Coronavirus is a highly contagious positive single-strand RNA virus that causes severe respiratory symptoms that could lead to death. The virus was named coronavirus disease 2019 (COVID-19) by the WHO on February 11, 2020, and was declared a pandemic on March 13, 2020. The first case of COVID-19 was detected in Saudi Arabia on March 2, 2020. The Saudi government took several quick stringent measures to control the spread of the virus. All schools and universities were closed, and online teaching began for all students; workplace attendance was suspended; shopping centers were closed, and a ban was imposed on traveling and on all mass gatherings in the entire kingdom.[4-7] On March 23, 2020, a curfew commencing from 7 pm to 6 am was enforced in all the cities in Saudi Arabia. On June 21, 2020, the curfew was fully lifted, but schools and universities were directed to continue online education.
Almost half of the world’s population has been under “off and on” “full or partial lockdowns” work from home and quarantines since March 2020. Although these worldwide strict preventative regulations helped to control the spread of virus, they adversely affected lifestyle behaviors (LSB) of people worldwide. LSB of student populations has been the most affected as COVID-19 resulted in school closure worldwide. While COVID-19 infection rates in countries differ, currently, more than 186 countries are affected by school closures and have shifted to online teaching. Two of the most recent reviews have raised the serious concerns about the increased screen time (ST), decreased physical activity (PA), negative changes in eating habits, and weight gain in the general population as well as in youngsters after the outbreak of the pandemic.
The WHO has advised people to stay healthy by eating homemade healthy balanced diet. Moreover, it endorsed staying physically active, minimizing SUT, managing stress, and getting enough sleep to improve immune functions.
During the pandemic, young students were expected to experience a maximum change in their LSB and body mass index (BMI), because the pandemic caused most educational sectors all over the world to change from physical to online/hybrid teaching. Most existing studies on young adults have pinned the short-duration effects of the pandemic (4–5 months) on LSB and BMI. Therefore, our aim was to “find out the perceived impact of long duration (2 years) of COVID-19 pandemic on ST, PA, eating habits and BMI of young Saudi adults.” Although an increase in the BMI in young populations after 2 years of the pandemic has been reported in various studies, the factors accounting for this change represent a research gap. Therefore, our aim was also to “identify the factors responsible for increased BMI in young adults in the pandemic.”
Materials and Methods
This descriptive exploratory study was conducted in January 2022 on 1815 students from various health colleges of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia (College of Medicine, College of Clinical Pharmacy, College of Nursing, College of Dentistry, and College of Applied Medical sciences).
The calculation of sample size was done by epidemiologic statistics for public health tools software (accessed at: http://epitools.ausvet.com.au/content.php?page = 1ProportionandProportion). The estimated minimum sample size was 1039 (we recruited 1815 participants, more than the minimum calculated sample size).” This calculation was based on the estimated prevalence of increased BMI after COVID-19 pandemic and a target adult population of 1519 in an Italian survey with: Proportion (increased BMI after pandemic) 58%; precision (d) 3%; confidence level 95%.
Ethical approval was obtained from the Institutional Review Board (IRB) vide Letter No. 2022-01-011 dated 10/01/2022, and informed written consent was taken from all participants.
The main tools of this study were: (1) BMI and a 30-item LSB and changes (LSBC) self-administrated structured online questionnaire, which assessed the perceived LSBC “one month immediately before the pandemic” and “ the present time, almost 2 years after the COVID-19 outbreak.” This questionnaire was designed by the authors based on various previous studies.[1-4] The reliability and validity of the questionnaire were confirmed by a retest technique done on 35 students (P = 0.003; r = 0.80). The component of LSBC, including 7-item International physical activity questionnaire (IPAQ), was not included in the test retest analysis as the reliability and validity of this questionnaire are already established at international level.
The LSBCs questionnaire (LSBCQ) was divided into three different sections assessing screen time (ST), physical activity (PA), and dietary intake as follows: ST was divided into four main categories: Total ST (including the time spent on a mobile, iPad, Laptop, computer, television, and video games); ST for mobile use only; ST for educational purpose only (including the time spent on mobile, iPad, laptop, and computer); ST for entertainment purpose only (including the time spent on mobile, iPad, laptop, computer, television, and video games). The subjects were divided into four categories based on their ST: Low ST ≤2 h/24 h; Medium ST = 3–5 h/24 h; high ST = 6–8 h/24 h; and very high ST ≥9 h/24 h.
PA was assessed by a seven-item IPAQ. Based on IPAQ, the subjects were divided into three main categories [Table 1].
Participants with low PA were categorized as inactive. Subjects with medium and high activity were categorized as active.
Information on food intake included data about the frequency and quality of food taken. The frequency of food was assessed by the number of meals per day, which determined the three main categories the subjects were divided into decreased frequency of food intake = 1 meal/day; Normal frequency of food intake = 2 or 3 meals/day; Increased frequency of food intake ≥4 meals/day. The quality of food was assessed by the following eating habits: Intake of junk food (including packaged sweets and baked products, sweet beverages, savory snacks, dressings, sauces, fast food, sugary drinks, and deep-fried food); Intake of homemade food; and Intake of healthy food (including fruits, vegetables, milk, nuts, fish, lean meat, and pulses). Increased intake= ≥5 days/week. Decreased intake = <4 days/week.
The response rate was 43.2%, as 1815/4200 students volunteered to participate in the study. The online LSBCQ was shared with the willing students who completed the LSBCQ and were then called to the physiology laboratory for anthropometric measurements. BMI was calculated by the formula = weight in kg/height in m2. Weight was measured in kilograms and height in centimeters. The anthropometric measurements were done by using standard procedures (light clothing, bare feet, empty bowel and bladder, and a minimum of 3 h of fasting). Subjects were categorized into four main groups based on their BMI: underweight (BMI ≤18.5); normal weight (BMI ≤24.9); overweight (BMI >25–29.9); and obese (BMI >30).
Criterion for inclusion was: students between 16 and 21 years willing to participate in the study. Students with any chronic physical or mental illness were excluded from the study. In total, 91 students were excluded, and 1724 selected.
Data analysis was done by Statistical Package for Social Sciences (SPSS) for Windows, Version 20.0 (IBM, Armonk, Newyork, USA). Demographic data were determined by descriptive statistics. All categorical variables including BMI categories, screen usage time categories, PA, and variables related to food were presented as frequencies and percentages. All continuous data, including BMI and screen usage time were presented as mean and standard deviation. Chi-square test or Fisher’s exact test was used to check the association between variables, t-test or ANOVA was used to compare the mean BMI between different variables. Odds ratios (ORs) with their 95% confidence intervals were measured in multivariate analysis. Statistical significance was set at P < 0.05.
The mean age of the study participants was 18 ± 2 years. A comparison of BMI before and after 2 years of the pandemic showed a statistically significant increase after the onset of the pandemic (P = 0.002). There was an increase in the number of overweight (15.7%–16.1%) and obese participants (11.2%–12.9%) and a decrease in the number of underweight participants (16%–14.85%) during the pandemic [Table 2].
Table 2 shows that perceived weight gain was seen in 48%, weight loss in 38%, but only 17.9% participants maintained their weight after 2 years of the pandemic [Figure 1].
Table 3 shows the comparison of ST of the participants before and after 2 years of the COVID-19 pandemic. The average total perceived ST before and during the pandemic was 6.8 ± 2.6 and 9.2 ± 2.2 h/24, respectively. Before pandemic, only 22.7% of the subjects perceived that they had very high ST (≥9). This increased to 68.6% during the pandemic (P = 0.0001).
A comparison of different categories of ST before and after 2 years of the COVID-19 pandemic is also shown in Table 3.
A perceived change (decrease) in the PA was seen after the 2 years (P ≤ 0.001) [Table 4]. The number of inactive subjects increased from 22.6% before pandemic to 37.9% in the pandemic (P < 0.001), while the number of active subjects decreased from 20.7% before pandemic to 11.9% during pandemic (<0.001).
A comparison of the frequency of food intake before and after the outbreak of the pandemic is highlighted in Table 4. Normal food intake (1–3 meals/day) was documented by 81.3% of the subjects before and 67.9% of subjects after the outbreak. There was a perceived significant increase in the frequency of food intake, as before pandemic only 18.7% of the subjects took ≥4 meals/day. This increased to 32.1% in the pandemic (P = 0.001).
Figure 1 provides the information about the quality of food taken by the subjects during the COVID-19 pandemic. There was perceived increase in homemade food (55.2%) and healthy food (37%), whereas no significant change was perceived in the intake of junk food.
Univariate analysis [Table 5] showed that increased BMI was significantly related to increased frequency of food intake (P < 0.001), decreased intake of homemade food (P = 0.023), and decreased intake of healthy food (P = 0.044) (perceived changes).
Multivariate logistic regression analysis [Table 6] revealed that subjects whose PA decreased, whose frequency of food intake rose, intake of junk food increased, and intake of homemade food reduced (perceived changes) had 1.3 times, 1.6 times, 1.2 times, and 1.5 times increased OR of having increased BMI. However, the only factor which showed a significant P value was perceived increased frequency of food intake (P = 0.048). This indicates that increased frequency of food intake is the strongest factor responsible for increased BMI 2 years after the pandemic outbreak in our study population.
This study identified the impact of 2 years of COVID-19 pandemic on various LSB and their effects on BMI of young Saudi adults. There was weight gain in 48% of our young adults. Similar findings were reported by the pooled results of two meta-analysis (including almost 100 studies worldwide), COVID-19 pandemic lockdowns led to body weight gain (P < 0.00001) in a significant number of children and young adults (11.1%–72.4%). The major contributor for increased BMI in young populations was a shift from physical to online education, resulting in increased: ST, sleeping hours, sitting hours, and the number of meals/day, resulting in the increasing trend of overweight and obesity.
This study also aimed to identify the factors responsible for increased BMI in our study population. Almost all educational sectors in KSA shifted from physical to online teaching after the pandemic outbreak, leading to an increase in the ST. Our data also showed an increase in the ST from 6.8 to 9.2 h/24. The highest increase in ST (≥9 h) was for education, i.e., (11.65% vs. 46.2%) before and after the outbreak. Moreover, our participants also indicated a significant increase in their use of the mobile phone ≥9 h after the pandemic (11.9% vs. 34%, respectively). Despite all these results, we were not able to find any relation or association between excessive ST and weight gain. Because of the expected negative effects of excessive ST on physical and mental health of the students, some governments have ordered a restriction on the number of online classes/day. However, educators appreciate the enormous educational benefits that technology can offer to students at this difficult time of pandemic. Moreover, a systematic review of “the screen time literature and educational policy and practice during COVID-19” concluded that the strengths and benefits of ST should be utilized in a purposeful way ensuring that any associated risks are minimized during these exceptional pandemic times. Negative effects of ST on BMI are usually mediated when ST displaces the time for PA, sleep, and social interaction. Therefore, these effects could be avoided when educational ST during the pandemic is not allowed to displace these important activities.
The results of this study also showed a significant reduction in the PA of the students, which was positively but insignificantly associated with increased BMI. Similar findings were reported in a study done in the initial months of COVID 19 lockdown (March–May 2020) on 10 121 participants from 67 countries, in which 31.25% of the young inactive population reported weight gain. Although our study was conducted almost 2 years after the onset of the pandemic, the number of inactive young adults had risen to 37.9%, while the number of active subjects had fallen to 11.9%, indicating that the unhealthy lifestyles adopted during the initial months of pandemic, were still in practice resulting in weight gain and obesity in the young adults.
This study also documented the changes in the eating habits of the young adults and their effects on BMI. It was observed that during the pandemic, there was an increase in homemade food (55.2%). The study results of Randah and Husain et al., also revealed a rise in home cooking during the pandemic. This may be due to the increase in the time spent at home as most people worked from home during the pandemic. Moreover, 37% of our study participants reported an increased intake of healthy food (including fruits, vegetables, milk, nuts, fish, lean meat, and pulses), during the pandemic. Our results contradict the findings of most other studies in which more fast food, sweet beverages, savory snacks, sugary drinks, and deep-fried food were reported to have been consumed during the pandemic.[33-36] This dissimilarity may be because our study population included students from the health science colleges who appreciated the fact that eating healthy food during the pandemic could boost their immune systems and provide protection against the COVID-19 infection. The univariate analysis of this study indicated that those subjects whose intake of homemade and healthy food fell showed weight gain and had 1.2 and 1.5 times increased OR of having increased BMI. This is in accord with the fact that a high intake of fats, sugars, and junk food can lead to weight gain and various other health issues.
The most important finding of the current study was that the increased number of meals/day (≥4), the strongest risk factor associated with increased BMI, could lead to 1.6 times increased OR of weight gain. There was a significant rise in the frequency of food intake. Before pandemic only 18.7% of our subjects had ≥4 meals/day, but this increased to 32.1% after pandemic outbreak. Increased consumption of food during the pandemic has also been reported by various other studies. Randha pointed out that during the pandemic, 58% of their study participants reported eating more; 86.0% of the respondents of the Ismail et al., study reported that they were unable to control their diet during the pandemic. This could be the result of the increased period of stay time at home, enhanced exposure to food because of boredom, having more time available to cook and eat, emotional eating, and negative moods that result in comfort eating. Increased frequency of food intake, together with decreased PA might have affected the energy balance in our young adults because when energy intake exceeds energy expenditure, a state of positive energy balance occurs resulting in increased BMI. Wang et al., estimated that excessive weight gain can be prevented in children and adolescents by reducing positive energy balance by about 150 kcal/day. Consequently, young adults should be motivated to increase their PA, adopt healthy eating habits, and keep a check on their daily caloric intake. These measures can help to minimize the impact of COVID-19 pandemic on BMI and LSB of young adults.
The data shows that stricter measures/lockdowns and curfews imposed in the first 4 months of the pandemic (March 2020–June 2020) compelled people to remain at home. During this period, there was a drastic negative shift in the LSB and eating habits in populations worldwide. However, when most of the restrictions were lifted after June 2020, and parks and shopping malls reopened, and most business and office activities resumed, physical classes for students did not resume. Most educational institutions continued online teaching, as a result of which the unhealthy lifestyles adopted during the initial periods of pandemic remained and ultimately turned into habits for young adults, and still remain 2 years on in the pandemic.
There was a perceived significant change in the lifestyle and behavior of young Saudi students during the pandemic. This included weight gain (48% of the population), increased screen usage time, decreased PA, and increased food intake (≥4 meals/day). Although there was a perceived increase in the consumption of homemade and healthy food during the pandemic, no significant change was seen in the intake of junk food before and in the pandemic. Reduced intake of homemade food, increased intake of junk food, and increased number of the meals/day were significantly related with increased BMI. However, perceived rise in the number of meals/day (≥4) was the strongest risk factor associated with increased BMI, that could lead to 1.6 times increased OR of weight gain.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors are thankful to the volunteer participants of the study.
1. Paules CI, Marston HD, Fauci AS Coronavirus infections-more than just the common cold JAMA 2020 23 126 34
2. Mahase E China coronavirus:WHO declares international emergency as death toll exceeds 200 BMJ 2020 368 m408
3. Listings of WHO's Response to COVID-19 2020 Available from:https://www.who.int/news-room/detail/29-06-2020-covidtimeline
Last accessed on 2022 Mar 10
4. Ministry of Health, Saudi Arabia. MOH Reports First Case of Coronavirus Infection;Published, 2020 Available from:https://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/News-2020-03-02-002.aspx
Last accessed on 2021 Mar 11
5. Yezli S, Khan A COVID-19 social distancing in the Kingdom of Saudi Arabia:Bold measures in the face of political, economic, social and religious challenges Travel Med Infect Dis 2020 37 101692
6. Algaissi AA, Alharbi NK, Hassanain M, Hashem AM Preparedness and response to COVID-19 in Saudi Arabia:Building on MERS experience J Infect Public Health 2020 13 834 8
7. Alshammari TM, Altebainawi AF, Alenzi KA Importance of early precautionary actions in avoiding the spread of COVID-19:Saudi Arabia as an Example Saudi Pharm J 2020 28 898 902
8. An Approval Issued to Fully Lift the Curfew from 06 am on Sunday, Ban on Umrah, Visit, Int'l Flights to Continue The Official Saudi Press Agency 2020 Available from:https://www.spa.gov.sa/viewfullstory.php?lang=en&newsid=2100088
Last accessed on 2022 Jan 10
9. World Health Organization The Current COVID-19 Situation in Saudi Arabia Available from:https://www.who.int/countries/sau
Last accessed on 2022 Feb 15
10. World Health Organization COVID-19 Public Health Emergency of International Concern (PHEIC) Global Research and Innovation Forum Available from:https://www.who.int/publications/m/item/covid-19-public-health-emergency-of-international-concern-(pheic)-global-research-and-innovation-forum
Last accessed on 2022 Feb 10
11. McCloskey B, Zumla A, Ippolito G, Blumberg L, Arbon P, Cicero A, et al. Mass gathering events and reducing further global spread of COVID-19:A political and public health dilemma Lancet 2020 395 1096 9
12. Alrashed S, Min-Allah N, Saxena A, Ali I, Mehmood R Impact of lockdowns on the spread of COVID-19 in Saudi Arabia Inform Med Unlocked 2020 20 100420
13. Zheng C, Huang WY, Sheridan S, Sit CH, Chen XK, Wong SH COVID-19 pandemic brings a sedentary lifestyle in young adults:A cross-sectional and longitudinal study Int J Environ Res Public Health 2020 17 6035
14. Jalal SM, Beth MR, Al-Hassan HJ, Alshealah NM Body mass index, practice of physical activity and lifestyle of students during COVID-19 lockdown J Multidiscip Healthc 2021 14 1901 10
15. Rawat D, Dixit V, Gulati S, Gulati S, Gulati A Impact of COVID-19 outbreak on lifestyle behaviour:A review of studies published in India Diabetes Metab Syndr 2021 15 331 6
16. Scapaticci S, Neri CR, Marseglia GL, Staiano A, Chiarelli F, Verduci E The impact of the COVID-19 pandemic on lifestyle behaviors in children and adolescents:An international overview Ital J Pediatr 2022 48 22
17. de Faria Coelho-Ravagnani C, Corgosinho FC, Sanches FF, Prado CM, Laviano A, Mota JF Dietary recommendations during the COVID-19 pandemic Nutr Rev 2021 79 382 93
18. World Health Organization Rolling Updates on Coronavirus Disease (COVID-19). World Health Organization 2020 Available from:https://www.who.int/emergencies/diseases/novel-coronavirus-2019
Last accessed on 2022 Feb 15
19. Woolford SJ, Sidell M, Li X, Else V, Young DR, Resnicow K, et al. Changes in body mass index among children and adolescents during the COVID-19 pandemic JAMA 2021 326 1434 6
20. Oraif I, Elyas T The impact of COVID-19 on learning:Investigating EFL learners'engagement in online courses in Saudi Arabia Educ Sci 2021 11 99 108
21. Izzo L, Santonastaso A, Cotticelli G, Federico A, Pacifico S, Castaldo L, et al. An Italian survey on dietary habits and changes during the COVID-19 lockdown Nutrients 2021 13 1197
22. Rafique N, Al-Asoom LI, Alsunni AA, Saudagar FN, Almulhim L, Alkaltham G Effects of mobile use on subjective sleep quality Nat Sci Sleep 2020 12 357 64
23. Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire:12-country reliability and validity Med Sci Sports Exerc 2003 35 1381 95
24. Rafique N, Al-Sheikh MH Prevalence of primary dysmenorrhea and its relationship with body mass index J Obstet Gynaecol Res 2018 44 1773 8
25. Bakaloudi DR, Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Chourdakis M Impact of the first COVID-19 lockdown on body weight:A combined systematic review and a meta-analysis Clin Nutr 2021 36 227 39
26. Chang TH, Chen YC, Chen WY, Chen CY, Hsu WY, Chou Y, et al. Weight gain associated with COVID-19 lockdown in children and adolescents:A systematic review and meta-analysis Nutrients 2021 13 3668
27. Nagata JM, Abdel Magid HS, Pettee Gabriel K Screen time for children and adolescents during the coronavirus disease 2019 pandemic Obesity (Silver Spring) 2020 28 1582 3
28. Wiederhold BK Children's screen time during the COVID-19 pandemic:Boundaries and etiquette Cyberpsychol Behav Soc Netw 2020 23 359 60
29. Zahedi S, Jaffer R, Iyer A A systematic review of screen-time literature to inform educational policy and practice during COVID-19 Int J Educ Res Open 2021 2 100094
30. Dumith SC, Garcia LM, da Silva KS, Menezes AM, Hallal PC Predictors and health consequences of screen-time change during adolescence-1993 Pelotas (Brazil) birth cohort study J Adolesc Health 2012 51 S16 21
31. Urzeala C, Duclos M, Chris Ugbolue U, Bota A, Berthon M, Kulik K, et al. COVID-19 lockdown consequences on body mass index and perceived fragility related to physical activity:A worldwide cohort study Health Expect 2022 25 522 31
32. Hussain W, Ashkanani F Does COVID-19 change dietary habits and lifestyles behaviours in Kuwait Health Prev Med 2020 13 1 5
33. Randah MA Changes in nutritional habits and lifestyles during the COVID-19 lockdown period in Saudi Arabia Curr Res Nutr Food Sci 2021 12 162 78
34. Ismail LC, Osaili TM, Mohamad MN, Al Marzouqi A, Jarrar AH, Abu Jamous DO, et al. Eating habits and lifestyle during COVID-19 lockdown in the United Arab Emirates:A cross-sectional study Nutrients 2020 12 3314
35. Al-Musharaf S Prevalence and predictors of emotional eating among healthy young Saudi women during the COVID-19 pandemic Nutrients 2020 12 2923
36. Di Renzo L, Gualtieri P, Cinelli G, Bigioni G, Soldati L, Attinà A, et al. Psychological aspects and eating habits during COVID-19 home confinement:Results of EHLC-COVID-19 Italian Online Survey Nutrients 2020 12 2152
37. Chaari A, Bendriss G, Zakaria D, McVeigh C Importance of dietary changes during the coronavirus pandemic:How to upgrade your immune response Front Public Health 2020 8 476
38. Hill JO, Commerford R Physical activity, fat balance, and energy balance Int J Sport Nutr 1996 6 80 92
39. Wang YC, Gortmaker SL, Sobol AM, Kuntz KM Estimating the energy gap among US children:A counterfactual approach Pediatrics 2006 118 e1721 33