Impact of Covid-19 Lockdown Measures on Lifestyle Behavior in Children and Adolescents With Severe Obesity
Authors: Abawi Ozair , Welling Mila Sofie , van den Eynde Emma , van Rossum Elisabeth F C , Halberstadt Jutka , van den Akker Erica L T , van der Voorn Bibian 
Published: May 2021

Abstract
Introduction: During the COVID-19 pandemic, lockdown measures were implemented with large impact on lifestyle behaviors and well-being of children (including adolescents). The impact on children with severe obesity, who plausibly are at even larger risk, has not yet been described. Aim of this study was to investigate the impact of COVID-19 lockdown on eating behaviors, physical activity, screen time and quality of life (QoL) of children with severe obesity. Methods: In this mixed-methods study, questionnaires and semi-structured telephone interviews were used to investigate impact of COVID-19 during the first wave in the Netherlands (April 2020) on children with severe obesity (adult BMI-equivalent ≥35kg/m2) treated at our obesity center. The Dutch Eating Behavior Questionnaire - Child, Pediatric Quality of Life Inventory, and Dutch Physical Activity Questionnaire were filled out by their families pre-pandemic and during lockdown. Changes over time in percentile scores, weekly physical activity and screen time were assessed. Qualitative analyses were performed according to the Grounded Theory. Results: We included 83 families, of which 75 participated in the interviews. Their children’s characteristics were mean age 11.5years (SD 4.6), 52% female, mean BMI SD score 3.8 (SD 1.0), indicating severe obesity. On group level, no changes in scores for emotional, restrained, external eating, and QoL nor in screen time were observed (Δ scores +9.2, +3.9, +0.3; and +3.0, respectively; -0.3 hr/wk; all p&gt;0.05). Weekly physical activity decreased (Δ -1.9 hr/wk, p=0.02). Age, pre-existent psychosocial problems and pre-pandemic questionnaire scores were associated with improved or deteriorated questionnaire scores in specific subgroups. For example, children who did not fulfill WHO physical activity criteria pre-pandemic showed a further decline from 2.8 to 0.7 h/wk (p=0.001). Children with high emotional and external eating during lockdown had the lowest QoL scores (p-values &lt;0.01). Qualitative data showed that an increased demand for food was frequently observed (n=21), mostly in children aged &lt;10 years (19/21). This was attributed to loss of daily structure, increased stress, or emotional eating. Families who reported no changes (n=15) or improved eating behaviors (n=11) attributed this to already existing strict eating schemes that they kept adhering to.
Conclusion: This study shows differential response profiles to COVID-19 lockdown in children with severe obesity. Although on group level lifestyle scores averaged out, a substantial part of families reported deterioration in physical activity and eating behaviors. Children with pre-existent psychosocial problems, high external or emotional eating scores were most at risk. Health care professionals should target these vulnerable children to minimize short- and long-term negative physical and mental health consequences.