The strategy adopted by many countries, as well as UAE to reduce the spread of COVID-19 has been “social distancing” and home quarantine. The tight precautionary measures that the UAE government imposed to curb the COVID-19 epidemic were needed to control the spread of the Coronavirus and mitigate the strains on the healthcare system. The majority of UAE residents, as reflected in this study, agreed that quarantine and wearing gloves and masks rules were effective ways to reduce the spread of Covid-19 pandemic virus. Although these restrictions were effective in flattening the curve of the epidemic, they could precipitate unintended negative consequences on lifestyle behaviors among the UAE residents. To that effect, this population-based survey was designed to provide a description of the unhealthy changes in lifestyle and their determinants among UAE residents during the Covid-19 lockdown, including decreased physical activity, increased food intake, increased weight, increased smoking, and decreased sleep. Among these changes, the highest prevalence was for increased food intake followed by decreased physical activity, increased weight, increased smoking, and decreased sleep. Over half of the study participants (62%) had one or two unhealthy lifestyle changes during the lockdown with 9% reporting more than 3. Except for increased smoking, females had higher odds of adopting unhealthy lifestyle changes as compared to males. Older adults were less likely to adopt any of these changes, with the exception of physical activity. Non-Emirati Arabs as compared to Emiratis were more likely to report an increase in their food intake, weight, and smoking. Living in an apartment, as opposed to living in a house with a yard or garden, or being overweight or obese increased the odds of all the lifestyle changes except for sleep where no associations were found. For the overall score on unhealthy lifestyle, females, living in an apartment and being overweight or obese were predictors of higher scores while older age was associated with lower values of the score. In addition to these findings, the study showed that almost half of the study population were angry and felt more stressed during the lockdown.
The findings of this study showed that the most prevalent unhealthy change in behavior among participants was increased food intake (32%). The confinement to one’s home and the interruption of the work-related routine could lead to irregular eating patterns and frequent snacking, both of which are associated with increased food intake and consequently a more positive caloric balance (16.). Such an increase in food intake could also be driven by fear and anxiety. During the quarantine, continuously hearing or listening about the pandemic spread and its associated mortality can be stressful (17). In fact, in this study more half of the participants reported anger and heightened levels of stress during the lockdown. For many people, the response to stress, distress, and emotional disturbance is not to avoid food but possibly to increase the consumption of energy-dense foods (18). It has been proposed that this emotionally-induced eating comes as a result of interference of eating by emotions, a by-product of emotions, and a consequence of regulatory processes (i.e., emotions may regulate eating, and eating may regulate emotions) (19). Of concern is the finding of this study that salty and sweet snacks (chips, crackers, cupcakes, cookies) were reported among the foods in which intake has increased most during lockdown. These foods are usually calorie-dense and also high in salt, sugar, saturated fats (20, 21). In addition, the higher consumption of these foods could displace more nutritious options in the diet such as fruits and vegetables. During the COVID-19 pandemic, optimal nutrition intake is paramount given its significant effects on the immune system. In fact, adequate dietary nutrient intakes are postulated to directly affect immunity through gene expression, cell activation, and signaling molecule modifications. In addition, many nutrients are implicated in the proper functioning of the gut microbiota and its composition and hence indirectly modulating the immune response (22). Therefore, promoting the adoption and maintenance of a healthy and well-balanced diet seems to be a prerequisite for a strong and well-functioning immune system that could withstand the assault of infections, including that of the Coronavirus.
In this study, one in three participants reported lower physical activity levels during lockdown. This significant prevalence of lower physical activity was also reported by a cross-sectional survey among Lebanese adults, whereby 41% reported no physical activity or exercise during lockdown (23). In fact, staying home for a prolonged period of time may lead to more prevalent sedentary behavior such as excessive sitting/reclining, increased screen time activities (video games, TV watching, use of mobile devices) (24). The negative consequences of the decrease in physical activity observed during COVID-19 affect both the physical and mental health. On one hand, lower physical activity levels lead to lower energy expenditure, a higher risk of overweight, obesity, and hence worsening of chronic health conditions (25). In addition, lower levels of exercise have been shown to lower the immune competency and regulation and increase the risk of developing systemic inflammation (26). Furthermore, accumulating evidence indicated that regular physical activity is beneficial for mental health as it reduces anxiety, depression, and negative mood, and improves self-esteem and improves the overall quality of life (27). These negative effects of lower physical activity on health, including a higher risk of chronic diseases, lower immunity, and compromised mental health, were in fact implicated in more severe symptoms and worse outcome for COVID-19 (25, 28, 29). Therefore, it is recommended to continue to maintain a healthy level of physical activity in a safe home environment using simple and easily implementable exercises such as walking in the house, lifting and carrying objects such groceries, alternating leg lunges, climbing the stairs, stand-to-sit and sit-to-stand using a chair and from the floor, and sit-ups and pushups. In addition, recently there has been an abundance of eHealth and exercise videos, which focuses on encouraging and delivering physical activity through the Internet, mobile technologies, and television (30).
The third most common unhealthy lifestyle behavior among study participants, after the increase in food intake and decreased physical activity was ‘increased weight’. It is, in fact, conceivable that these three unhealthy behaviors are interconnected, whereby the higher intake of food coupled to lower levels of physical activity would lead to a positive energy balance, a weight gain, and higher risk of overweight and obesity. Increasing evidence indicated that obesity is strongly associated with severe symptoms and death from COVID-19 (31–33). For instance, the risk for invasive mechanical ventilation in patients with COVID-19 infection admitted to the Intensive Treatment Unit increased by seven-fold for those with BMI > 35 compared with BMI < 25 Kg/m2 (31). In their review of the potential mechanisms by which obesity affects the disease outcome, Sattar et al. suggested that obesity and ectopic fat may lower the cardio-respiratory fitness, increase the cardiovascular susceptibility to immune driven vascular and thrombotic effects, impaired metabolic response, dysregulate the immune response and increase viral exposure, through more viral shedding and viral load in the breath (34). The higher risk of overweight and obesity during COVID-19 observed in this study is rather alarming when considered in the context of the UAE. Recent population-wide data (before the pandemic) showed that over 65% of adults residing in the UAE were already either overweight or obese, with 57% having central obesity (35). This high prevalence of obesity is accompanied by a heavy burden of Non-communicable diseases (NCDs) in the country, where the four main NCDs accounted for 77% of all deaths in UAE and 17% of premature deaths (30–70 years) in the year 2019 (36). Therefore, public health intervention tackling the prevention and management of obesity in the country is needed, now more than ever, in order to not only prevent chronic diseases but also limit the adverse reactions to viral pandemics. Decreased sleep and increased smoking were also among the unhealthy lifestyle changes which were reported in this study. Similar to these findings, previous studies showed that, among individuals who were self-isolated during the COVID-19 outbreak, a worsening of sleep duration and quality was observed (37). Furthermore, a survey of lifestyle habits conducted in Poland showed that over 45% of smokers experienced a rise in smoking frequency during the quarantine (38). Both decreased sleep and increased smoking can potentially increase vulnerability to infection by the coronavirus and worsen the clinical symptoms of COVID-19. Sleep is an important modulator of the immune response, whereby shorter duration of sleep was associated with a weaker immunity and an increased susceptibility to infection (39). Suggested mechanisms for this association included impaired mitogenic proliferation of lymphocytes, decreased HLA-DR expression, the upregulation of CD14+, and variations in CD4 + and CD8 + T lymphocytes (39). As for smoking, a review of its association with immunity indicated significant impacts of smoking on both innate and adaptive immunity by either exacerbation of pathogenic immune responses or attenuation of defensive immunity (40).
The unhealthy lifestyle changes described in this study call for evidence-based interventions to limit the undesirable effect of lockdown on the health of adults in the UAE, especially among population groups that exhibit a higher likelihood to adopt these unhealthy changes. To that effect, the findings of this study showed that females compared to males were more likely to report increased dietary intake, increased weight, lower physical activity, and decreased sleep. The vulnerability of women to such changes in their lifestyle could be explained by the fact that women, in general, are more susceptible to emotional exhaustion, stress, and their negative health implications (41). In this study, participants living in an apartment with no yard or garden were more likely to report all of the unhealthy lifestyle changes, except for decreased sleep. This finding underscores the role of built environment in affecting the lifestyle of individuals. A growing body of evidence supports built environment as a health promoter of individuals and communities by influencing risk factors, such as dietary choice and physical activity (42). In addition to gender and living conditions, weight status was shown to affect the odds of adopting unhealthy behaviors, whereby in this study, having a BMI ≥ 25 kg/m2 were more likely to report higher dietary intake, increase in weight, lower physical activity and increased smoking. It has been suggested that during quarantine, patients suffering from obesity may experience higher levels of stress which in turn makes them more vulnerable to over-eating and sedentary lifestyle, thus predisposing them to further weight gain (18). These findings suggest that obese subjects must be carefully informed about the risk of an unhealthy lifestyle during the quarantine due to the increasing risk of disease associated with obesity. In addition, it is important for overweight and obese subjects to carefully monitor their health and to receive strong psychological support to reduce their stress and anxiety levels.
In this study, among the factors that were associated with lower odds of adopting unhealthy lifestyle changes was older age (> 40 years). While older adults were at a higher risk of complications and severity of the coronavirus infection (43–45), it appeared that younger individuals seemed to be more vulnerable to the effect of confinement and exhibited an overall higher frequency of unhealthy changes in their lifestyles. It is possible that younger adults are less prepared to cope with the lockdown and its consequences as well as stress, anxiety, and fear.
The findings of this study ought to be considered in view of a couple of limitations. First, the online nature of the survey limits the ability to objectively verify the data. As such all the changes in the lifestyle are based on self-reports and could have been subject to self-selection and reporting bias. However, given the lockdown situation in the UAE, face-to-face data collection was not possible. Second, the low response rate in this survey could have resulted in a non-response bias and hence limit the generalizability of the findings. Such low response rate of the online survey has been previously reported, however, in the case of this study, the advantages of this method (speed, cost, no physical contact) outweighed its disadvantages and potential biases.