An Evaluation of the COVID-19 Pandemic and Perceived Social Distancing Policies in Relation to Planning, Selecting, and Preparing Healthy Meals: An Observational Study in 38 Countries Worldwide

Countries worldwide have implemented strict controls on movement in response to the covid-19 pandemic. The aim is to cut transmission by reducing close contact (box 1), but the measures have profound consequences. Several sectors are seeing steep reductions in business, and there has been panic buying in shops. Social, economic, and health consequences are inevitable. Box 1 Social distancing measures Advising the whole population to self-isolate at home if they or their family have symptoms Bans on social gatherings (including mass gatherings) Stopping flights and public transport Closure of “non-essential” workplaces (beyond the health and social care sector, utilities, and the food chain) with continued working from home for those that can Closure of schools, colleges, and universities Prohibition of all “non-essential” population movement Limiting contact for special populations (eg, care homes, prisons) The health benefits of social distancing measures are obvious, with a slower spread of infection reducing the risk that health services will be overwhelmed. But they may also prolong the pandemic and the restrictions adopted to mitigate it.1 Policy makers need to balance these considerations while paying attention to broader effects on health and health equity. Who is most at risk? Several groups may be particularly vulnerable to the effects of both the pandemic and the social distancing measures (box 2). Table 1 summarises several mechanisms through which the pandemic response is likely to affect health: economic effects, social isolation, family relationships, health related behaviours, disruption to essential services, disrupted education, transport and green space, social disorder, and psychosocial effects. Figure 1 shows the complexity of the pathways through which these effects may arise. Below we expand on the first three mechanisms, using Scotland as an example. The appendix on bmj.com provides further details of mechanisms, effects, and mitigation measures. Box 2 Groups at particular risk from responses to covid-19 Older people—highest direct risk of severe covid-19, more likely to live alone, less likely to use online communications, at risk of social isolation Young people—affected by disrupted education at critical time; in longer term most at risk of poor employment and associated health outcomes in economic downturn Women—more likely to be carers, likely to lose income if need to provide childcare during school closures, potential for increase in family violence for some People of East Asian ethnicity—may be at increased risk of discrimination and harassment because the pandemic is associated with China People with mental health problems—may be at greater risk from social isolation People who use substances or in recovery—risk of relapse or withdrawal People with a disability—affected by disrupted support services People with reduced communication abilities (eg, learning disabilities, limited literacy or English language ability)—may not receive key governmental communications Homeless people—may be unable to self-isolate or affected by disrupted support services People in criminal justice system—difficulty of isolation in prison setting, loss of contact with family Undocumented migrants—may have no access to or be reluctant to engage with health services Workers on precarious contracts or self-employed—high risk of adverse effects from loss of work and no income People on low income—effects will be particularly severe as they already have poorer health and are more likely to be in insecure work without financial reserves People in institutions (care homes, special needs facilities, prisons, migrant detention centres, cruise liners)—as these institutions may act as amplifiers Table 1 Health effects of social distancing measures and actions to mitigate them Mechanism Summary of effects Summary of mitigations Economic effects • Income losses for workers unable to work• Longer term increase in unemployment if businesses fail• Recession • Protect incomes at the level of the minimum income for healthy living• Provide food and other essential supplies• Reduce longer term unemployment• Prioritise inclusive and sustainable economic development during recovery Social isolation • Lack of social contact, particularly for people who live alone and have less access to digital connectivity• Difficulty accessing food and other supplies • Encourage and support other forms of social contact• Provide supplies• Provide clear communications• Restrict duration of isolation Family relationships • Home confinement may increase family violence and abuse• Potential exploitation of young people not in school • Offer support to vulnerable families• Ensure realistic expectations for home working and home schooling• Provide safety advice and support services for women at risk of domestic abuse Health related behaviours • Potential for increased substance use, increased online gambling, and a rise in unintended pregnancies• Reduction in physical activity as sports facilities closed and less utilitarian walking and cycling • Advice and support on substance use, gambling, contraception• Encourage daily physical activity Disruption to essential services • Direct effects on health and social care demand• Unwillingness to attend healthcare settings may affect care of other conditions• Loss of workforce may affect essential services • Robust business continuity planning• Prioritise essential services including healthcare, social care, emergency services, utilities, and the food chain• Guidance, online consultations, and outreach, for conditions other than covid-19• Attention to supply chains for non-covid medicines Disruption to education • Loss of education and skills, particularly for young people at critical transitions• Likely increase in educational inequalities from reliance on home schooling • Provide support for young people in critical transitions, and low income or at-risk children and young people who lack IT and good home study environments Traffic, transport, and green space • Reduced aviation and motorised traffic with reduced air pollution, noise, injuries, and carbon emissions in short term• Restricted public transport may reduce access for people without a car• Longer term reluctance to use public transport may increase use of private cars• Restricted access to green space, which has benefits for physical and mental health • Discourage unnecessary car journeys• Support active travel modes• Support safe access to green spaces• Post-pandemic support for public transport Social disorder • Potential for unrest if supplies run out or there is widespread discontent about the response• Harassment of people believed to be at risk of transmitting the virus • Mitigation of other effects will reduce risk of social disorder• Avoid stigmatising ill people or linking the pandemic to specific populations Psychosocial impacts • High level of public fear and anxiety• Community cohesion could increase as people respond collectively • Provide clear communications• Support community organisations responding to local needs Fig 1 Effects of social distancing measures on health Economic effects People may experience loss of income from social distancing in several ways. Although some people can work at home, many cannot, especially those in public facing roles in service industries, a group that already faces precarious employment and low income.2 Others may be affected by workplace closures, caused by government mandate, an infected co-worker, or loss of business. Yet more may be unable to work as school closures require them to provide childcare. In the UK, 3.5 million additional people are expected to need universal credit (which includes unemployment payments) as a result of the pandemic.3 The growth of the informal, gig economy in some countries has created a large group of people who are especially vulnerable as they do not get sick pay, are on zero hours contracts, or are self-employed.4 They can easily lose all their income, and even if this is only temporary they often lack the safety net of savings. An important risk is housing security, with loss of income causing rent or mortgage arrears or even homelessness. School closure will affect low income and single parent families especially severely because they need to meet an unexpected need for childcare and lose the benefit of free school meals. They may also face increased costs for heating their homes during the day. In some countries, welfare systems impose strict conditions on recipients that cannot be met by those in isolation. The link between income and health is well established and acts through several mechanisms.5 Income allows people to buy necessities for life, access health enhancing resources, avoid harmful exposures, and participate in normal activities of society. Low income also increases psychosocial stress. The minimum income for healthy living establishes a standard required to maintain health in different settings.6 Crucially, not everyone is equally likely to lose income. Women, young people, and those who are already poor will fare worst. To avoid widening health inequalities, social distancing must be accompanied by measures to safeguard the incomes of poor people. Future challenges The longer term effects may be substantial. If businesses fail, many employees will become unemployed. Those losing their jobs in middle age may never return to the workforce. Sectors that are especially vulnerable include hospitality, entertainment, transport, leisure, and sport. Unemployment has large negative effects on both physical and mental health,7 with a meta-analysis reporting a 76% increase in all-cause mortality in people followed for up to 10 years after becoming unemployed.8 The pandemic has already caused downgrading of economic forecasts, with many countries facing a recession. The health consequences of a recession are complex. Economic downturns have been associated with improvements in some health outcomes, especially traffic injuries, but worsening mental health, including increases in homicide and suicide.9 However, these harmful effects can be prevented by progressive social policies; it is the policy response to a recession, rather than the recession itself, that determines longer term population health.10 Throughout history, some people have viewed any crisis as an opportunity. Klein described how “disaster capitalists” take advantage of natural and human influenced disasters.11 There is clear potential for price gouging (profiteering through increased prices during supply or demand shocks) on essential goods. Once the pandemic recedes, there could be profound changes to the economy that may disadvantage less powerful populations, such as through privatisation of public sector services. However, there may also be opportunities for the economy to be rebuilt “better,” depending on public and political attitudes and power balance.12 Social isolation Advising or compelling people to self-isolate at home risks serious social and psychological harm. Quarantine of people exposed to an infectious disease is associated with negative psychological effects, including post-traumatic stress symptoms, which may be long lasting.13 The effects are exacerbated by prolonged isolation, fear of the infection, frustration, boredom, inadequate supplies and information, financial loss, and stigma. These effects are less when quarantine is voluntary and can be mitigated by ensuring clear rapid communication, keeping the duration short, providing food and other essential supplies, and protecting against financial loss.13 In Scotland, a third of the population lives alone and 40% of this group are of pensionable age.14 Older people are also less likely to use online communications, making them at particular risk of social isolation during social distancing. Social isolation is defined as pervasive lack of social contact or communication, participation in social activities, or a confidante. Long term, social isolation is associated with an increase in mortality of almost a third.15 Prolonged periods of social distancing could have similar effects. People who are socioeconomically disadvantaged or in poor physical or mental health are at higher risk.16 Online and telephone support needs to be provided for vulnerable groups, especially those living alone. Family relationships Social distancing measures will place many people in close proximity with family members all or most of the time, which may cause or exacerbate tensions. Concern has been raised about potential increases in family violence during restrictions in the UK.17 Risk factors for partner and child abuse include poverty, substance misuse in the home, and previous history of abuse.18 19 Around 60 000 domestic abuse incidents occur in Scotland every year, with young women most affected, 20 and over 2500 children are on the child protection register.21 It is important to maintain social work and community support for vulnerable families, including safety advice for women at risk of abuse. Domestic abuse advocates have called for enhanced support, including allocation of hotel rooms for women at risk.17 School closures may add to stress in families as parents try to home school children, often juggling this with home working. This burden may fall disproportionately on women. As well as academic learning, schools support development of social and other skills. Prolonged school closures could cause adverse effects on educational and social outcomes for young people in families that lack study space and access to home computing.22 Some children who are not at school may be at risk of online or other forms of exploitation—for example, by drug dealers—or of being recruited into gangs. Realistic expectations of home schooling, provision of food for those eligible for free school meals, and outreach support for the most vulnerable children will be needed during school closures. Many children will need extra support on return to school.22 Mitigating adverse effects In addition to the direct disease burden from covid-19, the pandemic response is already causing negative indirect effects such as those described above. These are borne disproportionately by people who already have fewer resources and poorer health. Prolonged or more restrictive social distancing measures could increase health inequalities in the short and long term. Our assessment is based on rapid scoping of potential impacts and a non-systematic review of diverse publications, so there is a high degree of uncertainty about the extent of some impacts. However, the range of health concerns identified, beyond those directly attributable to the virus itself, should be recognised in developing and implementing responses. The effects may also vary by context. In low and middle income countries without social safety nets, the effects on population health and health inequalities are likely to be worse than in richer countries, as is beginning to be seen in India.23 Actions must be targeted to support the most vulnerable people. The extraordinary measures in the UK to allow businesses to continue paying staff will help mitigate the harms for many workers. But it is important to consider people in precarious work who will not be covered by these measures, and to consider longer term support for those who continue to experience problems once the measures expire. A large multiagency response will be needed to deal with the wide range of needs we have identified. In the longer term, policy decisions made now will shape the future economy in ways that could either improve or damage sustainability, health, and health inequalities. These include decisions about which sectors to prioritise for support, whether to direct financial support to business or workers, and how to fund the costs. To protect population health it will be essential to avoid a further period of austerity and the associated reductions in social security and public service spending. Instead we must build a more sustainable and inclusive economy.10 Key messages Social distancing measures to control the spread of covid-19 are likely to have large effects on health and health inequalities These effects have numerous mechanisms, including economic, social, health related behaviours, and disruption to services and education People on low incomes are most vulnerable to the adverse effects Substantial mitigation measures are needed in the short and long term

COVID-19, a disease caused by a novel coronavirus, became a major global human threat that has turned into a pandemic. Coronavirus is one of the major pathogens that mainly targets the human respiratory system. In late December 2019, a cluster of patients were admitted to hospitals with an initial diagnosis of pneumonia of an unknown etiology [1]. Early reports predicted the onset of a possible coronavirus outbreak called SARS-CoV-2, causing the disease COVID-19. The ongoing epidemic has been declared by the World Health Organization (WHO) as a global public health emergency [2]. Experiences from previous outbreaks have shown that as an epidemic evolves, there is an urgent need to expand public health activities beyond direct clinical management and extend to cover basic principles of management and optimization of resource utilization [3]. Since the outbreak of the COVID-19, individual and community resilience emerged as a main resource while remaining the first line of defense in emergency preparedness. In fact, psychological and behavioral countermeasures of both the individual and the community are vital determinants to improve resilience and enhance the efficacy of public health approaches vis a vis a pandemic of a magnitude similar to that of COVID-19 [4]. The nutritional status of individuals has for long been considered as an indicator of resilience against destabilization [5]. The ecology of adversity and resilience demonstrates that substantial stressors, such as inadequate nutrition, can lead to long-lasting effects that are linked to health [6]. In fact, poor diet quality has been associated not only with physical but also mental health [7]. Optimal nutrition and dietary intake is a resource that transcends the individual, the community to reach global influence [8]. In order to enhance the physical and mental health of individuals vis a vis the COVID-19 pandemic, this commentary presents a framework for action to maintain optimal nutrition at the individual, community, national and global levels using an adapted version of the ecological model of health behavior (Fig. 1). Fig. 1 A multi-level framework of action to support nutrition during the COVID-19 pandemic. A multi-level framework to support nutrition and food security during the COVID-19 pandemic, using the various levels of the ecological health model: individual, community, national and global. At the individual level, the common denominator that drives most of the nutrition and dietary recommendations to combat viral infections, including COVID-19, lies within the link between diet and immunity. In fact, existing evidence highlights that diet has a profound effect on people’s immune system and disease susceptibility. It has been demonstrated that specific nutrients or nutrient combinations may affect the immune system through the activation of cells, modification in the production of signaling molecules, and gene expression [9]. Furthermore, dietary ingredients are significant determinants of gut microbial composition and consequently can shape the characteristics of immune responses in the body [10]. Nutritional deficiencies of energy, protein, and specific micronutrients are associated with depressed immune function and increased susceptibility to infection. An adequate intake of iron, zinc, and vitamins A, E, B6, and B12 is predominantly vital for the maintenance of immune function [11]. Therefore, the key to maintaining an effective immune system is to avoid deficiencies of the nutrients that play an essential role in immune cell triggering, interaction, differentiation, or functional expression. COVID-19 world pandemic imposed a new set of challenges for the individual to maintain a healthy diet. First, the state of lockdown announced in many countries around the globe led all public and private sector institutions, with the exception of health care facilities and a limited number of essential services, to close down and, if possible, carry its operations remotely (without face to face interactions). Individuals were asked to stay home and avoid contact with other people [12]. Such measures of self-isolation and social distancing are known to be crucial in limiting the spread of the virus, flattening the curve of incidence rate, and ultimately disease containment [13]. These measures have severe repercussions on both food access and utilization. Food access, however, is dependent on factors that could reach beyond the individual and are more directly related to actions and policies at the community, national as well as global levels. That said, the individual remains capable of making a few choices related to food utilization. The confinement to one’s home has direct effects on one’s lifestyle, including dietary habits, eating, and physical activity patterns. Confinement increases sedentary behaviors that involve activities with very low energy expenditure, performed mainly in a sitting or supine position [14]. The low physical activity levels, even for short periods, could negatively affect physical and mental health. The state of lockdown and confinement could also lead to irregular eating patterns and frequent snacking, both of which are associated with higher caloric intake and increased risk of obesity [15]. The changes in dietary patterns during the outbreak of COVID-19 could also be driven by the fear and anxiety many people around the globe are experiencing. Compelling evidence showed that dietary habits are affected by conditions of stress, distress, and emotional disturbance, whereby elevated distress levels are associated with unhealthy dietary patterns and poor quality of the diet [16]. Furthermore, emotions like fear and sadness are associated with less desire or motivation to eat and with lessened enjoyment during eating [17]. More recently, in explicating a five-way model of emotions and diet, it was found that changes in food intake may be the “natural” response to stress and heightened emotional states through both psychological and physiological mechanisms [18]. Therefore, the responsibility of the individuals during the COVID-19 pandemic lies in making an effort to choose a healthy lifestyle, eat diets high in fruits and vegetables, exercise during free time, try to maintain a healthy weight, and get an adequate amount of sleep. In addition to taking care of one’s dietary intake, the collective responsibility of individuals is to avoid the spread of misinformation related to nutrition and dietary intake, and the COVID-19. Since the outbreak, networks of social media were flooded by messages of single foods/herbs promising cure or prevention of the infection. The effects of such unfounded claims could lead to negative implications ranging from giving a false sense of protection against the infection to toxicity. At the community level, food access and availability are particularly vulnerable to the implications of the COVID-19 outbreak, primarily because of difficulties in transportation, distribution, and delivery [19]. This situation has led in many instances to ‘hoarding’. One way that a pandemic would indirectly impact the food supply chain is by changing consumer behavior. Pandemics create uncertainty and volatility in consumer demand, making it particularly challenging to maintain food inventories in a just in time economy [20]. In a study of the effect of an outbreak on behavior, the most recurrent response is to stockpile supplies, food, and water [21]. Those who can afford extra food may hoard more than they need and pose devastating consequences on at risk-populations. Hoarding could lead to extreme shortages in markets, leading to rapidly rising prices [22]. Therefore, at a community level, it is crucial to spread awareness against ‘Panic-buy’. Furthermore, during the COVID-19 pandemic, older adults and patients with chronic diseases became particularly vulnerable and most at risk to nutrition imbalance. Firstly, available research indicated that adults 60 years and older and patients with pre-existing medical conditions, especially heart disease, lung disease, diabetes or cancer are more likely to have severe—even deadly—coronavirus infection than other groups [23]. Second, the recommendations to stay home and abide by social distancing targeted these groups specifically, given their vulnerability. Third, the elderly and patients with chronic diseases may already be susceptible to malnutrition given their compromised health and limited purchasing ability. Therefore, at the level of the community, it is crucial to identify these vulnerable groups and extend assistance in food access and availability through a structured and reliable support system. At the national level, while governments of countries around the globe are dealing with the burden of the COVID-19 and its enormous strains on the healthcare system, they are also battling a destabilization in their economies and a rising threat of food insecurity. In light of these challenges to provide adequate and nutritious food at times of pandemics, each country is urged to define, finance, and distribute a food basket of a least-cost diet that supports the health needs of the population, ensure the use of the local agricultural produce of the country, and minimize reliance on food imports. Significant planning is needed at the national level to increase the nation’s preparedness, including the formulation of policies to support the production, distribution, and access of this food basket to different communities [24]. Among these policies are those related to mobilization of resources in order to finance food purchases and provisions, tax waiving for staple foods and commodities, and support for agricultural and food production industries. Given the effect of the COVID-19 pandemic on the demand and supply dynamics of food, price hikes became prevalent reaching at times uncontrollable levels, a situation that requires national efforts to closely monitor and inspect food prices and markets. The COVID-19 pandemic imposed a paradigm shift on governments, whereby it became imperative to build networks with the private sector, the international agencies, and local communities. It is only through a coordinated effort of these different entities that securing essential nutritious food stocks become possible. Also, governments are asked to build and maintain open and two-way communication with the public during this pandemic, especially that transparency is critical for building trust, support, and compliance. Specific methods to inform the public about adequate food consumption and intake might include public awareness campaigns, nutrition education, emergency news bulletins, radio and TV announcements and interviews, and the dedication of specific telephone hotlines for direct communication with government representatives [25]. At the global level, while border protection is legitimate in safeguarding the health of citizens from external threats; however, it can severely disrupt travel, trade, and tourism, as well as infringe civil liberties [26]. Countries that depend heavily on imported food to meet demand might face inconsistent risk from supply chain failures, especially in the face of border crossing closures. Therefore, it is essential to ensure the smooth flow of global trade and make full use of the international markets as a vital tool to secure food supply across the globe to prevent food insecurity. An important lesson of the COVID-19 relates to its global nature whereby no country is immune to its spread and infliction: a global threat requires global action. The protectionist strategies that each country is implementing should be complemented by global cooperation, solidarity, and coordination among countries to ensure that humanity emerges from this pandemic with the least possible losses. In conclusion, while much remains to be known about the COVID-19, the influence of this pandemic on nutrition and dietary intake has already gone beyond the individual and the community to reach national and global levels. A particular feature of this pandemic is highlighting the interdependence of these various levels, whereby the health of the individual became a direct function of his own awareness and choices, the unity of the community, the preparedness of the government, and ultimately the global engagement vis a vis this threat. In this perspective, a framework for action and recommendations is presented at each of those levels. A summary of these recommendations are presented in Fig. 2. The main goal of these recommendations is to maintain the physical and mental health of individuals, resilience of communities, and national and global food security. Fig. 2 Recommendations to mitigate the impact of COVID-19 on nutrition and food security. Recommendations to mitigate the impact of COVID-19 on nutrition and food security at the individual, community, national and global levels.