The Impact of Quarantine on Physical Activity, Body Weight, and Eating Behaviors During the COVID-19 Pandemic in Saudi Arabia

Background Since February 2020, the number of coronavirus disease 2019 (COVID-19) cases in Saudi Arabia has been rising. The Saudi Arabian government implemented strict lockdown measures in March 2020 in an effort to stop the spread of the virus. Globally, changes in socioeconomic levels and health during quarantine have been reported. Additional detrimental effects of the stay-at-home mandate include less physical activity among adult populations, anxiety, stress, and emotional eating. This study aimed to assess the impact of quarantine during the COVID‑19 pandemic on physical activity practice and weight. Methodology This cross-sectional study was conducted using a newly developed validated online questionnaire survey. The data were collected during quarantine in June 2020, including each adult who lived in Saudi Arabia during the quarantine. The data were reviewed and analyzed using SPSS version 21 (IBM Corp., Armonk, NY, USA). Results A total of 4,970 eligible participants completed the study survey. About 78.1% of the study participants performed physical activity inside the house during the pandemic. Overall, 30.9% reported increased body weight during the lockdown, and the most reported cause of increased body weight was feeling bored and empty. Regarding factors associated with physical activity and weight changes, 82.2% of participants aged 25-30 years performed physical activity during the pandemic. Increased weight was significantly higher among participants aged more than 30 years. Conclusions This study shows an increased level of physical activity among the study participants during the COVID-19 pandemic, especially among younger, female, and unmarried participants. More than half of the participants reported weight change, either weight gain or weight loss. Weight gain was higher in older participants. Regarding eating habits, there was an increased tendency toward eating a healthy diet.


Introduction
At the beginning of 2020, the world was facing the coronavirus disease 2019 (COVID-19) pandemic, which began in the city of Wuhan in China with an unknown cause of pneumonia cases [1][2][3], later discovered to be caused by severe acute respiratory syndrome coronavirus 2. However, it quickly spread and became a pandemic in March 2020 [4,5].The World Health Organization has become concerned with alarming levels of spread, severity, and level of infection [6].The pandemic impacted the world and caused significant damage, both socially and economically [7].At the beginning of the pandemic, no vaccine or treatment had been created, and quarantine became the best option and recommendation to stop the rapid spread of infection.Governments around the world have adopted strategies to limit the spread of the virus, and they have enforced restrictions on outdoor activities [8].The Saudi government has imposed strict measures to limit the spread of the virus, including the use of protective measures such as wearing face masks and gloves, travel restrictions, closure of schools and universities, and curfew [9].This situation has led to a change in the lifestyle and habits of the Saudi population, including factors that impact body weight such as physical inactivity, psychological situation, nutritional habits, and sleep behavior.
Physical activity (PA) plays a significant role in physical and mental health besides well-being, and it contributes to systemic inflammation, obesity, and chronic disease prevention.Up to five million deaths a year can be prevented if the worldwide population becomes more active.In 2018, the World Health Assembly agreed on an international goal to reduce physical inactivity by 15% by 2030 in alignment with the Sustainable Development Goals [10].In the context of the COVID-19 pandemic, regular PA enhances immunity and protects against viral infections by decreasing the risk, duration, or severity of viral infection [11].Furthermore, unclear routines and loss of time and space boundaries, for example, mealtime, and separation between work and home space increase the risk of developing an eating disorder [12].In addition, obesity has been associated with a worse prognosis of viral infection, higher mortality rates, more severe clinical course, and hospitalization [13].In the case of coronavirus, body mass index (BMI) was significantly high in patients with complications and severe forms of infection [14].
Globally, the negative impact of quarantine on PA and consumption of unhealthy food has been proven [15,16].According to Fitbit data during the COVID-19 pandemic, there was a dramatic decline in PA globally [17].A cross-sectional study showed significantly lower levels of PA among the Sicilian active population during the COVID-19 quarantine in comparison to before the quarantine, especially among the male and overweight group [3].Another study proved the remarkable reduction of PA levels among southern Croatia adolescents, especially boys.The PA level of boys may have contributed to less participation in formal sports and organized recreational activities [18].
Moreover, reduced PA along with an unhealthy diet contributed to weight gain during quarantine [19].The experience of Poland shows that a remarkable percentage of people changed their eating habits by increasing their eating and intake of snacks, as well as a change in weight [20].In an Italian study, 46.1% of the sample had changed their eating habits negatively by increasing their intake of comfort foods, which increased the weight of 19.5% of the sample.On the positive side, high consumption of vegetables and fruits was observed in 21.2% of the sample [21].Furthermore, during the COVID-19 pandemic lockdown in Brazil, respondents who engaged in sedentary behavior were more likely to consume an unhealthy diet [22].
A previous study showed that 22% of the study sample had gained 5-10 pounds.This increase in weight was related to many factors, including decreased PA, lack of sleep, snacking after dinner, and eating due to stress or the smell of food.On the other hand, 15% of the sample lost 5-10 pounds [23].In another study, Rundle et al. expected that the COVID-19 pandemic may amplify obesity risk factors in children due to school closings [24].Pietrobelli et al. tested this hypothesis and found unsatisfactory changes in the lifestyle and habits of children and adolescents associated with the risk of weight gain and obesity, thereby proving the findings of Rundle et al. [25].
Regarding Saudi Arabia, in a cross-sectional study done during the COVID-19 quarantine, about 45% of participants reported eating more snacks, and 28% had gained weight [26].In another study about the impact of COVID-19 home quarantine on lifestyle, the prevalence of participants who used to walk daily significantly decreased, and the prevalence of participants who often consumed snacks between meals increased, while the prevalence of participants who never ate fruits and vegetables significantly increased during home quarantine [27].Furthermore, a cross-sectional study conducted in Jeddah City, Saudi Arabia, found that major changes in eating behavior were reported in people exposed to the full COVID-19 quarantine period rather than the partial curfew [28].
Despite the intense influence of the COVID-19 pandemic on people's lifestyles worldwide, data are scarce on the impact of quarantine on the Saudi population's lifestyle during the pandemic.Therefore, this study aimed to measure the impact of quarantine on body weight, eating behaviors, and PA among the Saudi population during the COVID-19 pandemic as well as the factors affecting it.

Study design and procedure
This descriptive, cross-sectional study was conducted using an online questionnaire survey performed via the Typeform web survey platform.A research proposal and a request letter were submitted to the Dean of the College of Medicine and the Vice Dean of Scientific Research for approval before the study was conducted.Ethical approval was obtained from the Research Ethical Committee at Taif University (approval number: 42-0033).
The primary objectives were to estimate the general rate of increase or decrease in weight during quarantine and to compare the rate of change in weight in both sexes at different ages.In addition, we aimed to assess whether quarantine resulted in increased food consumption, snacking, and cooking.The study also estimated the changes in the level of PA during quarantine.

Study participants
The participants in the study completed the online questionnaire between June 2020 and June 2021.The number of participants was 4,970 at a confidence interval of 95% and a margin of error of 2%.The study included individuals of both sexes, aged 15 years old and above, who were in Saudi Arabia during the COVID-19 quarantine, irrespective of whether they were citizens or residents.We excluded those who were under 15 years old, pregnant, and who were outside Saudi Arabia during the COVID-19 quarantine.

Questionnaire
The newly developed, self-administered, English-language version of the questionnaire to assess PA and eating habits consisted of three sections.Section A consisted of personal and disease details.Section B comprised details of working (job) status and PAs.Section C included eating habits and their effect on health during the pandemic.The drafted English-language version was then subjected to validation.A standardized methodology was followed in the validation of the questionnaire, which included focus group discussion, expert evaluation, pilot study, reliability, and validity assessment.The content validity, face validity, and construct validity of the developed questionnaire were examined.

Data analysis
The data were collected, reviewed, and then entered into SPSS version 21 (IBM Corp., Armonk, NY, USA).All statistical methods used were two-tailed with an alpha level of 0.05, considering significance if the p-value was less than or equal to 0.05.Descriptive analysis was done by prescribing frequency distribution and percentages for study variables, including participants' personal data, work data, medical history, and habits with their BMI.Moreover, participants' PA practice before and during the pandemic, along with their reported types of activity, were tabulated.Sleep patterns, dietary habits, and weight changes during the COVID-19 pandemic were also tabulated, while reasons for weight changes were graphed.Cross-tabulation was used to identify factors associated with practicing PA and weight changes during the COVID-19 lockdown using the Pearson chi-square test and the exact probability test for small frequency distributions.

Results
A       study participants spent more than 20 hours at home during the lockdown.Regarding sleep hours during the lockdown, 50.8% reported sleeping for seven to nine hours, and 19.9% reported sleeping for more than nine hours.Overall, 65.5% of the participants experienced eating habit changes during the lockdown, mainly preparing baked goods (pastries) and sweets at home (50.2%), reducing fast food intake (46.7%), increasing daily food intake (40%), reducing daily food intake (36.7%), increasing the consumption of vegetables and fruits (35.8%), increasing the consumption of frozen and canned foods (22.1%), and using nutritional supplements and vitamins (13.8%).Moreover, 30.9% reported increased body weight during the lockdown, 30.5% experienced decreased body weight, and 38.5% had no weight change.For those who experienced increased weight, it was 1-2 kg among 34.1%, 3-4 kg among 34.5%, and 5-6 kg among 12.6%.For those who lost weight, it was 1-2 kg among 34.3% of them, 3-4 kg among 35.8%, and 5-6 kg among 11.5%.Table 5 presents the factors associated with practicing PA during the COVID-19 lockdown.Overall, 82.2% of participants aged 25-30 years performed PA during the pandemic versus 73.1% of those less than 20 years old, with a recorded statistical significance (p = 0.001).Moreover, 81% of females did PA versus 60.3% of males (p = 0.001).PA during the pandemic was practiced by 87.1% of non-Saudi participants compared to 77.5% of Saudi participants (p = 0.001).Likewise, 85.7% of married people performed activities during the pandemic versus 74.3% of unmarried people (p = 0.001).Additionally, 78% of those who did not work during the lockdown practiced activity compared to 62.9% of those who were working (p = 0.001).Around 79.5% of overweight and 78.1% of obese participants did PA during the quarantine.Overall, 95.3% of participants who performed PA inside the house before the pandemic still did it during the pandemic versus 41.9% who did not (p = 0.001).

Discussion
In this study, most participants were young and unmarried, with nearly normal body weight for half of the participants.Moreover, the vast majority (75.4%) were not employed.Of the employed participants, 42.6% said that their work needed effort, mainly at an average level.Regarding the home environment, 73.4% of the study participants owned outdoor space in their houses.All these factors (young age, unemployment, lack of diseases, and having home space) motivated them to practice PA, which was reported by about twothirds of the participants, with mainly walking and resistance exercises.This was done nearly daily by 35.7% of the participants, and four to five times a week by 44.9%, which implied high PA performance before the pandemic.This was consistent with what was reported by the general authority of statistics in Saudi Arabia, which showed that 48.2% of the Kingdom's population practices PA for at least 30 minutes per week.The results also showed a significant difference between the percentages of males and females who practiced PA for at least 30 minutes per week, as the percentage of males was 54.8%, and the percentage of females was only 38.3% [29].Another systematic review conducted by Al-Hazzaa [30] assessed that the prevalence of physical inactivity varied based on the population being assessed, region, age, gender, kind of PA instrument used, and physical inactivity criteria, ranging from 26% to 85% for Saudi males and from 43% to 91% for Saudi females.
During the COVID-19 pandemic, this study revealed that about 78% of the participants performed PA inside the house, which was regular among about 17% of the participants.Walking and resistance exercises were the most practiced activities, with around 40% of participants performing PA four to five times per week or daily.Due to the quarantine, the vast majority practiced sports inside their houses, and this was due to the presence of spaces in houses (garden or roof).This implies that the rate of performed PA increased during the quarantine, which was in contrast to the findings of Rasheed et al. [31], where more than half of the participants reported less PA than before the COVID-19 pandemic.Similarly, Park et al. [32] conducted a review study including studies in different world regions and demonstrated a substantial correlation between COVID-19 and increases in sedentary behavior and decreases in walking, mobility, and PA.A few studies also revealed conflicting findings, such as an increase in the use of parks and trails and a rise in recreational activities among particular demographic groups.In Saudi Arabia, Hamed et al. [33] conducted a study with no statistically significant difference between pre-and post-COVID-19 respondents in terms of PA.The estimated higher PA among the current study participants may be due to more female participants who had the time, and most of them were unemployed, which means their lifestyle was nearly unaffected by maintaining their traditional PA patterns.
Regarding eating habits and weight change, about 65.5% of the participants experienced eating habit changes during the lockdown.The nature of changed habits was contradictory, as increased preparation of baked goods (pastries) and sweets at home, reduced fast food intake, reduced daily food intake, and increased consumption of vegetables and fruits were reported.On the other hand, an increase in daily food intake and an increase in the consumption of frozen and canned foods were also reported.Weight change was reported by 60% of the participants, where nearly half of them (30.9%)experienced increased body weight, and the other half experienced decreased body weight (30.5%).The weight change was mostly around 1-4 kg.Similar results were reported by Bakhsh et al. [26], who found that about 28% of the participants gained weight as a result of their increased eating, as indicated by 40% and 45% of individuals, respectively.Regarding eating habits in this study, only 7% of the participants said they ate meals from restaurants compared to the majority who said they ate home-cooked (73%) and healthy meals (47%).The two primary motivators for food behavior changes were time constraints (40%) and feelings of emptiness and boredom (44%).Other studies have reported weight gain of nearly 3-4.5 kg during the quarantine [20].
Weight gain is anticipated because of the overall drop in PA during a quarantine, which is linked to restricting people's ability to go to work, the gym, parks, and even perform their regular daily activities.
Additionally, the psychological distress brought on by spending months confined to one's house, as well as the worry about novelty and the rapid development of COVID-19 [34].Furthermore, higher food intake was linked to the experienced worldwide lockdown, according to earlier reports from Poland, Italy, and the United Kingdom [20,21,35].The reported decreased weight in our study participants was mainly due to increased PA besides avoiding fast food intake.More engagement on social media with a lack of movement decreased the number of daily meals, which was reported as the main cause by the study respondents.
Although this study has an adequate sample size from various regions that represent the Saudi population, it has some limitations.As a result of COVID-19 and lockdown restrictions, the only way to collect data was through an online survey, which had some disadvantages such as recall bias, misunderstanding of survey questions, and the anthropometric measurements being measured incorrectly.In addition, as the survey was distributed online through social media, people without Internet access could not answer the questionnaire.
A phone call or physical interview would be more accurate.Furthermore, other variables were missed in this study, such as psychological and socioeconomic level changes, that may influence the lifestyle of participants.We recommend considering them in future studies.

Conclusions
This study revealed an increased level of PA among the study participants during the COVID-19 pandemic, mostly in younger, female, unmarried participants who had outdoor space in their houses.Regarding weight, more than half of the participants reported weight changes of mostly around 1-4 kg during the quarantine; gaining weight was higher in participants aged above 30 years.Furthermore, changes in feeding habits, such as increased intake of homemade food, having supplements and vitamins, and eating a diet higher in fruits and vegetables and lower in other unhealthy foods, were also reported.
Employee (move to Question No.

Figure 1
Figure1illustrates the reasons for weight changes among the study participants during the COVID-19 pandemic.Regarding the reasons for increased weight, most reported feeling bored and empty (67.9%), lack of movement, and increased sitting hours on TV or mobile phones (65.3%).About the reasons for weight loss, the most reported reasons were reducing the number of meals per day (49.5%) and cutting out fast food (43.7%).

FIGURE 1 :
FIGURE 1: Reasons for weight changes among the study participants during the COVID-19 pandemic.

21 . 22 . 24 . 26 . 27 . 29 .From 33 .Feeling 35 .
What kind of sport did you do before the pandemic?(you can choose more than one answer) Where did you play sports before the pandemic?Inside the house Outside the house 23.Do you do any physical activity inside the house (cleaning the house, preparing food, ironing, and washing clothes) during the pandemic period?Yes No Did you do any kind of sport (walking, resistance training, biking, swimming ...) during the pandemic period?No (move to Question No. 28) Rarely (move to Question No. 26) Sometimes (move to Question No. 26) Regularly (move to Question No. 25) 25.How many times per week?What kind of sport did you do during the pandemic?(you can choose more than one answer) Where did you play sports during the pandemic?Inside the house Outside the house 28.Your sleep hours during the day during the curfew period: Did your eating habits change during the curfew period?Yes (move to Question No. 30) No (move to Question No. 31) 30.How did your eating habits change?(you can choose more than one answer) Increase your daily food intake Reducing your daily food intake Increase your consumption of frozen and canned foods Reducing the consumption of frozen and canned foods Increase the consumption of vegetables and fruits Reducing the consumption of vegetables and fruits Preparing baked goods (pastries) and sweets at home Eating more fast food Reducing fast food intake Use of nutritional supplements and vitamins Other (mention it) 31.Did you notice any change in weight during the pandemic period?Increase (move to Question No. 32) Decrease (move to Question No. 34) No change (move to the end of the questionnaire) 32.The amount of the increase in kilograms: In your opinion, what are the reasons that led to your weight gain?(you can choose more than one answer) Psychological state (fear, anxiety, psychological stress) In your opinion, what are the reasons that led to your weight loss?(you can choose more than one answer) Psychological state (fear, anxiety, psychological stress)

Table 2
presents work and PA among participants before the COVID-19 pandemic.Overall, 24.6% of the study participants were employed, 25.4% worked during the lockdown, and 24.2% worked remotely.In addition, 42.6% stated that their work required them to make a movement effort, and 21.7% reported a need for strong effort at their work.During lockdown, 82.2% spent more than 20 hours at home.Overall, 73.4% reported having outdoor space in their house (yard, roof, garden).Considering PA, 67.8% performed PA inside the house before the pandemic.The most reported sports done before the pandemic included walking (79.8%), resistance exercises (30.4%), and dancing (27.7%).Furthermore, 44.9% of those who did any activity did it four to five times per week, and 35.7% did it daily.Overall, 50.1% performed the activity inside the home, and 49.9% performed it outside the home.Work and activity before COVID-19 No % 2024 Alsaqqa et al.Cureus 16(3): e56460.DOI 10.7759/cureus.564604 of 19 2024 Alsaqqa et al.Cureus 16(3): e56460.DOI 10.7759/cureus.564605 of 19

Table 3
shows the PA levels among participants during the COVID-19 pandemic.Overall, 78.1% of the study participants performed physical activity inside the house during the pandemic.A total of 42.3% practiced sports four to five times a week and 46.1% did daily.The most practiced sports during the pandemic included walking (74%), resistance exercises (45.2%), and dancing (29.6%).The vast majority of the participants (86.8%) played sports inside the home during the quarantine.

Table 6
presents the factors associated with weight change during the COVID-19 lockdown.Increased weight was significantly higher among participants aged more than 30 years (36.8%),married participants (37.5%), obese participants (43.4%), those who worked remotely (36.1%), those who did not practice PA before the pandemic (31.7%), and those who did not practice PA during the pandemic (40%).