Does COVID-19 change dietary habits and lifestyle behaviours in Kuwait?

Aim: This study was designed to understand the changes in dietary and lifestyle behaviours that are major determinants of health during the COVID-19 outbreak. Methods: A crosssectional study was conducted through an online questionnaire using a convenience sample of 415 adults living in Kuwait (age range 18-73 years). Results: The overall prevalence of being overweight and obesity among participants was 37.2% and 33.1% respectively. The study identified significant changes in the dietary habits and lifestyle behaviours of participants during COVID-19. In general, there was an increase in the percentage of participants that consumed four or more meals a day, skipped breakfast, and engaged in frequent late night snacking. Moreover, there was a drastic decrease in the frequency of fast food consumption and an increase in the percentage of participants who had their main meal freshly made. Furthermore, there was a great reduction in physical activity and an increase in the amount of screen time and sedentary behaviours. A notable increase was detected in day-time sleep and a decrease in night-time sleep among participants. Conclusion: This study indicates that due to the increased prevalence of habits conducive to increased rates of being overweight and obesity during the COVID-19 outbreak, there is a high likelihood that the pandemic will further exacerbate the already widespread problem of obesity and being overweight in Kuwait.


Introduction
The World Health Organization (WHO) has declared the COVID-19 outbreak a pandemic, since it is spreading rapidly worldwide. It has affected more than 200 countries around the world [1]. COVID-19 attacks the human respiratory system and can cause mild to severe illness [2]. Evidence from several studies has shown that the elderly and people with underlying medical conditions, such as cardiovascular diseases, hypertension, diabetes and cancer, are at a higher risk of death as a result of contracting COVID-19 [3][4][5][6]. In addition, it can cause severe complications among people with obesity related conditions [7]. A Chinese study found that among Chinese adults, obesity caused a threefold increase in the likelihood of having a severe case of COVID-19 [8,9].
It has been reported that Kuwait is one of the countries with the highest rates of obesity, estimated to be around 50% [10]. It has been suggested that the prevalence of this risk factor in Kuwait is due to nutrition transition and a lack of physical activity among the population [11][12][13][14][15][16].
COVID-19 is a new disease that spreads very easily and sustainably between people. There is insufficient information concerning the risk factors that can lead to severe illness and there is no vaccine or specific treatment to prevent or cure the disease. Therefore, WHO recommendations have focused on avoiding contracting the virus through the practice of good hygiene, social distancing and only leaving the house when necessary [17].
In line with international action and in order to counter the spread of COVID-19, Kuwait imposed a nationwide curfew on March 22 nd 2020 from 5:00pm until 4:00am until further notice. People were also encouraged to eat a healthy and balanced diet, be physically active and maintain a healthy lifestyle to support their immune system during these difficult times.
The result has been stress induced by the disruption of daily routine, along with fear and anxiety regarding the spread of the disease and its consequences for people's finances, work, family and personal matters.
The relationship between stress and emotional eating is well established. Previous studies have shown an association between stress and the amount of food consumed [18][19][20][21]. It has been shown that people under stress crave more high fat and high sugar foods, since the body under stress requires more energy to function [22]. In addition, the body increases storage of abdominal fat [23]. According to Geliebter and Aversa [24], emotional eating is related to higher weight status. Furthermore, Tomiyama [25] has reported that stress can lead to sleep disturbance, which increases the risk of developing obesity.
Since obesity is a serious concern in Kuwait, there is a need to understand the impact of the COVID-19 outbreak on dietary habits and lifestyle. Therefore, this study aims to investigate the effects of the COVID-19 outbreak on eating habits and other health-related behaviours among adults in Kuwait.

Design and data collection
A cross-sectional study was developed and conducted in Kuwait during the COVID-19 outbreak between March and April 2020. A web-based survey tool (SurveyMonkey®) [26] was used among a convenience sample to investigate changes to their dietary habits and lifestyle during this period. Participants were recruited via online advertisements on social media; an invitation letter was launched on Twitter, Facebook and Instagram, with a link to the questionnaire and a request to circulate the survey broadly to adults. Study information was provided at the start of the survey. It was anonymous and voluntarily to apply. Respondents who were at least 18 years of age and above living in Kuwait could participate in the study.
Respondents who were less than 18 years or not living in Kuwait were excluded. The study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving participants were conducted after obtaining agreement.

Questionnaire
The questionnaire was developed by the primary investigators following a review of related literature [16,27,28]. It was evaluated and assessed by a number of experts and specific modifications were made where needed. In addition, the questionnaire was piloted as a paper version among (n=10) participants to check clarity and the suitability of wording, as well as the average time needed for its completion. The questionnaire was then amended to address all comments and converted into a web-based survey to increase response rates and reduce participant burden.
The questionnaire was divided into three parts. The first part used 8 questions to gather data about socio-demographic characteristics, including date of birth, sex, nationality, marital status, and education level. Moreover, the respondents were asked for their height, weight, and their weight perception. The second part consisted of 30 questions and investigated dietary patterns and habits. Participants were asked about their usual meal patterns, food preparation and grocery shopping responsibilities, frequency of consumption of selected foods and food groups, and frequency of consumption of selected beverages and water. The final part of the questionnaire asked about physical activity and lifestyle. It consisted of 9 questions aimed at investigating participants' physical activity level, smoking status, and sleeping habits. Sleeping time (including naps) on a typical day were reported. Sleep duration was then categorised into three levels: <7 hours, 7-9 hours, or >9 hours. These categories were based on the sleep duration recommendations for adults (18 to 64 years) of the National Sleep Foundation [29]. The participants were also asked whether they perceived that their eating habits had changed or not since the start of the curfew instigated by the COVID-19 outbreak, and whether or not they believed the curfew would lead to weight gain. All questions were asked in pairs, to assess the same habits before and during the outbreak/curfew.

Anthropometry
Height and weight information obtained in the questionnaire was all self-reported by the respondents. Body mass index (BMI) was then calculated as the ratio of weight in kilograms to height in meters squared. Weight status was classified according to WHO [30] categories as follows: underweight (BMI< 18.5), normal weight (BMI between 18.5-24.9), overweight (BMI between 25-29.9), and obese (BMI ≥30).

Statistical analysis
Data was statistically analysed using Statistical Package for the Social Sciences, version 23 [31]. The cut-off point for statistical significance was p value ≤ 0.05. Descriptive statistics (means and standard deviations, or frequencies) were calculated for all variables. Variables were checked for normality by inspection and by using the Shipiro-Wilk. A chi-square (X 2 ) statistical test was conducted to examine the significant differences for categorical variables.
A nonparametric test Wilcoxon signed rank test was conducted to compare differences in dietary habits before and during COVID-19. The effect size Cohen's d was determined by dividing the z value by the square root of N, where N= total number of cases (N=830) r=Z/√N using Excel [32]. Cohen [32] criteria were used to consider the effect size: .1 = small effect, .3 = medium effect, and .5 = large effect.

Participants' characteristics and weight status based on BMI category
The socio-demographic characteristics of the study participants are presented in Table 1 and self-reported anthropometric measurements and body mass indexes in Table 2. In total, 415 adults participated in this descriptive cross-sectional study with a mean age of 38.47 ±12.73 years, of which 130 were males (31.3%) and 285 (68.7%) females. The majority of the sample was Kuwaiti (90.6%). With regards to marital status, a majority of the sample were married (56.6%), followed by single (31.8%), divorced (10.4%), and widowed (1.2%). In terms of education, 53.3% had earned a bachelor's degree, and 14.5% and 23.1% of participants held a diploma or postgraduate qualification respectively.  who perceived themselves as being obese than were obese in actuality, and more people who perceived themselves as being overweight than were overweight in actuality.  In terms of family grocery shopping, results indicated significant statistical differences before and during COVID-19 (p=0.000, r=0.031). There was an increase in the percentage of husbands or fathers that did the grocery shopping during the pandemic from 27.5% to 34.9%, and a reduction in the percentage of wives or mothers that did the grocery shopping from 23.9% to 16.9%, and of husbands and wives or fathers and mothers from 28% to 20.7%. Among the participants, husbands or fathers were found to be the main person to grocery shop for the family during COVID-19. In addition, the percentage of online grocery shopping increased from 3.9% before COVID-19 to 9.2% during COVID-19. Furthermore, there was a slight increase in the percentage of participants who did not consume red meat during COVID-19 (from 7.7% to 10.1%) and those who consumed it less than once a

Food group patterns
week (from 17.3% to 20.7%). (from 3.6% to 4.8%) and those who consumed it less than once a week (from 4.3% to 6.5%).
In addition, there was an overall significant reduction in the frequency of consumption of fish and seafood during COVID-19 compared to before (p=0.000, r=0.326). The most commonly reported frequency both before and during COVID-19 for the consumption of fish and seafood was 1-2 times per week (47% and 34.5% respectively), with a sizeable decrease during.
Furthermore, there was a great increase (more than double) in the percentage of participants who reported that they did not eat any fish or seafood during COVID-19 (from 10.6% to 26.5%).
In reference to the consumption of processed meat, canned fish, fruits and vegetables, and the type of bread, milk, cooking fat and snacks most often consumed, no significant differences were found before and during the pandemic. More than half of the participants never consumed canned fish (52.8%, 58.1%) and the majority never consumed processed meat ( Table 4 that most participants did not meet the USDA minimum recommended daily intake of fruits and vegetables of 5 servings a day (2 servings of fruits and 3 servings of vegetables

Drink patterns
The three most commonly consumed drinks among the participants before the pandemic were American coffee followed by water and black tea, consumed by 77%, 75% and 72% of participants respectively. During the pandemic the three most commonly consumed drinks were water followed by black tea and American coffee, consumed by 77%, 73% and 68% of participants respectively, Figure 1. The most commonly reported frequencies of water consumption both before and during the pandemic were 1-2 cups (32%, 35  Most commonly consumed drinks before and during COVID-19 Before During

Physical activity, smoking and sleeping habits
The overall prevalence of smoking was low among study participants. Only 19.8% reported that they were current smokers. The prevalence of smoking among males and females was statistically different (p=0.000); smoking was more common among males (40.8%) compared to females (10.2%).
The prevalence of physical activity and sedentary behaviours before and during COVID-19 is presented in Table 5. In general, it was noticed that during the pandemic there was a remarkable reduction in the prevalence of physical activity and an increase in the amount of time spent on sedentary behaviours, such as spending time on computers and smartphones or watching television, compared to before the pandemic.

Water consumption before and during COVID-19
Before After In terms of physical activity, significant differences were found before and during the pandemic (p=0.000, r=0.222). There was an increase in the percentage of people who never practice physical activity from 20.2% before the pandemic to 39.5% during, and a reduction in the percentage of people who always practice physical activity from 20.7% before the pandemic to 14.7% during.
The most commonly reported number of hours spent practicing physical activity per week among the participants both before and during COVID-19 was less than one hour or none.
Furthermore, there was a great increase in the percentage of participants who reported less than one hour or no hours spent on physical activity per week during COVID-19, increasing from 48.9% before to 61.9% during (p=0.000, r=0.211). Both before and during COVID-19, the majority of participants reported their main leisure activities to be watching television, listening to music, spending time on the computer or reading (55.4% and 81.7% respectively). The least commonly chosen leisure activity among the participants both before and during the pandemic was sports (8.9% and 4.6% of participants respectively). Significant differences were found between the types of leisure activities before and during COVID-19 (p=0.000, r=0.166).
Furthermore, there was a great increase in the percentage of participants who reported spending more than 6 hours per day on the computer, smartphone or television during COVID-19, increasing from 16.1% before to 43.6% during (p=0.000, r=0.430).
With regards to sleeping habits, results indicated significant statistical differences before and during COVID-19 (p=0.000, r=0.395). During COVID-19, there was a decrease in the percentage of participants who slept during the night (66.3% before to 29.7% during) and a marked increase in the percentage of participants who slept during the day (33.7% before to 70.3% during). In addition, results showed significant differences in the recommended amount of sleep before and during pandemic (p=0.000, r=0.264). Both before and during COVID-19, around half of the participants (49.5% and 58.1% respectively) reported meeting the recommended sleeping hours of 7-9 hours. However, there was a notable increase during COVID-19 in the percentage of participants who reported spending more than 9 hours sleeping (from 9.4% before to 20.2% during) and a great decrease in the percentage of participants who reported spending less than 7 hours sleeping (from 41.1% to 21.7%).  several studies suggests that the high prevalence of being overweight and obesity in Kuwait is due to nutrition transition and a lack of physical activity [11][12][13][14][15][16], which is confirmed in the current study. Maintaining a healthy and balanced diet and being physically active are important and recommended in these difficult times to support the immune system [34][35][36]. To have a balanced diet it is necessary to consume a variety of foods across and within all food groups.
Therefore, it is important to avoid skipping meals, particularly breakfast. A research review found that skipping breakfast may lead to a reduction in diet quality [37]. Moreover, regular intake of breakfast decreases the risk of obesity and chronic problems [38]. Nevertheless, unhealthy meal patterns were detected in this study, such as skipping breakfast and late night snacking. Both behaviours are likely associated with being overweight and obesity [39,40].
Consistent with the literature [41][42][43][44], this research found skipping breakfast was common among participants. Possible explanations for this behavior include a lack of time, intentionally skipping breakfast to cut calories and a lack of appetite [43]. However, other possible explanations for skipping breakfast during COVID-19 include staying up late, which leads to late night snacking, and oversleeping during the day, as shown in the results. These findings reflect those of Okada et al. [40], which was a study among 19,687 Japanese women that found a significant association between a late dinner or bedtime snack and skipping breakfast, as well as an association of this behavior with being overweight and obesity. Despite the recommendation to reduce one's intake of fats, sugar and salt during COVID-19 [34] and avoid irregular snacking [36], chocolate, nuts and crisps were reported to be the most commonly consumed snacks, and these are loaded with sugar, fat and salt. These results may be explained by the fact that feelings of boredom and stress (likely heightened due to quarantine, as shown in the results) lead to higher consumption of energy-dense foods that are high in sugar and fat [25,45]. Similar findings were also reported by Muscogiuri et al. [46], who found that many people over-eat sugary and salty comfort foods for snacking due to stress induced by quarantine and that this habit may increase the risk of developing obesity.
Furthermore, it is recommended that people should eat plenty of fruits and vegetables because of their benefits to health and the immune system, especially during the pandemic [34] since they are rich in micronutrients [47] and dietary fiber [48]. However, the results of this study show that more than 70% of the participants did not reach the minimum portions of fruits and vegetables recommended by the USDA of 5 portions a day [49]. This result is in line with findings from other studies that reported a low consumption of fruits and vegetables among Kuwaiti adults [50] such as the EMAN study [14] and the Kuwait Nutrition Surveillance System [15]. These results are likely related to a lack of awareness of the current recommendation for the consumption of fruits and vegetables (unpublished data). A finding from two cross-sectional questionnaire studies among the UK's population found an association between low knowledge of details of the 5-a-day recommendation and low consumption of fruits and vegetables [51]. In addition, another possible explanation is a predisposition towards energy-dense foods that are high in sugar and fat for snacking, as shown in the results. Moreover, the limited availability of fruits and vegetables and restricted food store opening hours due to quarantine during the pandemic could have caused a reduction in the consumption of fruits and vegetables.
The results of this study indicate a rise in home cooking during COVID-19. Participants started cooking more themselves (or their wives and mothers did so), resulting in reduced reliance on a housekeeper for cooking purposes. These results match those observed by an American study [52] that found about half of the participants reported they were cooking and baking more during the pandemic. Furthermore, the study detected a significant reduction in the frequency of fast food consumption. It seems possible that this rise in home cooking is related to attempts to occupy the increased free time resulting from quarantine. Another explanation is that people wanted to eat healthier in reaction to the spread of COVID-19 and thus resorted to home cooking more frequently. Finally, it could be related to the reduced consumption of fast foods as a result of fears regarding the transmission of COVID-19, whether it be from unhygienic practices at restaurants or from the delivery driver. However, it is difficult to conclude that people ate more healthily during the pandemic just because they reported consuming more home cooked meals, especially if unhealthy foods were still in circulation.
In accordance with the FAO recommendation for maintaining a healthy diet during COVID-19, it is important to stay hydrated and the best choice of fluid is water [34]. It has been suggested that to enhance the immune system it is important to be physically active, get enough sleep and quit smoking [33]. In the present study, a noticeable reduction was found in the prevalence of physical activity during COVID-19, while time spent on sedentary behaviours increased, similar to the findings of Ammar et al. [55]. This is most likely due to social distancing measures and the need for open spaces for people to be physically active [56].
Based on the results, more than half of the participants met the recommended sleeping hours during the pandemic. However, 70% of the participants slept during the day time instead of night time. This result may be explained by the fact that quarantine may cause stress, which results in sleep disturbances and abnormal sleep patterns, or because of changes in daily routine. This may negatively affect the immune system [57]. Moreover, it may increase food intake and increase the risk of developing obesity [46].
The prevalence of smoking was low among study participants. Smoking was more common among males than females. According to the WHO [33], smokers are more vulnerable to COVID-19 since smoking weakens the body's defenses, especially against respiratory illness.

Limitations of the study
It is acknowledged that the current study has some limitations. Firstly, all measurements, including height and weight, physical activity, dietary, smoking and sleeping habits, were selfreported. The poor informative status may increase information bias. Secondly, diet was only measured using questions that relied on daily or weekly frequency consumption; measuring of serving size was neglected. Moreover, the consumption substances that are specific dietary risk factors, such as fat, sodium and sugar, were not collected. Thirdly, although the study questionnaire was developed after a comprehensive review of literature, the tool was new and this could add to the limitations. Furthermore, as a convenience sample was used in this study, the number of individuals who agreed to take part in the study could be one of the limitations.

Conclusion
This study concludes that due to the increased prevalence of habits conducive to increased rates of being overweight and obesity during the COVID-19 outbreak, there is a high likelihood that the pandemic will further exacerbate the already widespread problem of obesity and being overweight in Kuwait, especially if the current situation persists for a longer period time. Poor dietary habits together with an unhealthy lifestyle can cause serious health problems. It is therefore important that the government considers the need for nutrition education programs in Kuwait, especially school-based nutrition education, since eating patterns are established early in life and school education is a reliable means to reach a wide range of individuals.