Archives of

1. Introduction
n late 2019, several cases of unknown infectious
diseases were identified in Wuhan
(China). This novel pathogen was named
nCov-2019, and the World Health Organization
(WHO) named it COVID-19. This
illness is an acute respiratory disease closely related to
SARS coronavirus, whose primary symptoms include
pneumonia, fever, muscle aches, and fatigue [1-4]. The
disease spread so fast that WHO declared a pandemic in
early March [1]. In late November 2020, more than 65
million people were infected with COVID-19, and more
than 1.5 million people died. In late December 2020,
COVID-19 has infected 900000 cases and claimed more
than 46000 lives in Iran. Since information about the
novel, coronavirus is limited, and no treatment has been
developed so far, and the world has faced a global public
health emergency. Therefore, WHO and many countries,
including Iran, are implementing particular public health
protocols such as strict quarantine restrictions to control
COVID-19.
The crisis of COVID-19 and measures such as social
distancing may have significant social consequences beyond
the lost lives [5-7]. For example, Daly et al., based
on data collected before and during restrictions imposed
to control COVID-19 in the United Kingdom, reported
that the number of adults experiencing mental health
problems had increased about 50% [8]. Brooks et al.
also argued that COVID-19 related restrictions caused
increased negative psychological consequences such as
stress and anxiety [9]. The effects of these restrictions
and their adverse psychological consequences on essential
elements of a healthy lifestyle and weight-related
behaviors, including physical activity and healthy nutrition,
are not apparent but probably will bear significant
adverse consequences [10]. Stress and anxiety caused
by this pandemic may change the nutrition pattern and
eating attitudes [11]. Attitude to eating is the core of all
disordered eating practices, ranging from healthy disordered
eating attitudes to unhealthy dieting [12]. Ammar
et al. reported that in the first few months of COVID-19
related restrictions, dietary intake in most parts of the
world moved toward unhealthy patterns [13].
Iran has also imposed public health restrictions since
the beginning of the pandemic. For example, the duration
of sports activities or outdoor sports activities is
limited. Besides, many people, especially the elderly and
women, have restricted their outdoor physical activities
due to fear of COVID-19 [5]. In this regard, Tison et al.
examined the global impact of COVID-19 on physical
activity and reported that only during the first month of
the pandemic the number of walked steps was reduced
by 27.3%; while it was reduced by 48.7% in Italy [10]. It
may cause several health consequences such as obesity,
diabetes, Cardiovascular Diseases (CVDs), and cancer
as well as increased prevalence of COVID-19 risk factors.
However, evidence regarding eating attitudes and
physical activity of Iranian men and women is limited,
and no research has investigated this issue. Hence, providing
evidence will help the government as well as
sports organizations in developing more effective public
health policies, reducing the consequences of the disease,
and promoting the public health of society. This
study aimed to investigate disordered eating attitudes
and physical activity in Iranian men and women during
the COVID-19 pandemic.
2. Materials and Methods
This work is a descriptive-analytical, cross-sectional
study that was conducted using a self-administered online
questionnaire. The statistical population was all men
and women aged 18 years and older living in urban areas
of Iran (nearly 40 million, based on the last population
census in 2016). Based on previous studies and by considering
a confidence interval of 95%, significance level
of 5%, and Cochrane Formula 1:
1. (n= Nz2pq
Nd2+z2pq ),
the sample size was determined as 385 [14]. In Cochran’s
formula for a limited community, N is equal
to the size of the community, Z is equal to 1.96, p is
equal to 0.5, and d is equal to 0.05. However, because
we were using an online questionnaire (https://forms.
gle/qYC4fJZbJEukm2yPA) and to increase the validity
of results and to address the possible problems, 770
people were invited to complete the questionnaire. In
total, 705 questionnaires were filled. The questionnaire
link was sent to potential participants (randomly and
non-randomly; from September 12 to October 3, 2020),
emphasizing those aged at least 18 years. The questionnaire
contained demographics (age, gender, place of
residence, education level, marriage status) and personal
information (height and weight). The collected information
from all individuals was anonymous and completely
confidential.
The Baecke Physical Activity Questionnaire (BPAQ)
was used to collect information regarding physical activity
both before and after the COVID-19 pandemic. It
contains three distinct dimensions. First, physical activ-
I
Pourrazi H, et al. Eating Attitudes, Physical Activity and COVID-19 Pandemic. Arch Hyg Sci. 2021; 10(2):133-142.
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Spring 2021. Volume 10. Number 2
ity, which contains eight items scored on a 5-point Likert
scale. The second part (items 9 to 12) is for those who
have first and second exercises. In this part, the total
score was divided by four. The third part is “physical activity
during leisure” (items 13 to 16). The total scores of
this part were divided by four. The sum of the three parts
gives an indicator of the total physical index. The highest
score is 15. The validity and reliability of BPAQ are
investigated in various countries, including Iran. Beck et
al. in 1982 reported a Cronbach alpha of 0.73. Soury et
al. reported a reliability coefficient of 0.78 and an internal
consistency of 0.87 [15].
To investigate the disordered eating habits before
and after the COVID-19 outbreak, the Eating Attitudes
Test (EAT-26) developed by Garner et al. was
used [16]. This test is widely using to measure attitudes
and behaviors regarding disordered eating. The EAT is
scored on a 3-point Likert scale, ranging from 1 to 3.
For items 1 to 25, also, a 3-point Likert scale was used,
ranging from 1 (always) to 3 (often). For item 26, the
scale ranged from sometimes to never. Therefore, the
total EAT-26 score ranges from 0 to 78. A score higher
than 20 indicates suspected disordered eating, and the
subject should be treated. In addition to a total score,
this measure also yields three subscales: dieting (13
items), bulimia and food preoccupation (6 items), and
oral control (7 items). Shayghan and Vafaei reported a
Cronbach alpha of 0.76 [17].
The Kolmogorov-Smirnov test was applied to test the
normal distribution. The findings are described using
mean, standard deviation, minimum, maximum, and
frequency percentage. Then, the 1-sample t test, paired t
test, and multivariate linear regression were used for inferential
analysis. Statistical significance was considered
when the P-value was less than 0.05. Data are analyzed
using SPSS version 21.
3. Results
In the present study, 705 adults aged at least 18 years
filled the questionnaire (502 females and 203 males).
The Kolmogorov-Smirnov test indicated a normal distribution
(P>0.05). Some of the individual characteristics
of participants (age, height, weight, and Body Mass Index)
are presented in Table 1.
In Table 2, some demographic characteristics of participants
in terms of age, gender, marriage status, degree
of education, and Body Mass Index (BMI) are described.
Concerning the eating attitudes, a score higher than
20 indicates that the person is suspected of disordered
eating and should refer to healthcare centers. Based on
Table 3 and the results of the 1-sample t test, the level
of eating attitudes of Iranian men and women before the
COVID-19 outbreak were significantly lower than 20
(t=-4.52, P=0.0001, t=-3.01, P=0.003, for women and
men, respectively). In this regard, and according to the
results of the paired t test, after the COVID-19 outbreak,
the level of disordered eating attitudes in women has increased
significantly (t=-5, P=0.0001; 5.3%). However,
there was no significant change in the disordered eating
attitudes of men (t=-0.6, P=0.54). Based on the findings,
the COVID-19 outbreak, regardless of gender, had significantly
increased the disordered eating attitudes of
Iranians (Table 3).
Based on Table 4 and the results of the 1-sample t test,
the level of physical activity of Iranian women before the
COVID-19 pandemic was significantly lower than the
average level (t=-4.7, P=0.001). In this regard, according
to the paired t test, since the onset of the pandemic, the
women’s physical activity has significantly declined by
3% (t=7.04, P=0.0001). For men, also before the COVID-
19 pandemic, the physical activity level was higher
than the average, but it was not statistically significant
(t=1.74, P=0.083). Similar to women, men’s physical
activity has declined since the onset of the pandemic by
2.47% (t=4.3, P=0.001). Based on the findings, regardless
of gender, the physical activity of Iranian adults has
decreased significantly since the onset of the COVID-19
pandemic (Table 4).
Moreover, multivariate linear regression was used to
predict disordered eating attitudes during the COVID-19
pandemic based on age, gender, marital status, education,
BMI, and physical activity. The results showed that
about 23% of changes in disordered eating attitudes during
the COVID-19 outbreak were explained by these factors
(R=0.48, R2=0.23). Considering that the analysis of
variance of regression was significant (F=5.57, P>0.01),
the standardized beta coefficient was used to determine
the most effective predictive modeling among the aforementioned
variables (Table 5). Based on the findings,
three variables of physical activity (beta=0.17), BMI
(beta=0.11), and gender (beta=0.072), respectively, were
the most important predictors of disordered eating attitudes
during the COVID-19 pandemic. In other words,
considering the positive and significant association between
these variables and disordered eating attitudes,
those with high BMI or more intensive physical activity
are more likely to experience increased disordered eating
during the COVID-19 pandemic. Besides, the same
Pourrazi H, et al. Eating Attitudes, Physical Activity and COVID-19 Pandemic. Arch Hyg Sci. 2021; 10(2):133-142.
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Spring 2021. Volume 10. Number 2
is true concerning gender, and women are more likely
to experience disordered eating during the COVID-19
pandemic (Table 5).
4. Discussion
The COVID-19 pandemic has caused significant psychological
consequences and adverse effects, which in
turn have affected essential components of a healthy lifestyle
and weight-related behaviors, including healthy nutrition
and physical activity. Therefore, the present study
aimed to evaluate the level of disordered eating attitudes
and physical activity among Iranian men and women during
the COVID-19 pandemic. This study demonstrated
that the COVID-19 pandemic has significantly reduced
the physical activity of Iranian men and women. However,
only women experienced a significant increase in
disordered eating attitudes during the COVID-19 pandemic,
and no significant changes were observed in men.
Of course, the results showed that, regardless of gender,
since the onset of the COVID-19 pandemic, the level of
disordered eating attitudes in Iranian adults has increased
Table 1. Individual characteristics of the subjects as a whole and gender separation
Gender (Mean±SD)
Variables Min. Max. Mean±SD
Female, n=502 (71.2%) Male, n=203 (28.8%)
Age (y) 18 75 29.71±10.66 28.4±9.88 32.94±11.78
Height (cm) 146 198 167.74±8.44 164.19±5.92 176.52±7.24
Weight (kg) 40 130 68.4±12.52 64.65±10.87 77.67±11.5
Body mass index (kg/m2) 15.6 42.97 24.27±3.88 23.99±3.95 24.95±3.63
Table 2. Demographic and individual characteristics of subjects
Variables No. (%)
Gender, No. (%)
Female Male
Age, y
18-30 468 (66.4) 359 (71.5) 109 (53.7)
31-45 148 (21) 97 (19.3) 51 (25.1)
Over 45 89 (12.6) 46 (9.2) 43 (21.2)
Marriage status
Single 425 (60.3) 308 (61.4) 117 (57.6)
Married 280 (39.8) 194 (38.6) 86 (42.4)
Degree of education
Diploma and sub-diploma 285 (40.0) 184 (36.7) 101 (49.8)
Post-diploma and bachelor’s degree 362 (51.3) 284 (56.6) 78 (38.4)
Masters and PhD 58 (8.2) 34 (6.8) 24 (11.8)
BMI, kg/m2
Underweight (<18.5) 34 (4.8) 28 (5.6) 6 (3)
Normal weight (18.5-24.9) 398 (56.5) 292 (58.2) 106 (52.2)
Overweight (25-29.9) 223 (31.6) 152 (30.3) 71 (35)
Obese (>30) 50 (7.1) 30 (6) 20 (9.9)
Pourrazi H, et al. Eating Attitudes, Physical Activity and COVID-19 Pandemic. Arch Hyg Sci. 2021; 10(2):133-142.
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significantly. In this line, three variables of physical activity,
BMI, and gender were the most important predictors
of disordered eating attitudes during the COVID-19 pandemic,
and there was a positive and significant association
between these variables and disordered eating attitudes.
Despite all the advice that restrictions and staying at
home should not hinder people’s physical activity [18],
the present study demonstrated that the COVID-19 outbreak
had reduced all subscales of physical activity so
that both women and men experienced reduced levels
of sports activity (3.79% and 2.72%, respectively) and
physical activity during leisure time (3.26% and 1.93%
for women and men, respectively). However, this decrease
was more evident in women than in men. Similar
results are reported by Ammar et al. [13], Sánchez et al.
[3], Robinson et al. [5], and Maugeri et al. [4]. Oliveira
et al. argued that the onset of the COVID-19 pandemic
and its restrictions dramatically affected lifestyle activities,
such as participating in various sports and everyday
physical activities [19]. Ammar et al. also reported
that decreased physical activity was associated with increased
sedentary habits such as sitting for long periods.
It is worth noting that the impact of the COVID-19 pandemic
on physical activity depends on various factors
such as the severity of restrictions and public health protocols.
So that, in China, different regional policies and
socioeconomic factors have been associated with different
levels of physical activity [13]. Regarding gender, as
in the present study, Sánchez et al. noted that the decrease
in physical activity was much more significant in women
than in men [3]. In contrast to the present study results,
Maugeri et al. reported that men experienced more drops
in their physical activities than women [4]. This difference
can be attributed to psychological factors, cultural
differences, and lifestyles of men and women in different
societies and countries, so that women are less engaged
in sports activities and outdoor leisure due to stress and
Table 3. Eating attitudes and their subscales before and during the COVID-19 pandemic as a whole and gender separation
Eating Attitudes Subscales
Mean±SD
Before the COVID-19 Pandemic After the COVID-19 Pandemic
Female Male Total Female Male Total
Dieting 10.19±3.11 8.61±2.89 9.73±2.07 10.73±4.79 8.96±3.46 10.22±3.73
Bulimia & food preoccupation 2.6±1.3 2.87±1.83 2.68±1.5 2.82±1.46 2.83±1.07 2.82±1.4
Oral control 4.68±1.1 5.34±1.76 4.87±1.3 4.73±1.01 5.21±2.31 4.87±1.15
Eating disordered attitudes 17.38±4.95 16.83±3.93 17.22±4.54 18.3±5.82* 17±4.79 17.93±5.1€
*P<0.01, Significant differences compared to before the COVID-19 pandemic in female; €P<0.01, Significant differences compared
to before the COVID-19 pandemic.
Table 4. Physical activity and its subscales before and during the COVID-19 pandemic as a whole and gender separation
Physical Activity
Subscales
Mean±SD
Before the COVID-19 Pandemic After the COVID-19 Pandemic
Female Male Total Female Male Total
Work 2.67±0.64 2.95±0.71 2.75±0.67 2.59±0.66 2.9±0.7 2.68±0.69
Sports 2.11±0.68 2.2±0.69 2.14±0.68 2.03±0.68 2.14±0.67 2.07±0.68
Leisure time 2.45±0.67 2.59±0.7 2.49±0.68 2.37±0.67 2.54±0.73 2.42±0.69
Total 7.2±1.41 7.68±1.54 7.34±1.46 7±1.46* 7.49±1.5# 7.14±1.49€
*P<0.01, Significant differences compared to before the COVID-19 pandemic in females; #P<0.01, Significant differences compared
to before the COVID-19 pandemic in males; €P<0.01, Significant differences compared to before the COVID-19 pandemic.
Pourrazi H, et al. Eating Attitudes, Physical Activity and COVID-19 Pandemic. Arch Hyg Sci. 2021; 10(2):133-142.
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anxiety caused by the pandemic and respect more the
restrictions of COVID-19. However, Maugeri et al. reported
that, before the COVID-19 pandemic, men had
a high level of physical activity compared to women
(2998 MET-min/wk vs 1994 MET-min/wk). But since
the onset of the COVID-19 outbreak, men’s physical
activity has decreased more compared to women (1754
vs 1443 MET-min/wk). The lower decline of physical
activity among women can be attributed to factors such
as household chores, dancing, aerobics, and yoga at
home [4]. Physical inactivity can cause various physical
diseases such as CVDs, diabetes, and cancer [20, 21].
WHO reported that around 3.2 million deaths could be
attributed to physical inactivity annually [22]. Mattioli et
al. stated that the COVID-19 pandemic, quarantine, and
restrictions could be associated with unhealthy lifestyles
and increased anxiety, resulting in decreased physical
activity and undesirable changes in the diet. These conditions
can also cause long-term consequences such as
CVDs [20].
Concerning disordered eating attitudes, regardless of
gender, the COVID-19 pandemic has increased the disordered
eating attitudes of Iranian adults significantly by
about 4.12%; while for women, it has increased by 5.3%,
but the increase was not considerable men (around 1%).
Although, in the present study, the mean score of eating
attitudes of Iranian men and women was lower than 20,
which does not indicate eating disorders in either period
before or after the COVID-19 pandemic; however, there
are two essential points. First, before the pandemic, the
disordered eating attitudes for women (17.38) and men
(16.83) had been less than 20, which were somehow high
and worrying. Furnham et al. reported a rate of 10.85 for
Indians, 11.27 for Pakistan, and 16.34 for Bangladeshis
[23]. Secondly, regarding the importance of healthy
nutrition in preventing the COVID-19, this increase in
disordered eating attitudes, especially in women, is undesirable
and may disrupt healthy nutrition. Papandreou
et al. reported that undesirable nutrition behaviors and
stress have significantly increased since the onset of the
COVID-19 pandemic in Spain and Greece [24]. Brooks
et al. also stated that restrictions related to COVID-19
are associated with increased anxiety, discomfort, nervousness,
and loneliness. In addition to negative physical
consequences, these factors may cause negative
emotional and effects on people’s eating attitudes and
behaviors [9]. Eating attitude is the core of disordered
eating, ranging from healthy attitudes to disordered eating
[12]. Disordered eating is a public health problem
that has significantly increased since the 1970s. Anorexia
nervosa and bulimia are common disordered eating in
women [25]. Refraining from eating to control weight
or overeating in times of excitement and stress are also
common [26]. A meta-analysis study showed that 0.5%
of people with anorexia die per year, 20% of whom are
due to suicide [27]. Furthermore, those with a family history
of disordered eating are at increased risk of wrong
eating behaviors [28]. Therefore, preventing disordered
eating attitudes and identifying high-risk individuals is
crucial, especially during the COVID-19 pandemic [11].
Also, based on the findings, in addition to gender, there
is a significant association between disordered eating attitudes
with BMI and physical activity. In other words,
the higher the BMI or, the more severe the physical activity,
the higher is the disordered eating attitudes. Robinson
et al. reported that unhealthy eating patterns and
behaviors were more prevalent among people with higher
BMI during the COVID-19 outbreak. In other words,
those with higher BMI have lower levels of physical
activity, their dieting is of lower quality, and they have
Table 5. Coefficients of predictive variables of eating disordered attitudes during the COVID-19 pandemic
Variables
Unstandardized Coefficients Standardized Coefficients
t P
B Std. Error Beta
Age -0.069 0.058 -0.056 -1.18 0.23
Gender (female) 2.09 1.1 0.072 1.89 0.05
Marriage status (single) -1.72 1.19 -0.064 -1.44 0.15
Degree of education (Diploma
and sub-diploma) -1.08 0.79 -0.051 -1.36 0.17
Body mass index 0.38 0.13 0.11 2.82 0.005
Physical activity 1.48 0.32 0.17 4.53 0.0001
Pourrazi H, et al. Eating Attitudes, Physical Activity and COVID-19 Pandemic. Arch Hyg Sci. 2021; 10(2):133-142.
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more overeating [5]. Sánchez et al. also reported similar
results [3]. It seems that regardless of the COVID-19
outbreak and its stress and anxiety, overweight and
obese people are more susceptible to disordered eating
attitudes and behaviors. Caradas et al. reported that the
prevalence rates of EAT-26 score over 20 in people with
underweight, normal weight, overweight, and obese
were 9%, 18%, 24%, and 33%, respectively [29]. However,
the association between BMI and eating attitudes
disordered is mutual, and they aggravate each other. This
issue is more critical during the COVID-19 pandemic.
Eventually, although the level of physical activity of Iranian
men and women has declined during the COVID-19
pandemic, the positive association between disordered
eating attitudes and physical activity indicates that more
active people are more susceptible to disordered eating.
It is well-documented that athletes and active individuals
are more prone to disordered eating (e.g. anorexia
mentale, anorexia athletica), which may be due to their
worries about the shape of their body or other psychological
factors, such as stress for optimal performance
and perfectionism [30, 31], which the COVID-19 pandemic
may exacerbate. The findings of the present study
can be used for promoting public health during the COVID-
19 pandemic. On the other hand, there is no clear
end to the pandemic. Motivating individuals to increase
their mobility and increasing the cost of energy along
with promoting healthy nutrition not only help prevent
the COVID-19 but will also help to avoid other complications.
It seems that training nutritional behaviors
and using a healthy diet along with increased physical
activity are of crucial importance during the COVID-19
pandemic. The current study had limitations, including
a low sample size and a high proportion of participating
women compared to their proportion in society. The questionnaire
contained several items, and therefore it was
not possible to directly measure the stress and anxiety.
The participants were asked to remind their physical activity
before the pandemic, which increases the risk of
recall bias. However, further studies are needed to address
the gaps.
5. Conclusion
This study demonstrated that the COVID-19 pandemic
and its restrictions negatively affect healthy lifestyles
and behaviors related to disordered eating attitudes and
physical activity. The COVID-19 pandemic has reduced
the physical activities of both men and women. However,
only women experienced a significant increase in
disordered eating attitudes. Also, women, those with
high BMI, and those with more severe physical activity
are at increased risk of disordered eating attitudes during
the COVID-19 pandemic.
Ethical Considerations
Compliance with ethical guidelines
The present study was approved by the Ethics and Research
Committee of Allame Qazvini University (No.
99/pk/1k/1001).
Funding
The article was extracted from the MSc. thesis of the
third author at the Department of Sport Sciences, Faculty
of Humanities, Allame Qazvini Institute, Qazvin (No.
99/30/1024).
Authors' contributions
Conceptualization and supervision: Hassan Pourrazi,
Shagayeg Modaberi; Data collection and data analysis:
Hassan Pourrazi, Rahele Kabiri; Writing – original draft,
and writing – review & editing: Rahele Kabiri
Conflict of interest
The authors declared no conflict of interest
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