To the best of the author’s knowledge, this research is the first to highlight the impact of both COVID-19 quarantine and Ramadan fasting on weight status, and the association between weight change and lifestyle factors including dietary habits, physical activity, water intake, screen and sleep times, and smoking, and the underlying factors that attributed to the change in weight status among the population living in the KSA. In general, this study has found that increasing number of meals and not adapting healthy cooking methods as the most dominant cooking technique of food consumption are the main risk factors for weight gain, while exercising as the main protective factor.
Weight change related to Covid-19 pandemic and Ramadan fasting
Around 42% of the recruited participants have had around 5% lockdown and Ramadan weight gain in the current findings, which is clinically significant amount of weight to be gained with its substantial predisposition of comorbidities over subsequent years . Thus, protection from unfortunate health effects will likely happen by managing weight gain during COVID-19 [20, 21]. This result is in line with other researches during COVID-19 quarantine internationally [3, 6, 11, 22,23,24,25], and nationally . Fewer people with weight gain have been reported in other studies in comparison to the current study .
On the other hand, around 38% of the recruited participants have had around 5% lockdown and Ramadan weight loss in the current findings, which is clinically significant amount of weight to be lost, as it is associated with physiological and biochemical benefits . This finding is in line with the result in the Chinese study  and other local ones [18, 26]. Other papers have reported fewer people with weight loss [5, 6, 22, 28]. When comparing between the groups, the percentage of participants who gained weight was minimally, but significantly, higher than the percentage of participants who lost weight.
Although the outcomes of the present research are in line with previous research concerning weight change during quarantine, they do not coincide entirely with previous research concerning weight change during Ramadan. It was shown that intermittent fasting (as in Ramadan) can cause significant weight loss in many previous studies, including a 2020 systematic review and meta-analysis [29,30,31]. However, these studies have been conducted earlier to the times of COVID-19 crisis, where people were less stressed and more living their normal life without being confined to their homes. High level of stress and low level of life satisfaction can both influence weight gain [32, 33]. Traditionally, specific ritual and social behaviours are known to take place during Ramadan; including social gatherings during main meals in a buffet style and prayers and worship. During the pandemic, many families could not have applied many of the traditions they used to, given the governmental lockdown and home confinement policies and the fear of contracting infection. This have massively affected people’s life satisfaction and anxiety levels, which can subsequently be manifested in weight gain . Obesity can be considered as a condition of chronic low-grade inflammation, given the immunomodulatory effects of the adipokine secreted from the adipose tissue , which can downregulate both the immune and adaptive immune responses, increasing the body’s vulnerability to infections and decrease its responsiveness to antimicrobial and antiviral drugs, and vaccinations . Moreover, the reduction of protective cardiorespiratory reserves due to excess ectopic fat can have detrimental effects on lung function [37, 38]. As a consequence, individuals with obesity are threatened from developing serious illnesses including COVID-19 infection, if infected, or other more severe forms of respiratory failure. Thus, global public health and community nutrition campaigns targeted towards sustaining normal weights, especially during times of quarantine, are required.
Dietary habits change related to Covid-19 pandemic
Analysis has showed that both increasing the quantity of meals and not adapting healthy cooking methods as the dominant technique of food preparation are directly associated factors with weight gain. The significance levels extend to the same factors when considering multivariate regression analysis, which indicates the importance of these factors to be considered as risk factors for weight gain during home confinement and Ramadan.
On the contrary, home cooking, not increasing the quantity of meals consumed, and adapting healthy cooking methods as the dominant technique of food preparation (as boiling and grilling) are all directly associated factors with weight loss. However, these factors did not reach significance levels when considering multivariate regression analysis, indicating the partial influence of these factors on weight loss during lockdown and Ramadan.
It can be concluded from the current results that home confinement is a serious dietary threat, especially to individuals with obesity and overweight, as more problematic eating behaviors are exhibited in these groups, including frequent food consumption and overeating in the absence of hunger [39, 40]. Such behaviors might get further stimulated during lockdown owing to, often, unlimited availability to large amounts of foods during the extended stay at home, as previous research showed . This can lead to a disturbance in the time-restricted feeding window; a known factor that has a positive effect in dysmetabolism and obesity and promote robust metabolic cycles . Previous research further supports the link between higher amounts of food consumption with the global lockdown [2, 3, 28, 37].
Foods cooked at home are considered healthier and/or lower in calories than foods away from home (as restaurants) . However, 53% of participants of the current study who gained weight have adapted home-cooking for their food intake than before the lockdown. Nevertheless, 51% and 44% of participants of the same weight group have reported an increase in quantity of foods and/or meals consumed and not acquiring healthy cooking methods as boiling and grilling, respectively. These findings could be explained by the fact that some cooking methods may not be considered as healthy, especially if people added large amount of fat and sugar which would add extra amounts of calories, and would increase food palatability and thus making it more appealing in such challenging circumstances. In addition, such foods are traditionally known to be consumed in Ramadan, even before the pandemic, and are known to increase the risk of infections [44,45,46]. Generally, these results are comparable to those in Bakhsh et al. study, and are further explained by studies in Spain and Italy, where they found that homemade cakes and breads were the most common Google search terms and were higher consumed than before lockdown [3, 4, 18, 28]. Thus, a similar trend in cooking and food choices may have been found in Saudi Arabia. Nevertheless, 64.6% of participants who lost weight have relied on consuming home-cooked meals, which seems to be healthier and less caloric way of cooking, as 54.5% of participants from the same group have considered healthy cooking methods (as boiling and grilling) as the main technique of food preparation. This outcome is in line with the Spanish study, where they found better adherence to healthy cooking methods for food preparation during the lockdown .
It is proposed that a healthy diet is considered as a crucial factor of the individual risk assessment and management strategy during pandemics as COVID-19, given its significant effect against responding to an infectious agent . This protective effect arises from the immunomodulatory effects of several phyto-, micro-, and macronutrients that have profound roles in immunocompetence. In contrast, nutritional deficiencies have been known to increase host vulnerability to infections and other severe diseases [48, 49]. For instance, during outbreaks as COVID-19, the Mediterranean diet was proposed to be followed due to its role in boosting the immune system , which was feasible and well-adhered to by Italian and Spanish population [4, 28]. Moreover, following healthy well-balanced diet during Ramadan is recommended, given its immunomodulatory effects against infections and to reduce or maintain weight . On the contrary, it has been suggested that unhealthy diets negatively affect host susceptibility to infections and subsequent recovery [52, 53]. Subsequently, a vicious cycle of weight gain and increased risk of infection will cause both COVID-19 and to obesity be regarded as two colliding public health pandemics [54, 55]. Therefore, it is mandatory for people with overweight or obesity to stick to an individual risk management strategy that includes healthy well-balanced diet [47, 56].
Lifestyle habits change related to Covid-19 pandemic
Analysis has showed that decreasing physical activity level is directly associated with weight gain. However, this factor does not reach significance level when considering multivariate regression analysis, indicating the partial effect of physical activity level on weight gain during lockdown and Ramadan.
On the other hand, increasing water intake, and maintaining physical activity level as before lockdown and Ramadan periods are all directly associated with weight loss. The significance level extends only to the physical activity levels when considering multivariate regression analysis, which indicates the importance of this factor to be considered as a protective element against weight gain during lockdown and Ramadan.
This finding support recent research, as it is well established the dose–response relationship between weight loss and physical activity levels . Moreover, the findings of the present research are in line with earlier research that show the dramatical global influence of COVID-19 quarantine on lifestyle activities, including the physical activity involvement [58, 59]. This is logical to expect, given the diverse governmental confinement policy on movement restrictions during COVID-19 pandemic which will directly affect the participation in physical activity . It was shown previously in China that differences in physical activity level was associated with both different regional policies on confinement and socio-economic levels . The decrease in physical activity level is even more affected due to Ramadan fasting, where it is reported previously to be reduced during the holy month . Thus, addressing these factors when designing physical activity interventions via the involvement of remote dietitian services, social media campaigns, and health care authorities are essential for such pandemic in the future.
It is interesting that the present study found no association between screen time and weight change. However, it is stated in a previous review that any link between sedentary lifestyle, including screen time, and weight gain may not appear as a causal relationship . The current study findings coincide with the mentioned review, where screen time may not be a predictor for weight change during lockdown and Ramadan.
Noteworthy, the current study took place in Saudi Arabia and was conducted in a relatively short time, as suggested previously . However, sharing a part of the middle east on how the lockdown resulted from the epidemic during Ramadan can influence the dietary and lifestyle behaviors and weight, as in Saudi Arabia, for the first time can provide valuable insights to the neighboring gulf and Arabian countries. Nevertheless, the current outcomes should be considered for future-similar circumstances aimed towards the prevention and preparation if any lockdown-incidents are to be necessitated. Future consideration should include the permissibility to not to fast and the fluctuation in weight as a result of water retention and hormonal changes during the menstrual cycle in child-bearing aged women, where excluding these days and this change in weight are needed before including this group in the analysis. Moreover, self-reported dietary and lifestyle behaviors and weight recall at the same time point based on an online and anonymous questionnaire rather than standardized baseline measures to objectively confirm the data prior to and following the study timeline, in addition to the mixed genders and the broad age groups can all be underlined as study limitations. Thus, the outcomes of the current research should be considered as a rough measure rather than an accurate value. Overcoming the mentioned weaknesses were, however, impossible baring in mind the challenges of running such a study in a restricted period of time as Ramadan in a national lockdown.