Changes in the Lifestyle in Spanish University Population during the Confinement for COVID-19

(1) Background: The aim of this study was to evaluate the influence of the lockdown due to COVID-19 pandemic, eating and physical activity behaviours, in a University population. A healthy diet such as the Mediterranean Diet (MD) pattern, rich in fruit and vegetables can prevent degenerative diseases such as obesity, diabetes, cardiovascular diseases, etc. (2) Methods: We conducted a cross-sectional study, data were collected by an anonymous online questionnaire. Participants completed a survey consisting of 3 sections: sociodemographic data;dietary and physical activity behaviour;questionnaire of the Mediterranean Diet (MEDAS-14) and the emotional eater questionnaire Garaulet (EEQ). (3) Results: A total of 168 participants completed the questionnaire 66.7% women, from Spain 79.2%, 76.8% students, living in family home 76.2% and in normal weight 66.1% . Our population did the grocery 1 or less per week (76.8%);decreased or stay the same the consumption of fruits (57.1%), vegetables (58.9%), dairy products (74.4%), pulses (73.2%), fish/seafood (76.8%), white meat (83.3%), red and processed meat (91.1%), snacks (78.6%), rice/pasta/potatoes (78.6%), nuts (83.9%), low alcohol drinks (89.3%), spirits (98.8%) and sugary drinks (91.7%) . Increased cooking time (73.2%) and decreased or stay the same their physical activity (63.7%). University Employees increased more weight (1.01±0.02) than students (0.99±0.03) (p<0.05). 79.8% of the participant obtained a Medium/High Adherence to the MD. Emotional and very emotional eaters were higher in women group (p<0.01). (4) Conclusions: In the event of further confinement, strategies should be implemented to promote a balanced and healthy diet together with the practice of physical activity, taking special care of the group of women and University Employees.


Introduction
At the end of 2019, a new highly infectious and pathogenic strain of RNA viruses belonging to the Coronaviridae family has emerged in Wuhan, China [1]. 'Coronavirus disease 2019'  showed high mortality rates and a rapid human-to-human worldwide spread that switched into a global health emergency a few months after its outbreak, leading the World Health Organization (WHO) to declare it a pandemic in March 2020 [2]. Every country around the world confirming COVID-19-positive cases established strict preventive health measures to avoid viral transmission, including exhaustive testing, case tracing, and severe social restrictions. However, these limitations showed poor efficacy against infection thus, governments were finally forced to determine mandatory quarantine at home [3]. Due to the gravity of situation in Spain a State of Alarm was declared on March 24, 2020 [4] , which for the population resulted in serious social restrictions. During this period there was the confinement of the Spanish population in their homes, leaving only allowing them to perform very limited core activities. This confinement lasted until May 2, 2020. From that moment on, the entire population was allowed to leave their homes, regulating their presence on public roads by age and time zone [5]. In the case of university education, at first it was suspended for a few days or weeks, depending on the decision of each entity. Subsequently, and with the extension of the confinement, the majority chose to continue teaching online until the next academic year. In the case of Universidad Europea del Atlántico, teaching online was carried out sequentially subject by subject and in-person optional reinforcement classes in June and ordinary face-to-face exams in July and September.
These rigorous social measures affected the lifestyle habits of the population, mostly those related to eating patterns and physical activity [6]. It is worth mentioning that this imposed isolation at home was considered as a stressful situation that further influenced our diet routine since people used to cook more and consume more appetizing meals, snacks, or alcohol [7][8][9][10][11]. Intending to avoid a poor nutritional diet during the lockdown, the WHO published dietary guidelines highlighting the need for balanced diet patterns suggesting the consumption of 9 fruits and vegetable servings/day (4 and 5 servings/day respectively) together with legumes, meat, and foods made of whole grain cereals Intending to avoid a poor nutritional diet during the lockdown, the WHO published dietary guidelines highlighting the need for balanced diet patterns suggesting the consumption of 9 fruits and vegetable servings/day (4 and 5 servings/day respectively) together with legumes, meat, and foods made of whole grain cereals [2]. It is important to note that these dietary recommendations described all the main nutritional elements of the Mediterranean diet (MD) [11,12].
It is currently a fact that MD is one of the most beneficial dietary patterns known around the world [13][14][15]. Fruits, vegetables, nuts, legumes, whole grains, and olive oil are the most representative foods of this diet rich in bioactive components such as polyphenols (the main group of plant-derived metabolites [16]), conferring high anti-inflammatory, antioxidant, antimicrobial, immunomodulatory, antiviral, or neuroprotective beneficial properties [17][18][19][20][21]. Thanks to these healthy phytochemicals, MD has been widely associated with a lower risk of developing chronic inflammatory diseases and related comorbidities (obesity, type 2 diabetes, and metabolic syndrome), cancer, or ageassociated disorders among others [14,15].
In the current pandemic situation, the lockdown imposed by the governments due to the SARS-Cov-2 spread has critically influenced our lifestyle habits. Numerous studies worldwide from many countries and regions have analysed the consequences on our health after the quarantine with diverse outcomes depending on the adherence to a specific diet pattern and physical activity schedule [7,11,[22][23][24][25][26][27][28][29]. But very few have focused on studying the consequences of this situation in the university population [30,31], which, in addition to the stress caused by the global pandemic, in the case of students, had to continue with their studies preparing papers and preparing final exams and the university staff that had to readapt their work and teaching to the virtual environment in real time and nobody else has investigated the effect of confinement in the emotional eating behaviour. In this context, we aimed to evaluate whether the quarantine associated with the COVID-19 pandemic situation has influenced or modified the dietary habits (specifically the adherence to MD) and emotional eater behaviour and physical activity practices of a population comprising staff and students belonging to the Universidad Europea del Atlántico.

Selection of Participants and Study Design
A cross-sectional descriptive study based on a self-administered questionnaire was carried out. It was a non-probabilistic sample used for the convenience since the questionnaire was directed towards people of legal age (≥ 18 years old) from the University community recruited online. The collection of information began on April 28, 2020; 46 days after lockdown had begun (Phase1) and the last data was sent on May 29, 2020.
For the correct collection of the information, the Google forms application which allows the anonymity of the participants was used. The questionnaire was directed towards the whole University community (students, teachers, and administrative staff), by email. After agreeing to complete the questionnaire, participants were asked to answer the questions of the self-administered online questionnaire (filling in time of less than 30 min) informing them that they could interrupt the compilation at any time, without the obligation to justify the decision. Participation in the study was voluntary and completely free.
The study was approved by the Committee of Ethics of Investigation of the Universidad Europea del Atlántico (C-12 /2020), being that all the compiled information anonymously was treated with maximum confidentiality, in accordance with the law of data protection (LOPD) 15/1999, and saving itself for works of investigation following the scientific method demanded in every case, it respected the Regulation (EU) of the European Parliament and of the Advice 2016/679 of April 27, 2016, relative to the protection of natural persons with regard to the processing of personal data and to the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation).

Instrument and Variables
Within the questionnaire, information was organized in 3 sections. A first section (25 items) included the sociodemographic profile: sex, age range, birthplace, weight before of confinement, weight variation, coexistence with other persons, place of residence during the confinement, position in the University; and for students, the faculty and degree program.
Dietary behaviours and physical activity habits were described in the second section (17 items) where questions about grocery shopping, change in consumption of fruit, vegetables, dairy products, pulses, fish/seafood, white meat, red meat and processed meat, pastries and snacks, rice/pasta/potatoes, nuts, alcohol drinks, sugary drinks, based on the healthy eating pyramid [32], portions of food, number of meals and physical activity over 30 minutes doing moderated or vigorous activity a minimum of 4 times during the week were included.
A pilot study was carried out among 15 subjects to verify the effectiveness of the questionnaire to learn if it provided the necessary information or if any of the questions needed to be modified.

Statistical Analysis
Normality distribution for quantitative variables was assessed using Shapiro-Wilk normality test. The quantitative variables were expressed as mean and standard deviation. Body mass index (BMI) was distributed using WHO ranges classification.
The following variables were regrouped to establish more robust results: MEDAS-14 (Low adherence and Medium/High), BMI (Under/Normal weight and Pre-obesity/Obesity I and II) EQQ (Non-emotional /Low emotional eater and Emotional /Very emotional eater).
For the quantitative variables, the Student's test or non-parametric Mann-Whitney U test was used. Univariate comparisons were investigated between groups and explicative variables using the Pearson X2 test or non-parametric Fisher's exact test for categorical data. The criterion of significance was established at p <0.05. All computer data were analysed using "The jamovi project (2021). jamovi. (Version 1.8) [Computer Software]. Retrieved from https://www.jamovi.org."

Characterization of the sample population
A total of 170 completed questionnaires were received and two of them were eliminated because were the same data in all the answers as the previous one. Thus, 168 questionnaires were considered valid.
Two thirds (66.7%) of the participants were women, 79.2% from Spain, students (76.8%) and living in the family home (76.2%). The BMI, calculated with the weight prior the lockdown, showed that 7.1% were underweight, 66.1% of the sample had a normal weight, while the 26.8% were pre-obese or had some type of obesity.
Specific for students, the analysis for the weight's change, non-statically significant differences were found, comparing if students were from the Degree of Human Nutrition (1±0.03) or others (0.99±0.03) (p=0.828) and comparing by Faculty of Health Sciences (0.99±0.03) or others (0.99±0.03) (p=0.910) using Mann-Whitney U test. However, considering the role, students (0.99±0.03) and University employees (Research Professor and Administrative Staff) (1.01±0.02), significant differences were found between the two groups (p<0.05) using Mann-Whitney U test. (Figure 1) (weight increased during the lockdown in kg / weight before the lockdown in kg); 1 means that maintain the currently weight, <1 implicated a weight reduction and >1 weight gain. University Employees (Research Professor and Administrative Staff). Differences were evaluated by the Mann-Whitney U test (p<0.05).

Students
To highlight how the lockdown affected the dietary behaviours of the population, the individuals were questioned about the changes in their habits and dietary pattern compared to the preceding period (Table 3).
Data was compared between students and University Employees, by the significant difference in the weight variation found between them. Significant differences were found on the consumption of vegetables, increasing a (20.1%) more in the group of students (p<0.05); consumption of low alcohol drinks (wine and beer), increasing a (16.1%) more in the group of University Employees (p<0.05); physical activity, increasing a (17.2%) more in the group of students (p<0.05) ( Table 3). Comparing by sex, significant differences were found, in women did the grocery 1 or less per week a (16%) more than men (p<0.05); and women increased the consumption of fish/seafood (16.1%) more than men (p<0.05), nonsignificant differences were found in the rest of questions (Table 4).

Adherence to the MD (MEDAS-14) during the confinement
Analysing the adherence to de MD, during the confinement, (20.8%) of the individuals had a low level of adherence to DM, and Medium/High on the (79.2%) (

Discussion
The spread of COVID-19 around the world forced governments to make very restrictive decisions [35] . In the case of Spain, a strict confinement of the entire population was imposed on March 14, 2020, which limited their mobility [4]. Being forced to stay indoors for a long-time can dramatically change our eating habits and physical activity practices. Lockdown was an unpleasant experience for everyone and, for those who lived alone [36]. Job uncertainty, loneliness, and fear about illness [37,38], adding the closure of the schools, work activities, social distance, and the ban of physical activities, radically disrupted the concept of normality [39,40]. In this work, we have analysed these modifications in a population sample from the university community of the Universidad Europea del Atlántico located in Santander, Cantabria, Spain. In our knowledge this is the first study that analysed in the college population differences among staff population and student's population.
Before the lockdown, the prevalence of overweight and obesity was 26.8%, being lower compared to the data reported for the Spanish population by Sánchez-Sánchez et al. [11] who found a 39.8% of incidence, and similar to the to the data reported by Sidor et al. [7] for the Polish population. It should be noted that in this case, the distribution of overweight and obesity also coincided with those of our sample. The incidence in our sample was also lower compared to the data reported for the Chilean (52.2%) [41] and the Dutch (55.6%) [42] populations. This may be due to the average age of our population because they are mostly made up of students. In general, weight variations were observed in the participants: 36.3% loss weight while a 35.7% gain weight with significant differences between students and University Employees. Weight loss was observed mostly in students than in University Employees (p<0.05) and didn't find correlation between BMI and weight gain/loss. Our results show a percentual lower weight gain in the population than those found in Sinisterra-Loaiza [29], Sidor et al [7] and Sánchez-Sánchez et al. [11], who reported a weight loss in obese people during the confinement and Di Renzo et al [28]. But is consistent with the weight gain reported in Celorio-Sardá et al [43]; Reyes-Olavarria et al [41] and Deschasaux-Tanguy et al [9]. It is interesting to note that no differences have been found between health science students and the rest of the university population.
Regarding the dietary and lifestyle adaptations during the lockdown in our popula-  [42] in 1030 Dutch adults. The diminution in the consumption of pastries and snacks is contrary to what was found in French population by Marty et al [8].
Because the significant difference found in the weight variation, we analysed differences between students/ University Employees in the dietary and lifestyle adaptations.
Significant differences were found in vegetables (were students increased more the consumption), low alcohol drinks (were students decreased or stay the same more the consumption) and physical activity (were students increased it more) what is consistent with the results shown by Celorio-Sardá et al [43] who reported an increased consumption in vegetables and decreased consumption in fermented alcoholic beverages, especially in students.
Physical activity combined with a healthy diet is essential to achieve a beneficial health effect. During the confinement, the 36.3% of our population increased their physical activity. Our results are similar, although higher, to those reported by Rodríguez-Pérez et al. [44] and Di Renzo et al. [28] and somewhat lower than those found by Celorio-Sardá et al [43], contrary to those of Romero-Blanco et al. [45] who found that all groups increased their physical activity on average, while in our study significant differences were found between students and University Employees, with students being the ones who increased their physical activity practice in the highest percentage (40.3% vs 23.1%).
During the COVID-19 pandemic was recommended to follow the MD pattern due to its ability to stimulate the immune system [19,20]. According to Pérez-Araluce et al. [46] a better adherence to this pattern may be associated with a lower risk of COVID-19. MD, considered as a reference to a healthy balanced diet, is characterized by the intake of olive oil, fresh fruits, and vegetables [47] which are associated to the reduction of inflammatory stress markers, improvement in lipid profile, and insulin sensitivity. These effects are attributable to the phenolic compounds and mono and poly-unsaturated fatty acids it contains [20,48,49] , who found that nutrition students were the ones who most improved their eating habits during confinement.
The restrictions of confinement, explained above, have been linked to an increase in mental illness, especially depression and anxiety [50]. In this sense, different authors relate an increase in anxiety to emotional eating [51,52].
According to the results of the EEQ, most of the participants were categorized as non/low-emotional eaters (72.6%), similar to the data reported by López-Moreno M et al [53] for Spanish adults (67.2%). Women scored significantly higher than men as emotional/very emotional eaters (35.7% vs 10.7%) (p<0.01). Similar results were obtained by Di Renzo L et al. [39], who reported that women were more prone to emotional eating than men and no differences were found by age range groups. The social isolation imposed during the COVID 19 pandemic could pose a psychological burden for many individuals, but, for women, who continue to carry the burden of household chores in our current models of society, leading to eating more frequently or in greater quantity as a mechanism to cope with increasing fear and anxiety. It is known that during prolonged stress, our body releases cortisol, which increases the feeling of hunger [54].
This study has several limitations. The cross-sectional design does not provide any information on the possible casual nature. Our sample size is small to be a representative population and the distribution among genders and age range groups is inadequate. Besides, self-reported data are susceptible to biased information. The lack of a validated questionnaire can omit relevant information and raised the problem of generalization of results.

Conclusions
We can affirm that under the lockdown caused by the COVID-19, the UNEAT community decreased or stay the same dietary and lifestyle habits; students increased the intake of fruits and vegetables and physical activity compared with University Employees.
Whereas University Employees during the lockdown increased more the intake of low alcohol drinks (wine and beer). As mentioned before, fruits and vegetables are the principal source of bioactive compounds that help maintain a state of health and could be a therapeutic approach to COVID-19.
In addition, our sample limited the consumption of pastries and snacks, sugary drinks, and alcoholic beverages, having a Medium/High adherence to the MD, and practiced physical exercise regularly. This has resulted in a reduction or maintenance of weight, especially in the youngest subjects in the community. In an exceptional situation as a pandemic scenario, it is difficult to establish a bidirectional relationship between foods and mods. In any case, in our sample, women were more likely to be emotional eaters than men, eating for other reasons than hunger, increasing the intake of more palatable foods.
Future strategies should be implemented to promote a balanced and healthy diet, especially improving the consumption of fruits and vegetables, together with the practice of physical activity, for the entire University population, and for the University Employees, who increased more weight during the lockdown. Funding: This research received no external funding.