Comparison of the General Dietary Habits and Lifestyle between Before and During COVID-19 among the Saudi Adult's Population in Riyadh



The global outbreak of COVID-19, for which there is few evidence-based effective vaccines or treatments available yet, has led to many attempts to find alternative options.



This study aimed to compare the general dietary habits and lifestyle between before and during COVID-19 among the Saudi adult population in Riyadh



It was a cross-sectional study, targeting the Riyadh population, from 16 May 2020 to 16 June 2020. The study comprised a structured questionnaire design that inquired demographic information examples include:(age, gender, place of residence, and health status); dietary habits information (daily intake of certain foods, food frequency, number of meals/days, and number of times drinking the tea and coffee); lifestyle habits information (physical activity, sleep quality, time that spend using the internet, social media and electronic devices for fun daily and stresses) using Google form. A total of 1,193 participants have been included in the study aged over 18 years.



During the COVID-19 period, a significant increase in the number of meals eaten daily, the number of times of fruits and vegetable intake, the number of sweets, cakes, and biscuits, the number of hours of sleep per day, the time using the internet and social media were observed more than at in the before COVID-19 pandemic period. However, the number of running exercise or physical activity were significantly reduced.



 In this study, the dietary and lifestyle habits have changed among the Saudis during the COVID-19 period. Future large-scale similar studies should be undertaken to confirm the results of the study.


Even though the exact mechanisms of transmission of SARS-CoV-2 are presently uncertain, it is clear now that SARS-CoV-2 can be transmitted by human-to-human despite the majority of the early cases.
Infection is also acquired by inhalation of these droplets or touching surfaces contaminated by them and then touching the nose, mouth and eyes [11]. Within a short period, and due to the number of countries reporting cases, the WHO declared the COVID-19 outbreak as a pandemic [12], until of Jun 16th 2020, the virus affected more than 205 countries with more than 6,5 million con rmed cases of COVID-19. Of these, more than 400,000 had lost their lives globally [13]. Although the case fatality rate of  (estimated at 2-3%) is lower than those of severe acute respiratory syndrome (SARS) (approximately 10%) and MERS (approximately 40%), the pandemic associated with COVID-19 has been far more severe.
In Saudi Arabia, within 3 months of outbreak, despite a bunch of restriction rules, the virus spread to most regions of the Saudi Arabia and infected more than 200,000 individuals with more than 2000 deaths [14].
To date, global public health bodies and governments have ignited strategies and issued advisories on various handwashing and hygiene guidelines such as handwashing and hand antisepsis, wearing a face mask [15] and social distancing strategies [16]. Some countries have adopted partial/complete curfew, and travel restrictions to prevent COVID-19 spread. In Saudi Arabia, rapid spread of the virus with the high fatality rates has left the world scrambling to bring the pandemic under control, at the beginning of March 2020, the Saudi Government early decided for more stringent containment measures and issued a curfew and imposed a strong nancial penalty on lawbreakers, curfew in speci c hours and most of the major cities have 24 hours' curfew and also stopped religious gathering in orders to prevent the spread of virus [17,18].
Good nutrition is an important implication in host defense against COVID-19 [19]. Various dietary patterns have been linked to the risk of in ammatory conditions [20] and respiratory disease [21]. Fruit and vegetable intakes have been investigated for potential bene ts in association with respiratory and in ammatory conditions due to their nutrient pro le consisting of antioxidants, vitamins, minerals [22,23]. All of this caused a sudden change including lifestyle and dietary habits through social distancing and isolation at home, with social and economic. This study aimed to compare the general dietary habits and lifestyle between before and during COVID-19 among the Saudi adult's population in Riyadh.

Study design and population
A cross sectional survey conducted among the general population of Riyadh, from 16 May 2020 to 16 June 2020, data were collected online, via questionnaire, using Google form. Given the high internet usage among people in the Saudi Arabia, a link to the survey was distributed to respondents, via Twitter, WhatsApp and Instagram. According to the latest Saudi Arabia census, Riyadh has a population around 4.21 million [24]. To achieve the study objectives and su cient statistical power, sample size was calculated using sample size calculator [25], which was 1,193 participants, using a margin of error of ± 4%, a con dence level of 99%, a 50% response distribution. Ethical approval was obtained from the Ethics Committee of the College of Science Research Center of King Saud University, Riyadh, Saudi Arabia.
Eating habits and lifestyle changes in COVID 19 period (EHLC-COVID19) questionnaire EHLC-COVID19 questionnaire was specially built in Arabic langue. On the rst page of the questionnaire, respondents were clearly informed about the background and the purpose of the study. EHLC-COVID19 questionnaire consists of three primary sections that inquired, the rst section was about demographic information (age, gender, place of residence, current employment, education and health status); The second assessed participants' dietary habits that included 12 question about (daily intake of certain foods, food frequency, number of meals/day and number of times drinking the tea and coffee); The nal section of the questionnaire assessed the lifestyle habits. This section consisted of ve questions related to practices and behavior, including (physical activity, sleep quality, time that spend using the internet, social media and electronic devices for fun daily and stresses). Once completed, each questionnaire was transmitted to the Google platform and the nal database was downloaded as a Microsoft Excel sheet.

Statistical analyses
Data were analyzed using Statics Package for Social Science (SPSS) version 22 (SPSS Inc. Chicago, IL, USA). Categorical data were presented as frequencies and percentages (%). Continuous data were presented as mean ± standard deviation (SD) for normal variables and non-Gaussian variables were presented as median. Independent Sample T-test, and The Chi-Square independence test was used to indicate differences as all variables are nominal. Results were signi cant for P value<0.05.

Participants
On the 16th of Jun 2020, the web-survey was stopped, and the collected data were analysed. A total of 1,100 participants completed the questionnaire. The participants (7) that live outside of Riyadh city Saudi Arabia were excluded, so, the nal sample consisted of 1,093 participants aged over than 18 years.
According to gender distribution, the female respondents represent (76.9%) of the population. The majority of the participants (71.5%) were married, (69.9%) of those had university education. The majority of the participants (67.1%) without diseases and the percentage of those a had different disease (32.9%). The most important diseases were respiratory problems, cholesterol, blood pressure, thyroid and diabetes as shown in Table 1. Dietary habits and lifestyle changes during COVID-19 pandemic: With regards to dietary habits, a signi cantly reduced intake of breakfast was observed during COVID-19 pandemic than that in the before COVID-19 pandemic (P =0.000). There was a signi cant increase in the number of meals eaten daily (more 5 meals) during COVID-19 pandemic than that in the before COVID-19 pandemic (P =0.000). The family members ate the meal together were signi cantly elevated during COVID-19 pandemic more than before COVID-19 pandemic (P =0.000). However, the number of times of eat in restaurants or home delivery were signi cantly reduced during COVID-19 pandemic in comparison to before COVID-19 pandemic (P =0.000). A signi cantly increase in the number of times of fruits and vegetables intake (3-4/day) was showed during COVID-19 pandemic than that in the before COVID-19 pandemic (P =0.000), there was also a clear increase in the number of sweets, cakes and biscuits intake (twice/day and 3-4/day) during COVID-19 pandemic than that in the before COVID-19 pandemic (P =0.000) as shown in Table 2.
With regards to lifestyle changes during the COVID-19 pandemic, a signi cantly decrease in the number of running exercise or physical activity (1-2/week and 3-4/week) than that in the before COVID-19 pandemic (P =0.000). However, the number of hours of sleep per day were signi cantly elevated during COVID-19 more than before COVID-19 pandemic (P =0.000). A signi cantly increase the time using the internet, social media and electronic devices for fun daily was noted during COVID-19 pandemic as compared to before COVID-19 pandemic (P =0.000), there was also a clear increase in the feeling anxious, afraid and depressed during COVID-19 pandemic more than at in the before COVID-19 pandemic (P =0.000) as shown in Table 3.  Note: Data presented as number (%). **Significant at P <0.01

Discussion
This cross-sectional study was aimed to compare the general dietary habits and lifestyle between before and during COVID-19 among the Saudi adult's population in Riyadh. To our knowledge, this is the rst study to investigate the immediate impact of the COVID-19 pandemic on dietary and lifestyle patterns among the Saudi adult's population in Riyadh. The web-survey was conducted from 16 May 2020, to 16 June 2020 [17,18]. The total number of assessed cases in Saudi Arabia was more than 200,000 individuals with more than 2000 deaths, the virus spread to most regions of the Saudi Arabia, mostly in Riyadh, Jeddah, Makkah, Al Madinah and Dammam [14].
Eating habits may be substantially changed due COVID-19 pandemic, the results of the current study showed that increase in the number of meals eaten daily (more 5 meals) and the number of times of fruits and vegetables intake (3-4/day) during COVID-19 pandemic than that in the before COVID-19 pandemic. These observations, in parallel with previous study, suggest that 15% of Italian population increased their consumption of fresh fruit and vegetables, especially in the North and Center of Italy during COVID-19 pandemic [26]. Similarly, a recent study reported that 21.2% of Italian population upped their consumption of fresh fruit and vegetable. Considering the current pandemic of COVID-19 has no effective preventive and curative medicine is available, healthy eating habits are crucial and elective micronutrient supplementations (e.g. vitamins, trace elements, nutraceuticals and probiotics) may be bene cial in nutritionally especially for vulnerable populations, such as the elderly [27]. Another recent study also reported that healthy foods is reduced susceptibility to and long-term complications from COVID-19 [19]. Fruit and vegetable intakes may be important modi able risk factors for the development, progression and management of obstructive lung diseases such as asthma and chronic obstructive pulmonary disease [28]. Furthermore, various previous studies have associated low intake of fruits and vegetables with chronic diseases such as chronic obstructive pulmonary diseases respiratory problems [29][30][31]. Fruits and vegetables support the immune system are likely to be in excess of intakes that can easily be achieved through diet alone. This is the case for vitamins C, D and E and zinc and selenium [32], which contributes to immune defense by supporting various cellular functions of both the innate (nonspeci c) and acquired (speci c) immunity immune system [33][34][35]. Vitamin C is an essential dietary component which unable to synthesize vitamin C endogenously due to loss of a key enzyme in the biosynthetic pathway [36]. Fruits (mainly oranges) (51 %) and fruiting vegetables (mainly tomato and sweet pepper) (20 %) for vitamin C; vegetable oils (sun ower and olive) (40 %), non-citrus fruits (10 %), and nuts and seeds (8 %) for vitamin E [37]. Furthermore, most dietary pro-vitamin A comes from leafy green vegetables, orange and yellow vegetables, tomato products, fruits, and some vegetable oils [38]. However, high zinc fruits include avocados, blackberries, pomegranates, raspberries, guavas, cantaloupes, apricots, peaches, kiwifruit, and blueberries [39].
Lifestyle may be substantially changed due to COVID-19 pandemic, in the present study, to COVID-19 pandemic greatly reduced the amount of running exercise or physical, increased in the number of hours of sleep per day, the number of hours of sleep per day, the time using the internet and social media and electronic devices for fun daily. The staying at home (which includes digital-education, smart working, limitation of outdoors and in-gym physical activity) and stockpiling food, due to the restriction in grocery shopping may cause increase of body weight. There is evidence to support that low tness and physical activity, excess body weight [40]. Another previous study compared interventions consisting of diet alone, physical activity alone, and the combination of diet plus physical activity. The results of this study demonstrated that following the initial 6-month intervention period revealed weight decrease of 9.1, 2.1, and 10.4%, respectively [41]. An early study also suggested that subjects reporting exercise of higher intensities were less likely to gain weight than those reporting low intensity exercises [42]. Another previous study demonstrated that the physical activity of 45min/day on 5 days/week over a 16-month period in overweight and obese adult resulted in revealed weight losses of 5.2 kg vs. a 0.5 decrease observed in non-physical-activity control men, when dietary intake is unchanged [43].
A limitation of our data was represented by a self-reported questionnaire, which may lead to the actual misreporting of data. Another limitation is the skewing in the geographical distribution of participants, which were from the Riyadh. Our data need to be con rmed and investigated in future larger population studies.

Conclusion
In conclusion, in this study, the dietary and lifestyle habits have changed among the Saudi during the COVID-19 period. Future large-scale similar studies should be undertaken to con rm the results of the study.