Impact of Nationwide Lockdowns Resulting from The First Wave of the COVID-19 Pandemic on Food Intake, Eating Behaviours and Diet Quality: A Systematic Review.

The lockdowns resulting from the first wave of the COVID-19 pandemic impacted deeply on all life activities, including diet. We performed a systematic review to investigate changes in food intake, eating behaviours and diet quality during lockdown as compared to before. A literature search was performed using three electronic databases from inception until June 13, 2021. Observational studies evaluating changes in general populations during the COVID-19 pandemic lockdown were eligible. Out of 1,963 studies achieved from the search strategy, 95 met inclusion criteria (85 on adults, 10 on children/adolescents), and the majority were of high quality (72.6%). Most of the studies were web-based surveys using convenience sampling, mainly focused on variations in the consumption of foods and eating behaviours during lockdown, whereas only 15 studies analysed diet quality through dietary indices. On the basis of the definition of a healthful diet as reflected by a traditional Mediterranean diet, an increase in recommended foods such as fruit and vegetables, legumes, cereals and olive oil was observed, although a sharp decrease in fish intake and an increase in dairy products were documented. Accordingly, a reduction in foods that should be eaten less frequently was reported, namely, red and processed meat. However, a higher consumption of unhealthy foods (e.g., snacks and sweets) was also observed. Results indicated improved diet quality in Europe, especially among Mediterranean countries, with the exception of France, while a switching to poor nutrient patterns was observed in Colombia and Saudi Arabia. Analyses of eating behaviours suggest an increase in food intake, number of daily meals and snacking. In conclusion, changes in intake of major food groups, apart from fish intake, were in line with the definition of a traditional Mediterranean diet, indicating a consistent moderate improvement of dietary habits worldwide. This review protocol was registered at https://www.crd.york.ac.uk/prospero/ as CRD42020225292.

Habitual adherence to a traditional Mediterranean diet and risk of SARS-CoV-2 infection and Coronavirus disease 2019 (COVID-19): a longitudinal analysis.

Evidence on habitual Mediterranean diet (MD) and risk of SARS-CoV-2 infection, and COVID-19 is limited. 1,520 participants from the Moli-sani Study (2017-2020) were tested during January-September 2021 and adherence to MD was ascertained through the Mediterranean Diet Score (MDS). SARS-CoV-2 infection cases were determined through serology, and previous clinical diagnosis of COVID-19 disease was self-reported. Results were presented as odd ratios (OR) with 95% confidence intervals (CI). The MDS was not associated with the likelihood of SARS-CoV-2 infection (OR= 0.94; 95% CI: 0.83-1.06) and COVID-19 (OR= 0.82; 95% CI: 0.62-1.10) diagnosis. High consumption of cereals was associated with lower odds of SARS-CoV-2 infection (OR = 0.91; 95% CI: 0.83-1.00; for each 25 g/d increase). Likelihood of having being diagnosed with COVID-19 disease decreased in association with increasing olive oil intake (OR= 0.10; 95% CI: 0.01-0.79; for each additional 10 g/d), moderate alcohol consumption (OR= 0.18; 95% CI: 0.04-0.82) and higher intakes of fruits and nuts (OR = 0.89; 95% CI: 0.79-0.99). Our findings emphasise the adoption and maintenance of a balanced MD as a key strategy to reduce the risk of future SARS-CoV-2 infections and COVID-19.

Changes in a Mediterranean lifestyle during the COVID-19 pandemic among elderly Italians: an analysis of gender and socioeconomic inequalities in the "LOST in Lombardia" study.

Little is known on potential socioeconomic and gender disparities in dietary changes during the COVID-19 pandemic. We conducted a telephone-based survey during fall 2020 on 4400 participants representative of the population aged 65-99 years living in Lombardy, Italy. Changes in a Mediterranean lifestyle were assessed retrospectively by scoring modifications in the consumption of nine food groups and five diet-related behaviours compared to 2019. A Mediterranean COVID-19 Pandemic Score (MedCovid-19 Score) was computed, reflecting changes during pandemic, with increasing values indicating improvements in line with a Mediterranean lifestyle. Predictors of favourable dietary changes (MedCovid-19 Score ≥ 1) were education (odds ratio [OR] = 1.52; 95% confidence interval 1.19-1.95 for postgraduate vs. lower), wealth (OR = 1.52; 1.14-2.02 for high vs. low) and skilled manual occupations (OR = 1.57; 1.28-1.92 vs. white collars). Women were more likely than men to move away from a Mediterranean lifestyle (OR = 1.86; 1.58-2.21). In conclusions, changes towards a Mediterranean lifestyle were disproportionately distributed across gender and socioeconomic strata.

COVID-19 confinement impact on weight gain and physical activity in the older adult population: Data from the LOST in Lombardia study.

BACKGROUND & AIMS: COVID-19 containment measures significantly impacted lifestyle of the general population, including physical activity. Although the older adults are particularly susceptible to the potential consequences of sedentary lifestyle and inactivity, few studies investigated pandemic effects in this segment of the population. We aimed to evaluate COVID-19 pandemic effects on weight gain and physical activity in the Italian older adults, and assess the impact of possible changes in physical activity on mental health wellbeing. METHODS: In November 2020, a cross-sectional survey was conducted on a representative sample of 4400 older adults (aged 65 or more) from the Lombardy region, Northern Italy. Changes in body mass index (BMI) and physical activity were assessed, compared to the previous year. Using unconditional multiple logistic models, we estimated the odds ratios (OR) and the corresponding 95% confidence intervals (CI) of a decrease in physical activity during COVID-19 pandemic and we evaluated if decreased physical activity was a determinant of a worsening in psychological wellbeing. RESULTS: Neither weight gain nor increase in obesity prevalence occurred during the pandemic. Mean time spent in physical activity significantly decreased, with 43.8% of participants reporting a decrease of 1 h/week or more during COVID-19 pandemic. A decreased physical activity was determinant of a worsening of selected mental health outcomes, such as: sleep quality (OR = 2.45; 95% CI: 1.91-3.15) and quantity (OR = 1.54; 95% CI: 1.18-2.02), anxiety (OR = 1.31; 95% CI: 1.14-1.52) and depressive symptoms (OR = 1.61; 95% CI: 1.38-1.88). CONCLUSION: During the COVID-19 pandemic, while no major changes in BMI were observed, physical activity significantly declined in the older adults. In this population, the lack of physical activity might have contributed to the observed worsening in mental health. During emergency periods, encouraging physical activity might be effective also to preserve psychological wellbeing.

Retrospective Recall of Psychological Distress Experienced During the First COVID-19 Lockdown in Italy: Results From the ALT RISCOVID-19 Survey.

Objectives: To estimate psychological distress experienced during the Italian lockdown (March-May 2020) by assessing, in the transition period of the pandemic (June-September 2020), participants' recalling of their psychological state. Methods: Cross-sectional analysis on 1,880 adults (mean age 48.9 ± 14.5 years) from the web-based ALT RISCOVID-19 survey. Participants were asked to retrospectively recall their psychological state during lockdown concerning symptoms of depression (Patients' Health Questionnaire), anxiety (General Anxiety Disorder), stress (Perceived Stress Scale) and post-traumatic stress (Screening Questionnaire for Disaster Mental Health). Results: Experienced symptoms of depression, anxiety and post-traumatic stress was recalled by 15.8, 15.3 and 13.1% of respondents, respectively. These psychometric scales tended to decrease during the 4-month period of assessment (p < 0.05), while perceived stress levels did not (p = 0.13). Men and older individuals reported lower symptoms of depression (ß = -0.42 and ß = -0.42; p < 0.0001, respectively), anxiety (ß = -0.41 and ß = -0.45; p < 0.0001, respectively), stress (ß = -0.36 and ß = 0.50; p < 0.0001, respectively) and post-traumatic stress (ß = -0.42; p < 0.0001, men vs women). Conclusion: Recalled psychological distress experienced during COVID-19 lockdown tended to decrease during the transition period of the pandemic, except for stress. Women and younger people were at higher risk to recall psychological distress.

Psychological distress resulting from the COVID-19 confinement is associated with unhealthy dietary changes in two Italian population-based cohorts.

PURPOSE: To examine the relationship between psychological distress resulting from the COVID-19 lockdown and dietary changes. METHODS: Cross-sectional analysis from 2 retrospective Italian cohorts recruited from May to September 2020: (1) The Moli-LOCK cohort consists of 1401 participants from the Moli-sani Study (n = 24,325) who were administered a telephone-based questionnaire to assess lifestyles and psychological factors during confinement; (2) the ALT RISCOVID-19 is a web-based survey of 1340 individuals distributed throughout Italy who self-responded to the same questionnaire using Google® forms. Psychological distress was measured by assessments of depression (PHQ-9 and depressive items from the Screening Questionnaire for Disaster Mental Health- SQD-D), anxiety (GAD-7), stress (PSS-4), and post-traumatic stress disorder (SQD-P). Diet quality was assessed either as changes in consumption of ultra-processed foods (UPF) or adherence to Mediterranean diet (MD). RESULTS: In ALT RISCOVID-19, increased UPF intake was directly associated with depression (both PHQ-9 and SQD-D; p < 0.0001), anxiety (p < 0.0001), stress (p = 0.001) and SQD-P (p = 0.001); similar results were obtained in the Moli-LOCK cohort except for perceived stress. When psychometric scales were analysed simultaneously, only depression (SQD-D) remained associated with UPF (both cohorts). In both cohorts, psychological distress poorly influenced changes toward an MD, except for depression (SQD-D) that resulted inversely associated in the ALT RISCOVID-19 participants (ß = - 0.16; 95% CI - 0.26, - 0.06). CONCLUSIONS: Psychological distress from the COVID-19 confinement is directly associated with unhealthy dietary modifications in two Italian cohorts. In view of possible future restrictive measures to contain pandemic, public health actions are warranted to mitigate the impact of psychological distress on diet quality.

Adherence to the Mediterranean Diet during the COVID-19 national lockdowns: a systematic review of observational studies.

BACKGROUND AND AIM OF THE WORK: During the COVID-19 pandemic, many countries adopted restrictive measures to mitigate infection spread, which might have influenced people's lifestyle and dietary habits. We conducted a systematic review to evaluate the impact of national lockdowns on adherence to the Mediterranean Diet (MD). METHODS: Studies were identified searching Medline, Embase, Web of Science, and the Cochrane Library. Studies published until 4th May 2021 were included. We only considered studies reporting original data from quantitative analysis and assessing changes in adherence to the MD, using validated dietary scores, or in consumption of MD food items. Data extraction, pooling, and quality appraisal of included studies were conducted following the PRISMA guidelines. RESULTS: Forty-two studies were retrieved. After screening, 12 studies met inclusion criteria and were included in the review, of which 4 (33%) were longitudinal studies. Six (85.7%) of the seven studies that measured changes in MD adherence before-during lockdown reported an increase (rate of change of high-adherence to MD ranged between +3.3% and +21.9%). Evidence indicates that consumption of MD food items increased during lockdown but is heterogeneous in study design, quality, and findings. CONCLUSIONS: Our results suggest adherence to the MD during lockdown might have increased in some settings, while the determinants of such a trend are to be further explored. We raise awareness of the need to research further the impacts and long-term consequences of COVID-19 containment measures on dietary and lifestyle habits.

Disentangling the Association of Hydroxychloroquine Treatment with Mortality in Covid-19 Hospitalized Patients through Hierarchical Clustering.

The efficacy of hydroxychloroquine (HCQ) in treating SARS-CoV-2 infection is harshly debated, with observational and experimental studies reporting contrasting results. To clarify the role of HCQ in Covid-19 patients, we carried out a retrospective observational study of 4,396 unselected patients hospitalized for Covid-19 in Italy (February-May 2020). Patients' characteristics were collected at entry, including age, sex, obesity, smoking status, blood parameters, history of diabetes, cancer, cardiovascular and chronic pulmonary diseases, and medications in use. These were used to identify subtypes of patients with similar characteristics through hierarchical clustering based on Gower distance. Using multivariable Cox regressions, these clusters were then tested for association with mortality and modification of effect by treatment with HCQ. We identified two clusters, one of 3,913 younger patients with lower circulating inflammation levels and better renal function, and one of 483 generally older and more comorbid subjects, more prevalently men and smokers. The latter group was at increased death risk adjusted by HCQ (HR[CI95%] = 3.80[3.08-4.67]), while HCQ showed an independent inverse association (0.51[0.43-0.61]), as well as a significant influence of cluster∗HCQ interaction (p < 0.001). This was driven by a differential association of HCQ with mortality between the high (0.89[0.65-1.22]) and the low risk cluster (0.46[0.39-0.54]). These effects survived adjustments for additional medications in use and were concordant with associations with disease severity and outcome. These findings suggest a particularly beneficial effect of HCQ within low risk Covid-19 patients and may contribute to clarifying the current controversy on HCQ efficacy in Covid-19 treatment.

Lopinavir/Ritonavir and Darunavir/Cobicistat in Hospitalized COVID-19 Patients: Findings From the Multicenter Italian CORIST Study.

Background: Protease inhibitors have been considered as possible therapeutic agents for COVID-19 patients. Objectives: To describe the association between lopinavir/ritonavir (LPV/r) or darunavir/cobicistat (DRV/c) use and in-hospital mortality in COVID-19 patients. Study Design: Multicenter observational study of COVID-19 patients admitted in 33 Italian hospitals. Medications, preexisting conditions, clinical measures, and outcomes were extracted from medical records. Patients were retrospectively divided in three groups, according to use of LPV/r, DRV/c or none of them. Primary outcome in a time-to event analysis was death. We used Cox proportional-hazards models with inverse probability of treatment weighting by multinomial propensity scores. Results: Out of 3,451 patients, 33.3% LPV/r and 13.9% received DRV/c. Patients receiving LPV/r or DRV/c were more likely younger, men, had higher C-reactive protein levels while less likely had hypertension, cardiovascular, pulmonary or kidney disease. After adjustment for propensity scores, LPV/r use was not associated with mortality (HR = 0.94, 95% CI 0.78 to 1.13), whereas treatment with DRV/c was associated with a higher death risk (HR = 1.89, 1.53 to 2.34, E-value = 2.43). This increased risk was more marked in women, in elderly, in patients with higher severity of COVID-19 and in patients receiving other COVID-19 drugs. Conclusions: In a large cohort of Italian patients hospitalized for COVID-19 in a real-life setting, the use of LPV/r treatment did not change death rate, while DRV/c was associated with increased mortality. Within the limits of an observational study, these data do not support the use of LPV/r or DRV/c in COVID-19 patients.

Changes in the consumption of foods characterising the Mediterranean dietary pattern and major correlates during the COVID-19 confinement in Italy: results from two cohort studies.

We investigated the effect of confinement during the COVID-19 pandemic on the consumption of foods characterising the Mediterranean dietary pattern (MDP) and its major correlates in two Italian population-based cohorts comprising 3161 subjects (mean age 57.7 ± 15.4 y). At population level, 38.8% of participants reported an improvement of diet quality during the first nationwide lockdown. Healthful dietary changes were associated with older age (ß = 0.41; 95% confidence interval [CI] 0.08, 0.73 for 56-65 vs. 18-39 y), greater wealth (ß = 0.45; 0.01, 0.89 for >40,000 ≤ 60,000 vs. ≤ 10,000 EUR/y), increased physical activity (ß = 0.52; 0.22, 0.81) and reduced body weight (ß = 0.36; 0.11, 0.62). Switching to healthy eating was also related to increased consumption of organic (ß = 1.24; 0.88, 1.60) and locally-grown food (ß = 0.74; 0.51, 0.96). The first Italian lockdown led, in a substantial part of the population, to higher intake of foods characterising a MDP; this was also accompanied by healthier lifestyle and more sustainable food choices.

Changes in ultra-processed food consumption during the first Italian lockdown following the COVID-19 pandemic and major correlates: results from two population-based cohorts.

OBJECTIVE: To evaluate changes in ultra-processed food (UPF) intake and its major correlates during the first Italian lockdown (9 March-3 May 2020). DESIGN: Retrospective observational study. SETTING: Italy. PARTICIPANTS: We analysed 2992 subjects (mean age 57·9 ± 15·3 years, 40·4 % men). Individual participant data were pooled from two retrospective cohorts: (1) The Moli-LOCK cohort consists of 1501 adults, a portion of the larger Moli-sani study (n 24 325; 2005-2010) who were administered a phone-based questionnaire to assess lifestyles and psychological factors during confinement and (2) the Analysis of Long Term Risk of Covid-19 Emergency is a web-based survey of 1491 individuals distributed throughout Italy who self-responded to the same questionnaire by using Google forms.UPF was defined according to NOVA classification based on degree of food processing. An UPF score was created by assigning 1 point to increased consumption, -1 to decreased and 0 point for unchanged intakes of nineteen food items, with higher values indicating an increase in UPF during confinement. RESULTS: Overall, 37·5 % of the population reported some increase in UPF (UPF score ≥1). Adults were more likely to decrease UPF (multivariable regression coefficient ß = -1·94; 95 % CI -2·72, -1·17 for individuals aged >75 years as compared with 18-39 years) as did individuals from southern Italian regions as compared with Northern inhabitants (ß = -1·32; 95 % CI -1·80, -0·84), while UPF lowering associated with increased exercise (ß = -0·90; 95 % CI -1·46, -0·35) and weight loss (ß = -1·05; 95 % CI -1·51, -0·59) during confinement. CONCLUSIONS: During the first Italian lockdown, about 40 % of our population switched to unfavourable eating as reflected by increased UPF intake and this may have long-term effects for health.

Heparin in COVID-19 Patients Is Associated with Reduced In-Hospital Mortality: The Multicenter Italian CORIST Study.

INTRODUCTION: A hypercoagulable condition was described in patients with coronavirus disease 2019 (COVID-19) and proposed as a possible pathogenic mechanism contributing to disease progression and lethality. AIM: We evaluated if in-hospital administration of heparin improved survival in a large cohort of Italian COVID-19 patients. METHODS: In a retrospective observational study, 2,574 unselected patients hospitalized in 30 clinical centers in Italy from February 19, 2020 to June 5, 2020 with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection were analyzed. The primary endpoint in a time-to event analysis was in-hospital death, comparing patients who received heparin (low-molecular-weight heparin [LMWH] or unfractionated heparin [UFH]) with patients who did not. We used multivariable Cox proportional-hazards regression models with inverse probability for treatment weighting by propensity scores. RESULTS: Out of 2,574 COVID-19 patients, 70.1% received heparin. LMWH was largely the most used formulation (99.5%). Death rates for patients receiving heparin or not were 7.4 and 14.0 per 1,000 person-days, respectively. After adjustment for propensity scores, we found a 40% lower risk of death in patients receiving heparin (hazard ratio = 0.60; 95% confidence interval: 0.49-0.74; E-value = 2.04). This association was particularly evident in patients with a higher severity of disease or strong coagulation activation. CONCLUSION: In-hospital heparin treatment was associated with a lower mortality, particularly in severely ill COVID-19 patients and in those with strong coagulation activation. The results from randomized clinical trials are eagerly awaited to provide clear-cut recommendations.

Common cardiovascular risk factors and in-hospital mortality in 3,894 patients with COVID-19: survival analysis and machine learning-based findings from the multicentre Italian CORIST Study.

BACKGROUND AND AIMS: There is poor knowledge on characteristics, comorbidities and laboratory measures associated with risk for adverse outcomes and in-hospital mortality in European Countries. We aimed at identifying baseline characteristics predisposing COVID-19 patients to in-hospital death. METHODS AND RESULTS: Retrospective observational study on 3894 patients with SARS-CoV-2 infection hospitalized from February 19th to May 23rd, 2020 and recruited in 30 clinical centres distributed throughout Italy. Machine learning (random forest)-based and Cox survival analysis. 61.7% of participants were men (median age 67 years), followed up for a median of 13 days. In-hospital mortality exhibited a geographical gradient, Northern Italian regions featuring more than twofold higher death rates as compared to Central/Southern areas (15.6% vs 6.4%, respectively). Machine learning analysis revealed that the most important features in death classification were impaired renal function, elevated C reactive protein and advanced age. These findings were confirmed by multivariable Cox survival analysis (hazard ratio (HR): 8.2; 95% confidence interval (CI) 4.6-14.7 for age ≥85 vs 18-44 y); HR = 4.7; 2.9-7.7 for estimated glomerular filtration rate levels <15 vs ≥ 90 mL/min/1.73 m2; HR = 2.3; 1.5-3.6 for C-reactive protein levels ≥10 vs ≤ 3 mg/L). No relation was found with obesity, tobacco use, cardiovascular disease and related-comorbidities. The associations between these variables and mortality were substantially homogenous across all sub-groups analyses. CONCLUSIONS: Impaired renal function, elevated C-reactive protein and advanced age were major predictors of in-hospital death in a large cohort of unselected patients with COVID-19, admitted to 30 different clinical centres all over Italy.