|Year : 2021 | Volume
| Issue : 2 | Page : 227-233
Lifestyle behavior of patients with noncommunicable diseases during COVID-19 pandemic: An observational study
Renu Bala, Amit Srivastava
Regional Research Institute (H), Imphal, Manipur, India
|Date of Submission||23-Mar-2021|
|Date of Acceptance||03-May-2021|
|Date of Web Publication||31-May-2021|
Dr. Amit Srivastava
Regional Research Institute, New Checkon, Opposite Tribal Colony, Imphal East - 795 001, Manipur
Source of Support: None, Conflict of Interest: None
CONTEXT: Coronavirus disease (COVID-19) poses an unprecedented challenge and adversely affects the lifestyle of people with noncommunicable diseases (NCDs) due to enforced restrictions by the governments.
AIMS: The study aimed to assess the physical activity and prophylactic behavior, along with change in sleep, alcohol intake, and tobacco consumption during the enforced lockdown.
MATERIALS AND METHODS: The study was conducted in August 2020 and recruited NCD patients visiting the institute's outpatient department. Questions were formed on prophylactic behavior, changes in sleep, and alcohol and tobacco consumption along with a validated scale of International Physical Activity Questionnaire (IPAQ) Short Form.
RESULTS: The study recruited 413 patients with a mean age of 54.34 years. The median IPAQ score was 536 metabolic equivalent task-minutes/week, with 41.96% of the patients demonstrating low physical activity. A statistically significant difference between the IPAQ scores was found among different NCD groups (P = 0.009). There was a statistically significant decrease in number of hours of sleep during the pandemic as compared to before the pandemic (P = 0.000). Furthermore, there was a significant change in tobacco consumption (P = 0.000) and alcohol consumption (P = 0.000) during the pandemic. The patients followed preventive practices to a larger extent.
CONCLUSION: The study highlighted that the NCD patients should follow an optimal physical activity schedule, take proper sleep, and continue following prophylactic behavior.
Keywords: Coronavirus, coronavirus disease, International Physical Activity Questionnaire Short Form, lifestyle, noncommunicable diseases, physical exercise, preventive health
|How to cite this article:|
Bala R, Srivastava A. Lifestyle behavior of patients with noncommunicable diseases during COVID-19 pandemic: An observational study. Indian J Health Sci Biomed Res 2021;14:227-33
|How to cite this URL:|
Bala R, Srivastava A. Lifestyle behavior of patients with noncommunicable diseases during COVID-19 pandemic: An observational study. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Jun 17];14:227-33. Available from: https://www.ijournalhs.org/text.asp?2021/14/2/227/317408
| Introduction|| |
An outbreak of novel coronavirus (SARS-CoV-2) infection was first reported in Wuhan, China, in December 2019 that spread rapidly to the rest of the world and was declared a pandemic by the World Health Organization (WHO). Coronavirus disease (COVID-19) alters the overall mortality and burden of disease through impact on noncommunicable diseases (NCDs). NCDs kill approximately 41 million people worldwide each year, which will increase to 55 million by 2030. In India, nearly 5.8 million people die from NCDs every year. Physical inactivity, unhealthy diets, tobacco use, and harmful use of alcohol are the main behavioral risk factors for NCDs.
During the pandemic, the most prevalent comorbidities were hypertension (HTN) and diabetes mellitus (DM), followed by cardiovascular diseases (CVDs) and respiratory system diseases. Worldwide, one in five people is at an increased risk of severe COVID-19 if they become infected, mostly because of underlying NCDs. For this reason, NCD patients are urged to stay at home without their routine medical follow-up though it may increase the risk of worse outcomes due to reduced mobility., Furthermore, they need long-term medications, which may be difficult to access during the pandemic, especially in remote areas.
Healthcare systems began postponing and scaling down some aspects of routine NCD management, outpatient visits, and nonurgent surgery to avoid unnecessary hospital visits, reduce the burden on hospitals, and decrease infection risk. Indian Government initiated containment measures with different approaches. Self-isolation recommendations were particularly targeted to older persons and/or to individuals with chronic medical conditions, but these restrictions inevitably reduced opportunities to exercise, which is essential for controlling symptoms and risk factors.
The imposed restrictions may have relevant clinical implications in terms of daily functioning and night-time sleep, deleterious effects of insufficient physical activity, and change in smoking and drinking behavior. The objective of the study was to assess the lifestyle pattern of persons suffering from NCDs and preventive behavior displayed during the time of COVID-19 pandemic.
| Materials and Methods|| |
Study design and setting
A cross-sectional study was conducted from August 3 to September 1, 2020, at the outpatient department (OPD) of author's institute. The state government had enforced an extended lockdown due to COVID-19 pandemic in the region till August 31, 2020.
The study aimed to assess the lifestyle pattern of NCD patients during the enforced restrictions. The proportion of burden of NCDs in the region is around 58.5%. Open-Epi software (The OpenEpi Project, Atlanta, Georgia) was used for calculating the sample size. Considering level of significance 5% (confidence interval 95%) and design effect of one, the estimated sample size for the study was 373 to be representative of the population. However, the study recruited 413 participants, so the confidence limit was increased to 95.8%.
The participants were recruited from the patients with NCD who were under treatment at the institute. Participants suffering from one or multiple NCDs, aged 18 years or above, of both the sexes and who agreed to participate were included in the study after taking written informed consent. A convenience sampling method was used to recruit participants in the study.
The study questionnaire was in the English language. Participant's sociodemographic characteristics were recorded in a predesigned format.
The questionnaire in this study included questions from scales that are:
- Questions on preventive behavior were formed as per the recommendations of the Ministry of Health and Family Welfare, Government of India. A total of 13 questions were formed to assess the practices adopted by the participants. Each question was measured on a five-point Likert scale with response choices ranging from “not at all” (1) to “always” (5). Scores of the 13 items were summed, yielding a minimum score of 13 and a maximum score of 65 with higher scores indicating better practices
- Questions were formed to assess changes in sleeping pattern, smoking/tobacco habit, and alcohol intake during the pandemic as compared to the period before the pandemic. One question each enquired the number of hours of sleep, consumption of tobacco or cigarettes, and alcohol intake before the pandemic. Similarly, one question each enquired the same during the pandemic
- International Physical Activity Questionnaire (IPAQ) Short Form: This scale assesses the types of intensity of physical activity and sitting time that people do as part of their daily lives. The obtained data were cleaned and processed as per the scale guidelines, and the IPAQ analysis was performed on 348 participants. The total physical activity was calculated and expressed as median metabolic equivalent task (MET)-minutes/week. This physical activity questionnaire is publicly available, it is open access, and no permissions are required to use it.
Ethical Clearance was obtained from Regional Research Institute (H), Imphal Institutional Ethical Committee with Ref no 2-28/315.
The information gathered was entered into a spreadsheet, and statistical tests were performed using Microsoft Excel software (Microsoft, Redmond, WA, USA). The descriptive analysis gave frequency, percentage, mean scores, and standard deviation (SD) of response, while median MET-minutes/week and interquartile range (IQR) were used for IPAQ scores. Analysis of variance or t-test was performed for preventive behavior to identify any significant difference depending on demographic variables. A paired t-test was performed to assess the difference in sleeping habits before and during the pandemic. A Wilcoxon signed-rank test was performed to assess the significant difference in smoking and drinking habits before and during the pandemic. The IPAQ data were processed, and after cleaning of the data, nonparametric test of Mann–Whitney U-test or Kruskal–Wallis H-test was performed on this subsample of 348 subjects to find if any significant difference exists between the groups. The P value was kept at 0.05. The post hoc test revealed groups that were significantly different from each other. Dunn's post hoc analysis was performed for IPAQ score, and significant difference was assessed with the help of Benjamini–Hochberg false discovery rate (FDR) adjusted P value at https://astatsa.com/.
| Results|| |
The study recruited a total of 413 subjects [Supplementary Table 1]. The mean age (SD) of the study sample was 54.34 (13.80) years with maximum participants from the age group up to 45 years (N = 112, 27.12%). The majority of participants were female (211, 51.09%), married (384, 92.98%), lived in urban area (246, 59.56%), and in joint family (339, 82.08%). Furthermore, 55.45% (229) of the population did not take any prophylactic medicine, while 44.55% (184) of people took Homeopathic medicine as a prophylactic measure against COVID-19. The most common NCDs found among the study participants were HTN (234, 56.66%) and DM (43, 10.41%), while 14.29% (59) of the participants suffered from more than one NCD.
The patients with NCD visiting the OPD followed preventive practices to a larger extent [Supplementary Table 2] such as frequent hand washing with soap and water or using alcohol-based hand rub (407, 98.55), wearing face masks in public places (410, 99.28%), avoid shaking hands and other contacts with people (411, 99.51%), avoiding public transport (410, 99.28%), and avoid spitting in public (409, 99.03%). The subjects were less diligent in cleaning or disinfecting things and surfaces touched by them or others (287, 69.49%). The mean score (SD) of the preventive behavior in the study sample was 60.024 (3.893). Preventive practices were significantly greater among females (P = 0.000), unmarried individuals (P = 0.024), and persons living in the nuclear family (P = 0.000). Interestingly, participants who did not took any prophylactic medicine for COVID-19 were also less diligent in following preventive practices (P = 0.000) [Table 1]. There was a significant difference in preventive behavior among the demographic groups of education (P = 0.000) and occupation (P = 0.003). The post hoc analysis revealed that the subjects with education up to high school (vs. junior high school, Q = 4.253, P = 0.015), higher secondary (vs. junior high school, Q = 5.549, P = 0.001), graduate and higher (vs. junior high school, Q = 5.626, P = 0.001), occupation of government job (vs. unemployed, Q = 4.138, P = 0.042), and homemaker (vs. unemployed, Q = 4.166, P = 0.040) showed significantly higher preventive practices [Table 2].
|Table 1: Comparison of preventive behavior based on demographic variables (n=413)|
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The analysis of IPAQ score was performed on the subsample of 348 subjects as per the scoring guidelines [Table 3]. The median (IQR) IPAQ score in the study subsample was 536 (510) MET-minutes/week. The level of activity in the participants were categorized into low (146, 41.96%), moderate (191, 54.89%), and high (11, 3.16%). A Mann–Whitney test indicated that the median (IQR) IPAQ score for male of 693 (530.25) MET-minutes/week and female of 462 (363) MET-minutes/week was statistically different (U = 10518, P = 0.000). The Kruskal–Wallis test showed that there was a statistically significant difference between the IPAQ scores among the demographic group of education (H (3) =22.304, P = 0.000), occupation (H (5) =27.053, P = 0.000), and type of NCD (H (5) =15.331, P = 0.009). A pair-wise comparison using post hoc Dunn's test with Benjamini–Hochberg FDR correction [Table 4] indicated that the IPAQ score of education group graduate and higher (media n = 678, IQR = 532.5) was observed to be significantly different from those of education up to junior high school (median = 431, IQR = 523.88, P = 0.003), high school (median = 495, IQR = 477.5, P = 0.046), and higher secondary education (median = 462, IQR = 363, P = 0.002). Furthermore, the IPAQ score of occupation of homemaker (median = 400, IQR = 371.25) was observed to be significantly different from business persons (median = 693, IQR = 599.75, P = 0.007), government job (median = 693, IQR = 517.88, P = 0.013), and unemployed (median = 693, IQR = 862.5, P = 0.013).
|Table 3: Comparison of International Physical Activity Questionnaire scores based on demographic variables (n=348)|
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|Table 4: Post hoc analysis of International physical activity questionnaire score|
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Sleeping pattern, smoking/tobacco habit, and alcohol intake
Since the onset of COVID-19 pandemic, the number of hours of sleep was the same in 85.23% (352) of the participants as compared to the period before the pandemic while the sleep hours decreased in 11.86% (49) of the participants. There was a significant difference in number of hours of sleep before the pandemic (mean = 6.697, SD = 1.028) and during the pandemic (mean = 6.563, SD = 1.321) conditions (t(412) =4.134, P = 0.000).
Consumption of tobacco products or cigarette was the same in 86.68% (358) of the subjects during the pandemic, while the consumption decreased in 11.86% (49) as compared to the period before the pandemic. A Wilcoxon signed-rank test determined that there was a statistically significant change (z = 5.090, P = 0.000) in tobacco consumption during the pandemic as compared to the period before the pandemic. Similarly, the participants demonstrated significant change (z = 5.119, P = 0.000) in alcohol consumption during the pandemic compared to the period before the pandemic. Alcohol consumption was the same in 90.80% (375) of the subjects during the pandemic, while the consumption decreased in 8.96% (37) of the subjects as compared to the period before the pandemic [Table 5].
|Table 5: Comparison of sleep, tobacco consumption, and alcohol intake before and during the lockdown|
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| Discussion|| |
This study explored the preventive behavior and physical activity among the patients suffering from NCD along with changes in sleep and alcohol and tobacco consumption during COVID-19 pandemic. The prevalence of NCD such as HTN (56.66%), DM (10.41%), and multimorbidity (14.29%) in the present study was similar to the findings of other comparable studies. Restriction measures for the pandemic do not imply that all forms of physical activities must be eliminated. Indoor exercises that can be safe, simple, and easily implementable can help in preserving fitness levels while maintaining social distancing. Majority of the participants performed a low (41.96%) or moderate level (54.89%) of physical activity with similar findings in another study from the region on diabetic patients where half of the participants (50%) were physically active, though specific exercises as walking were limited to a small group only (24.07%). Studies have showed that patients followed some form of exercise (62%) or were regular with their exercise routine (80%)., Similar results were found in another study with 61% performing physical activity during the quarantine. The ability of individuals, families, and communities to promote health, prevent disease, maintain health and to cope with illness and disability with or without the support of a healthcare provider is of paramount importance in these troubled times. It is imperative to empower individuals as self-carers and caregivers as it might be beneficial in preventing and reducing underlying risk factors, optimizing treatment, and managing complications.
The preventive behavior displayed by the NCD subjects was remarkable which is consistent with finding of other studies., Practice of disinfecting surfaces or things was found wanting among the participants (69.49%) as in a similar study from the region. It can be attributed to the fact that some preventive measures are deemed less feasible as they require greater effort (e.g. cleaning frequently touched surfaces) or pose greater difficulties (e.g. staying home) than others.
The COVID-19 pandemic may lead to changes in health behaviors such as smoking, alcohol use, and sleep. People may manage social isolation and distress by increasing adverse health behaviors such as smoking or alcohol use. The stress related to quarantine and social isolation could serve as a trigger, and an increase in alcohol consumption and alcohol abuse is a matter of growing concern. An increase in alcohol use would add to the usual disease burden associated with alcohol and may weaken the innate and acquired immune system that will add to the COVID-19 load. However, this study reported no change in alcohol drinking in majority of participants (90.79%) during the pandemic, similar to other studies. Minimal decrease in alcohol intake was observed among very few (7.74%) participants only. Tobacco consumption also remained the same in majority of the participants (90.79%) which are in compliance to other studies. Mean sleep duration was assessed as 6.69 h before the COVID-19 pandemic which meets the guidelines of 7–9 h for adults, and it decreased significantly to 6.56 h during the pandemic which is in line with the findings of another study.
There are several strengths of the present study, including the inclusion of multiple health behaviors, a large sample size, and the timing of data collection relative to lockdown restrictions in the region. However, there are also some limitations to consider. First, this was a cross-sectional study assessing the variables on a single observation and no causal relation could be inferred. A follow-up study can be undertaken to observe changes over time to assess the impact of changes in social restrictions. Second, a convenient sampling method was used for recruiting subjects, and therefore, the results might have been affected by the cultural norms and may not be generalizable to populations with different characteristics. A larger study may be designed to recruit participants from diverse cultural backgrounds. Third, the responses may have been subject to recall bias.
| Conclusion|| |
The study highlighted the effect of COVID-19 pandemic on lifestyle pattern of patients with NCDs and the burden it placed on health resources. The disruption of services due to enforced restrictions has compounded the problems of NCD patients and forced changes in lifestyle pattern might also generate new long-term disabilities that will add to the NCD burden. It has changed everyday life, and lessons should be taken from the experience to build a healthcare system that can protect the most fragile people in our society. A concentrated effort is the need of the hour to create awareness through education campaign and to ensure that NCD patients receive continuous healthcare services. People living with NCDs should be encouraged to monitor their symptoms, practice self-care, adhere to medication, seek healthcare services including counseling, practice physical distancing, wash their hands with soap, and wear masks. To reduce the risk of NCDs, a combination of effective tobacco and alcohol control and health interventions for HTN, diabetes, and other NCDs should be implemented.
The authors acknowledge the support provided by the Central Council for Research in Homoeopathy, New Delhi, in the conduction of this study. The authors would like to thank Dr. Thadoi Potsangbam, Ex-Senior Research Fellow (SRF), Dr. Gouri Devi Ningthoujam, SRF, and Dr. Lily Anal, Junior Research Fellow, of the author's institute, for their contribution to the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Supplementary Tables|| |
| References|| |
Clark A, Jit M, Warren-Gash C, Guthrie B, Wang HHX, Mercer SW, et al.
Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: A modelling study. Lancet Glob Health 2020;8:e1003-17.
National Health Portal of India. Non-communicable Diseases. New Delhi: Ministry of Health and Family Welfare, Government of India; 2019. Available from: https://www.nhp.gov.in/healthlyliving/ncd2019
. [Last accessed on 2021 Mar 03].
Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, et al.
Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: A systematic review and meta-analysis. Int J Infect Dis 2020;94:91-5.
Huang I, Lim MA, Pranata R. Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia-A systematic review, meta-analysis, and meta-regression. Diabetes Metab Syndr 2020;14:395-403.
Pranata R, Lim MA, Huang I, Raharjo SB, Lukito AA. Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta-regression. J Renin Angiotensin Aldosterone Syst 2020;21:1470320320926899.
Aebischer Perone S, Martinez E, du Mortier S, Rossi R, Pahud M, Urbaniak V, et al.
Non-communicable diseases in humanitarian settings: Ten essential questions. Confl Health 2017;11:17.
Willan J, King AJ, Jeffery K, Bienz N. Challenges for NHS hospitals during covid-19 epidemic. BMJ 2020;368:m1117.
Golechha M. COVID-19, India, lockdown and psychosocial challenges: What next? Int J Soc Psychiatry 2020;66:830-2.
Dekker J, Buurman BM, van der Leeden M. Exercise in people with comorbidity or multimorbidity. Health Psychol 2019;38:822-30.
Dean A, Sullivan K, Soe M. OpenEpi-Open Source Epidemiologic Statistics for Public Health, Version 3.01. 2013. Available from: http://www.OpenEpi.com
. [Last accessed on 2020 Jul 10].
Ministry of Health and Family Welfare, Government of India. FAQ.pdf. New Delhi: Ministry of Health and Family Welfare, Government of India; 2020. Available from: https://www.mohfw.gov.in/pdf/FAQ.pdf
. [Last accessed on 2021 Mar 03].
Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al.
International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381-95.
Bala R, Srivastava A, Potsangbam T, Anal L, Ningthoujam GD. Self care practices and psychological distress among diabetic patients in Manipur during COVID-19: A scenario from the North East. Diabetes Metab Syndr 2021;15:93-8.
Nachimuthu S, Vijayalakshmi R, Sudha M, Viswanathan V. Coping with diabetes during the COVID-19 lockdown in India: Results of an online pilot survey. Diabetes Metab Syndr 2020;14:579-82.
Ghosh A, Arora B, Gupta R, Anoop S, Misra A. Effects of nationwide lockdown during COVID-19 epidemic on lifestyle and other medical issues of patients with type 2 diabetes in north India. Diabetes Metab Syndr 2020;14:917-20.
Tornese G, Ceconi V, Monasta L, Carletti C, Faleschini E, Barbi E. Glycemic Control in Type 1 Diabetes Mellitus During COVID-19 Quarantine and the Role of In-Home Physical Activity. Diabetes Technol Ther 2020;22:462-7.
World Health Organization, Regional Office for South-East Asia. Self care for health: A Handbook for Community Health Workers and Volunteers. New Delhi: The Regional Office; 2014. Available from: https://apps.who.int/iris/handle/10665/205887
. [Last accessed on 2021 Mar 03].
Bala R, Srivastava A, Ningthoujam GD, Potsangbam T, Oinam A, Anal CL. An Observational Study in Manipur State, India on Preventive Behavior Influenced by Social Media During the COVID-19 Pandemic Mediated by Cyberchondria and Information Overload. J Prev Med Public Health 2021;54:22-30.
Srivastava A, Bala R, Shil R, Shaw P, Karso L, Bhaumik H, et al.
Knowledge, attitude, practices and perception towards COVID-19 in North Eastern States of India: An online cross sectional study. Asian J Pharmaceut Clin Res 2020;13:165-72.
Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: Mental health consequences and target populations. Psychiatry Clin Neurosci 2020;74:281-2.
Rehm J, Kilian C, Ferreira-Borges C, Jernigan D, Monteiro M, Parry CDH, et al.
Alcohol use in times of the COVID 19: Implications for monitoring and policy. Drug Alcohol Rev 2020;39:301-4.
Shield K, Manthey J, Rylett M, Probst C, Wettlaufer A, Parry CD, et al.
National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: A comparative risk assessment study. Lancet Public Health 2020;5:e51-61.
Molina PE, Happel KI, Zhang P, Kolls JK, Nelson S. Focus on: Alcohol and the immune system. Alcohol Res Health 2010;33:97-108.
Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al.
Depression, Anxiety and Stress during COVID-19: Associations with Changes in Physical Activity, Sleep, Tobacco and Alcohol Use in Australian Adults. Int J Environ Res Public Health 2020;17:???.
Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al.
National Sleep Foundation's updated sleep duration recommendations: Final report. Sleep Health 2015;1:233-43.
Ammar A, Trabelsi K, Brach M, Chtourou H, Boukhris O, Masmoudi L, et al.
Effects of home confinement on mental health and lifestyle behaviours during the COVID-19 outbreak: Insight from the ECLB-COVID19 multicenter study. Biol Sport 2021;38:9-21.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]