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Dietary habitslifestyle changes, and glycemic control in patients with type 2 diabetes mellitus during coronavirus disease 2019 (COVID-19): A cross-sectional study in Egypt

Hussein, Yasmin H. H.; Soliman, Al-Zahraa M.1

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Journal of Family and Community Medicine 30(1):p 1-11, Jan–Mar 2023. | DOI: 10.4103/jfcm.jfcm_114_22
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The coronavirus disease 2019 (COVID-19) lockdown had a significant effect on people’s lifestyles and dietary habits resulting in a possible negative health impact, particularly for patients with type-2 diabetes mellitus (T2DM). The objective of the study was to assess the changes in dietary habits and lifestyle and how these relate to glycemic control in patients with type 2 diabetes (T2D), who attended Zagazig Diabetes Clinic, Sharkia Governorate, Egypt, during the COVID-19 pandemic.


A total of 402 patients with T2D were included in this cross-sectional study. A semistructured questionnaire was used to collect information on socioeconomic status, dietary habitslifestyle changes, and previous medical history. Weight and height were also measured, and hemoglobin A1C levels before and after lockdown were compared. Data analysis was performed using the SPSS. To determine statistical significance, Chi-square test was used for categorical variables whereas, paired t-test or McN-Nemar test, as appropriate, was used to compare change in HbA1c before and after lockdown. Ordinal logistic regression was used to determine factors associated with weight change, whereas binary logistic regression was used to determine factors related with glycemic control.


During the COVID-19 pandemic, 43.8% of the studied groups consumed more than their usual diet with an increase in fruits, vegetables, and immunity-boosting food; 57% depended on home-cooked food, 48.3% did not practice exercise. About 57% reported to have gained weight, 70.9% suffered from mental stress, and 66.7% reported inadequate sleep. Collectively, there was a statistically significant decrease in the percentage of good glycemic control in the studied groups (28.1% vs. 15.9%) before and after the COVID-19 lockdown, respectively (P < 0.001). Weight gain, physical inactivity, mental stress, and inadequate sleep were significantly associated with poor glycemic control.


COVID-19 pandemic has had a negative impact on the lifestyle and dietary habits of the studied groups. Therefore, it is very important to ensure better diabetes management in this critical period.


On December 12, 2019, a new coronavirus (SARS-CoV2) was discovered in Wuhan, China, triggering a pandemic of acute respiratory syndrome in humans (coronavirus disease 2019). SARS-CoV-2 spread quickly from Wuhan, Hubei Province, China, to the rest of the world.[1] Owing to the massive international spread of cases, the World Health Organization’s Emergency Committee declared it a global pandemic on January 30, 2020.[2]

The coronavirus disease 2019 (COVID-19) pandemic created life-altering issues for people worldwide, where “social detachment” and “self-isolation” became commonplace, and people were required to stay inside their homes for a lengthy period to combat the outbreak resulting in such side effects as boredom and stress. These side effects were often associated with overeating, particularly “comfort foods” mostly rich in calories to break the monotony.[3] Obesity is an important risk factor for increased morbidity and mortality in T2DM patients, and weight gain has been proven to diminish glycemic control and increase the risk of diabetes progression.[4]

The prevalence of type 2 diabetes (T2D) has increased worldwide,[5] almost doubling between 1980 and 2014 worldwide in adults (85%–95% T2D). These increases are more prominent in low- and middle-income countries and in men than in women.[6] Egypt is the eighth leading country in the prevalence of diabetes mellitus (DM). In 2022, it was estimated that more than ten million adults live with DM in Egypt, which represents a prevalence of almost 18.4%.[7]

Uncontrolled diabetes is one of the leading causes of death in COVID-19 patients, which possibly occurs as a result of the lack of physical activity, dietary changes, trouble obtaining drugs, insulin, or glucose test strips, or inability to seek medical advice. All these lifestyle factors could have had an impact on type 2 diabetes progression and management (T2DM).[8]

The COVID-19 pandemic could last long, with long-term implications for people’s lifestyle choices such as nutrition, physical activity, and sleep habits.[9] Therefore, clinicians must evaluate the effect of COVID-19 on lifestyle-related behavior in those at risk, particularly those on treatment for T2DM.[3]

In addition, the gene expression levels of all cytokines are regulated by a diet that can impact inflammation and oxidative stress processes; therefore, it is essential to maintain a healthy nutritional status. Furthermore, because diet influences the gene expression levels of all cytokines, which can modulate inflammation and oxidative stress processes, the maintenance of healthy nutritional status is critical, particularly when the immune system is required to fight back.[10]

Furthermore, sleep has a tremendous impact on the immune system because it allows the body to repair and relax, which is especially important during critical diseases. During the Spanish flu pandemic, clinicians regarded sleep as vital for their patients’ recovery.[11,12]

Uncontrolled diabetes has emerged as one of the leading causes of death in patients with COVID-19. The dietary and lifestyle habits of this vulnerable group may be impacted by the restrictive measures taken in Egypt to prevent the spread of the virus. Early detection and handling of these changes could help improve diabetic control with minimal complications. This research was conducted to assess the changes in dietary habits and lifestyle as well as their relationship to glycemic control in patients with T2D who attended the Zagazig Diabetes Clinic, Sharkia Governorate, Egypt, during COVID-19 pandemic.

Materials and Methods

This cross-sectional study was carried out from March 1, 2021, to the end of August 2021 among patients with T2DM. Both male and female patients aged 18 or older, who visited the Zagazig Diabetes Clinic in Sharqia Governorate for routine follow-up and had been diagnosed for at least six months were eligible for the study. This clinic is one of the sectors of the general authority for health insurance in the Sharkia Governorate. It provides comprehensive services for diabetic patients with health insurance, including free examination and investigations, the disbursement of treatment “insulin-tablets,” and periodic follow-up, in addition to DM counseling seminars for patients.

Patients with type 1 diabetes, gestational diabetes, severe psychiatric disorders or mental retardation, or end-stage organ failure were excluded from the study. Ethical approval was obtained from the Zagazig University Institutional Review Board vide letter No. ZU-IRB #6766 dated 21/02/2021 and written informed consent was taken from all participants. Check these prodentim reviews.

Epi Info™[13] was used for sample size calculation if the weight gain compared to before lockdown was 19%.[11] From records, the attendance rate of type 2 diabetic patients at Zagazig Diabetes Clinic was 110 cases/month. Therefore, the total population size in 1 year was 1320 cases. The total sample was 402 at a 5% confidence limit and a design effect of 2.

The study participants were chosen using systematic random sample technique. We selected the day randomly, based on the interviewers’ availability and the day the diabetes clinic was run; then, the first patient was selected randomly. After that, we selected every third patient who arrived at the clinic and could be approached in the waiting area. Patients who met the study’s eligibility requirements and agreed to participate were interviewed using a self-administered questionnaire. Their weight, height, and glycated hemoglubin (HbA1C) were measured. The researchers provided them with clear information about the rationale and study objectives and assured them of complete confidentiality of all data and opinions provided.

Data were collected using a semistructured questionnaire based on previous studies.[3,8] It consisted of the following main parts: (a) sociodemographic level assessment[14] and (b) eating habits and lifestyle with questions on diet and lifestyle issues before the COVID-19 pandemic in the form of past medical history (duration of DM, type of treatment, complications, and history of SARS-CoV-2 infection), diet (changes in quality and quantity, meal times, frequency of snacks and food orders from restaurants, and the consumption of fruits, sugar, and ready-to-cook meals), exercise (type and frequency), and other lifestyle habits (smoking, appetite, mental stress, and the ways to cope with irritation, and sleep).

By reviewing the participants’ records, baseline data on weight and height before the COVID-19 pandemic were obtained and compared to those measured by the researchers. The subject’s weight and height were estimated when standing straight barefooted on scales. Weight in kilograms was divided by the square of height in meters, and the percentile body mass index (BMI) was calculated. BMI ranges from 18.5 to 24.9 kg/m2 were used to define normal body weight.[15] Read more at

The baseline level of HbA1C before the COVID-19 pandemic was obtained from patients’ records, and the level at the study time was measured at the diabetic clinic laboratory. HbA1c below 6.4% was considered good glycemic control.[16]

Linguistic experts translated the questionnaire into Arabic and then back into English. Internal consistency measurement was used to assess the reliability of the eating habits and lifestyle questionnaire. It had a good level of consistency (Cronbach’s alpha = 0.85).[17]

A pilot study was conducted on 40 patients (10% of the study participants) to identify any data collection challenges, assess the questionnaire’s validity and reliability after translation, and determine the amount of time required to collect the data. Because no changes were made, the pilot sample was included in the main sample.

Data analysis was performed using the SPSS (Statistical Package for the Social Sciences, version 25).[18] When appropriate, quantitative data were presented as mean and standard deviations or median and interquartile range (IQR), and categorical variables were labeled with their absolute frequencies. The Chi-square test was used for categorical variables to compare the studied groups. For quantitative data, paired t-test was used to compare HbA1c before and after lockdown in no change, increased, and decreased weight groups, while the Mc-Nemar test was used to compare HbA1c before and after lockdown between no change, increased, and decreased weight groups. Ordinal logistic regression was used to determine factors associated with weight change, whereas binary logistic regression was used to determine factors related with glycemic control. P < 0.05 was considered statistically significant, and P < 0.001 was considered highly statistically significant. Visit


The average age of the studied group was 47.99 years and 55.2% were males. About three-quarters (74.9%) were married, 56.2% were highly educated, 69.2% were working, 61.7% resided in rural areas, and about half of the studied group belonged to a moderate socioeconomic level [Table 1].