COVID-19 and Lifestyle Changes: A Cross-Sectional Study at Primary Care Settings in Dubai Open Access

The first report on COVID-19 was in Wuhan, Hubei Province, China on December 31, 2019. COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020 [1]. A large part of the world population was in quarantine by the beginning of April 2020. Lockdown in most countries lasted till the end of April 2020. To prevent the spread of a new infectious disease, social distancing or lockdown is an efficient tool to be used [2].

In this study, we would like to understand the effects of those measures on dietary and lifestyle behaviors. Boosting the immune system to fight against infections requires maintaining a healthy lifestyle, which consists of a balanced diet rich in vitamins and minerals, adequate sleep, and exercise [3]. While excess weight and lack of physical activity can compromise the immune system and promote the inflammatory process by the adipocytokines released by the fatty tissue [4]. A sedentary lifestyle and a poor diet lacking essential nutrients both can suppress the production and normal activity of the immune cells and antibodies [5].

The definition of health by WHO is not only about the absence of disease, it is a comprehensive state of mental, physical, and social well-being [6]. Lifestyle is a combination of habits, behaviors, and living conditions of a person or group of people that together form the mode of living. A healthy lifestyle is about choosing beneficial health behaviors for today and the future. It consists of eating and exercising right, taking adequate time for rest, and good dealing with stress [7]. A healthy lifestyle is very important to release stress, reduce the incidence and the impact of health problems, and improve recovery.

Maintaining a healthy lifestyle is an important aspect for Dubai residents; an example is the Dubai Fitness Challenge launched in 2017. This annual initiative aims to make Dubai one of the most active cities in the world. It is about encouraging Dubai residents to complete 30 min of continuous exercise per day for 30 days. Dubai Health Authority (DHA) launched the Lifestyle Clinics in 2018; it provides preventive medicine services for persons at risk of chronic illnesses like diabetes and cardiovascular disease. It also provides prevention programs to persons with risk factors, such as being overweight and obese, lacking in physical activity, consuming unhealthy food, having a family history of diabetes, suffering from psychological stress, and being a smoker.

Since the beginning of the COVID-19 pandemic, certain restrictions (i.e., lockdown, isolation) were made to properly contain the transmission of the disease. These modifications led to changes in the lifestyle habits of all populations, including COVID-19 patients, healthcare workers, and the general population, in terms of sleeping habits [8‒10], smoking habits [11], dietary habits [12], and physical activity [12]. However, data on lifestyle changes during the COVID-19 pandemic among patients presenting at primary healthcare settings are scarce.

Therefore, we conducted this research to assess the lifestyle changes that occurred during the COVID-19 pandemic in the patients attending primary health care centers in Dubai. The objectives of this study were to estimate the change in sleeping habits, physical activities and exercise habits, dietary habits, and tobacco smoking habits of patients attending primary health care centers in Dubai during the COVID-19 Pandemic.

This study was conducted among patients attending Primary Health Care Centers in DHA in Dubai. Dubai is the second largest emirate of the Seven United Arab Emirates, with the biggest population of 3,499,535 inhabitants as of 2022 [13]. The Primary Health Care Centers included in the study were Al Barsha Health Center, Al Safa Health Center, Nad Al Hammar Health Center, and Al Mizhar Health Center. The study was approved by the Dubai Scientific Research Ethics Committee (DSREC) before the conduct of the study.

This was a cross-sectional study conducted among patients (>18 years of age) attending primary health care centers in DHA. The study was conducted during the period from November 2020 to August 2021. DHA has 12 primary health care centers divided into two regions (Bur Dubai and Deira), seven centers in Bur Dubai, and five Centers in Deira. We randomly selected two clinics from each region.

During the study period, presenting patients at our centers were informed about the study during their waiting time, and participants who agreed to participate were asked to fill out an online questionnaire on an iPad provided by the researchers. Then, non-probability, convenience sampling was used to recruit the required sample size during the study period. Eligible participants filled out an informed consent at the start of filling out the study questionnaire. The study inclusion criteria are patients who follow in primary health care centers in Dubai health authority of all nationalities and genders with ages above 18 years old. Patients were excluded if they could not fill out the questionnaire through the iPad, if they were less than 18 years of age, and if they had neurological problems that prevented them from understanding and filling out the study questionnaire. A total number of 385 patients were approached for the study.

This study used an online, self-reported structured questionnaire divided into four sections. The first section included patients’ sociodemographic characteristics such as age, gender, current employment, weight, and height. The second and third section included questions relating to the dietary habit changes following the COVID-19 pandemic through the use of the Mediterranean Diet Adherence Screener. The final section included questions about lifestyle habits in terms of cigarette smoking, sleeping habits, and sports activities before and during the pandemic. The questions included were added from the previously validated questionnaire of Di Renzo et al. [14]. This questionnaire was originally published and used in an Italian study. Therefore, we translated their questionnaire into its Arabic version. The translated version underwent linguistic and cultural validation. Then our questionnaire was approved by DSREC before the conduct of the study. As for dietary habits, it used the Mediterranean Diet Adherence Screener (MEDAS) which was first used in the PREDIMED Trial and it originally contains 14 questions related to the daily consumption of different types of food (i.e., fat, oil, vegetables, etc.). Additionally, one question was added to reflect the dietary changes that occurred before and during the COVID-19 pandemic: “did you change the number of meals during this period?” Noteworthy, patients needed to recall their lifestyle habits before the pandemic to be able to answer the items provided in the questionnaire. Additionally, care was taken to ensure that the questionnaire was not too long to allow participants to fill it in their waiting time and they were given a choice to choose either an Arabic or English questionnaire, whichever was easier for them.

We calculated the sample size based on the formula proposed by Charan et al. [15]. In order to find a 27.5% change in sleeping habits (before vs. during the COVID-19 pandemic) among patients recruited from primary care settings, the minimum sample size required to detect such a change with 80% power and 0.05 alpha level was 306 patients. However, we included patients who presented at our centers during the study center which surpassed the required sample size and reached 385 patients. This number increased our power to detect even smaller changes which add to the strengths of our study.

Collected data were entered into the Excel sheet and then imported to the Statistical Package for Social Sciences (SPSS-version 28) for data analysis. The accuracy of the data was checked before performing any statistical analysis. Data collected at baseline are presented as numbers (percentages) for dichotomous and categorical variables, and as mean (standard deviation) for continuous variables. Since outcomes (sleeping, smoking, and sporting habits) data are categorical (including >2 levels), we used the McNemar-Bowker test to determine the difference between multiple categories of each outcome across 2 timepoints (before vs. during COVID-19). Statistical significance was determined by a p value of less than 0.05.

A total of 385 patients completed the questionnaire and were included in the final analysis. The baseline sociodemographic characteristics of included patients are summarized in Table 1. The majority of respondents were females (80.7%), in the 18–30 years age category (40.5%), who go to work as usual (35.3%). The mean weight and height of patients were 66.25 (SD = 14.35) kg and 159.99 (SD = 17.95), respectively.

We noted statistically significant differences in sleeping habits before and during the COVID-19 pandemic (Table 2). Overall, the COVID-19 pandemic was associated with a negative trend in sleeping habits among included patients (p = 0.004). For instance, the rate of patients who reported sleeping less than 7 h a day increased during the pandemic as compared to before (48.57% vs. 39.74%). Consistently, the rate of patients who slept 7–9 h a day was reduced following the pandemic (52.72% vs. 46.75%).

A similar trend was observed in male and female strata. Among females (N = 311), we observed a negative trend in sleeping during the COVID-19 pandemic when compared to before (p = 0.025). For example, the rate of patients who slept <7 h a day increased during the COVID-19 pandemic as compared to before (49.19% vs. 40.83%), while the rate of patients who reported 7–9 h of sleep per day was reduced during the pandemic as compared to before (51.12% vs. 45.65%). Although we observed a difference in sleeping habits among male patients (N = 74), it failed to reach statistical significance (p = 0.121) (Table 2).

The changes in smoking habits before and during the COVID-19 pandemic are illustrated in Table 3. Overall, no significant change in smoking habits was noted between the two time periods (p = 0.306). However, it should be noted that the majority of patients reported being non-smokers both before (92.98%) and during (92.46%) the pandemic. Upon stratifying smoking habits based on gender, no significant differences were noted among male (p = 0.503) and female patients (p = 0.391), respectively (Table 3).

The changes in playing sports between the time of COVID-19 and before are highlighted in Table 4. The majority of patients did not play any sports before the pandemic (61.81%); however, during the pandemic, this rate was significantly reduced (41.81%; p = 0.0001). Overall, there was a positive trend in the habit of playing sports during the pandemic as compared to before. For instance, the rate of patients who played sports 3–4 times increased during the pandemic as compared to before (25.45% vs. 16.88%), respectively. This was consistent among those who played 1–2 and >5 times.

This finding was consistent among female and male patients who reported a positive trend in the frequency of playing sports during the COVID-19 pandemic as compared to before. This difference between the time of COVID-19 and before was statistically significant among female (p = 0.0001) and male (p = 0.0005) patients, respectively.

The changes in the number of meals eaten per day following the pandemic are illustrated in Figure 1. The majority of patients reported no change in the number of daily meals (193/385, 50.13%), followed by skipping 1 or more meals (63/385, 16.36%), adding 1 or more snacks between meals (48/385, 12.46%), and eating out of the meals (30/385, 7.79%), respectively.

In order to effectively deal with the COVID-19 pandemic, the general population, COVID-19 patients, patients with other diseases, and healthcare workers had to adapt to certain lifestyle modifications. In this paper, we discuss the changes in sleeping, sporting, smoking, and dietary habits among patients who presented at our centers in Dubai during the time of the pandemic. Also, we were interested in studying their changes based on gender, as a potential effect modifier.

Sleeping troubles have been perceived as a major concern following the COVID-19 pandemic. In a systematic review conducted across 36 articles, the prevalence rate of sleeping problems ranged from 17.65% to as high as 81% among the general population [10]. In another meta-analysis of 44 studies (54,231 participants), 35.7% of the overall included population reported having sleeping problems, which was highest among COVID-19 patients (74.8%) followed by healthcare workers (36%), and the general population (32.3%), respectively [9]. Additionally, a recent report indicated that such problems are slightly more prevalent among males (27% of 45,718 participants) than females (24% of 67,722 participants) [8].

Nonetheless, none of these studies reported changes in sleeping habits among patients presenting to primary healthcare settings. Our study found significant changes in the sleeping habits in the overall included population, revealing a negative trend in the number of sleeping hours reflected by the increase in the rate of patients who reported sleeping <7 h and the reduction in the rate of patients reporting 7–9 h of sleep. However, our findings are inconsistent with the literature. A recent study conducted among Saudi women (297 participants) reported a significant increase in the number of sleeping hours during the pandemic as compared to before (mean = 7.8 vs. 5.1 h, p < 0.001). This difference could be related to the heterogeneity among studied populations, as in our study, we included patients in primary healthcare settings, while the previous study was conducted among the general population through the internet [16]. Moreover, in our study, we noted that such differences in sleeping habits remained statistically significant among females; however, this difference did not reach statistical significance among male peers. A major concern about this observation is the small sample size in the male subgroup (74 patients) which lacked enough power to detect a significant change in sleeping habits before and during the pandemic.

In terms of smoking habits, the majority of our patients did not smoke both before (92.98%) and during (92.46%) the pandemic. No significant change in the number of smoked cigarettes per day was noted in the overall population. Additionally, gender did not play any modifying effect on the reported observation, revealing nonsignificant changes in smoking habits during the pandemic as compared to before. This observation is similar to that of Bommele et al. [11], who included 957 Dutch current smokers, of whom 67% reported no significant change in their smoking habits, while 18.9% and 14.1% reported increased and decreased smoking tendencies, respectively.

Our study highlighted a positive change in the tendency of playing sports during the pandemic as compared to before. This was supported by the reduction in the rate of patients who were not involved in any sporting activities (−67.64% change) and the increase in the rate of patients playing sports 1–2 times (+71% change), 3–4 times (+66.32% change), and >5 times per week (+42.31% change), respectively. These positive changes in sporting habits were maintained across both male and female patients (p < 0.001). In a study conducted among 6,140 Australian adults, a significant reduction in the number of sporting sessions played (every 2 weeks) was reported during the pandemic as compared to before (−30.4% change) [17]. This change was more pronounced among males (−34.5% change) as compared to females (−23.5% change). However, it should be noted that the latter study included physically active individuals who had sporting membership, and this could account for the difference observed between our findings.

The changes in dietary habits, in terms of daily meals, were assessed in our study, where the majority of patients reported no change (50.12%), followed by skipping 1 or more meals (16.36%), and adding one or more meals (12.46%), respectively. These results signify that the majority of the people attending primary care did not change their eating habits. Our findings are quite similar to that of Canello et al. [12] who reported no changes in food intake in 43% (out of 490 adult healthy individuals) of the population.

Although our study provides novel insights into lifestyle changes following the COVID-19 pandemic among patients presenting at primary healthcare settings in Dubai, there are several drawbacks that limit the interpretation and generalizability of our findings. First, this is not a longitudinal study since patients were asked to recall their lifestyle habits before the start of the pandemic during the time of the interview. Thus, we were not able to account for recall bias, which is the major limitation of our study. Second, the small sample of male participants could not have allowed us to detect statistically significant differences in sleeping and smoking habits. Therefore, prospectively conducted studies with longer follow-up periods and larger sample sizes are still needed to confirm our observations.

Our data suggest that lifestyle habits of patients presenting at primary healthcare settings in Dubai had changed during the COVID-19 pandemic as compared to before. Although sleeping habits were negatively changed, patients adopted a positive sporting habit accompanied by no change in smoking habits during the pandemic. Additionally, our data suggest no substantial change in dietary habits between the pandemic and before. However, more studies are still needed to provide more evidence in this regard.

We would like to express our very great appreciation to Dr. Shamsa Al Suawidi (Head of Professional Development Office, Primary Health Care Sector, DHA) and Dr. Ibtehal Makki (our colleague from Primary Health Centers Department, Primary Health Care Sector, DHA), for their valuable and constructive suggestions during the planning and development of this research work. Their willingness to give their own time so generously has been very much appreciated.

The proposal of this study was approved by DSREC, DHA, Dubai, United Arab Emirates, Reference number: DSREC-11/2020_05, Dated DEC 17, 2020. Permission from the Primary Healthcare Centers was also obtained to conduct this study among their patients. Online electronic consent was obtained from all participants after the DSREC approved obtaining the online consent.

None of the authors has any conflicts of interest.

The authors declare that they have no funding or financial support.

Alia MHD Waleed Al Sakkal, Alia Juma AlFalasi, Mouza Khalifa Mohd Saeed, AlMehairi, and Heba Ahmed Reda Hassan Mohamed: wrote the literature review and collected the data. Jawad Ahmad Khan and Imad Saaid Dabbous: collected the data. Alia MHD Waleed Al Sakkal and Heba Ahmed Reda Hassan Mohamed: performed data analysis, conceived, and designed the analysis. Alia MHD Waleed Al Sakkal, Alia Juma AlFalasi, and Mouza Khalifa Mohd Saeed AlMehairi: revised and edited the paper.

The data that support the findings of this study are not publicly available due to privacy and security reasons but are available from the corresponding author.