Impact of the Coronavirus Disease 2019 (COVID-19) Curfew Restrictions on the Body Mass Index and Dietary and Physical Activity Behaviors of Saudi Adults: A Cross-Sectional Study

Objectives: The objective of the current study was to assess the effect of the coronavirus disease 2019 (COVID-19) curfew restrictions on the body mass index (BMI) and dietary and physical activity behaviors of Saudi adults. Methods: This cross-sectional study was conducted using an online questionnaire in Saudi Arabia in May and June 2020, during the curfew restriction period. The questionnaire included three sections with questions regarding sociodemographic data, dietary behaviors, and moderate and vigorous activities. Results: A total of 504 Saudi adults participated in this study. Even though there were no significant differences in the BMI status before and during COVID-19 curfew restrictions, the percentage of overweight participants slightly increased during the period of COVID-19 curfew restrictions. The frequency of intake of fruits and beverages were significantly increased (p<0.05), whereas the consumption of meat and fish, bread and cereals, and sandwiches and burgers showed a significant reduction (p=0.001). Although the overall percentage of participants engaged in moderate physical activities increased during curfew restrictions, there was a reduction in vigorous physical activities. Conclusion: This study demonstrated changes in BMI and dietary and physical activity behaviors due to the COVID-19 curfew restrictions.


Introduction
The coronavirus disease 2019 (COVID- 19) is an infectious disease and may cause mild to moderate respiratory illnesses such as the Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV) [1,2].However, elderly people and those with underlying medical conditions (such as cardiovascular disease, diabetes, chronic respiratory disease, or cancer) are more likely to develop serious illnesses.Up to now, there have been over 750,000,000 confirmed cases of COVID-19, including nearly 7,000,000 deaths, reported to WHO [3].The rapid increase of COVID-19 cases has challenged the capacity of healthcare systems.
Once COVID-19 was declared a pandemic in March 2020 [2], most countries started drastic strategies like travel bans, lockdowns, and curfew restrictions to prevent COVID-19 spread during its peak.That, in turn, led to challenges in lifestyles, including dietary and physical activity behaviors, among people across the globe [4][5][6].Specifically, drastic strategies of curfew restrictions and closures of restaurants might impact individuals' dietary behaviors through increased "comfort food" consumption due to emotional distress.In addition, curfew restrictions and lockdowns of parks and fitness centers might disrupt physical exercise routines, limit outdoor activities, and encourage sedentary behaviors.
The Saudi Ministry of Health (MOH) announced the first case of COVID-19 infection on March 2, 2020 [1].In April 2020, the Saudi government announced a curfew for 24 hours a day in cities that witnessed a high number of COVID-19 cases and excluded leaving the house for necessary needs through an application that granted electronic permits to employees of government and private sectors [1].Soon after, all Saudi cities introduced similar measures, mainly enforcing social distancing by the closure of restaurants, sport centers, and cultural facilities as well as prohibiting mass gatherings and interaction of people from different households.Most Saudi individuals had to experience online working, learning, and attending/conducting meetings for the first time.
Being forced to stay home due to the COVID-19 pandemic for a long time might eventually lead to stress conditions that could cause a dramatic change in individuals' dietary and lifestyle behaviors [7].A study by Pietrobelli et al. [8] found increased consumption of unhealthy foods and decreased physical activities among Italians during the lockdown.In addition, Janssen and others used a food frequency questionnaire and found an overall reduction in the consumption of fresh foods and an increased intake of foods with a longer shelf life in Denmark and Germany [9].Decreased consumption of fresh foods (especially fruit and fish) and increased consumption of sweets, cookies, and cakes were also reported in France as well as decreased physical activity and increased sedentary time [10].Such dietary and physical activity behaviors might have impacted individuals' weight as well [11,12].
While much of the emerging research investigated weight changes, eating habits, and physical activities of different populations due to COVID-19 curfew shutdowns [13,14], a few studies have focused on changes in both dietary and physical activity behaviors of Saudi populations during the COVID-19 pandemic [14][15][16][17][18].Moreover, no previous research, to our knowledge, reported changes related to dietary behaviors using a validated Saudi food frequency questionnaire (SFFQ) nor measured changes in both moderate and vigorous physical activity behaviors in Saudi adults during the COVID-19 curfew restrictions.The current study aimed to assess the effect of COVID-19 curfew restrictions on body mass index (BMI) and dietary and physical activity behaviors of Saudi adults.

Materials And Methods
This cross-sectional study was conducted at the end of May and the month of June 2020 (during the COVID-19 curfew restrictions) using convenience and snowball sampling methods of both Saudi female and male adults (18 and above).The data was collected through the Google Forms platform, and the online survey (see Appendices) was distributed via social media networks (Twitter, Snapchat, and WhatsApp).The study protocol and questionnaire were approved by the Research Ethics Committee of King Faisal University (approval number: KFU-REC/2020-05-14).
The first page of the survey included the objectives of the study, the duration of the survey, voluntary declaration, confidentiality, the anonymity of the study, and a digital consent form.The study participants were required to provide consent of participation before they started the survey by clicking on the "agree to participate in this study" button.The participants also had the option to exit the survey at any point if they felt uncomfortable or did not want to continue participating in the study.
The study survey was available in Arabic for the participants and consisted of three sections.The first section collected sociodemographic data (including gender, age, marital status, education level, occupation, region of residence, and monthly household income level).A closed-ended question on a change of household income during the curfew restrictions was provided with options (no; yes: increased income; and yes: decreased income).The survey also included questions on height and body weight (before and during the curfew restrictions) to calculate BMI with the formula of weight in kilograms divided by height in meters squared and categorize it as underweight (below 18.5), normal weight (18.5-24.9),overweight (25-29.9),and obese (30 and above) [19].
The second section of the survey collected dietary behaviors before and during the curfew restrictions using an SFFQ.The SFFQ was developed by Gosadi et al., and its reliability and validity were established [20].Each set (before and during the curfew restrictions) of the SFFQ included a list of 140 food items of eight food categories (meat and fish, bread and cereals, sandwiches and burgers, dairy products and fat, sweets and snacks, beverages, fruits, and vegetables), and nine answer options were provided for each closed-ended question.The consumption frequency choices were stated as the following: never or less than a month, 1-3 per month, once a week, 2-4 per week, 5-6 per week, once a day, 2-3 per day, 4-5 per day, and 6+ per day.At the end of the food frequency questionnaire, open-ended questions were provided to gather information regarding other non-listed food items.
The third section included questions on both moderate and vigorous physical activities before and during the curfew restrictions.Definitions of both moderate and vigorous physical activities [21] were provided to the study participants with the following statements: "moderate physical activity refers to activities equivalent in intensity to brisk walking, bicycling, cleaning the house, or landscaping the garden" and "vigorous physical activity produces large increases in breathing or heart rate, such as jogging, fitness exercises, or hard-working in the house garden."The physical activity questions were based on the Behavioral Risk Factor Surveillance System (BRFSS) Questionnaire [22].For each type of physical activity, participants were asked about the number of days and the total amount of time (minutes/week) by openended questions.
Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States).Categorical data were presented in frequencies and percentages, and continuous data were expressed in means and standard deviations.The normal distribution of a variable was evaluated using the Kolmogorov-Smirnov test.To measure dietary behaviors, a scoring system was used.For example, food items which were never or rarely consumed were given a score of 0, while food items which were consumed more than six times daily were given a score of 8.A sum of consumption frequency score was calculated for each food item and the eight food categories.The paired sample t-test or Wilcoxon signed-rank test was used to compare the total scores for food frequency consumption and physical activity behaviors before and during COVID-19 curfew restrictions.The McNemar-Bowker test was used to compare the BMI status before and during COVID-19 curfew restrictions.A p-value of less than 0.5 was considered statistically significant.To measure the food consumption frequency, a scoring system was used.For example, items which were never or rarely consumed were given a score of 0, while items which were consumed more than six times daily were given a score of 8.A sum of consumption frequency score was calculated for each food type.

Results
In this study, 537 individuals completed the online survey.After eliminating non-Saudi participants (n=19) and duplicated entries (n=14), the participation sample included 504 Saudi adults (18 years old and above).The study participants' characteristics are presented in Table 1.The majority of the study participants were female (n=379, 75.2%), had a bachelor's degree (n=289, 57.3%), were employed (n=207, 41.1%), and were married (n=244, 48.4%).The age mean of the participants was 31.6(±10.21).About 50% (n=253) of the study participants were from the eastern region.Over 60% (n=326) of the participants had a monthly household income of SR 10,000 (~USD 2,666) or above, and their income did not change during the COVID-19 curfew.Table 3 shows the study participants' dietary behaviors before and during the COVID-19 curfew restrictions.It was found that the consumption of meat and fish, bread and cereals, and sandwiches and burgers was significantly (p=0.001)reduced during the COVID-19 curfew period.On the other hand, the intake of sweets and snacks (p=0.015),beverages (p=0.001), and fruits (p=0.010)showed a significant increase.The change in consumption of dairy products and fat and vegetables before and during the COVID-19 curfew restrictions was found to be statistically insignificant.As for practicing physical activity, 83.2% (n=420) of the participants reported practicing at least 10 minutes of moderate physical activity per week (data not shown).In addition, 55.6% (n=281) of the participants reported practicing at least 10 minutes of vigorous physical activity per week.Moreover, the number of participants reporting over 120 minutes of practicing daily moderate physical activity before COVID-19 curfew restrictions remained the same at 3.6% (n=18), as compared to 3.6% (n=17) during COVID-19 curfew restrictions.However, it was concluded that the numbers of minutes of practicing daily moderate physical activity were statistically not significant at p<0.05.
As for practicing vigorous physical activity, 23.2% (n=117) of the participants reported zero days of practicing weekly vigorous physical activity before and during COVID-19 curfew restrictions.Also, the number of participants who reported 1-3 days of practicing weekly vigorous physical activity before COVID-19 curfew restrictions was the same at 49% (n=246) as compared to 49.2% (n=248) of the participants during COVID-19 curfew restrictions.In addition, the percentage of the participants reporting 4-6 days of practicing weekly vigorous physical activity before COVID-19 curfew restrictions reduced from 28% (n=141) to 27.6% (n=139) during COVID-19 curfew restrictions.Nevertheless, it was concluded that the numbers of days of practicing weekly vigorous physical activity were statistically not significant at p<0.05.
Over 70% (n=355) of the participants reported 0-30 minutes of practicing daily vigorous physical activity before COVID-19 curfew restrictions, as compared to 72% (n=363) during COVID-19 curfew restrictions.Also, the number of participants reporting 31-60 minutes of practicing daily vigorous physical activity before COVID-19 curfew restrictions reduced from 20.2% (n=102) to 18.7% (n=94).In addition, only 3% (n=15) of the participants reported 61-90 minutes of practicing daily vigorous physical activity before COVID-19 curfew restrictions, as compared to 3.6% (n= 18) during COVID-19 curfew restrictions.Furthermore, there was a reduction in the number of participants who reported 91-120 minutes of practicing daily vigorous physical activity before COVID-19 curfew restrictions from 5% (n= 25) to 4% (n=20).Moreover, 1.4% (n=7) of the participants reported over 120 minutes of practicing daily vigorous physical activity before COVID-19 curfew restrictions as against 1.8% (n=9) during COVID-19 curfew restrictions.Yet, it was concluded that the numbers of minutes of practicing weekly vigorous physical activity were statistically not significant at p<0.05.

Discussion
As a result of the COVID-19 pandemic, different countries had forced strict measures to manage the spread of the disease.That, in turn, could directly or indirectly affect eating and physical activity behavior.Like other countries, Saudi Arabia experienced diverse magnitudes of social distancing actions, which included the shutting down of sports events and places and limiting the number of customers as well as the total timing of the restaurant's opening hours.Even though these strict measures might decrease the virus communication in many parts of the world including Saudi Arabia [14][15][16], these procedures had augmented worries about following a healthy lifestyle including eating patterns and exercise behaviors.The current study assessed the effect of COVID-19 curfew restrictions on the BMI and dietary and physical activity behaviors of 504 Saudi adults.
In terms of BMI change, Hossain et al. reported increased BMI within prolonged (over a year) COVID-19 lockdown in Bangladeshi university students [4].However, there were no significant differences in the BMI status before and during COVID-19 curfew restrictions in Saudi adults who participated in the current study.
The study was done in a relatively short period of time; BMI change would occur overtime.Another important indicator of health is dietary behavior.It has been concluded that a poor dietary regimen would negatively affect mental well-being and cognitive performance [8,13].The present study showed a significantly increased intake of beverages, fruits, and sweets and snacks.This observation was reported in other populations too.Specifically, a higher intake of fruits was depicted, whereas no change was found in vegetable consumption in Italian populations during the COVID-19 lockdown [8,23].In addition, a higher intake of sweets, cookies, cakes, and sugar-sweetened beverages was found in other populations due to the COVID-19 lockdown [10,24].It should also be considered that during the pandemic curfew, there was limited time for the public to do shopping for meal preparation.Moreover, people could feel pressured concerning the food reserves for the future, and that might lead them to getting pre-packaged and non-perishable eatables and "comfort foods" such as sweets and snacks in place of fresh ones.That, in turn, might lead to the consumption of excessive amounts of calories and overweight [25].To avoid negative consequences, the efforts of public health officials should include increased awareness on healthy eating during pandemics.
Being physically active is the most powerful determinant of decreased anxiety and depression [26], and it also contributes to weight control and develops healthy immunity.While previous studies suggested reduced physical activities during the pandemic lockdowns [10,17,[27][28][29], the number of days the Saudi participants reported practicing moderate physical activities significantly increased (p=0.012) as a result of the COVID-19 curfew restrictions.One explanation to increased moderate physical activities in Saudi adults during the COVID-19 curfew restrictions might be having extra time while staying home.However, no significant change was found regarding practicing vigorous physical activities because of the COVID-19 curfew restrictions.The study took place during the pandemic's highest restrictions imposed in Saudi Arabia including the closure of recreational centers.During the COVID-19 curfew restrictions, the public should be encouraged to shift in outdoor physical activities to different intensities of home-based exercises.For instance, the nationwide Fit from Home (FFH) campaign, which was promoted by public health officials in Thailand during the lockdown period, illustrated improvement of desirable physical activities in Thai populations [30].
We would like to highlight the strengths of the present study.The present study used a valid and reliable usual dietary assessment tool for Saudis [20].The physical activity questions used in the present study were based on the BRFSS Questionnaire [22].In addition, the present study measured changes in both moderate and vigorous physical activity behaviors in Saudi adults during the COVID-19 curfew restrictions.Moreover, the effects of COVID-19 restrictions on the BMI, diet, and physical activity were assessed in a sample that represented Saudi adults from all regions, so the results of the study could be generalized to all the Saudi adult population.
However, our study has certain limitations.First, the demographic and anthropometric parameters of the study participants were self-reported in online questionnaires instead of measuring them personally.These could lead to decreased reliability and biasing on the part of the respondent.Second, the present study did not consider the psychological determinants in the design of the questionnaire, which may intervene in the correlation between behavior imposed by the curfew restrictions.In addition, the study questionnaire was relatively long, as the section of assessing dietary behavior changes included 208 items.Lastly, lifestyle changes may contribute to reasons besides the pandemic, so research similar to the present study performed in areas with minimal effect of the COVID-19 pandemic could give comparative results for a more valid conclusion.

Conclusions
The present research findings showed that curfew restrictions probably proposed a chance for the communities to be at home and opt for healthy meal choices.Nevertheless, along with the extended duration of limited societal interactions, the deteriorating effect on the maintenance of regular physical activities could prove a remarkable public health consequence.Community healthcare providers are therefore guided to observe and evaluate physical well-being on population-based criteria.Especially, modified interceding to encourage healthy behaviors seems mandatory to promote the health of the communities afflicted by the pandemic.

Table 2
presents the study participants' BMI before and during COVID-19 curfew restrictions.Based on the self-reported weight and height before and during the COVID-19 curfew restrictions, about 8% (n=40) of the participants were underweight before COVID-19 curfew restrictions, and about 7% (n=35) of the participants were underweight during COVID-19 curfew restrictions.Out of the study participant, 40.7% (n=205) had a normal weight before COVID-19 curfew restrictions, and 42.1% (n=212) of the participants had a normal weight during COVID-19 curfew restrictions.In addition, 28.6% (n=144) of the participants were overweight before COVID-19 curfew restrictions, and almost 30% (n=149) of the participants were overweight during COVID-19 curfew restrictions.Furthermore, 22.8% (n=115) of the participants were obese before COVID-19 curfew restrictions, and 21.4% (n=108) of the participants were obese during COVID-19 curfew restrictions.However, there were no significant differences in the BMI status before and during COVID-19 curfew restrictions.

Table 4
shows the results of the univariate regression analysis of BMI depending on consumption frequency within each food category of study participants before and during COVID-19 curfew restrictions.It was concluded that the results were statistically not significant at p<0.05.Food category Before COVID-19 curfew During COVID-19 curfew Regression coefficient 95% confidence intervals p-value Regression coefficient 95% confidence intervals p-value

TABLE 4 : Univariate regression analysis of BMI depending on consumption frequency within each food category of study participants before and during COVID-19 curfew restrictions (n=504)
BMI: body mass index; COVID-19: coronavirus 2019

Table 5
illustrates study participants' physical activity behaviors before and during COVID-19 curfew restrictions.As for practicing moderate physical activity, the number of participants reporting zero days of practicing weekly moderate physical activity before COVID-19 curfew restrictions reduced from 12.5% (n=63) to 8.5% (n=43) during COVID-19 curfew restrictions, whereas the number of participants who reported 1-3 days of practicing weekly moderate physical activity before COVID-19 curfew restrictions increased from 39% (n=195) to 42.9% (n=216) during COVID-19 curfew restrictions.In addition, the number of participants reporting 4-6 days of practicing weekly moderate physical activity before COVID-19 curfew restrictions were almost the same 48.8%(n=246), as compared to 48.6% (n=246) during COVID-19 curfew restrictions.It was concluded that the numbers of days of practicing weekly moderate physical activity were statistically significant (p=0.012).Item Before COVID-19 curfew (%) During COVID-19 curfew (%) p-value

TABLE 6 : Food frequency consumption
If you have a job, please answer questions 1-7.If you do not have a job, skip question 1 and answer questions 2-7.1.When you are at work, which of the following best describes what you do?If you have multiple jobs, include all jobs.For questions 2-7, we are interested in two types of physical activity: moderate and vigorous.Moderate activities cause small increases in breathing or heart rate, while vigorous activities cause large increases in breathing or heart rate.2.Now, thinking about the moderate activities you do when you are not working in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate?How many days per week do you do these moderate activities for at least 10 minutes at a time?_________ days per week Do not do any moderate physical activity for at least 10 minutes at a time (Go to question 5) 4. On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?________ minutes per day 5. Now, thinking about the vigorous activities you do when you are not working in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?No Yes 6.How many days per week do you do these vigorous activities for at least 10 minutes at a time?________ days per week Do not do any vigorous physical activity for at least 10 minutes at a time 7. On days when you do vigorous activities for at least 10 minutes at a time, how much total time per day do 2024 Tami et al.Cureus 16(1): e52669.DOI 10.7759/cureus.52669