To the best of our knowledge, this is the first study to evaluate the influence of COVID-19-related home confinement on dietary habits and physical activity in Saudi Arabia. Overall, this study has found that quarantine has negatively affected body weight, dietary habits, and physical activity among the Saudi Arabian population.
The prevalence of obesity and overweightness is increasing dramatically in Saudi Arabia, with a projection rate reaching 59.5% by 2022 [30]. Data from the current study agrees with this trend, with 67% of the participants having high BMI levels (> 25 kg/m2). However, other studies from different countries that were conducted during the COVID-19 pandemic have shown that the majority of their participants were within normal BMI range [18, 31]. This could be explained by the differences in daily routines, lifestyles, and modes of transportation between other countries and Saudi Arabia.
As evident from previous research, during this critical period, obese and overweight individuals could be at greater risk related to the current COVID-19 situation or similar situations in the future compared to individuals with normal weight status. Obese individuals tend to have more breathing difficulties, more intubation complexities, prolonged hospitalization, higher ICU admissions, and higher rate of mortality than other COVID-19 infected groups [32, 33]. Obesity is associated with disturbing major functions of the immune system [34]. This, in turn, could leave the person less reactive to vaccines and antivirals, more susceptible to infections, or even cause them to suffer severe complications. Thus, more attention and support should be paid to overweight and obese individuals regarding the positive impact of losing weight on overall health during pandemics, especially in countries with higher rates of obesity, such as Saudi Arabia.
An initial objective of the current study was to identify the effect of a prolonged lockdown on weight changes. As hypothesized, the highest percentage of participants reported weight gain rather than weight loss or no weight change during the lockdown, with a reported weight gain of around 3–5 kg. Similarly, other studies have reported weight gain of ~ 3–4.5 kg during quarantine [18]. Since quarantine is associated with limiting people’s ability to go to work, the gym, parks, and even practicing normal daily routines, weight gain is expected due to the general decrease in energy expenditure. Moreover, the emotional distress accompanied with being locked at home for months and fear of the novelty and the high spread of COVID-19 [35] might provoke emotional eating and cravings. This result is in line with those of recent studies that captured weight gain concerning COVID-19 home confinement [13, 18, 31]. In this study, however, a comparable percentage of participants did not notice any weight change. This could be due to an increased level of awareness, or they may have not been as majorly affected by quarantine as people who continued to go to their workplaces during the curfew in comparison to the weight gain group.
The present study has demonstrated similar percentages between people who admitted an increase in the consumption of food in general and those who did not report any changes in the amount of food consumed during quarantine. When it comes to snacking between meals, however, almost half of the participants admitted an increase in frequency since the start of quarantine. In regard to weight changes, weight gain was associated with increased amounts and frequency of meals and snacks. These findings support previous research, which links the current global lockdown with higher amounts of food intake [18, 19, 31, 36]. A logical explanation is the nature of quarantine, with people spending most of the day locked at homes with minimal activities available, watching more television and having an abundance of stocked groceries. Prior evidence has shown that the availability of large food quantities for many days might lead to overeating, not necessarily due to hunger [37]. During home confinement periods, people tended to stock their kitchens with different foods to reduce unnecessary grocery trips due to the fear of contracting the infection [18]. The majority of these foods are ready-to-eat meals, canned foods, and products with long-shelf-life, which are often dense with calories.
Cooking at home is usually perceived as healthier or at least lower in calories than eating from restaurants. Surprisingly, almost 80% of participants in this study who gained weight also reported a significant increase in their home-cooked meals than before the lockdown. This result might be elaborated by the fact that not all cooking methods are considered healthy; some people might add large amounts of fat and/or sugar, which could lead to a substantial amount of added calories. Although such ingredients are high in calories, they play a role in increasing the palatability of food, making it more appealing in such stressful situations. Interestingly, it was found by Rodríguez-Pérez et al. [20] that people in Spain have increased their Google searches of the term “homemade cake” since the start of the lockdown. Homemade bread and cakes intake were also found to be higher during quarantine in Italy [19, 31]; therefore, a similar trend in food and cooking could possibly be applied in Saudi Arabia. However, a significant increase in home-cooked meals was also shown in 74% of the group who lost weight, which is apparently due to a healthier and less caloric way of cooking. This finding is consistent with that of Rodriguez-Perez et al. [20] who found a better adherence to healthy types of cooking during the COVID-19 quarantine among the Spanish population.
The main two reasons indicated in the study sample for changing dietary habits during the quarantine were more due to boredom and emptiness or having more time for meals preparation. Staying home for long periods may raise the feeling of boredom, which is often associated with overeating to escape monotony [38]. This behavior was also reported by Zachary et al. [13].
In this study, participants were also asked if their overall intake of healthy foods had changed compared to before quarantine. Almost half of the participants declared an increased intake of healthy food; however, the definition “healthy food” was not stated in the question and was thus dependent on the perception of each individual. Expectedly, two-thirds of the participants, who were in the weight loss group, expressed an increase in healthy food consumption. The same group has reported, as mentioned previously, a notable increase in home cooking.
The current study also inspected changes in the intake of particular foods during the lockdown. Unexpectedly, higher water intake was reported by more than half of the participants. This is a positive behavior for the Saudi population, as hydration status has been linked to innate mucosal immunity [39]. This behavior might because of easier access to water and increased awareness of the amount of water consumption during quarantine. An Italian study also showed a sufficient water drinking habit among the Italian population [31]. Similar to the findings of other studies [18, 19, 31], however, the majority of subjects in the present study have shown an increased intake of sweets, including cakes, chocolate, and ice cream. This also accords with this study's observation of dietary patterns, which showed that subjects in this study increased their snacking frequency during quarantine; thus, it can be assumed that the bulk of snacks consumed were sugary ones rather than savory. During confinement, people were facing incredibly stressful conditions, between continuously reading or watching updates in the news and being afraid to get infected with the COVID-19. Subsequently, stress can urge people to have food cravings, especially to sweets known as “comfort food,” which are loaded with calories. Craving for carbohydrates, in particular, stimulates the production of serotonin (a neurotransmitter found in the brain), which positively affects mood [40]. Such behavior, in turn, could make people at a higher risk for obesity and serious COVID-19 complications. In the current study, almost half of the subjects increased their fruit and vegetable consumption. This is noteworthy, particularly in a society that relies on an omnivorous diet that is rich in red meat and poor in fruits and vegetables, as discussed by Afshin et al. [41]. However, this may not help with avoiding the potential risk of low vitamin and mineral levels and the susceptibility to chronic and infectious diseases in the Saudi population, as only a small percentage have met these dietary recommendations while the majority have poor dietary practices during regular days [42]. Therefore, nutrition professionals in Saudi Arabia should pay further attention to increase awareness regarding the importance of adopting healthier diets that have higher intake of fruits, vegetables, and other anti-inflammatory components, such as olive oil (the Mediterranean diet), especially in stressful conditions like in the COVID-19 pandemic. Recently, the Mediterranean diet has been recommended to be followed during COVID-19 quarantine owing to the role it plays in strengthening the immunity [17]. Regarding the intake of fruits and vegetables during quarantine in other studies, findings were inconsistent. The intake of fruits and vegetables were increased in Spain [20], decreased in Poland [18], and did not changed in Italy [31].
Since there is still no vaccine or treatment to cure COVID-19, the main reliance is on the power and capability of the immune system to protect us from the virus. The study revealed that the most commonly consumed natural food during quarantine was honey, followed by lemon. As mentioned before, consuming honey is part of Saudi culture; furthermore, honey is known for its general potent antiviral effects by many researchers [43–45]. Some efforts have been conducted in Saudi Arabia to examine the effect of honey and other natural products on COVID-19 patients [21]. However, further research is needed.
At this point, there is still no strong evidence to support using dietary supplementation to prevent or treat COVID-19. However, some vitamins and minerals might have some positive effects in relation to COVID-19 [46, 47]. In the current study, half of the participants who admitted to taking dietary supplements reported that they were taking vitamin C supplements, while a quarter reported the intake of multivitamins and vitamin D. It is unsurprising that vitamin C was the most consumed dietary supplement, as it is well known for its immune-boosting effects, especially in individuals with subnormal levels of the vitamin, as stated by Carr et al. [48].
A general decline in the level of physical activity was found in this study. This was in line with previous studies that assessed physical activity during quarantine among different populations [18, 20]. In the present study, approximately half of the population reported not practicing any kind of physical activity; however, the other half reported performing 60–120 minutes per week of moderate intensity exercise (predominantly walking indoors or outdoors), which is still less than the recommended level of physical activity to provide protective effects against chronic diseases [49]. Expectedly, lower levels of physical activity were associated with weight gain, while increased levels were associated with losing weight. This study supports recent evidence from an international observation showing a universal decline in all physical activity levels during COVID-19 pandemic [36]. More efforts should be paid regarding educating Saudi adults about the importance of physical activity even with minimal practices, which might increase energy expenditure and promote neuromuscular, cardiovascular, and metabolic health [50]. Moreover, the government should help increase motivation and exposure to alternative activities that could be practiced from home, such as using videos or virtual online classes designed for different age groups.
The study was done in a relatively short period of time as suggested by previous studies [7]. It also took place amid the pandemic’s highest restrictions imposed in Saudi Arabia, a G20 country that is part of the Middle East and shares many cultural, habitual, and dietary behaviors that can also provide insights into neighboring countries. To the best of the authors’ knowledge, this is the first study to provide the previously mentioned insights in Saudi Arabia. Although this study might be specific to certain circumstances, the outcomes and results are significant in the prevention and preparation of any future incidents that necessitates a lockdown.
Although this study provides a general insight on how dietary habits and physical activity changed during the pandemic, it has some limitations. Many considerations were put in mind when structuring the questionnaire to encourage all societal groups to participate. Although the questionnaire was relatively short and used simple language, it was limited in providing specific information, such as the exact quantities of food consumed and details about food preparation methods. It is also evident that this study used self-reported information, including weight and height measurements and expected weight changes during quarantine due to its anonymous nature, and thus might introduce misreported data. Although data were collected from all regions of Saudi Arabia, the variations in dietary habits and lifestyle between these regions were not considered. However, the aim of this study focused on the overall dietary habits and physical activity changes in the whole country.