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. 2021 Apr 10;164:105244. doi: 10.1016/j.appet.2021.105244

Relationship in dietary habits variations during COVID-19 lockdown in Kosovo: The COVIDiet study

Erhan Sulejmani a,∗, Arjeta Hyseni a,b, Gafur Xhabiri a, Celia Rodríguez-Pérez c,d,e
PMCID: PMC8035802  PMID: 33848591

Abstract

Changes in dietary habits and association with lifestyle during the coronavirus disease 2019 (COVID-19) lockdown in the Kosovo population have not been studied yet. Therefore, the intent of the present study was to determine whether if COVID-19 lockdown had any impact in lifestyle, including dietary habits and physical activity (PA) patterns of people from different areas of Kosovo. Dietary habits, PA, body weight and sociodemographic variables were measured through validated online survey started one week after lockdown decision and lasted for next two month (May and June 2020). Six hundred eighty-nine participants (women 79% and men 21%) aged between 20 and 65 years from the Kosovo territory participated in the research. Multivariate models showed that participants in family home residence, participants from Gjilan, participants female and participants with professional educations reported a higher likelihood of turning into a higher adherence to the Mediterranean diet (MedDiet) (OR: 6.09, 5.25, 5.17, 4.19, respectively). The weight gained during the lockdown was positively associated with a higher cooking frequency (OR; 2.90, p < 0.01), lower meat and fish consumption (OR; 1.15, p = 0.02; OR; 1.04, p = 0.04, respectively), higher fast-food consumption (OR; 0.49, p = 0.02) and no physical activity performance (OR; 0.43, p = 0.02) during the COVID-19 lockdown. The dietary habits during COVID-19 lockdown could be related to the improvements in adherence to the MedDiet and physical activities that may minimize related health complications.

Keywords: COVID-19, Body weight, Lockdown, Mediterranean diet, Nutritional survey, Physical activity

1. Introduction

Investigations show that the lockdown during COVID-19 has had an inverse effect on psychological conditions such as psychological disturbance (Brooks et al., 2020). It has been associated with negative attitude changes involving a rise in smoking (45%), increased and decreased consumption of alcohol, weight gain or, uncontrolled eating of unhealthy food and snacks (Ammar et al., 2020; Anne et al., 2020; Carroll et al., 2020; Sidor & Rzymski, 2020). On March 13, 2020, the first cases of COVID-19 were recorded in Kosovo and according to the analysis of NIPHK (National Institute of Public Health of Kosovo) two people have tested positive for COVID-19, with stable health (Kosovo Government, 2020). From March to December, there were various measures and decisions which were taken by the Government of the Republic of Kosovo. The measures were strict, starting with closing and moving at certain times making people spend a longer time with their families, preparing food and meals at home. Since some of the main food products consumed in this period were pastries and other sweets, this affected the increase in body weight. But over time the measures began to soften, the citizens began to move freely and continued with their work, until the second wave of the pandemic with more cases affected psychological, emotional and health condition (Kosovo Government, 2020). Changes in dietary habits were noticed during the lockdown reported by some research, evidenced a correlation between a higher Body Mass Index (BMI) and higher intake of junk food, snacks, and sugar drink during the lockdown (Ashby, 2020; Di Renzo et al., 2020; Pietrobelli et al., 2020). On the contrary, other research showed an adherence to a healthier diet during the first weeks of lockdown (Giacalone et al., 2020; Kriaucioniene et al., 2020; Rodríguez-Pérez et al., 2020). The relationship between diet and health is well-stablished, thus, nutritional behavior threatens the health and therefore managing an excellent diet is essential for boosting the immune system (Kriaucioniene et al., 2020). Indeed, serious obesity is one of the groups with the highest risk for COVID-19 difficulties because the adipose tissue contributes to the inflammatory medium and oxidative stress level (Di Renzo et al., 2019; USA Government, 2020).

The MedDiet is made of a perfect mix of good foods, containing all macro and micronutrients, which is the key factor against inflammatory responses, due to their low cholesterol levels and high levels of antioxidants and monounsaturated fatty acid (De Lorenzo et al., 2017). Moreover, Rodríguez-Pérez et al. (2020) reported that a higher MedDiet adherence could have a positive impact on the prevention of COVID-19-related complications. Therefore, taking this into consideration, the purpose of this research was to investigate self-reported nutritional behavior and weight gain/physical activity performance during the COVID-19 lockdown among a representative adult population from Kosovo and to evaluate socio-demographic variance in nutrition and eating behaviors.

2. Materials and methods

2.1. Study sample and data collection

The online cross-sectional survey was carried out between individuals older than 18 years in Kosovo as part of the international COVIDiet (COVIDiet_Int) project with ID number: NCT04449731 (https://clinicaltrials.gov/ct2/show/NCT04449731) managed by the University of Granada, Spain (Rodríguez-Pérez et al., 2020). The survey began on 5 May; a week after COVID-19 lockdown started in Kosovo and lasted eight weeks. A self-administered anonymous web-based questionnaire was developed to collect data. The respondents were grouped into five age groups: under 20 years, 20–35 years, 35–50 years, 51–65, and older (over 65). Education level respondents were categorized into six groups: primary, secondary, high, bachelor, master, and Ph.D. level of education. The full questionnaire is available online at https:// www.mdpi.com/2072-6643/12/6/1730/s1 (the Albanian translation can be obtained from the authors upon request). Briefly, three main sections of the items were divided as follow (1) Socio-demographic information questions (sex, age, place of residence, country, dependent children, level of studies), (2) PREDIMED MedDiet Adherence Screener (14 questions of MEDAS) (Martínez-González et al., 2012) and actual changes and lastly (3) 21 questions with the purpose to research variation during regular eating habits throughout the lockdown, i.e., frequency and way of cooking, type of oil for frying, alcohol intake, snacking, between others. All items were also arranged to realize if contributors decreased, increased, or maintained their routine during the COVID-19 lockdown. Also, physical activity and body weight changes were assessed through two questions. The link to the survey was disseminated using social networking sites, web-pages of some institutions, which agreed to participate and social media such as Facebook, with the intention of reaching the highest number of participants from all administrative districts of Kosovo.

2.2. Ethical issues

The international COVIDiet study was approved by the Research Ethics Committee of the University of Granada (1526/CEIH/2020). Additionally, the Kosovo COVIDiet study was approved by the Bioethics Centre of the University of Tetova. Participation was voluntary, anonymous and no personal data were collected. The participants were informed about the objectives of the study.

2.3. Statistical analyses

Descriptive statistics for all the collected variables were derived by levels of adherence to the MedDiet and by sex, age, level of education, and region. Student's t-test or Kruskal-Wallis test (for continuous normal or non-normal distributed data, respectively), and Chi-squared tests (for categorical data) were used to evaluate differences in means or proportions by these variables across the strata. Box-plots were also used to evaluate further the distribution of the variable on adherence to the MedDiet by the aforementioned subgroups. Adherence to the MedDiet was assessed on the continuous scale (range: 0–14) and on the categorical scale by classifying participants into low, medium, and high adherence levels (<5, 6 to 8 and > 9 points, respectively) to the MedDiet at the two-time points: before and during the COVID-19 Kosovo lockdown. A binary variable to assess the change in adherence to the MedDiet was built to distinguish between those who kept adherence to the MedDiet alike (reference category, set to zero) and those who changed their adherence towards a greater adherence (set to one). Logistic regression models were used to explore variables associated with the change in adherence (change versus non-change, as reference) to the MedDiet. Odds ratios (ORs) and corresponding 95% Confidence Intervals (CIs) were estimated in univariate regression models. The threshold for statistical significance in two-sided tests was set at p-value = 0.05. Data were analyzed with SPSS (version16.0).

3. Results and discussion

3.1. Sociodemographic and regional characteristics of the study sample

In total, 689 individuals from Kosovo (488 females and 200 males) participated in the survey and completed the questionnaire (Table 1 ). Most participants were 20–35 years old (59%) and the highest percentage of the sample had university studies (54%), were living in the family home (56.7%), and with no children in care (62%) (Table 2 ). About 71% of the participants were females, 57% were from the district of Pristina (Fig. 1 ), and only few participants became from the oldest (0.4%) and middle oldest age groups (8.8%). No statistical difference was found for participants that were more likely to live in family homes, and no significant differences by regions between gender levels were noted (except for Mitrovica). However, a statistically significant interaction by gender was observed between change in adherence to the MedDiet and children in care (p-value = 0.000 and 0.004, respectively). According to Table 5, positive answers to the MEDAS questionnaire and the adherence to MD are reported in terms of territorial coverage over the Kosovo administrative districts. Results from the MEDAS questionnaire in our population sample, classified according to the regional participation, demonstrated significantly variations (p = 0.018) and that most of subjects had more than 50% of olive oil (61% in Gjilan, 57% in Pristina, 55% in Mitrovica, and 51% in Gjakova). Olive oil consumption has been traditionally highlighted to contribute to the prosperity well-being of the Mediterranean people, and nowadays there is consistent evidence supporting its association with lower all-cause mortality and reduced risk of cardio vascular disease (Campanini et al., 2017). The highest percentage of the study samples consumed 1–2 portions of vegetables per day (51%), 1–3 fruits per day (53%), and legumes 1 time per week (47%) with no significant difference between the regions were found. Regarding vegetable consumption, results from the MEDAS questionnaire showed that more than 50% increased their intake only the region of Pristina (54%) while the increase of fruits consumption was higher in the regions from Prizren (63%), Ferizaj (61%) and Gjilan (58%). Our finding pertaining higher fruit and vegetable consumption during Kosovo COVID-19 lockdown were inconsistent with the previous findings which reported the opposite trend (Amar et al., 2020; Deschasaux-Tanguy et al., 2020; Di Renzo et al., 2020; Pellegrini et al., 2020). Fruits and vegetables are rich in Zinc which is a necessary mineral in the maintenance and growth of adaptive and innate immune cells (Bonaventura et al., 2015). In agreement to the Italian study, positive changes related to the decrease of meat consumption, carbonated or sugary drinks and increased consumption of fresh fruits and vegetables were reported during the COVID-19 lockdown (Di Renzo et al., 2020; Rodríguez-Pérez et al., 2020). The lower consumption of meat could be related with the lack of stock in some supermarkets, the same that happened in the Spanish supermarkets and grocery stores after the state of alarm was declared (Rodríguez-Pérez et al., 2020). Vieux et al. (2018) stated that meat consumption is proportional to the amount of greenhouse gas (GHGs) emissions whereas others declared that consumption of red meat has been associated with chronic diseases like cancer (Springmann et al., 2018). The chi-square test showed differences in MEDAS score among the seven Kosova regions (p = 0.204), with higher scores in Gjilan and Prizren when compared to other administrative regions.

Table 1.

Characteristics of the study population (%).

Characteristics n %
Gender
 Male 200 29
 Female 488 71
 Another 1 0.1
Group ages
 18–35 492 71
 36–50 133 19
 ≥51 64 10
Education
 University 605 88
 Lower 84 12
Body mass index
 <25 kg/m2 446 65
 25–29 kg/m2 195 28
 ≥30 kg/m2 48 7
Weight gain during quarantine
 Gained 258 38
 No changes/didn't know 431 62
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Table 2.

Standards characteristics of respondents by level of adherence to the MedDiet during the COVID-19 Kosovo confinement.

Low (N = 339)
 Medium (N = 325)
 High (N = 25)
 p Valuec
N % N % N %
Gendera 0.000
Men 132 39 63 19 5 20
Woman 206 61 262 81 20 80
Another 1
Place of Residence 0.089
Family home 325 96 312 96 24 96
Alone 5 2 6 2 1 4
Student residence 8 2 2 1 0 0
Shared flat 1 0 5 1 0 0
Region by Areasb 0.204
Prishtina 184 54 193 59 14 56
Peja 37 11 36 11 3 12
Ferizaj 40 12 33 10 2 8
Prizren 24 7 17 5 2 8
Gjilan 16 5 19 6 3 12
Gjakova 24 7 13 4 0 0
Mitrovica 14 4 14 5 1 4
Children in Care 0.004
Yes 110 32 139 43 14 56
No 229 68 186 57 11 44
Education Level 0.310
Faculty 192 57 166 51 13 52
Master 75 22 87 27 9 36
Secondary 42 12 33 10 2 8
High 12 4 23 7 1 4
PhD 13 4 14 4 0 0
Elementary 5 1 2 1 0 0
Age 0.429
<20 50 15 35 11 1 4
20–35 202 59 189 58 15 60
35–50 59 17 69 21 5 20
51–65 26 8 31 9 4 16
>65 2 1 1 1 0 0
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a

Numbers do not add up because there were five respondents who reported another gender (data not shown).

b

Kosovo Administrative regions.

c

Differences between the three MedDiet adherences groups were evaluated by the Chi-squared test.

Fig. 1.

Fig. 1

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Districts of Kosovo.

Table 5.

Comparisons between dietary behaviours relative to the MedDiet pattern by region during the COVID-19 Kosovo lockdown.

Total
 Ferizaj
 Gjakova
 Gjilan
 Mitrovica
 Peja
 Pristina
 Prizren
 p-Value
(689) 75 (10.9) 37 (5.4) 38 (5.5) 29 (4.2) 776 (11) 391 (56.8) 43 (6.2)
Olive oil for cooking 0.018
Yes 361 (52) 32 (43) 19 (51) 23 (61) 16 (55) 28 (37) 223 (57) 20 (47)
No 328 (48) 43 (57) 18 (49) 15 (39) 13 (45) 48 (63) 168 (43) 23 (53)
Olive oil (tablespoons/d) 0.243
>4 169 (25) 13 (17) 6 (16) 12 (32) 8 (28) 18 (24) 106 (27) 6 (13)
2–3.9 242 (35) 27 (36) 12 (32) 9 (24) 10 (34) 22 (28) 145 (37) 17 (40)
0–1.9 278 (40) 35 (47) 19 (52) 17 (44) 11 (38) 36 (47) 140 (36) 20 (47)
Vegetables (servings/d) 0.289
>2 222 (32) 30 (40) 14 (38) 8 (21) 9 (31) 27 (36) 120 (31) 14 (33)
1–1.9 354 (51) 35 (47) 18 (49) 17 (45) 14 (48) 37 (48) 212 (54) 21 (49)
0–0.9 113 (17) 10 (13) 5 (14) 13 (34) 6 (21) 12 (16) 59 (15) 8 (18)
Fruits (units/d) 0.346
>3 211 (31) 15 (20) 13 (35) 12 (32) 11 (38) 24 (32) 127 (32) 9 (21)
1–2.9 356 (52) 46 (61) 19 (51) 22 (58) 16 (55) 36 (47) 190 (49) 27 (63)
0–0.9 122 (17) 14 (19) 5 (14) 4 (10) 2 (7) 16 (21) 74 (19) 7 (16)
Red meat (servings/d) 0.487
>1 248 (36) 24 (32) 19 (51) 12 (34) 11 (38) 29 (38) 140 (36) 13 (30)
0–0.9 441 (64) 51 (68) 18 (49) 26 (68) 18 (62) 47 (62) 251 (64) 30 (70)
Fats (servings/d) 0.201
>1 146 (21) 14 (19) 14 (38) 5 (13) 6 (21) 16 (21) 84 (21) 7 (16)
0–0.9 543 (79) 61 (81) 23 (62) 33 (87) 23 (79) 60 (79) 307 (79) 36 (84)
Sweet beverages (servings/d) 0.074
>1 244 (35) 27 (36) 13 (35) 11 (29) 14 (48) 38 (50) 127 (32) 14 (33)
0–0.9 445 (65) 48 (64) 24 (65) 27 (71) 15 (52) 38 (50) 264 (68) 29 (67)
Wine (glasses/d) 0.072
0 509 (74) 61 (81) 31 (84) 28 (74) 26 (90) 47 (62) 283 (71) 33 (77)
>7 9 (1) 1 (1) 0 (0) 0 (0) 0 (0) 3 (4) 4 (1) 1 (2)
3–6.9 20(3) 0 (0) 1 (3) 1(3) 2 (7) 1 (1) 15 (4) 0 (0)
0–2.9 151 (22) 13 (18) 5 (13) 9 (23) 1 (3) 25 (33) 89 (23) 9 (21)
Legumes (servings/w) 0.701
>3 74 (10) 10 (13) 1 (3) 6 (16) 4 (14) 9 (12) 37 (8) 7 (16)
1–2.9 294 (43) 33 (44) 16 (43) 19 (50) 12 (41) 32 (42) 167 (43) 15 (35)
0–0.9 321 (47) 32 (43) 20 (54) 13 (34) 13 (45) 35 (46) 187 (48) 21 (49)
Fish (servings/w) 0.165
>3 36 (5) 3 (4) 1 (3) 2 (5) 1 (4) 7 (9) 16 (4) 6 (14)
1–2.9 252 (37) 28 (37) 13 (35) 15 (39) 16 (55) 22 (29) 144 (37) 14 (33)
0–0.9 401 (58) 44 (59) 23 (62) 21 (56) 12 (41) 47 (62) 231 (59) 23 (53)
Non-homemade pastries (units/w) 0.021
>2 291 (42) 29 (39) 18 (49) 14 (37) 11 (38) 47 (62) 155 (40) 17 (40)
0–1.9 398 (58) 46 (61) 19 (51) 24 (63) 18 (62) 29 (38) 236 (60) 26 (60)
Nuts (servings/w) 0.016
3 133 (19) 8 (11) 4 (11) 12 (32) 4 (14) 20 (26) 79 (20) 6 (14)
1–2.9 245 (36) 33 (44) 12 (32) 13 (34) 17 (58) 28 (37) 130 (33) 12 (28)
0–0.9 311 (45) 34 (45) 21 (57) 13 (34) 8 (28) 28 (37) 182 (47) 25 (58)
White meat preference 0.973
yes 540 (78) 58 (77) 27 (73) 29 (76) 23 (79) 62 (82) 307 (79) 34 (79)
no 149 (22) 17 (23) 10 (27) 9 (24) 6 (21) 14 (18) 84 (21) 9 (21)
Sofrito3 (servings/w) 0.109
>2 350 (51) 34 (45) 13 (35) 19 (50) 15 (52) 49 (65) 202 (52) 18 (41)
1–1.9 217 (31) 30 (40) 19 (51) 11 (29) 8 (28) 16 (21) 119 (30) 14 (33)
0–0.9 122 (18) 11 (15) 5 (14) 8 (21) 6 (20) 11 (14) 70 (18) 11 (26)
Adherence to the MD
Low 339 (49) 40 (53) 24 (65) 16 (42) 14 (48) 37 (49) 184 (47) 24 (56)
Medium 289 (42) 33 (44) 13 (35) 19 (50) 14 (48) 36 (47) 193 (49) 16 (37)
High 61(9) 2 (3) 0 (0) 3 (8) 1 (3) 3 (4) 14 (4) 3 (7)
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Positive answers to MEDAS questionnaire. Compliance rates of at least 50% are indicated in bold. Data are expressed as number and percentage in parenthesis (n %). Differences between the regions groups were evaluated by the Chi-squared test (p < 0.05).

3.2. Dietary behaviours during the COVID-19 confinement

Socio-demographic factors associated with the change in the adherence to the MedDiet are presented in Table 6. Multivariate models found that female participants (OR: 5.17), participants lived in the family home (OR: 6.09), participants with high education level and participants with ages from 51 to higher than 65 years old (OR < 0.70) presented a higher odd of change to adhere to the MedDiet during the lockdown. On the contrary PhD respondents (OR: 0.04) and those who lived alone (OR: 0.99) from Gjakova had lower adherence to the MedDiet (Table 6). Kruskal Walli's analysis showed that no significant association was observed between the change in MedDiet adherence and the age and region but the level of education showed significant association to the change in MedDiet adherence (Fig. 2 ). So the age and geographical region were not found to modify the associations with adherence. Dietary and lifestyle adaptations by gender during the COVID-19 Kosovo lockdown are shown in Table 3 . Overall, most participants did not increase their intake of alcohol level (52% maintained it and 43% decreased it), as well as their physical activity level (41%) which remained lower during the lockdown. Furthermore, the majority cooked in a higher frequency than before the lockdown and used boiling as the main technique for cooking (53%). The intake of snacks and fried foods was reported similar as before COVID-19 lockdown for 45% and 52% of participants, respectively while 51% of participants showed significant (p < 0.05) lower frequency of fast-food intake. However, around 57% of the participants continued consuming fried foods 1–3 days a week and around 32%, more than 7 times per week. Similarly to the Spanish COVIDiet Study (Rodríguez-Pérez et al., 2020), 62% of participant reported not to eat more during the lockdown. The greater part of the participants (52%) used sunflower oil for frying. In contrast to our results, a study conducted in Spanish adults reported that the subjects increased consumption of olive oil during lockdown (Reyes-Olavarría et al., 2020). Concerning anthropometric principle, 37% of the participants reported weight gain and 47% reported the opposite with a higher prevalence in female participants (68.9%). According to the World Health Organization (WHO) guidelines, overweight was defined as BMI 25–29 kg/m2 and obesity as BMI ≥ 30 kg/m2 (WHO, 2000). The participants reported a lower PA (times/week and min/session, p > 0.05) than before lockdown.

Table 6.

Factors associated with adherence to the MedDiet during Kosovo lockdown.

High vs medium - low adherence to MedDiert
Crude Model
OR 95% CI
Gender
Male Ref Ref
Female 5.17 [2.04–13.10]
Another 0.0 0.0
Place of Residence
Shared flat Ref Ref
Family home 6.09 0.00
Student residence 1.00 0.00
Alone 0.99 0.00
Region by Areas
Mitrovica Ref Ref
Gjilan 5.25 0.59–46.30
Pristina 3.19 0.42–24.08
Ferizaj 0.77 0.67–8.80
Gjakova 0.00 0.00–0.00
Prizren 2.10 0.21–21.24
Peja 3.76 0.45–31.10
Children in Care*
No Ref Ref
Yes 0.52 [0.31–0.89]
Education Level
Elementary Ref Ref
Secondary 1.81 [0.20–16.19]
High 4.19 [0.46–38.20]
University 2.29 [0.30–17.45]
Master 3.66 [0.47–28.43]
PhD 0.04
Age
>65 Ref Ref
<20 0.17 [0.02–1.56]
20–35 0.58 [0.19–1.80]
35–50 0.45 [0.11–1.84]
51–65 0.70 0.00
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Fig. 2.

Fig. 2

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Adherence to the MedDiet during the Kosovo COVID-19 lockdown by subgroups of age (a), educational level (b) and region (c).

Table 3.

Dietary and lifestyle adjustment by level of adherence to the MedDiet during the COVID-19 Kosovo confinement.

All
 Low
 Medium
 High
 p-Value
(N = 689)
 (N = 339)
 (N = 325)
 (N = 25)
N % N % N % N %
Meals out of home 0.174
0 112 16 51 15 58 18 3 12
1 193 28 90 26 97 30 6 24
2 273 40 131 39 128 39 14 56
3 111 16 67 20 42 13 2 8
Alcohol intake 0.003
As before 362 52 174 51 176 54 12 48
Lower 299 43 156 46 136 42 7 28
Higher 28 4 9 3 13 4 6 24
Type of Cooking 0.104
Microwave 6 1 2 1 4 1 0 0
Bake 205 30 116 34 79 24 10 40
Fried 54 8 31 9 21 7 2 8
Frying 58 8 24 7 32 10 2 8
Boiling 366 53 166 49 189 58 11 44
Frequency of Cooking 0.150
As before 255 37 131 39 119 36 5 20
Lower 49 7 26 8 22 7 1 4
Higher 385 56 182 53 184 57 19 76
Fried Foods Intake 0.678
As before 355 52 184 54 156 48 15 60
Lower 174 25 79 23 90 28 5 20
Higher 160 23 76 23 79 24 5 20
Fried Foods Frequency Per Week 0.718
<1 178 26 80 24 91 28 7 28
1–3 392 57 201 58 178 55 13 52
4–6 77 11 36 10 37 11 4 16
Never 34 5 19 7 15 5 0 0
>7 8 1 3 1 4 1 1 4
Oil used for frying 0.744
Another 15 2 6 2 8 2 1 4
Canola Oil 3 0 1 0 2 1 0 0
Sunflower Oil 355 52 175 52 168 52 12 48
Corn Oil 85 12 35 10 45 14 5 20
Olive Oil 231 34 122 36 102 31 7 28
Snacking frequency 0.940
As before 311 45 151 44 152 47 8 32
Lower 139 20 68 21 65 19 6 24
Higher 239 35 120 35 108 34 11 44
Fast food frequency 0.022
As before 243 35 105 31 127 40 11 44
Lower 352 51 190 56 151 46 11 44
Higher 94 14 44 13 47 14 3 12
Eating more 0.616
upper/yes 262 38 131 39 123 38 8 32
lower/no 427 62 208 61 202 62 17 68
Physical activity 0.275
As before 190 28 100 29 85 26 5 20
Lower 283 41 129 38 143 44 11 44
Upper 152 22 71 21 73 22 8 32
Never 64 9 39 12 24 8 1 4
Weight gain 0.436
Yes 258 37 119 35 124 38 15 24
Unknown 109 16 56 17 50 15 3 12
No 322 47 164 48 151 47 7 28
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1Numbers do not add up because there were five respondents who reported another gender (data not shown).

2Kosovo Administrative regions.

3Differences between the three MedDiet adherences groups were evaluated by the Chi-squared test.

Changes in the MedDiet adherences and association of variables with Body weight Increase.

From the Chi-square test analyses, it is obvious that age, children in care, alcohol intake, fast food frequency, and sweet beverage consumption were significantly associated with adherence to the MeDdiet levels (Table 2, Table 3, Table 4 ). According to changes in eating habits (Table 4), the highest percentage of the study sample consumed the same olive oil (67.34%), legumes (75.18%) and higher portions of vegetables (49.6%), and fruits (51.24%) per day as before lockdown. Regarding meat consumption, 47.9% consumed red meat as before, and 71.84% consumed fish as before the lockdown. Also, the highest percentage of participants declared no change in the consumption of non-homemade pastries (43.1%) and sweet beverages (40.34%) that was statistically significant (p < 0.003) (Table 4). Since dietary and lifestyle habits changed, several food choices were associated with the change in weight gain during lockdown (Table 7 ). Multivariate-adjusted models showed that those participants who reported a lower intake of meat (OR: 0.79, 95% IC: 0.65–0.97) during the COVID-19 Kosovo lockdown had a statistically significant higher likelihood of gaining weight because of higher consumption of bakery products compared to those who eat higher meat portion during the lockdown. Similarly, OR associated with weight gain increased significantly in respondents who had a lower intake of pan fried trout fish weekly (OR: 1.04 95% IC: 0.99–1.08). Also, a significantly higher odds (OR: 0.43; 95% CI: 0.21–0.87) of changing, respectively gaining weight during lockdown, compared to those who kept being with lower activity or inactive respondents was found. There was a significant inverse correlation between higher BMI and olive oil intake and obviously weight gain was significantly correlated with eating more during the COVID-19 lockdown than before (data not shown). Table 6 displays multivariate-adjusted ORs associated with the change in adherence to MedDiet in relation to the MEDAS-derived foods, considering mutual adjustment by each other food item. The weight gain was associated with the BMI of participants which means that those with higher BMI gained weight more often compared to those having normal BMI (Fig. 3 ). The logistic regression showed that women were more likely to be associated with higher adherence to MedDiet during the COVID-19 lockdown (Table 6). Similarly Bouzas et al. (2020), reported that women participants had higher desired weight loss, related to higher education levels. Moreover, weight management has been associated with a higher consumption of fruits and vegetables, especially in women (Kuk et al., 2009; Rodríguez-Rodríguez et al., 2009; Romieu et al., 2012; Tsai et al., 2016). No associations were found with age and education of respondents. In multivariate logistic regression analyses, the association of weight gain with the increased intake of fast food, eating more, no physical activity and higher frequency of cooking remained statistically significant. Also, the odds of weight gain also increased with higher pastries intake, higher beverage or sugary drinks, and increased snacking intake. The main strength of this project was the cooperation of scientists from different countries and many disciplines which were widely distributed in several countries. The investigation exceeded the minimum sample size of 385 participants with 5% of margin of error and the confidence of 95% and provides novel results applicable to lockdown times and after. The common limitation in the field of behavioral nutrition research which uses surveys that measures dietary behaviors has relied on self-reported survey studies and the validity of answers is a general problem. The second limitation is its cross-sectional design; and the use of unvalidated measures such as self-reported body weight and physical activity level.

Table 4.

Dietary behaviors relative to the MedDiet pattern during the COVID-19 Kosovo lockdown.

MEDAS Food All
 Low
 Medium
 High
(N = 689) (N = 339) (N = 325) (N = 25) p-Value
N % N % N % N %
Olive Oil 0.402
As before 464 67 218 64 229 70 17 68
Lower 67 10 37 11 29 9 1 4
Higher 158 23 84 25 67 21 7 28
Vegetables 0.835
As before 318 46 159 47 148 45 11 44
Lower 29 4 12 3 15 5 2 8
Higher 342 50 168 50 162 50 12 48
Fruits 0.739
As before 293 43 136 40 150 46 7 28
Lower 43 6 23 7 18 6 2 8
Higher 353 51 180 53 157 48 16 64
Red Meat 0.121
As before 324 48 151 44 158 49 15 60
Lower 261 37 144 43 112 34 5 20
Higher 104 15 44 13 55 17 5 20
Sweet Beverages 0.003
As before 278 40 124 36 142 44 12 48
Lower 257 37 149 44 101 31 7 28
Higher 154 23 66 20 82 25 6 24
Legumes 0.188
As before 518 75 253 75 247 76 18 72
Lower 74 11 44 13 28 9 2 8
Higher 97 14 42 12 50 15 5 20
Fish 0.102
As before 495 72 243 72 235 72 17 68
Lower 121 18 67 20 51 16 3 12
Higher 73 10 29 8 39 12 5 20
Non- homemade Pastries 0.128
As before 297 43 132 39 153 47 12 48
Lower 153 22 87 26 61 19 5 20
Higher 239 35 120 35 111 34 8 32
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Differences between the MedDiet adherence groups (low. medium and high) were evaluated by the Chi-squared test.

Table 7.

The proportion of participants changes in health behaviours by changes in weight (%) and Odds Ratios (OR) for the likelihood of weight gain.

Logistic regression
Gained No Changes/Doesn't Know OR (95% CI) p-Value
Sex 1.02 (0.72–1.43) 0.921
Male 31.1 28.5 –
Female 68.9 71.3 –
Another 0 0.2
Meat ratio 0.67 (0.50–0.94) 0.030
Under 1 58.4 67.1 1.15 (1.02–1.31) 0.021
Upper 41.6 32.9 0.79 (0.65–0.97) –
Fish ratio 1.95 (0.99–3.82) 0.058
Upper 3 7.4 3.9 0.53 (0.28–1.01) 0.049
Under 92.6 96.1 1.04 (0.99–1.08) –
Olive oil 0.80 (0.59–1.09) 0.791
Lower 10.9 9 1 –
No change 70.8 65.3 1.21 (0.59–2.45) 0.602
Higher 18.3 25.7 1.19 (0.71–1.99) 0.500
Vegetable 1.17 (0.87–1.57) 0.771
Lower 3.1 4.9 1 –
No change 44 47.5 0.77 (0.32–1.89) 0.578
Higher 52.9 47.7 0.90 (0.63–1.28) 0.567
Pasta 1.11 (0.89–1.39) 0.366
Lower 17.5 25 1 –
No change 48.2 40 0.76 (0.44–1.29) 0.311
Higher 34.2 35 1.13 (0.76–1.67) 0.537
Fish 0.602
Lower 20.6 16.7 1 –
No change 67.7 73.1 1.08 (0.60–1.95) 0.778
Higher 11.7 10.2 0.88 (0.52–1.47) 0.637
Beverage Sweet 0.229
Lower 32.7 40 1 –
No change 44.7 37.7 0.80 (0.52–1.21) 0.301
Higher 22.6 22.2 1.10 (0.72–1.67) 0.645
Physical activity 0.000
No change 18.3 33.1 1
Lower 52.9 34.0 0.38 (0.19–0.77) 0.007
Higher 16.7 25.2 0.87 (0.45–1.65) 0.667
No activity 12.1 7.6 0.43 (0.21–0.87) 0.020
Fast Food 0.023
No change 28.4 39.4 1
Lower 47.9 53.0 0.42 (0.22–0.79) 0.007
Higher 23.7 7.6 0.49 (0.28–0.88) 0.017
Snack Eating No change 35.4 50.7 1 0.171
Lower 19.5 20.6 0.91 (0.58–1.40)
Higher 45.1 28.7 1.52 (0.87–2.63)
Frequent cooking 0.92 (0.76–1.10) 0.009
No change 1.9 2.3 1
Lower 0.4 0.5 0.85 (0.55–1.31)
Higher 54.9 49.5 2.90 (1.37–6.11)
Often Eating 0.000
No 1
Yes 0.10 (0.06–0.16)
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Fig. 3.

Fig. 3

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Association between body mass index (BMI) of the participants and weight gain during the lockdown (%).

4. Conclusion

This is the first study targeted on assessment of changes in eating behavior in a Kosovo adult population during the COVID-19 lockdown. Overall, our results highlighted that most participants decreased unhealthy nutritional behaviors and physical activity level during the lockdown. Furthermore, the majority of participants increased fruits and vegetable consumption and cooking frequency being boiling the main employed technique. The weight gained during the lockdown presented positive association with the higher frequency of cooking than before the lockdown started. However, the present study is considered as a preliminary description of the assessment of nutritional status and identification of potential risk factors of the negative eating behaviors highlighted the importance with intention of making possible nutritional intervention for healthy lifestyle improving. Our intention is to highlight the need for better promotion of general well-being with future studies assessing maintains after the lockdown.

Author contributions

ES analyzed the data and wrote the manuscript. AH and GXh collected the data while CRP designed the data and provided critical feedback on the manuscript. All authors read and ensured input on the manuscript before approving.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical statement

The studies involving human participants were reviewed and approved by Research Ethics Committee of the University of Granada. The patients/participants provided their written informed consent to participate in this study.

Declarations of competing interest

None.

Ethics

The international COVIDiet study was approved by the Research Ethics Committee of the University of Granada (1526/CEIH/2020). Additionally, the Kosovo study was approved by the Bioethics Centre of the University of Tetova. This study is anonymous and it follows the existing regulations regarding Confidentiality and Data Protection Policy (Spanish Organic Law of Personal Data Protection (LOPD) 15/1999). The following questionnaire is addressed to the adult citizens of Kosovo, who by answering the questions provide their consent for their voluntary participation in the study. The questionnaire has been translated to 14 different languages and the study is being conducted in 18 countries simultaneously.

Acknowledgements

We would like to thank the participants in the present study. We thank the Head of Project Management Office of the University of Tetova: Gjeraqina Leka and administrative team of the international COVIDiet survey, the AGR-141 research group: Celia Rodríguez-Pérez, Esther Molina-Montes, Vito Verardo, Reyes Artacho, Belén García-Villanova,Eduardo Jesús Guerra- Hernández and Maria Dolores Ruíz-López from the Department of Nutrition and Food Science, University of Granada, Spain, for sharing COVIDiet questionnaire.

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