was approved by the Research Ethics Committee of Clinical Hospital (approval number: 31314220.5.0000.0068). The consent form was signed digitally by all adolescents and their legal guardians before the beginning of the survey. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) 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 April 16, 2021. ; https://doi.org/10. 1101 Descriptive data are presented as mean and 95% confidence interval (95%CI) for continuous variables and absolute and relative frequency (n [%]) for categorical variables. Potential between-group differences for all dependent variables were tested by generalized estimating equations (GEE) models, based on the assumption of a multinomial distribution, cumlogit link function, and an exchangeable working correlation, with group as fixed factor. All GEE models were adjusted for age and sex. Analyses were performed using the statistical package SAS (version 9.4). The level of significance was set at p≤0.05. The mean age of patients and healthy adolescents was 14.3 years (95%CI: 14.0, 14.5) and 14.2 years (95%CI: 13.7, 14.7), respectively (p=0.753). Baseline characteristics were comparable between groups (all p>0.050). Most patients and controls were male (60.0% and 62.4%), Caucasians (60.0% and 51.4%) and attended public school (65.3 and 74.4%). Most adolescents reported changing daily routine after the implementation of social distancing measures (patients: 91.6%; controls: 92.8%; Table 1 ). pandemic are illustrated in Figure 1 (left panel). A small proportion of the adolescents with chronic conditions (7.5%) stated eating convenience foods more often than before quarantine, whereas 44.3% reported a less frequent consumption than before COVID-19 quarantine. The proportion of patients declaring consuming home-made meals more often than before quarantine was 33.8% vs. only 2.9% reporting a less often consumption than before quarantine. The percentage of patients reporting eating with others more often than before quarantine was 21.7%, while 14.2% declared doing so All rights reserved. No reuse allowed without permission. (which was not certified by peer review) 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 April 16, 2021. ; https://doi.org/10.1101/2021.04.16.21255582 doi: medRxiv preprint less often than before quarantine. While 21.1% of patients reported mindful eating more often than before quarantine, 11% stated doing it less frequently. An expressive percentage of the adolescents with chronic conditions (32.2%) reported eating in front of television more often than before quarantine vs. only 17.4% reporting doing so less frequently than before quarantine. More than a third (35.8%) of the patients reported participation in cooking more often than before quarantine vs. only 3.5% declaring doing so less frequently. The proportions of patients and healthy controls did not differ for changes in the following eating habits during COVID-19: consumption of home-made meals (p=0.933), eating with others (p=0.612), eating in front of television/tablet/cellphone (p=0.080), mindful eating (p=0.198), and participation in cooking (p=0.827) during the pandemic did not differ between groups. However, the proportion of patients and healthy controls changing consumption of convenience foods was significantly different (more often than before quarantine: 7.5 vs. 19.1%; less often than before quarantine: All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. To our knowledge, this is the first study to report on the impact of COVID-19 pandemic on lifestyle behaviors in a cohort of 347 adolescents with multiple chronic conditions. The main findings of this study were that adolescents with chronic conditions showed important changes in eating habits (e.g., less often consumption of convenience foods and more often eating in front of television than before quarantine) and substantial increase in screen time, a proxy of sedentary behavior, during the COVID-19 pandemic. Overall, changes in eating habits and sedentary behavior were similar across patients and controls. The COVID-19 pandemic and the set of social distancing measures adopted to contain disease spread have been shown to impact eating habits worldwide (Ammar, et al., 2020; Ruiz-Roso, et al., 2020) which is also reflected in our sample. Some of these changes appear to be positive, such as the decrease in the frequency of convenience foods consumption and the increase in the proportion of consumption of home-made meals, eating with others, mindful eating and participation in cooking. Conversely, the increased proportion of eating in front of television is worrisome, as it has been associated with unhealth food choices (Avery, Anderson, & McCullough, 2017; Martines, Machado, Neri, Levy, & Rauber, 2019; Trofholz, Tate, Miner, & Berge, 2017) and poor healthy indexes. (Vik, et al., 2013) Considering that parents are generally responsible for providing food, making it available to eat and structuring when and where to eat, (Savage, Fisher, & Birch, 2007) they should be informed on how to mitigate the potentially negative changes in eating habits brought about by COVID-19 pandemic. Perhaps the most concerning finding of this study was the dramatic increase in the proportion of patients increasing sedentary behavior during the pandemic, with approximately half of the patients reporting screen time over 6 hours/day. While these All rights reserved. No reuse allowed without permission. (which was not certified by peer review) 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 April 16, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 data align with others (Dunton, Do, & Wang, 2020; Pecanha, et al., 2020) showing excessive sedentary behavior as a consequence of the pandemic, this is of particular relevance for clinical population. Adolescents are known to spend excessive time in sedentary behavior, (Wu, et al., 2017) which may be exacerbated in adolescents with chronic diseases. (Bourdier, et al., 2019; Dohrn, et al., 2019) In this specific group, hypoactivity has been considered a risk factor for poor clinical condition and worse symptoms. (Bar-Or & Rowland, 2004; Gualano, Bonfa, Pereira, & Silva, 2017 ) Parents and healthcare providers should encourage physical activities and limit screen time whenever possible, particularly in the context of the pandemic. As some chronic conditions (e.g., obesity, immunosuppressive conditions) may aggravate COVID-19 prognosis, (Richardson, et al., 2020; Varley, Ku, & Winthrop, 2021) forcing home confinement, home-based exercise programs may be a valuable and feasible alternative to maintain or increase physical activity levels. (Schwendinger & Pocecco, 2020) Strengths of this study involve the assessment of a relatively large cohort of patients with several chronic conditions during the most restrictive quarantine in Brazil. This study has limitations, however. First, the cross-sectional design does not allow inferring causative relationships between lifestyle changes and pandemic. Second, the use of self-reported questionnaire may reflect in some degree of imprecision on data reporting. Third, the relatively low number of patients for each disease did not allow for disease-specific sub-analysis. Finally, as a result of the suspension of face-to-face health care in our tertiary hospital (which was adapted to accommodate 1,000 hospital beds exclusively for COVID-19), (Miethke-Morais, et al., 2020) patients' attendance to inhospital sessions were not possible, limiting the assessment of more in-depth clinical variables. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) 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 April 16, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 In conclusion, adolescents with chronic conditions exposed to social distancing measures due to COVID-19 pandemic showed substantial changes in lifestyle. The findings from this study stress the need for specific care for these patients to mitigate poor eating habits and excessive sedentary behavior. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Data presented as mean and 95% confidence interval (95%CI) or absolute and relative frequency (n[%]). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) 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 April 16, 2021. ; https://doi.org/10.1101/2021.04.16.21255582 doi: medRxiv preprint FIGURE CAPTIONS Figure 1 . Changes in eating habits and sedentary behavior among adolescents with chronic conditions (n = 347) and healthy controls (n = 95) during the COVID-19 pandemic. *significant difference between groups (p<0.05). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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