The global COVID-19 pandemic has severely impacted Hong Kong. In response, the government implemented social distancing measures to control the COVID-19 outbreak, including the tracing app "LeaveHomeSafe," lockdown measures, and group gathering prohibitions (1). Specific restrictions were also imposed on the food and beverage industry. For example, dine-in prohibition from 6 p.m. to 5 a.m., the limit of diners per table, and bar closure. These measures may affect the lifestyle of Hong Kongers, such as dietary habits and the frequency of physical activities, since there are alarming increases in the mortality rate of diet-related chronic diseases: for example, the age-standardized death rate of diabetes (from 2.8% in 2019 to 3.3% in 2020), cerebrovascular diseases (from 15.8% in 2019 to 16.6% in 2020), and heart diseases increased (from 32.8% in 2019 to 34.0% in 2020) (2).
The food environment closely links to the physical, social, cultural, and economic environment constructed by humans (3). A healthy food environment secures access to healthy food, such as fresh fruits, vegetables, and whole food. Good access to food should accompany a wide variety of food available for all with ensured food safety and balanced nutrition in a healthy food environment. It is also essential to secure stable food production and distribution networks over time. In addition, food education and community support can cultivate healthy dietary habits among the population (3). Undeniably the ongoing COVID-19 pandemic has substantially changed and impacted the food environment. However, such change and impact may vary by each people in her/his own daily life. Therefore, it is important to explore various changes in people's everyday dietary habits, including food choice, food expenditure, and dining habits, in detail.
1.1 Literature Review
The negative effects of COVID-19 on the food environment were observed from multiple perspectives. Overeating was commonly observed with increased snacking, larger meal size, and higher meal frequency. As people spent more time at home during the pandemic, they ate more because they had little to do. The increased meal frequency to 6–8 meals a day was reported in the United States (4), as eating helps control the negative emotions elicited during COVID-19 such as loneliness and anxiety (5). However, overeating may lead to a higher risk of obesity in the long run through lifestyle changes (4).
Food choices also became less healthy due to the decreased food accessibility since COVID-19 had impacted food accessibility by changing the way of buying food and increasing food expenditure. The closure of markets and restaurants pushes people to order food online. A higher frequency of online grocery shopping was reported globally, such as in the US, England, and China (5, 6). Accordingly, the consumption of highly-processed food, such as pizza and fried food, increased because of its durability and convenience (7). Meanwhile, healthy, fresh food became less accessible due to financial pressure. Since the suspended supply of school meals increased household food expenditure, people became less afford healthy food at an increased price (4). The rocketed price of staple food and fresh food further worsened the situation, as a group of researchers in Brazil recorded a price increase in rice and beans during COVID-19. This exerted great financial pressure on the low-income group, especially families that lost their income due to the pandemic (7). Fresh food is more expensive than processed food, which made food-insecure individuals buy fewer fresh food, such as milk, fruits, vegetables, and meat and more purchase unhealthy food, such as canned food and processed meat (8). Fresh food also became more difficult to purchase as people had fewer shopping trips to avoid infection. Therefore, people preferred to purchase more processed food for storage (6, 8). Such changes in food choices and purchasing behaviors often lead to increased consumption of less nutritious food with higher saturated fat, sugar, and salt, while intaking fewer fresh vegetables and fruits (5). For example, higher consumption of sugary drinks and alcohol was also reported in Brazil, which may associate with higher risks of overweight, hypertension, fatty liver, and other health issues (7). Researchers were concerned with the weight gain observed, as it could contribute to health risks in the long run, such as diabetes mellitus and stroke (4).
In contrast, positive outcomes on food were also observed during the pandemic. Enhanced awareness of the food waste issue was reported in Europe and Tunisia, while positive behavioral changes to reduce food waste were identified in the U.S., China, and Japan (6). This could be attributed to the increased valuation of food under the uncertainties and supply disturbance from COVID-19. Improved awareness can lead to better food management. A UK study demonstrated that people would check their refrigerators and write shopping lists to avoid impulsive purchases. Besides, the changes in food utilization also help minimize the amount of food waste. According to a study from Spain, Italy, and the Netherlands, people cooked at home more often during the lockdown and reduced food waste by using leftover food to prepare meals (6). In addition, cooking at home allowed people to rediscover traditional recipes, which is important to the inheritance of food culture (6).
A Hong Kong cross-sectional study conducted by random telephone survey research found that higher frequency of cooking at home and ordering a takeaway. While no observable change was identified in fast food consumption, the consumption of vegetables and fruits had increased significantly. In addition, people with a lower socioeconomic status were likely to consume more sugary drinks and less fruit and vegetable (9). However, there is a paucity of research dedicated to exploring the changes in food intake habits and the notions of food environment in Hong Kong where a most stringent COVID-19 interventions among advanced economies have been implemented during the ongoing pandemic times.
1.2 Research Questions
This study aimed to investigate the associations between the food environment and dietary habits of individuals in Hong Kong using these three research questions (1) "How does COVID-19 change the food environment in Hong Kong?" (2) "How does COVID-19 change the dietary habits among different age groups in Hong Kong?" And finally (3) "How do these changes directly or indirectly contribute to health issues, such as overweight, diabetes mellitus, and heart disease?"