**4. Discussion**

This population-based, cross-sectional study assessed eating habits and lifestyle behaviors among residences of the UAE, via an online survey during the COVID-19 pandemic between April and May 2020. The results indicate that the COVID-19 pandemic and the subsequent lockdown resulted in weight gain in about one-third of the respondents with changes in important and highly modifiable dietary and lifestyle behaviors that are considered essential for optimal somatic and psychological health. Specifically, participants also reported an increase in the number of meals consumed per day and a reduction in the percentage of skipping meals particularly breakfast during the pandemic. The present study also indicated that dietary habits were distanced from the Mediterranean diet principles and closer to "unhealthy" dietary patterns, characterized as high in energy but with low nutrient density; viewed as a detrimental combination for immune status. Although more homemade meals were prepared, a factor associated with healthy weight status, at the same time more non-nutritious foods were chosen, as well as being more frequently consumed (since an increase was also seen among frequency of meals per day). These data, therefore, are informative on the potential alterations of food prepared and consumed although at home.

In agreemen<sup>t</sup> with our study, the results from Kuwait, United States, Italy and France revealed an increase in caloric intake and indicated weight gain during the current COVID-19 home confinement [10,35–37]. Data from Kuwait, a close Gulf country to UAE, showed a significant increase in weight of respondents during the quarantine and the weight gain was 4.5 times higher among those consuming unhealthy diets [38]. The actual weight increase was not assessed in this study considering the short time interval of COVID-19 lockdown, however, the large percentage of the population that reported an increase in weight can be used as a proxy pertaining to changes in eating behavior and activity level. It has been suggested that the negative alterations in eating behaviors could be due to anxiety or boredom [39], lack of motivation to maintain healthy habits [40], or reduced availability of goods and limited access to food due to restricted store opening hours [41]. The prevalence of overweight and obesity in the UAE even before COVID-19 was high and has increased over time [42]. It is estimated that over one third of the population in the UAE is living with obesity with higher rates among females [43]. Thus, extra efforts are needed to reduce the burden of obesity and its risk factors especially during the COVID-19 pandemic.

Over half of the surveyed participants in this study did not consume fruits daily and about one third did not consume vegetables and dairy products on daily basis. Instead, almost half of the same population reported consuming sweets and desserts at least once per day and over one third consumed salty snacks daily. This transition towards a Westernized diet in the UAE was reported in 1998, where the consumption of fresh fruit and vegetables and of milk and dairy products was found low [32]. Moreover, in 2003, 77.5% of males and 75.7% of females in the UAE had less than five servings of fruit and vegetables per day [44]. Likewise, a recent study among Emirati adolescents revealed that only 28% of them met the recommended daily fruit and vegetable intake [45]. This is concerning especially as fruits and vegetables are an important source of fiber, vitamins, minerals, and antioxidants. Diets rich in antioxidants (such as the Mediterranean diet and Dietary Approaches to Stop Hypertension (DASH) diet) are vascular protective. The Mediterranean diet is recognized as an anti-inflammatory dietary pattern, focusing on high consumption of plant foods, low red meat and dairy and moderate consumption of monounsaturated fat sources such as olive oil [46]. Evidence suggests that the Mediterranean diet is associated with better health status, lower risk of chronic disease and inflammation as well as increased immunity [47–49]. The Mediterranean diet is not only a healthy dietary pattern, but is also a sustainable diet that has a lower environmental impact than the typical Western diet [50]. Moreover, mounting evidence indicates that the Mediterranean diet has a favorable effect on diseases related to chronic inflammation, including visceral obesity, type 2 diabetes mellitus and the metabolic syndrome [51–55]. Knowing that the prevalence of cardiovascular disease incidence is high in the UAE (40%) [56] and rates of dyslipidemia are strikingly elevated (72.5%) [57] makes it imperative that diets such as the Mediterranean diet should be encouraged to prevent the potentially negative e ffect of quarantine on dietary habits and overall health [41].

Due to the increase in obesogenic behaviors related to the COVID-19 pandemic, two dietary patterns were revealed among the studied population, named the "Western-type diet" and the "Free Sugars diet". These patterns indicate unhealthy eating behaviors during the period of the pandemic. This is in agreemen<sup>t</sup> with previous studies reporting a transformation of the diet in Eastern Mediterranean countries from a traditional Mediterranean diet to a more Westernized diet which is high in energy, saturated fat, cholesterol, salt, and refined carbohydrates, and low in fruits, vegetables, fiber, and polyunsaturated fats [25,58–60]. Therefore, current dietary behaviors in the UAE may not be e ffective against the COVID-19 virus since it can adversely a ffect the immune system response among other health factors. Furthermore, it is unclear whether these dietary patterns were due to the lockdown that followed the COVID-19 outbreak; however, the implications can be detrimental considering an adequate supply of macro- and micro-nutrients are essential for optimal immune function and response [11,61].

Amidst these passive changes in food behavior, some beneficial aspects emerged from this study, such as a significant increase in home-made food preparations, regular breakfast consumption and lower intakes of fast foods. Similarly, a consumer online based survey conducted by Ipsos across the Middle East and North Africa (MENA) region revealed that 57% out of the 5000 consumers who took part in the survey were preparing their own meals, and 79% were eating less often at restaurants [62].

Among the surveyed participants, more than one third reported a non-engagemen<sup>t</sup> in any physical activity during coronavirus pandemic lockdown. This was mostly observed among males in this study, with a simultaneously greater likelihood of increased sedentary time, compared to females. The findings of this questionnaire are in accordance with other studies indicating that the current COVID-19 pandemic had a dramatic impact on lifestyle behaviors globally, including diminished engagemen<sup>t</sup> in sports and physical activity in general [63–65]. Moreover, the "E ffects of home Confinement on multiple Lifestyle Behaviours during the COVID-19 outbreak (ECLB-COVID-19)" international survey revealed that the COVID-19 pandemic had a negative e ffect on all levels of physical activity (vigorous, moderate, walking and overall) and increased daily sedentary time by more than 28% [14]. Similarly, in the current study the proportion of participants who spent more than five hours per day on screens for entertainment increased by 23.3%. Together with the unhealthy diet,

the reduction of physical activity would not only contribute to weight gain, but also to an increase in cardiovascular risk during quarantine. Thus, awareness about the importance of regular physical activity and its benefits on overall health is necessary during such times [66,67]. It is also important to identify groups at a higher risk of unhealthy lifestyle behaviors during the COVID-19 pandemic to design interventions targeted towards these groups.

During the COVID-19 pandemic higher levels of anxiety, stress and depression have been observed among individuals [68–70]. In this study, the percentage of participants experiencing exhaustion, irritability, and tension more often during the coronavirus pandemic increased significantly. Sleep was mostly a ffected in females and needs to be further evaluated since it is linked with multiple endocrine functions, as well risk for obesity and depression. The risk of obesity is underlined by the significant increase in daily meal frequency among participants over 36 years with the majority being female. Also, despite WHO recommendations to minimize listening to unreliable news that could cause anxiety or distress and to seek information only from trusted sources [71], over two thirds of participants in this survey used social media as a main source for health updates. Studies have shown the negative and harmful e ffect of misinformation overload "infodemic" on the mental health of individuals [72,73]. Moreover, stress and anxiety could disrupt sleep quality during the night and energy levels during the day. Results of the current survey indicated a 10.8% increase in participants reporting poor sleep quality and 26.2% increase in those feeling lazy during the pandemic. Xiao and his co-workers found a significant negative correlation between anxiety levels and sleep quality and suggested the use of telepsychiatry consultation as an important therapeutic strategy [74]. The use of telehealth has been shown to be useful in providing support to patients and is appropriate for the delivery of mental health services [75]. Additionally, the Mediterranean diet does not only have a protective e ffect on the risk of cardiovascular diseases and certain types of cancer [54,76], but also an increased compliance with it could be associated with lesser mental distress, better sleep quality, and higher scoring for self-perceived health status [77–79].

It is acknowledged that this study has limitations related to the use of self-reported questionnaire, snowball sampling method and the cross-sectional study design. The study information was acquired after lockdown, and although comparisons are critical to be made in order to draw inferences, no conclusive remarks can be drawn. Results stratified by sex should be interpreted with caution, since the majority of the participants were females. Furthermore, in order to minimize selection bias that may arise with snowball sampling (including interrelated-similar individuals), each individual could refer a maximum of three people who were not family members, and only one individual per age group (young adults, older adults, elderly) was enrolled from a household. Moreover, the change in dietary pattern was not assessed in this study, since data on food frequency were only obtained during COVID-19 pandemic, although these can be used as a reference for further studies performed, in these uncertain times. This was done to reduce the probability of including recall bias, since the participants had to respond to multiple questions on food frequency and quantity during COVID-19 lockdown and for a prolonged period prior to that. Also, the presence of obesity and eating disorders were not determined in the study, nor was information on infection with COVID-19 reported. Such analysis would require a longer questionnaire, hence may have decreased the compliance and response rate, but also would have required a larger sample size based on the prevalence of all factors to acquire adequate study power. Another potential limitation of the study was that respondents were mostly females. Although this is usual in online questionnaires [80], it should be considered when generalizing the results. However, using an online survey facilitated data collection during COVID-19 pandemic from all seven emirates. It also guaranteed the anonymity of the participants, thus reducing the social desirability bias. The strengths of this research include data collection timing one month after lockdown which minimizes memory failure for previous habits. In addition, the survey provided was in multiple languages in a multilingual environment like UAE.

The results of the study indicate that individuals in the UAE experienced negative lifestyle changes, unbalanced food choices, a reduction in physical activity, and psychological problems during the COVID-19 pandemic. Although quarantine is an essential measure to protect public health and control the transmission of the virus, these findings should be taken into consideration for future regulations in the UAE.

**Supplementary Materials:** The following are available online at http://www.mdpi.com/2072-6643/12/11/3314/s1, Eating Habits and Lifestyle during COVID-19 Lockdown in the United Arab Emirates: A Cross-Sectional Study.

**Author Contributions:** Conceptualization, L.C.I., T.M.O. and A.S.A.D.; methodology, L.C.I., T.M.O., A.S.A.D., M.N.M., M.H., and S.T.S.; validation, L.C.I., T.M.O., A.S.A.D., M.N.M. and E.M.; formal analysis, L.C.I., M.N.M., S.T.S., E.M. and H.H.; investigation, L.C.I., T.M.O., M.N.M., A.S.A.D., A.A.M., A.H.J., D.O.A.J., H.I.A., H.A.S., H.H., L.M.R.A., L.S., M.H., R.R.S.O., and S.T.S.; writing—original draft preparation, L.C.I., M.N.M., A.S.A.D. and S.T.S.; writing—review and editing, L.C.I., T.M.O., M.N.M., A.S.A.D., A.A.M., A.H.J., D.O.A.J., E.M.,H.I.A., H.A.S., H.H., L.M.R.A., L.S., M.H., R.R.S.O., and S.T.S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
