As far as is known, this study is one of the few studies that tested how the COVID-19 pandemic changed the Egyptians’ eating patterns as well as their way of life. First of all, the COVID-19 pandemic had a noticeable effect on human behavior. “Social separation” has been a common tactic used by many countries to stop COVID-19 from spreading. The lockdown had the advantage of reducing the pandemic curve as containment measures were kept in place for subsequent pandemic waves to reduce the number of cases and the strain on the healthcare system. Moreover, fears of illness and dying as well as constraints on personal freedom increased people’s stress levels and led to changes in routine activities [13]. In the current study, most of the participants were females. To explain this, the Egyptian government allowed all women with children that were under 12 years old to be exempted from work even if they were working in organizations that were abiding by the curfew hours (i.e. hospitals, or medical centers, or media outlets, or transportation of medical supplies as well as petroleum organizations). Thus, this may explain the high response rate from females.
Dietary habits
The current study reported a changed hunger sensation and satiety; hence, there was a significant increase in the mean BMI. The amount of daily meals changed in a significant percentage of the sample. Low MD adherence was found in about half of the study participants. Moreover, both changed hunger sensation and moderate MD adherence were significantly associated with unhealthy dietary habits. These results correspond with an Italian study that was done to check the immediate effect of the COVID-19 pandemic on the people’s eating habits as well as lifestyle changes; the results reported that more than 50% of the population had a change in sense of hunger and satiety. Only 34.4% had an increased appetite to eating food; this percentage is different from that of the current study (64.7%). As for preparing and consuming homemade desserts, bread, as well as pizza, the percentage also increased. This increase is similar to that of the current study (3–5 times /week in 20% of participants) [13]. The increase in the consumption of carbohydrates (whether simple or complex) noticed in this study was obviously linked to the significant increase in the participants’ BMI (p = 0.001). Accordingly, the weight that is gained in the short period of any lockdown may be hard to lose for some individuals and may further lead to gaining more weight in the future if the unfavorable nutritional behaviors observed during the lockdown were not reversed [30].
The lockdown has affected the dietary habits of Danish adults as well. Around 28% of the respondents reported eating and snacking more with a significant degree of emotional eating. Dietary changes during that period reflected the pre-existing unhealthy eating habits that some people had. That being said, some positive health outcomes were seen in respondents with high MEDAS scores, and negative outcomes (i.e. gaining weight as well as increased intakes of carbonated beverages and pastries) were observed in respondents with low MEDAS scores [31].
The current study findings are different from what was observed by Renzo et al. in their Italian study; they found low, moderate, and high adherence to MD in 21.7%, 63.1%, and 15.3% of their participants, respectively [13]. Another Italian study concluded that some consumers reduced purchasing and consuming ready-to-eat foods. Also, these same consumers followed the MD carefully and ate healthier food, including adding more fresh fruits as well as vegetables in their diets [19]. This higher adherence in Italian studies may be explained by the fact that Italy is one of the origin countries that first started this important diet pattern [32]. Accordingly, additional follow-up studies are needed to examine if these habits among the Egyptian population will stick or improve with time.
Changes in dietary habits were also reported by Matsungo and Chopera in the African people of Zimbabwe. Matsungo and Chopera’s study showed that 57.8% of the participants had decreased the consumption of fruits and vegetables, while 45% showed a decrease in consuming nuts and seeds. Participants also reported a significant increase in food prices during the COVID-19 pandemic. Accordingly, this increase might undermine food security in the country. In contrast, food prices were not studied in the current study [33].
In the United Arab Emirates, “unhealthy” dietary patterns were also observed, with distancing from MD principles. This is added to a reported weight gain, with the majority of participants having fewer than eight cups of water per day [34]. The variation in the effect of the pandemic on the participants’ dietary habits in the above-mentioned studies may be due to the variation in the pre-pandemic habits from one country to another, as well as the availability of food items, and market accessibility. Accordingly, a change in eating habits due to the increased hunger and decreased satiety could lead to weight gain. When added to the pandemic containment measures, this might result in spending more than the usual time at home, being psychologically affected, and resulting in a consequent increase in emotional eating.
Physical activity
As for physical activity, the study sample’s level of physical activity clearly decreased. Recreational areas and PA facilities were closed during the lockdown, followed by a partial closure during the second wave, which can explain these results. The results are similar to those of Fanelli’s research in 2021; Fanelli found that the closure of gyms and fitness facilities as well as the restrictions on visiting parks and playgrounds resulted in a decrease in PA among Italian participants [19]. Likewise, the same findings were reported in Zimbabwe, Pakistan, and Denmark [31, 33, 35]. Additionally, Barrea et al., 2020, observed that patients with normal weight and Class I and II obesity showed a substantial rise in BMI values [36]. Also, Ingram et al.,2020, found that only 16.8% of the participants maintained the same PA level compared to the 47.4% of participants who reported a decrease in their activity [37].
Barkley et al., 2020 found that the university closure increased sedentary behavior; however, the PA was decreased only in those participants who were conversely the most active before the universities were closed [38]. Closing down facilities that are designed for PA for pandemic-related reasons may disproportionately affect active individuals. This same finding was also reported in the U.S.A [39]. On the other hand, in Italy, exercise frequency increased and was done at home among those who already took part in sports, and those who used to exercise only occasionally before [13]. In Ethiopia, adopting PA increased after the pandemic in the form of performing household chores [40]. This difference in findings between studies may be attributed to the different cultures, availability of recreation places, and different methods of PA assessment.
Overall, diet and lifestyle factors, such as physical activity, are among the main risk factors -that can be modified and altered- for non-communicable diseases. These factors have thus been shown to increase the likelihood of having more severe COVID-19 negative consequences [11]. For that reason, identifying individuals most likely to engage in poor lifestyle choices during the COVID-19 pandemic is also crucial for developing interventions that are aimed at targeting these populations [34]. Further follow-up studies are required to study the long-term effects of the COVID-19 pandemic which resulted in significant disruptions to daily life.
Smoking
In the current study, participants reported bidirectional changes in smoking habits. Similarly, in a Saudi Arabia study, about 20% of participants reported that they had already been frequent smokers; 6% reported a decline in smoking; while 4.8% reported an increased smoking rate [41]. In Italy, 3.3% of smokers managed to quit smoking, and the amount of smokers who used to smoke more than 10 cigarettes per day decreased by 0.5% [13]. The elevated risk of respiratory distress and death by COVID-19 may explain the cause of the phenomenon of decreasing or ceasing smoking [42]. Accordingly, participants who consider smoking as a stress-reliever increased their frequency of smoking, while those who perceive it as a risk factor for complications could give smoking up completely. Thus, it is seen that personal perception of danger and how to deal with it can have an impact on a smoker’s response. Follow-up studies are strongly needed to find out if those who quit or reduced smoking have consolidated their behavior or not.
Sleeping hours
As for sleeping hours, they significantly increased among participants in the current study. Similarly, in Pakistan, most of the respondents indicated increased duration of sleep (59.5%) [35]. In the Ethiopian study, it was found that its participants had a significantly increased number of sleeping hours during the COVID-19 pandemic (with p < 0.0001) [40]. Also, Ingram et al.,2020, who assessed the change in sleep quality, reported that only 31.1% of the studied sample maintained the same sleeping pattern, while 52.4% and 16.6% showed worse and better changes, respectively [37].
In the U.A.E, sleep disturbances were common in 60.8% of the participants, with a major decrease in the number of participants who reported sleeping < 7 h at night, i.e. decreasing from 51.7% before the pandemic to 39% after it. An Italian study also reported a deterioration in the percentage of good sleepers after quarantine, without a significant change in the sleep duration [34, 36]. In other words, an increase in sleep duration was not necessarily accompanied by good sleep quality. Conversely, the quality of sleep was not measured in the current study. The increased sleep duration happened as a result of staying at home, nonessential businesses closing, and working online or from home rules that were applied to reduce spreading the COVID-19 infection. Enough sleep is vital for the proper functioning of the immune system as insufficient sleep may increase the susceptibility to viral infection [43, 44].
Factors affecting the unhealthy change in dietary habits
Examining the factors affecting the unhealthy changes in dietary habits shows that feeling hungry more frequently and being moderately active are the main factors (p < 0.05). This is different from what was seen in a French study among adults NutriNet-Santé cohort. The aforementioned participants were grouped into multiple clusters. Cluster 3, for example, showed favorable nutritional changes along with an increased physical activity, compared to before [45]. This difference may be explained by the fact that they are different cultures. In the current study, this may relate to the belief that one’s body is able to manage excess energy intake if the person is in a state of being active. Another explanation is that some people tend to exaggerate their physical activity level. Significant connections were seen between an increased BMI, a change to unhealthy eating behavior due to the lockdown, and an increased hunger sensation. Moreover, a study performed in Belgium had similar results; the study found that an increase in BMI occurred because of the increase in sweet or salty snacks as well as carbonated beverages [46].
However, that being said, one of the significant characteristics of the Egyptian meals (which may have contributed to the increased BMI) is using bread as ghomous (means cutting bread into small pieces and used as a dip). Moreover, the Egyptian meals are mainly dependent on oil rather than on diary-divided fats. Falafel or Ta’ameyya, for example, is one of the common Egyptian traditional foods that is eaten by the majority of Egyptians on a daily basis. Falafel is made from mashed beans and is cooked by deep-frying in the pan [47]. For that reason, the type of meals may explain the increased BMI.
To complicate matters more, income is also a great obstacle for the Mediterranean communities to adhere to a nutritional system that is both successful and professional [48] Because there is a significant rate of poverty in Egypt, Egypt is a clear example of why its poor population would depend mainly on bread or the subsidized staple food, unwillingly resulting in a high energy content that is mainly empty calories. For that reason, Egypt’s poverty allows almost no room for having rich and diverse food or for adequate consumption of vital nutrients [49].
According to the WHO report that explained the non-communicable diseases’ risks of COVID-19, poor nutrition is a main risk factor for these non-communicable diseases. Consequently, poor nutrition reduces the immune system’s ability to prevent as well as recover from various infections. Moreover, consuming high levels of high-energy-dense food, like high-fats processed foods and simple sugars, may further lead to obesity compared to the consumption of low-energy dense and rich in fiber food, such as fruits and vegetables [50].
It was clear that the study sample embraced an obesogenic behavior during the COVID-19 era. It consisted of an unhealthy change in dietary habits; a reduced physical activity; and may have resulted in people’s their emotional stress and hence, emotional eating. For that reason, nation-wide surveys are strongly recommended to follow up these behaviors as well as follow up the non-communicable disease trend.
Limitations of the study
The current study was limited in a few ways. Although the questionnaires were verified and useful, they were admittedly self-reported. Accordingly, self-reported questionnaires have one drawback, which is that respondents can change their responses to fit a preferred image of themselves (i.e. they can misrepresent data). As for the participants’ exact weight prior to the lockdown, recall bias may sadly exist. Another potential limit could be the convenience sampling method, which involved selecting participants via an online questionnaire and having a high percentage of sharing from females. This limits the generalizability of the results and hence, the external validity as well. In order to examine the long-term effects of the pandemic lockdown in this cultural setting, more research is thus required.
Conclusion and recommendations
This study aimed to examine how the Egyptian population’s eating and exercise patterns changed during the COVID-19 lockdown and subsequent pandemic wave. According to the estimated sample size, a self-administered web-based questionnaire was done to gather the participants’ responses. The findings indicate that the lockdown significantly changed Egyptian adults’ eating and lifestyle patterns. A substantial portion of participants reported unfavorable changes to their eating and exercise routines. There were high levels of eating delivered food (up to three times per week) (60%); low levels of exercise (57.6%); and low Mediterranean Diet adherence (52.7%). A statistically significant increase was found in BMI which is a consequence of reduced activity and increased hunger sensation as reported. Moreover, emotional eating was also seen, as baking homemade pastries and sweets was also abundant. However, several individuals used the lockdown and pandemic situation as an opportunity to improve their eating habits. It is feared that establishing these habits would be difficult to reverse. To prevent the negative effects of such unhealthy habits (obesity, type II diabetes mellitus, cardiovascular illnesses, etc.), urgent public health policies and actions are required to guard against the consequences of such unhealthy behaviors.Various campaigns on mass and social media are also required to stress the importance of healthy dieting and maintaining physical activity. Institutional-based campaigns (i.e. in schools, universities, different organizations etc…) are encouraged as well. Engaging various stakeholders, including healthcare professionals, policymakers, community leaders, and the public, in designing and implementing these public health interventions is vital to make any initiative succeed. Additional follow-up studies are required to investigate the behavioral changes and health implications that occurred during this exceptional era.
On the other hand, and on a positive note, it was seen that some participants took the advantage of the lockdown and the worldwide pandemic and decided to: cease smoking i.e. 14 participants (6.8%), improve their physical activity levels i.e. 15 participants (7.3%), and change their dietary pattern to healthier i.e. 58 participants (28.2%). Some participants also feared the potential weight gain, so they reduced their number of snacks during the day i.e. 29 participants (14.1%).
