Psychological impact of overweight/obesity among pediatric age group before and during COVID-19 lockdown in Saudi Arabia.

Objectives: : Obesity is a primary public health concern in Saudi Arabia. The COVID-19 pandemic has profoundly affected people's lives, putting considerable pressure on children and adolescents, leading to psychological problems. Therefore, we aimed to assess obesity's psychological and behavioral impact among children and adolescents before and during the COVID-19 lockdown in Jeddah. Materials and
Methods: : A cross-sectional study was conducted in the pediatric endocrine outpatient clinic at King Abdulaziz University Hospital(KAUH). The sample included 360 participants. Data were collected through clinical interviews by telecommunication from April to June 2020. Demographic factors and answers to questions about behavior, feelings, and daily life (pre and during home quarantine) were assessed against the participants' body mass index (BMI) and reported daily life difficulties. The BMI standard deviation was calculated based on the Center of Disease Control and Prevention standards.
Results: Compared to other groups, a significantly higher percentage of overweight/obese participants reported low self-confidence (22.1%), 61.7% reported that their friends or family rarely bullied or picked on them and 66.4% reported that the people who they lived with rarely made fun of or bullied them due to their weight before home quarantine.
Conclusion: Children with a higher BMI reported lower self-confidence than their average weight peers before home quarantine. However, a higher BMI did not increase the risk of being bullied by family members and friends. The majority of the participants changed for the worse in every research aspect during quarantine.

INTRODUCTION

Obesity is one of the major public health concerns in Saudi Arabia, and it is continuously increasing.[1] Overweight and obesity are defined as abnormal or excessive accumulation of fat, potentially affecting health.[2] In 2016, the World Health Organization (WHO) reported an 18% obesity prevalence rate for children and adolescents aged 5–19 years.[3] It has been estimated that by 2025 the number of obese or overweight children will increase to 70 million if no preventative measures are put in place.[45] The obesity prevalence in eastern Mediterranean countries has been ranked second in the world, after the Americas.[6] Moreover, a 2015 study among Saudi children and adolescents indicated that the prevalence rate for being overweight was 13.4% and the prevalence rate for obesity was 18.2%.[1]

Overweight and obesity substantially correlate with physical and psychological complications.[17] Although not considered a psychiatric condition, obesity may manifest many psychological symptoms, including anxiety, feelings of worthlessness, low self-esteem, aggression, social withdrawal, and depression.[8] In addition, weight stigma (from peers, educators, or parents) negatively affects academic performance, emotions, or social relationships.[910] One study reported that 58% of obese children were diagnosed with at least one psychological disorder, mostly an anxiety disorder.[11] Furthermore, a study conducted in the United States found that there is an association between a child being overweight and having emotional/behavioral problems. Children who perceived themselves as being overweight were twice as likely to have emotional or behavioral problems compared to those who did not.[8] However, Rankin et al. reported that despite extensive research over the past decade, it remains unclear whether psychiatric disorders and psychological problems are a cause of childhood obesity, or a consequence thereof.[12]

In December 2019, the WHO was informed about multiple cases of pneumonia of unknown etiology in Wuhan, China. The Coronavirus Disease 2019 (COVID-19) outbreak (declared a pandemic by the WHO on March 11) was later discovered to be caused by Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2).[13]

The first COVID-19 case in the Kingdom of Saudi Arabia was identified on March 2, 2020[1415] and the Ministry of Health implemented gradual, yet stern measures including school closures (on March 8), social distancing, and home quarantine (which included 10–24 h lockdowns) to control the spread of the disease. In addition, extensive multi-platform campaigns were launched to increase public awareness about COVID-19.[16] The pandemic has profoundly affected children, adolescents, and their families, potentially resulting in mental health problems.[1718]

Few studies have been conducted to evaluate the effect of the lockdown on children's psychological well-being and behavior. We aimed to study the psychological and behavioral impact of obesity among children and adolescents before and during the COVID-19 lockdown Jeddah, Saudi Arabia.

MATERIALS AND METHODS

Selection and description of participants

The Institutional Review Board (Reference 297-20) of King Abdulaziz University Hospital(KAUH) in Jeddah, and the chairman of the Pediatric Endocrine Department approved this cross-sectional study. Participants (n = 360) were boys and girls aged 6-18 years, representing all ethnic groups living in Saudi Arabia, who were patients of the endocrine outpatient clinic of the King Abdulaziz University Hospital(KAUH). Patients with a history of premorbid psychological or behavioral disorders, cognitive disability, syndromes affecting intellectual ability, chronic diseases, and use of medications (including antipsychotics) were excluded from the research.

Due to the COVID-19 pandemic lockdown, we interviewed 360 patients through telecommunication, between April and June 2020. The researchers collected participants’ personal data (age, sex, and date of birth) and anthropometric measurements (height and weight). Participants were questioned about any changes that occurred during lockdown in the following variables, compared to before lockdown: (1) feeding patterns (frequency, amount, and quality), (2) screen time, (3) physical activity, (4) psychological well-being (being considerate, thoughtful, anxious, angry, popular, sociable, friendly, attentive, compliant, aggressive, controlling, emotional, self-confident, bullied, belittled, and having phobias), (5) school performance (in relation to weight, online teaching, and the lockdown period), (6) activities (in relation to weight, the lockdown period, sleeping difficulties), and (7) relationship difficulties.

Statistical analysis

SPSS version 21 (Armonk,NY,IBM corp) was used to analyze the data. Moreover, numbers and percentages to express the qualitative data, and the Chi-square test to assess the relationship between body mass index (BMI) categories (A = underweight, B = healthy weight, and C = overweight or obese) and other variables were used. Quantitative data were expressed as M (standard deviation). Furthermore, the Kruskal–Wallis test was applied for nonparametric variables, and the Spearman's test for correlations analysis. Statistical significance was considered with a P < 0.05.

RESULTS

Demographic and personal data

This study examined the psychological and behavioral impact of obesity among children and adolescents before and during the COVID-19 lockdown in Saudi Arabia at KAUH, Jeddah. A total of 360 participants (female = 51.4%, male = 48.6%) were interviewed remotely. The prevalence rate was 8.9% (n = 32) for underweight, 49.7% (n = 179) for average weight, and 41.4% (n = 149) for overweight/obese. The mean age was 12.8 (3.7) years, the mean weight was 50.6 (20.75) kg, and the mean BMI was 33.15 (10.6) kg/m2.

Eating habits before and during home quarantine

Among the study participants, 60.7% consumed three (2.73 [0.63]) main meals daily before home quarantine. However, 47.2% of participants reported a change in the number of main meals (2.89 [1.4]) during home quarantine. In terms of daily snacks, 2.8% consumed one snack and 42.8% consumed two snacks per day (1.77 [0.83]). However, 56.4% of participants reported a change in the number of snacks consumed daily during home quarantine (2.63 [1.19]). About half (50.8%) of the participants ate fast food once weekly before lockdown, and 53.3% reported a change in the number of times per week they consumed fast food meals during home quarantine (2.04 [1.24]).

The Spearman correlation analysis indicated a significant positive correlation between BMI and the weekly number of snacks and fast food meals before home quarantine, and the number of daily hours spent in front of electronics before and during the home quarantine period (P < 0.05).

Daily use of electronics and exercising before and during home quarantine

Results showed that 38.1% of the participants spent 2-4 h daily in front of electronic devices prior to home quarantine, and 66.4% reported an increase in the number of daily hours of screen time during quarantine (7.28 [2.68]). When asked about exercise habits before home quarantine, 35.3% answered “rarely,” 47.8% “sometimes,” and 16.9% exercised daily. In regards to the exercise habits of the participants during quarantine, 55.3% reported a change.

Psychological feelings and behavior before and during home quarantine in relation to weight

Tables 1 and 2 show the participant distribution according to their BMI with regard to psychological questions about their behavior, feelings, and daily life before and during home quarantine. Responses to each of the questions revealed that the majority of participants (82.8%) felt their situations worsened during home quarantine. Nevertheless, compared to other weight groups, a significantly higher percentage of the overweight/obese participants (45.6%) rarely preferred isolation and spending time alone (P = 0.002). In addition, the percentage of overweight/obese participants (26.8%) that rated their self-confidence as high was significantly lower than those who were underweight (59.4%) or average weight (53.6%). Moreover, a higher percentage of obese/overweight (22.1%) participants reported low self-confidence, compared to underweight (9.4%) and average weight (7.3%) respondents. They (namely, the underweight and average weight groups), also reported that friends or family rarely bullied or picked on them (underweight group, 61.7%), and people they live with rarely made fun of or bullied them (average weight group, 66.4%) due to their weight (P ≤ 0.05).

Table 1

Participant distribution according to psychological feelings and behavior before and during home quarantine with relation to body mass index categories

Parameter	n (%)	A (underweight), n (%)	B (average weight), n (%)	C (overweight/obese), n (%)
I am nice to other people and I care about their feelings
Rarely	14 (3.9)	2 (6.3)	3 (1.7)	9 (6)
Sometimes	112 (31.1)	8 (25)	60 (33.5)	44 (29.5)
Always	234 (65)	22 (68.8)	116 (64.8)	96 (64.4)
Have you changed during lockdown?
Yes, for the better	63 (17.5)	6 (18.8)	31 (17.3)	26 (17.4)
Yes, for the worse	265 (73.6)	25 (78.1)	130 (72.6)	110 (73.8)
No	32 (8.9)	1 (3.1)	18 (10.1)	13 (8.7)
I usually share my belongings with others
Rarely	39 (10.8)	6 (18.8)	15 (8.4)	18 (12.1)
Sometimes	170 (47.2)	18 (56.3)	84 (46.9)	68 (45.6)
Always	151 (41.9)	8 (25)	80 (44.7)	63 (42.3)
Have you changed during lockdown?
Yes, for the better	45 (12.5)	4 (12.5)	23 (12.8)	18 (12.1)
Yes, for the worse	299 (83.1)	28 (87.5)	148 (82.7)	123 (82.6)
No	16 (4.4)	0	8 (4.5)	8 (5.4)
I get very angry and often lose my temper
Rarely	152 (42.2)	15 (46.9)	83 (46.4)	54 (36.2)
Sometimes	173 (48.1)	14 (43.8)	80 (44.7)	79 (53)
Always	35 (9.7)	3 (9.4)	16 (8.9)	16 (10.7)
Have you changed during lockdown?
Yes, for the better	35 (9.7)	3 (9.4)	17 (9.5)	15 (10.1)
Yes, for the worse	252 (70)	20 (62.5)	130 (72.6)	102 (68.5)
No	73 (20.3)	9 (28.1)	32 (17.9)	32 (21.5)
I enjoy spending time with myself, and prefer playing alone
Rarely	168 (46.7)	24 (75)	76 (42.5)	68 (45.6)
Sometimes	136 (37.8)	8 (25)	77 (43)	51 (34.2)
Always	56 (15.6)	0	26 (14.5)	30 (20.1)
Have you changed during lockdown?
Yes, for the better	35 (9.7)	5 (15.6)	15 (8.4)	15 (10.1)
Yes, for the worse	298 (82.8)	27 (84.4)	150 (83.8)	121 (81.2)
No	27 (7.5)	0	14 (7.8)	13 (8.7)
I obey and do what older people ask me to do
Rarely	18 (5)	1 (3.1)	8 (4.5)	9 (6.0)
Sometimes	147 (40.8)	13 (40.6)	70 (39.1)	64 (43.0)
Always	195 (54.2)	18 (56.3)	101 (56.4)	76 (51.0)
Have you changed during lockdown?
Yes, for the better	42 (11.7)	6 (18.8)	16 (8.9)	20 (13.4)
Yes, for the worse	294 (81.7)	26 (81.3)	153 (85.5)	115 (77.2)
No	24 (6.7)	0 (0.0)	10 (5.6)	14 (9.4)
I feel anxious and worry a lot
Rarely	150 (41.7)	14 (43.8)	79 (44.1)	57 (38.3)
Sometimes	175 (48.6)	16 (50.0)	86 (48.0)	73 (49.0)
Always	35 (9.7)	2 (6.3)	14 (7.8)	19 (12.8)
Have you changed during lockdown?
Yes, for the better	34 (9.4)	3 (9.4)	16 (8.9)	15 (10.1)
Yes, for the worse	271 (75.3)	25 (78.1)	133 (74.3)	113 (75.8)
No	55 (15.3)	4 (12.5)	30 (16.8)	21 (14.1)
I love making new friends, and I have a lot of friends
Not true	43 (11.9)	3 (9.4)	20 (11.2)	20 (13.4)
Somewhat true	186 (51.7)	16 (50.0)	90 (50.3)	80 (53.7)
Certainly true	131 (36.4)	13 (40.6)	69 (38.5)	49 (32.9)
Have you changed during lockdown?
Yes, for the better	28 (7.8)	3 (9.4)	15 (8.4)	10 (6.7)
Yes, for the worse	305 (84.7)	29 (90.6)	151 (84.4)	125 (83.9)
No	27 (7.5)	0 (0.0)	13 (7.3)	14 (9.4)
Generally, I’m loved by the people around me
Not true	3 (0.8)	0	2 (1.1)	1 (0.7)
Somewhat true	108 (30)	10 (31.3)	49 (27.4)	49 (32.9)
Certainly true	249 (69.2)	22 (68.8)	128 (71.5)	99 (66.4)
Have you changed during lockdown?
Yes, for the better	31 (8.6)	3 (9.4)	17 (9.5)	11 (7.4)
Yes, for the worse	323 (89.7)	29 (90.6)	158 (88.3)	136 (91.3)
No	6 (1.7)	0	4 (2.2)	2 (1.3)
When I’m offended, I react by fighting with others
Rarely	121 (33.6)	15 (46.9)	63 (35.2)	43 (28.9)
Sometimes	176 (48.9)	12 (37.5)	91 (50.8)	73 (49)
Always	63 (17.5)	5 (15.6)	25 (14)	33 (22.1)
Have you changed during lockdown?
Yes, for the better	25 (6.9)	2 (6.3)	13 (7.3)	10 (6.7)
Yes, for the worse	303 (84.2)	28 (87.5)	152 (84.9)	123 (82.6)
No	32 (8.9)	2 (6.3)	14 (7.8)	16 (10.7)

Table 2

Participant distribution according to psychological feelings and behavior before and during home quarantine with relation to body mass index categories

Parameter	Total, n (%)	A (underweight), n (%)	B (average weight), n (%)	C (overweight/obese), n (%)
When I deal with others, they must follow my rules
Not true	114 (31.7)	10 (31.3)	61 (34.1)	43 (28.9)
Somewhat true	214 (59.4)	17 (53.1)	103 (57.5)	94 (63.1)
Certainly true	32 (8.9)	5 (15.6)	15 (8.4)	12 (8.1)
Have you changed during lockdown?
Yes, for the better	19 (5.3)	3 (9.4)	6 (3.4)	10 (6.7)
Yes, for the worse	331 (91.9)	28 (87.5)	167 (93.3)	136 (91.3)
No	10 (2.8)	1 (3.1)	6 (3.4)	3 (2.0)
I often feel unhappy, or easily tearful
Rarely	125 (34.7)	8 (25.0)	68 (38.0)	49 (32.9)
Sometimes	165 (45.8)	17 (53.1)	80 (44.7)	68 (45.6)
Always	70 (19.4)	7 (21.9)	31 (17.3)	32 (21.5)
Have you changed during lockdown?
Yes, for the better	23 (6.4)	2 (6.3)	12 (6.7)	9 (6.0)
Yes, for the worse	283 (78.6)	26 (81.3)	138 (77.1)	119 (79.9)
No	54 (15.0)	4 (12.5)	29 (16.2)	21 (14.1)
When facing new situations, I easily lose my temper
Rarely	152 (42.2)	15 (46.9)	83 (46.4)	54 (36.2)
Sometimes	173 (48.1)	14 (43.8)	80 (44.7)	79 (53.0)
Always	35 (9.7)	3 (9.4)	16 (8.9)	16 (10.7)
Have you changed during lockdown?
Yes, for the better	35 (9.7)	3 (9.4)	17 (9.5)	15 (10.1)
Yes, for the worse	252 (70.0)	20 (62.5)	130 (72.6)	102 (68.5)
No	73 (20.3)	9 (28.1)	32 (17.9)	32 (21.5)
How would you rate your self-confidence because of your weight?
High	155 (43.1)	19 (59.4)	96 (53.6)	40 (26.8)
Average	156 (43.3)	10 (31.3)	70 (39.1)	76 (51.0)
Low	49 (13.6)	3 (9.4)	13 (7.3)	33 (22.1)
Have you changed during lockdown?
Yes, for the better	44 (12.2)	3 (9.4)	23 (12.8)	18 (12.1)
Yes, for the worse	274 (76.1)	28 (87.5)	140 (78.2)	106 (71.1)
No	42 (11.7)	1 (3.1)	16 (8.9)	25 (16.8)
Do friends and family pick on you or bully you because of your weight?
Rarely	274 (76.1)	24 (75.0)	158 (88.3)	92 (61.7)
Sometimes	72 (20.0)	8 (25.0)	17 (9.5)	47 (31.5)
Always	14 (3.9)	0	4 (2.2)	10 (6.7)
Have you changed during lockdown?
Yes, for the better	29 (8.1)	1 (3.1)	9 (5.0)	19 (12.8)
Yes, for the worse	324 (90)	30 (93.8)	167 (93.3)	127 (85.2)
No	7 (1.9)	1 (3.1)	3 (1.7)	3 (2.0)
My family and the people who I live with make fun of or bully me because of my weight
Rarely	276 (76.7)	27 (84.4)	150 (83.8)	99 (66.4)
Sometimes	72 (20)	4 (12.5)	25 (14.0)	43 (28.9)
Always	12 (3.3)	1 (3.1)	4 (2.2)	7 (4.7)
Have you changed during lockdown?
Yes, for the better	32 (8.9)	2 (6.3)	15 (8.4)	15 (10.1)
Yes, for the worse	315 (87.5)	30 (93.8)	156 (87.2)	129 (86.6)
No	13 (3.6)	0	8 (4.5)	5 (3.4)
I love to help others (such as parents, teachers, other children)
Rarely	18 (5)	1 (3.1)	6 (3.4)	11 (7.4)
Sometimes	115 (31.9)	12 (37.5)	54 (30.2)	49 (32.9)
Always	227 (63.1)	19 (59.4)	119 (66.5)	89 (59.7)
Have you changed during lockdown?
Yes, for the better	49 (13.6)	6 (18.8)	20 (11.2)	23 (15.4)
Yes, for the worse	303 (84.2)	26 (81.3)	153 (85.5)	124 (83.2)
No	8 (2.2)	0	6 (3.4)	2 (1.3)
I have many fears (phobias) for example, meeting new people, visiting new places or fear of heights
Rarely	207 (57.5)	20 (62.5)	107 (59.8)	80 (53.7)
Sometimes	120 (33.3)	9 (28.1)	57 (31.8)	54 (36.2)
Always	33 (9.2)	3 (9.4)	15 (8.4)	15 (10.1)
Have you changed during lockdown?
Yes, for the better	26 (7.2)	2 (6.3)	15 (8.4)	9 (6.0)
Yes, for the worse	324 (90)	30 (93.8)	159 (88.8)	135 (90.6)
No	10 (2.8)	0	5 (2.8)	5 (3.4)

Difficulties in daily life due to weight

Table 3 describes the daily life difficulties faced by participants due to their weight, and the effect of home quarantine on them. Results showed 90% of participants reported that their weight slightly affected their academic performance before home quarantine. However, compared to other groups, a significantly higher portion of the average weight group (64.8%, P = 0.008) reported that their academic performance had been negatively affected by online and distance education during home quarantine.

Table 3

Relationship between participants’ weight and difficulties in daily life

Parameter	n (%)	A (overweight), n (%)	B (average weight), n (%)	C (overweight/obese), n (%)
Weight affected studying and the concentration level? (before lockdown)
No	249 (69.3)	21 (65.6)	125 (69.8)	103 (69.1)
Slightly	68 (18.8)	7 (21.8)	32 (17.9)	29 (19.5)
Moderately	31 (8.6)	2 (6.3)	17 (9.5)	12 (8.1)
Severely	12 (3.3)	2 (6.3)	5 (2.8)	5 (3.4)
Online and distance education during home quarantine affected study level and academic activity
Yes, worsened	206 (57.2)	13 (40.6)	116 (64.8)	77 (51.7)
No	154 (42.8)	19 (59.4)	63 (35.2)	72 (48.3)
Weight affected home and physical activity before home quarantine
No	103 (28.6)	10 (31.3)	40 (22.3)	53 (35.6)
Slightly	180 (50)	15 (46.9)	108 (60.3)	57 (38.3)
Moderately	49 (13.6)	6 (18.8)	19 (10.6)	24 (16.1)
Severely	28 (7.8)	1 (3.1)	12 (6.7)	15 (10.1)
Home and physical difficulties increased during home quarantine
Yes, worsened	95 (2.6)	6 (18.8)	45 (25.1)	44 (29.5)
No	265 (73.6)	26 (81.3)	134 (74.9)	105 (70.5)
Did you have any sleeping difficulties before home quarantine?
No	82 (22.8)	7 (21.9)	43 (24.0)	32 (21.5)
Slightly	234 (65)	21 (65.6)	113 (63.1)	100 (67.1)
Moderately	25 (69)	2 (6.3)	14 (7.8)	9 (6.0)
Severe	19 (5.3)	2 (6.3)	9 (5.0)	8 (5.4)
Did sleeping difficulties increase during home quarantine?
Yes, worsened	74 (20.6)	7 (21.9)	37 (20.7)	30 (20.1)
No	286 (79.4)	25 (78.1)	142 (79.3)	119 (79.9)
Did you have difficulties in your personal relationships (with family) before the home quarantine?
No	276 (76.7)	26 (81.3)	134 (74.9)	116 (77.9)
Rarely	56 (15.6)	4 (12.5)	29 (16.2)	23 (15.4)
Moderately	18 (5)	2 (6.3)	10 (5.6)	6 (4.0)
Severe	10 (2.8)	0 (0.0)	6 (3.4)	4 (2.7)
Did difficulties in your personal relationships increase during home quarantine?
Yes, worsened	57 (15.8)	4 (12.5)	26 (14.5)	27 (18.1)
No	303 (84.2)	28 (87.5)	153 (85.5)	122 (81.9)
How long ago did any of these difficulties (such as studying, physical or home activities, sleep, relationships) start?
Only during home quarantine	240 (66.7)	25 (78.1)	120 (67.0)	95 (63.8)
Less than a month	22 (6.1)	0 (0.0)	17 (9.5)	5 (3.4)
1-5 months	27 (7.5)	2 (6.3)	15 (8.4)	10 (6.7)
6-12 months	10 (2.8)	0 (0.0)	6 (3.4)	4 (2.7)
More than a year	61 (16.9)	5 (15.6)	21 (11.7)	35 (23.5)
How long ago did any of these difficulties (such as studying, physical or home activities, sleep, relationships) start?
Only during home quarantine	240 (66.7)	25 (78.1)	120 (67.0)	95 (63.8)
Less than a month	22 (6.1)	0 (0.0)	17 (9.5)	5 (3.4)
1-5 months	27 (7.5)	2 (6.3)	15 (8.4)	10 (6.7)
6-12 months	10 (2.8)	0 (0.0)	6 (3.4)	4 (2.7)
More than a year	61 (16.9)	5 (15.6)	21 (11.7)	35 (23.5)

A significantly high percentage (38.3%) of overweight/obese participants reported that weight slightly affected their activity level before home quarantine (P = 0.007). Moreover, the majority of the overweight/obese participants (70.5%) reported that home and physical activity difficulties did not increase during home quarantine.

In addition, among the overweight/obese participants, 63.8% reported difficulties in sleep, studies, personal relationships, and daily life difficulties during home quarantine. Moreover, no significant difference was found between the BMI categories and the other daily life difficulties due to weight change (P > 0.05).

DISCUSSION

This study is one of the few studies that investigated the psychological impact of childhood obesity on mental health simultaneously with the impact of COVID-19 on children and adolescents in Saudi Arabia. Our study suggested that the lockdown had an important effect on overweight/obese children and adolescents’ emotions and behaviors. Among the overweight/obese participants, 35.6% were physically inactive and 38.3% were slightly active before home quarantine. A recent study highlighted that children avoided exercise due to feelings of discomfort, and they often pondered previous negative experiences that occurred during physical education classes.[19] Similarly, our results showed that participants’ physical inactivity has worsened during lockdown due to home confinement.

In this study, there was a highly significant relationship between self-confidence and weight, a higher percentage of obese than average weight participants reported low self-confidence due to weight. Several studies have found a significant relationship between low self-confidence and increased weight.[2021] Our results found that overweight/obese participants (71.1%) reported diminished self-confidence during the lockdown. This may be due to the increased meal/snack consumption during home quarantine contributing to weight gain and decreased self-confidence. In this regard, a study from the COVID-19 period showed that 22% of participants reported weight gain, stress eating, and snacking during quarantine.[22]

Contrary to many studies that reported obesity as a predictor of bullying,[2324] our results showed that overweight/obese participants were not bullied by their families and friends before the home quarantine; 92 out of 149 (61.7%) answered “rarely” for having been bullied. The majority of overweight/obese participants (66.4%) answered “certainly true” when asked if they felt loved by the people around them. This is a surprisingly positive perspective considering that multiple Chinese and Taiwanese studies have reported that overweight/obese children face hatred, bullying, low self-confidence, and some emotional neglect.[2526] This study's finding is interesting, which possibly stemmed from years of educational bullying campaigns. However, bullying worsened for the majority of overweight/obese participants during home quarantine.

Most overweight/obese children love making new friends and having many friends. This finding matched that of a study conducted in the United Kingdom that failed to demonstrate that overweight girls had fewer friends and were less popular.[27] In contrast, an American study found that obese children and adolescents have difficulties with peer relationships.[28] In addition, this study found a significant relationship between being overweight/obese and self-isolation before lockdown; a higher percentage of participants who said that they always prefer spending time alone were overweight/obese. A previous study reported an association between obesity and loneliness, which was related to depressive symptoms, stigmatization, and discrimination.[29] However, 81.2% of the overweight/obese participants in our study became more self-isolated during quarantine, similar to 82.8% of the total participants that also reported their psychosocial symptoms worsened during the lockdown.

Studies conducted before the COVID-19 pandemic showed that there was a significantly higher anxiety rate in obese/overweight children.[30] Research conducted during the pandemic has shown that one in three children displayed nervousness when hearing news about the pandemic, and students’ anxiety levels increased (due to online teaching) during lockdown.[3132] All three BMI groups in this study showed increased anxiousness and developed phobias during lockdown due to coronavirus-related fears, concerns for the health of loved ones, extra precautions, and online studying. Furthermore, one study suggested that increased coronavirus media exposure could heighten fear.[33]

Depression among youth can stem from increased BMI, considering research, which reported that depression scores were highest among adolescents who had the greatest BMI increase.[34] In this study, the overweight/obese participants conveyed that they often felt unhappy. Strikingly, most of the overweight/obese participants admitted that their unhappiness increased during quarantine. A Chinese study found that 20% of a sample of 1,800 children, regardless of their weight, had depression or anxiety symptoms due to quarantine.[35]

Similar to a Taiwanese study that reported no relation between weight and anger,[26] our results showed no significant correlation between weight and anger. Moreover, 70% of the participants reported less anger control during the lockdown. These expected results were compatible with several studies conducted during both the SARS, 2004,[36] and COVID-19, lockdowns.[37]

In addition, previous studies indicated that cognitive performance declines with physical inactivity, and increased BMI,[3839] perhaps explaining why 19.5% of overweight/obese participants answered that weight “slightly” affected their studying level before quarantine. However, it could also be explained by other individual characteristics (including parental schooling and the home environment), suggesting that being overweight was a predictor but not a causal factor.[40] Moreover, 206 (57.2%) participants, of which 77 (51.7%) were overweight/obese, answered that their study level and academic activity changed for the worse during online and distance education under home quarantine. This may have been due to many factors, including not having a proper separate studying room for the child/youth that possibly spent less time studying due to many distractions.[33]

Results further showed that 66.7% of participants reported that their difficulties (sleep, study, personal relationships, and daily life) started during home quarantine. An Italian study revealed similar COVID-19 pandemic-related effects on children's emotions and behaviors, such as increased irritability, intolerance to rules, mood changes, sleep problems, and agitation.[31]

Limitations

First, this study had a cross-sectional design and clinical interviews were conducted one time to obtain answers about the periods before and during the COVID-19 lockdown. Furthermore, no preliminary or follow-up interviews were conducted to compare the results. Moreover, the data were based on participant's recall of information and not based on the objective documentation. Second, we studied a small sample size due to telecommunication-interviewing and the consequent inability to reach everyone. Third, the ongoing COVID-19 pandemic affects everyone in many ways, and the clinical interviews were conducted while children/youth were still living at home during quarantine through the peak months. Finally, the data showed that the psychological characteristics for obese children changed during the lockdown. However, we cannot exclude the magnifying impact of social, genetic, and physiological factors on these symptoms.

CONCLUSION

This study revealed that the COVID-19 pandemic, including forced quarantine, had a significant negative effect on the behavior of overweight/obese children and adolescents. The results demonstrated that childhood is a very critical age and thus special care should be given to children.

Recommendations

Considering this study's results, we urge families to decrease their children/adolescents’ exposure to the COVID-19-crisis media coverage, since studies have shown that it may increase anxiety. In addition, measures should be taken to increase awareness of the psychological and behavioral difficulties children/adolescents face because of their weight and help them through it. We recommend further research about these behavioral and psychological changes to ascertain whether they persist, intensify, or are temporary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.