Abstract

Methods

This paper reports results of a short, anonymously completed, self-report survey of people living in Australia and aged at least 18 years, with data collected from 3 April 2020 to 2 May 2020. The questionnaire included sociodemographic questions, fixed-response-option questions about the experiences of living with the COVID-19 pandemic and resulting restrictions, and two widely used standardised psychometric instruments of symptoms of depression and anxiety. The survey methods have been published⁽²⁾.

Symptoms of anxiety were assessed using the Generalised Anxiety Disorder Scale-7⁽¹⁵⁾. The Generalised Anxiety Disorder Scale-7 is a seven-item validated scale assessing frequency of experiencing common symptoms of anxiety in the preceding 2 weeks. Scores of 5–9 represent mild anxiety, 10–14 moderate anxiety and 15–21 severe anxiety. Clinically significant anxiety is defined as a Generalised Anxiety Disorder Scale-7 score ≥ 10.

Symptoms of depression were assessed using the Patient Health Questionnaire 9⁽¹⁶⁾, a nine-item validated scale assessing frequency of experiencing common symptoms of depression in the preceding 2 weeks. Aggregated responses to the nine items provide an indicative scale of depression symptom severity. Patient Health Questionnaire 9 scores of 5–9 represent mild, 10–14 moderate, 15–19 moderately severe and ≥20 severe depressive symptoms. Clinically significant symptoms of depression were defined as Patient Health Questionnaire 9 scores ≥10.

Bothersome poor appetite or overeating was determined from item 5 of the Patient Health Questionnaire 9⁽¹⁶⁾, which asks respondents ‘Over the past 2 weeks, how often have you been bothered by poor appetite or overeating?’ with response options of ‘not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’.

Results

A total of 13 829 adults (mean age 50·4 (sd 14·9) years) contributed complete data. Their demographic characteristics are presented in Table ​Table1.1. The weighted prevalence of being bothered at all by poor appetite or overeating in the previous 2 weeks was 53·6 %, with 11·6 % (95 % CI 10·6, 12·6) of respondents bothered by poor appetite or overeating nearly every day (Table ​(Table22).

Multiple logistic regression analysis indicated that age, gender, socio-economic status, living circumstances, being born overseas, concern about contracting COVID-19 and being highly affected by the COVID-19 pandemic restrictions were associated with odds of being bothered by poor appetite or overeating (Table ​(Table3).3). Above the age of 40 years, after multivariate adjustment, increasing age was incrementally associated with decreasing odds of being bothered by poor appetite or overeating in the previous fortnight.

Being male was associated with lower odds of being bothered by poor appetite or overeating, as was high socio-economic advantage (Table ​(Table3).3). Those living alone, with children and without a partner, or in a shared house with non-family members had significantly greater odds of being bothered by poor appetite or overeating than people living in a household with a partner and no children (Table ​(Table33).

Being in unpaid caring roles, unemployed before the COVID pandemic and still unemployed, retired or on government welfare benefits were associated with slightly lowered odds of being bothered by poor appetite or overeating compared with those who were continuing paid work or study from home.

Discussion

These findings demonstrate that, in the first month of COVID-19 pandemic restrictions, more than half of the sampled adults reported that they were bothered by poorer appetite or eating more than usual. Women, those living alone, those living with children and without a partner, those very worried about contacting COVID-19 and those who felt a greater adverse effect of pandemic restrictions, were particularly likely to report being bothered by poor appetite or overeating. Older age, living with adult family members without children, higher socio-economic status, not being in paid work or study before COVID-19 and living in a regional area appeared to reduce the risk of being bothered by appetite and overeating during the pandemic. Clinically significant depression and anxiety were also associated with substantially increased odds of reporting being bothered by poor appetite or overeating.

Emotional eating (eating in response to negative emotions) is a well-described phenomenon⁽¹⁸⁾ and has been implicated in the pathway between depression and obesity⁽¹⁹⁾. Emotional eating is most commonly reported in response to boredom, loneliness and anxiety⁽²⁰⁾. Stress can suppress appetite⁽²¹⁾, and loss of appetite is a common feature of depression and anxiety⁽²²⁾.

Living alone, living with children or living in shared accommodation with non-family members were all associated with increased odds of being bothered by poor appetite or overeating, compared with living with a partner. Eating alone is a known risk factor for malnutrition in older adults⁽²³⁾, and eating either alone or with non-family members is associated with increased risk of obesity when compared with eating with family⁽²⁴⁾. At the time of the survey, schools were shut to all but the children of essential workers, and most households with children, were ‘learning from home’. While those with sole responsibility for children were most bothered by poor appetite or overeating, those living with a partner and children were also more likely to be bothered by poor appetite or overeating than those living with a partner only. This suggests the possibilities that having children at home during the lockdown may induce stress which affects appetite or overeating or that catering to the dietary needs of children in the home may present additional eating opportunities. Living outside major metropolitan cities was associated with lower odds of being bothered by poor appetite or overeating. Possible explanations for this regional resilience may include feeling somewhat removed from the epicentre of the pandemic (which was concentrated at the time in major cities⁽¹⁾), or perhaps having working and daily lives that were less disrupted by lockdown.

There were important age and gender differences in the reports of being bothered by poor appetite or overeating. Women were more likely to report being bothered by poor appetite or overeating than men. This is consistent with evidence that women tend to report greater weight/body shape concerns, eating concerns and binge eating than men⁽²⁵⁾. Increasing age was associated with lower odds of being bothered by poor appetite or overeating, despite older age being associated with more worry about contracting COVID-19⁽²⁾. Possible explanations for this age-related resilience to eating behaviour change may be more habitually stable eating patterns⁽²⁶⁾, age-related decline in concern about body shape or weight change⁽²⁷⁾, being more financially secure or having greater life experience of difficult situations and thus more capacity to regulate emotions in the face of the life changes imposed by lockdown. In young adult men, higher anxiety has been reported to be associated with uncontrolled eating, but uncontrolled eating also decreased with age⁽²²⁾. However, a similar pattern of age-related decline in disordered eating was not noted in young women⁽²²⁾.

Environmental factors are known to be associated with food consumption. Overeating is related to the presence of palatable food in the environment⁽²⁸⁾; with a pandemic-related lockdown, some people may have found themselves working from home in close proximity to the kitchen and its temptations. Those who were not working or studying outside the home before lockdown (and perhaps more accustomed to spending time at home) appeared to fare better in not being bothered by dietary behaviour, even though this group included people on low or fixed incomes (e.g. pensions), a population group generally considered to be at increased dietary risk⁽²⁹⁾. In a US study of economically disadvantaged women, resistance to emotional eating and favourable social eating behaviours were associated with better diet quality and lower BMI, with evidence that these factors were key to mediating the relationship between food insecurity and BMI in women living on low incomes⁽³⁰⁾. A feature of the early stages of the first pandemic wave lockdown in Australia was panic-buying or stockpiling of long-life foods such as flour, sugar, dried pasta, rice, biscuits, and bottled and canned foods. Baking and home cooking (notably ‘iso-baking’) were also prominent during this period⁽³¹⁾ and may have contributed to an increase in the available food in the home environment.

There appeared to be a socio-economic gradient in these findings, with those of greatest advantage least bothered by poor appetite or overeating, although following adjustment for other factors only the two extreme quintiles of socio-economic area status remained significantly different. The ability of economic advantage to buffer against any personal economic stress arising from the pandemic lockdown (e.g. losing or being stood down from employment, business downturn) may be one explanation. Greater access to health and well-being services and preventive healthcare may be another.

These findings of adult eating behaviour concerns in Australia during the early stages of the COVID-19 pandemic do bear some similarities to what has been observed in other countries. The proportion of those who reported being bothered by poor appetite or overeating in this study was similar to self-reported dietary behaviours in Italy⁽¹⁰⁾ and Poland⁽¹²⁾. In the survey of 1932 Italians, 53 % reported that they were eating more during confinement; 42 % of survey respondents attributed their dietary change to stress, anxiety or boredom⁽¹⁰⁾. Another survey covering Northern, Central and Southern Italy found that 17·8 % of the sample reported reduced appetite, while 34·4 % reported increased appetite during the COVID-19 lockdown⁽¹¹⁾.

Implications and conclusions

The findings of this study indicate that bothersome poor appetite or overeating was experienced by over 50 % of adults during the first month of COVID-19 restrictions during the first wave of the pandemic. While short periods of dietary behaviour change may not significantly impact upon weight, with longer periods of lockdown, this may become of greater public health concern. Prolonged overeating increases risk of weight gain and obesity, with obesity being a well-known risk factor for chronic disease⁽³³⁾. Weight gain may also cause psychological distress associated with unwanted changes in body shape⁽²⁵⁾. During the first wave of the pandemic, research has emerged indicating that obesity is a risk factor for greater severity of COVID-19⁽³⁴⁾. Weight gain might therefore heighten distress among those already concerned about contracting COVID-19. With subsequent waves of the pandemic and variability in responses to these across different countries, longitudinal studies of eating behaviour and other behavioural risk factors are needed to understand both short-term and long-term mental and physical health impacts⁽³⁵⁾.

There are factors that may limit (older age, regional dwelling, being more accustomed to spending time at home) or increase (female gender, anxiety, depression, being in lockdown with children) risk of being bothered by poor appetite or overeating for adults living in a high-income country during lockdown necessitated to control a pandemic. From a public health perspective, this research can inform universal and targeted public health promotion strategies to assist people to restore healthier eating patterns during periods of society-wide confinement and disruptions to routine. It has been suggested that cognitive behavioural therapy may be one option for improving emotional regulation and assisting development of coping strategies associated with lockdown, and e-health delivery of cognitive behavioural therapy may be appropriate for those experiencing severe distress⁽³⁶⁾. As more than half of adults in this large sample reported being bothered by poor appetite or overeating, population-wide public health strategies may also be warranted for subsequent pandemic waves and periods of lockdown.

Acknowledgements

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