The Impact of the COVID-19 Outbreak on Lifestyle-Related Behavior Among the General Population

Introduction: Coronavirus has affected more than 200 countries around the world. Due to lockdowns, people have limited outdoor activities and started adopting new and healthy lifestyle behaviors. Method: A cross-sectional study was conducted to explore the impact of COVID-19 on lifestyle-related behavior. Data were collected from different regions of North India using Google Forms (Google, Inc., Mountain View, CA, USA) with the help of a standardized questionnaire. Both descriptive and inferential statistics were used for analysis. The p-value was set at <0.05. Results: A total of 468 responses were recorded (mean age: 28.51 years). A significant improvement was found in the intake of fruits and vegetables as well as pulses, eggs, or meat during the COVID-19 pandemic. Participation in household chores and screen time in watching mobile or television were significantly increased. The majority (44.4%) of participants had stable weight, and 37.8% gained weight during the COVID-19 pandemic. The anxiety they felt in a day also increased, which was predominantly due to fear of COVID-19. During the COVID-19 pandemic, a significant association was found between physical activity scores and gender, residence, nature of work, and hours of work of study subjects. Conclusion: There is an improvement in healthy eating behavior, quality of sleep, and participation in household chores during the COVID-19 pandemic. Further, domains of lifestyle can be explored to bring a positive style of living for the achievement of healthy lifestyle behavior by the general population.


Introduction
The novel coronavirus outbreak began in December 2019.Coronavirus spreads rapidly from person to person.The World Health Organization declared COVID-19 as a pandemic on March 11, 2020 [1].After that, the coronavirus pandemic continued to transform and affect the daily lives of communities worldwide.It has affected more than 200 countries around the world.Many governments adopted emergency measures such as total lockdowns and travel restrictions to prevent further transmission of infection.These restrictions help minimize the rate of infections.Such limitations negatively affected individuals by limiting participation in normal daily activities, sticking to a physical fitness regime due to closed gym, having no group gatherings, and increasing social distancing.Due to these lockdowns in several countries, people face limited access to participate in outdoor activities or avoid outdoor activities entirely [2].
Lockdown and travel restrictions also impose a burden on an individual's health by compromising physical fitness, which strongly affects the ability to cope with infections and compromises the immunologic system.The most important risk factors for morbidity from major illnesses are physical inactivity and poor mental health.This is applicable to the general population and specifically to chronically ill populations, as well as older adults at the highest risk of COVID-19-induced mortality [3].
It is noteworthy that healthy lifestyles enhance the immune system, reduce the risk of respiratory infections and inflammation, and are effective in the prevention of many chronic conditions that increase the risk of severe COVID-19 infections.In addition, physical activities are beneficial in preventing anxiety and depression in stressful situations.The COVID-19 pandemic not only adversely affected the physical health of individuals but also brought significant positive changes in their lifestyle behavior [4].
The COVID-19 outbreak has impacted the daily life of many people.To limit the spread of COVID-19 and prevent disease severity, people started changing their lifestyles, especially their eating habits, and getting involved in physical activities.The intervention to stay at home, limitations of social interactions, and self-isolation changed the daily routine of individuals [5].
The lockdown intervention succeeded in reducing the exponential transmission of COVID-19 and resulted in positive health outcomes.However, major lockdowns have also led to other changes in life.Many studies have been conducted to highlight the negative impact of COVID-19 on physical and mental health, but recent studies found some positive lifestyle changes among adults, such as improvement in healthy eating behavior, more physical activities, and increased quality time with family [6].
Since the cure for COVID- 19 is not yet known, optimizing the host immune system should be a vital strategy to combat the disease, limit its complications, and reduce mortality.The practice of a healthy lifestyle, such as a healthy diet, regular physical activity, adequate restorative sleep, good stress management, avoidance of tobacco and harmful substances, positive psychological well-being, and healthy social connections with friends, family, and colleagues, can significantly improve the efficacy of the immune response to diverse diseases, especially those of viral origin such as COVID-19 [7].While countries are grappling with the imminent dangers that this virus poses to humanity, people started following a few key measures that can fight this pandemic [8].
Washing hands frequently, using an alcohol sanitizer to disinfect hands, wearing a mask to cover the nose and mouth, and avoiding touching the mouth or nose with dirty hands have become hygiene standards for people.Certain methods to improve immunity are also paramount at this juncture [9].
There is a strong positive correlation between a healthy lifestyle and enhanced immune function.Also, there are relationships between lifestyle modification and immune system improvement.Available evidence suggests that healthy lifestyle practices among patients with infectious diseases, especially those of viral origin, may boost their immune systems and shorten the duration of their disease.Evidence also exists suggesting that some components of an unhealthy lifestyle (such as poor diet, physical inactivity, stress, smoking, alcohol, loneliness, and poor sleep) may significantly impair the immune system and predispose people to greater susceptibility to infectious diseases [10].
Thus, we felt the need to conduct a cross-sectional study to evaluate the overall impact of the COVID-19 outbreak on lifestyle-related behavior.

Materials And Methods
A quantitative research approach and a cross-sectional study design were adopted in the present study.The research variable of the study was lifestyle-related behavior.The demographic variables of the study were age, educational status, occupation, type of family, family income, residential area, job profile, and nature of work.The inclusion criteria for the sample were those in the age group above 18 years, able to speak and understand Hindi or the English language, and willing to participate in the study; those who did not meet these criteria were excluded.The sample size calculated for the study was 450 using the following formula: The sample taken for the study was 468.

Data collection tool
The tools for data collection were a demographic data sheet and a standardized questionnaire by Chopra et al. [11] to evaluate the impact of COVID-19 on lifestyle-related behavior.The internal consistency of the tool was 0.83.The questions were prepared in Hindi and English language.Written permission to use and create the tool using Google Forms (Google, Inc., Mountain View, CA, USA) was obtained from the author.Data were collected by interview technique or online survey as feasible from July 2021 to December 2021.The Google Forms link was created and circulated via emails and WhatsApp (Meta, Menlo Park, CA, USA).

Ethical consideration
Before commencing the study, ethical clearance was obtained from the Ethics Committee of All India Institute of Medical Sciences, Jodhpur (AIIMS/IEC/2021/3543).Informed consent was obtained from all respondents.The information about the person to be contacted for queries was provided on the first page of the questionnaire and Google Forms.

Statistical analysis
The collected data was analyzed using Statistical Package for the Social Sciences (SPSS) version 20 (IBM SPSS Statistics, Armonk, NY, USA).Descriptive and inferential statistical measures such as frequency, percentage, mean, standard deviation (SD), mean difference, paired t-test, independent t-test, analysis of variance (ANOVA), and post hoc test were used to analyze the data.For all analyses, a p-value of <0.05 was considered statistically significant.

Demographic characteristics
A total of 468 responses were collected using Google Forms.The mean age of the participants was 28.51 years.Among the participants, 42.3% were male and 57.7% were female, 56% were unmarried, and 60% were residing in a nuclear family.The majority of the participants (82.5%) graduated from a university.Only 7.3% have a family income of less than 10,000 Rupees, and 55.1% are residing in urban areas.Nearly 30.8% were performing long-standing work, 61.5% were doing 6-8 hours of work per day, and only 7.9% were suffering from any illness.Many of the participants (44.4%) maintained a stable weight, whereas 37.8% gained some weight during the COVID-19 pandemic (Table 1).

Comparison of lifestyle behavior before and during COVID-19
Lifestyle behavior was assessed on various parameters such as eating behavior, physical activity, sleep patterns, and other lifestyle behaviors such as smoking habits, alcohol consumption, and family and friends' support for maintaining a healthy lifestyle (Table 2).Comparison of mean score difference in lifestyle-related behavior during and before COVID-19 reveals that there was a significant reduction in the consumption of regular meals (0.12, SD: 0.96, p<0.05), fast food (0.10, SD: 0.71, p<0.05), junk foods (0.08, SD: 0.74, p<0.05), sweetened beverages (0.06, SD: 0.58, p<0.05), food with high sugar (0.06, SD: 0.60, p<0.05), and food to avoid boredom (0.07, SD: 0.72, p<0.05).Also, there was a significant reduction in participation in leisure activities (0.25, SD: 1.08, p<0.001) and friends and family support to maintain a healthy lifestyle (0.06, SD: 0.55, p<0.05).

Association Between Eating Behavior and the Demographic Characteristics of the Study Participants
There was a significant association found between eating behavior scores of participants and gender, marital status, nature of work, and current or past history of illness.The eating behavior scores of the participants before COVID-19, during COVID-19, and in total were higher in females than in males at 2.469 (0.014), 2.815 (0.005), and 2.833 (0.005), respectively.Healthy eating behavior was found in participants who were divorced/unmarried (2.142 (0.033)) and without a history of past/present illness (2.076 (0.044)) before COVID-19.There was a significant association between eating behavior lifestyle score and nature of work during COVID-19 (3.017 (0.011)) and in total (2.642 (0.023)).Field workers tended to have healthier eating habits than long-standing (3.277 (0.024)) and sedentary/computer (3.821 (0.016)) workers during the pandemic.The total mean eating lifestyle behavior score of field workers was higher than long-standing (5.849 (0.035)) and sedentary/computer (6.420 (0.043)) workers.

Association Between Physical Activity and the Demographic Characteristics of the Study Participants
Before COVID-19, a significant association was found between physical activity score and type of residence (6.900 (0.001)) and hours of work ( 10.724 (<0.001)).During COVID-19, a significant association was found between physical activity and gender

Association Between Sleeping Behavior and the Demographic Characteristics of the Study Participants
A significant association was found between sleeping patterns and the gender of participants.Before COVID-19, females had better sleeping patterns than males (3.109 (0.002)), and during COVID-19, male participants had significant improvement in sleeping patterns (2.443 (0.015)) than females.

Association Between Other Lifestyle Behaviors and the Demographic Characteristics of the Study Participants
Before COVID-19, other lifestyle behaviors were higher in those 31-60 years of age (2.350 (0.020)), males (2.180 (0.030)), those qualified as graduate (2.076 (0.040)), and those with a current or past history of chronic disease (2.624 (0.012)).During COVID-19, other lifestyle behaviors were higher in participants aged 31-60 years (1.977 (0.049)) and those with a current or past history of chronic disease (2.697 (0.010)).The association between total scores related to other lifestyle behaviors shows that there was a significant increase in other lifestyle behaviors among those 31-60 years (2.221 (0.027)), males (2.158 (0.032)), and those who have chronic past/present illness (2.703 (0.010)).A significant association was found between hours of work and other lifestyle behaviors before COVID-19 (3.082 (0.047)) and in total (3.123 (0.045)).Before COVID-19 (0.393 (0.036)) and in total (0.777 (0.034)), other lifestyle behaviors were higher in those working for 6-8 hours than those working for eight hours per day.There was a significant association found between other lifestyle behaviors and the residence of the participants before COVID-19 (4.896 (0.008)), in total (3.351 (0.036)), and in the difference in score between before and during COVID-19 (3.328 (0.037)).Before COVID-19, participants who lived in rural areas had higher other lifestyle behaviors than those who lived in semi-urban areas (0.588 (0.009)) and urban areas (0.407 (0.033)).The total other lifestyle behavior score reflects that participants in rural areas had higher other lifestyle behaviors than participants in semiurban areas (0.995 (0.030)).The difference in lifestyle behavior scores before and during COVID-19 shows that participants in rural areas had higher other lifestyle behaviors than participants in urban areas (0.228 (0.028)) (Table 5).

Discussion
Lifestyle behaviors are everyday activities that result from an individual's values, knowledge, and norms shaped by broader cultural and socioeconomic contexts.These behaviors affect an individual's overall health and are influenced by several social characteristics.The present study revealed the impact of the COVID-19 outbreak on lifestyle-related behavior among the general population.Of all the participants, 57.7% were females, and 42.3% were males.The majority of the study participants (44.4%) had a stable weight during COVID-19.This finding is in agreement with the study conducted by Scarmozzino and Visioli [12], Zachary et al. [13], Fernandez-Rio et al. [14], Reyes-Olavarría et al. [15], and Al-Musharaf et al. [16], where most of the participants had a stable weight during the COVID-19 pandemic.However, a study by Al-Domi et al. [17] found an increase in body weight among most of its participants.
The present study revealed a decrease in the consumption of fast food, junk food, and fried food.The reason for the same was less eating out/socialization, fear of the spread of COVID-19, and non-availability of cooks.Interestingly, the present study showed an increase in the intake of fruits and vegetables (3.70 (<0.001)).Similar findings were seen in a study conducted by Scarmozzino and Visioli [12], in which 21.2% of respondents increased their fruit and vegetable intake, and the purchase of ready-made snacks was reduced by 50%.In a study conducted by Chopra et al. [18], an improvement in healthy meal consumption patterns and a restriction of unhealthy food items were observed.Contrary to this, a study done by Werneck et al. [19] reported less consumption of fruits or vegetables and more ultra-processed foods.
The present study shows decreased participation in leisure-related activities (5.08 (<0.001)), and an increase in screen time spent daily, e.g., watching television and mobile phones (10.60 (<0.001)).Similar findings were seen in a study done by Chopra et al. [18], Werneck et al. [19], and Cheikh Ismail et al. [20], where the majority of participants reported having more screen time and less physical activity.
The current study also investigated the impact of the COVID-19 pandemic on sleep patterns, which revealed an increase in sleeping hours, as well as the quality of sleep, which is similar to the findings of Al-Musharaf et al. [16].The study done by Marelli et al. [21] showed an increase in sleep time, but the quality of sleep was found to be poor.
The stress or anxiety the participants felt in a day was also found to be significantly increased (12.87 (<0.001)) in the present study.The reason for the same was reported by study subjects as fear of COVID-19 infection and concern about family and friends.A systematic review and meta-analysis by Salari et al. [22] also revealed similar findings.

Strengths of the study
The area under study is less explored by other researchers, and a standardized tool is used in the study, which shows its credibility.

Limitations of the study
Data were collected using Google Forms, so a few participants experienced technical difficulties when attempting to answer the questionnaire.Also, due to the convenience sampling technique, the findings of this study can not be generalized to the entire Indian population.The lifestyle behavior of mankind is a complex phenomenon.Researchers have tried to explore information on selected domains of lifestyle behavior, viz., eating habits, sleep patterns, and consumption of alcohol.Further research can be done on various other domains of interest that could have been affected or changed by the COVID-19 pandemic (e.g., cultural influence).Additionally, more intensive information through a phenomenological research approach can be explored.This data will help identify and mitigate any negative lifestyle behavior.Public health promotion platforms can also be installed to provide one point of solution for any guidance or support to enhance a positive and healthy lifestyle behavior during the present or possible future pandemic.

Conclusions
The recent COVID-19 pandemic has influenced individual lifestyle behavior and preferences globally.Much can be attributed to lockdown, other imposed restrictions, and the availability of resources.The present study findings indicate a positive lifestyle behavior in certain aspects such as healthy food intake, participation in household chores, marginal reduction in alcohol consumption and smoking, and improvement in sleep patterns.This study also showed an increase in screen time spent and no significant improvement in time spent on physical exercises.The anxiety experienced by the participants was also reported to be increased.A detailed study on further exploration of ways to improve and sustain healthy behavior can help promote health and a positive lifestyle.

TABLE 5 : Association between lifestyle behaviors (before, during, total, and the difference between COVID-19 mean score) and demographic variables
*: significance at p<0.05, t: independent t-test value, F: analysis of variance value, COVID-19: coronavirus disease 2019, SD: standard deviation