EFFECT OF LOCKDOWN ON HEALTH PROFILE OF MEDICAL STUDENTS

OF ASSAM
AUTHOR : DR ARPANA HAZARIKA,

CORRESPONDING AUTHOR : DR MADHURIMA BORA

ABSTRACT

Covid 19 pandemic has caused worldwide havoc. India is also passing through a challenging
situation as the number of infected or positive cases is increasing day by day. With strict
preventive measures and restriction by the Indian government in the form of nationwide
lockdown is trying to contain the contagious disease . The citizens are going through a range of
psychological and emotional reactions, ,fear and uncertainity being one of them. Schools and
colleges are closed for almost five months the lockdown has affected mental and other the
health profile of the students immensely. Disturbance in the mental health not only have negative
impact to the particular student but also have negative impact on the community as today’s
students are tomorrow’s future

AIM: This study was conducted out on 486 students of six medical colleges of Assam to
assess the effect of lock down due to covid 19 on health of the students.

RESULT:

It was seen that sleep profile was much affected. Sleep increased in most cases ( 69.11%).
appetite( 41.77%), intake of water ( 49.25%), intake of fruits( 49.46%), and intake of
vegetables(57.63%) increased during lockdown. Diagnosed cases of depression had frequent
attacks (52.3%) during lockdown. However hours spent on mobile increased (82.4%)
excessively. Physical activities decreased during lockdown leading to increased body weight
( 54.15%)

Key words

Lock down Mental health Depression Anxiety

INTRODUCTION

The outbreak of this novel respiratory virus has been associated with reports of increased
anxiety, depression, insomnia and fear among the general population [1]. In addition, extensive
media coverage, stay at home orders and unprecedented unemployment rates have only
intensified the sense of societal anxiety and panic [2] Existing studies suggest that patients with
psychiatric disorders are more susceptible to stress than the general population and may have
heightened symptoms during a time of crisis [3]. In the USA, approximately 20% of adults
experience mental illness [4] Healthcare crises such as pandemics have a profound psychological
impact. Multiple studies have demonstrated that heightened stress responses during or following
a crisis are associated with potentially long lasting adverse physical and mental health outcomes
[5]]. The outbreak of the Ebola virus in West Africa in 2014 received global media attention. A
team, led by Dr. Maria Loades, clinical psychologist from the Department of Psychology at the
University of Bath, established how loneliness and disease containment measures could impact
the mental health of both children and adolescents. For the last few months the majority of
children and adolescents in the US are experiencing a prolonged state of physical isolation from
their friends, as well as teachers, extended family and community networks. While quarantining
adults has generally led to negative psychological effects, including confusion, anger, and post-
traumatic distress, it is unknown how these measures have impacted children. [6] The studies
were mainly from the US, China, Europe, and Australia, but also included studies conducted in
India, Malaysia, Korea. Thailand, Israel, Iran, and Russia. Overall, the investigators found that
social isolation and loneliness increased the risk of depression, as well as the possibility of
anxiety at the time of loneliness, which was measured between 0.25-9 years later. The duration
of loneliness was strongly correlated with mental health symptoms than the intensity of
loneliness.[7] The investigators found young people were as much as 3 times more likely to
develop depression in the future due to social isolation, with the impact of loneliness on mental
health lasting up to 9 years later.[8] “Children and adolescents are probably more likely to
experience high rates of depression and probably anxiety during and after enforced isolation
ends,” the authors wrote. “This may increase as enforced isolation continues. Clinical services
should offer preventative support and early intervention where possible and be prepared for an
increase in mental health problems.”[9] So it is evident Mental health of the students is the topic
of interest throughout the world. The entire performance of the students depends on his mental
health. As students are our futures, disturbance in mental as well as other health parameters
affect not only the student but also has negative impact on society as well, because they are our
future teachers ,doctors, engineers ,nurses, administrators. Hence the mental health of the student
has to be given at most importance. Till date there is no proven treatment to manage the novel
corona disease. As the rate of spread is increasing day by day, lock down is the only option
available to slow down the rate of spreading infection. In this process all the educational
institution were lock down all of sudden. The students were in different phase of their academic
years, some were about to write their entrance examination and some are writing their
examination .It is well known that the students experience lot of stress especially before and
during the examinations. The examinations were postponed due to lockdown effect and the
actual date is awaited. In this context many students were undergoing mental Stress and there is a
strong need to consider their mental health status which also affect other health parameters .The
students were preparing the examinations specially the entrance examination for years together.
the medical students were also Under mental stress due to sudden transition from routine
teaching method to online method .There should be mental health cell that comprises of
psychiatrist, psychologist and senior faculty members.

Aim :
To see the health profile (both physical and mental status) of medical students of Assam

Study Design: Descriptive study

Study Population: Medical students both undergraduate and post graduate within the age group
of 18ys to 28yrs of age.

Sample size : 486

Study duration : 1 month

Inclusion criteria : Medical students (undergraduates belonging to all semesters and post
graduate students.)

Exclusion criteria : 1) general category students

2) Medical students of other states

Methodology :

A digital questionnaire was prepared and circulated among the medical students of Assam. The
form was duly filled up by willing 486 students of six medical colleges of Assam. Then the
answers were analyzed taking into account the mental health, physical health and food habits of
the students. The parameters used to see the health status of students were shown by bar diagram
and Pi Charts.

Statistical analysis :

All the parameters to check the mental and physical health of the student were shown in
percentage when compared with the same parameters at time of lockdown. To assist it the bar
diagram and pi charts are also used.
RESULT:

The questions answered are shown in the following tables:

Table 1

parameters Increased Decreased Same as No answer

during LD during LD before

Sleep profile 69.11% 11.02% 19.87% 23

Time taken to 61% 16% 23% 23

fall asleep

Appetite 41.77% 24.03% 34.2% 24

during LD

Intake of 18.57% 30.02% 51.4% 23

coffee during
LD

Intake of 49.25% 11.83% 38.92% 21

water during
LD

Intake of 49.46% 23.44% 27% 21

fruits during
LD
 Intake of 57.63% 14.41% 27.96% 21
vegetables
during LD

Body weight 51.15% 14.38% 33.48% 20

Hours in 82.4% 2.36% 15.24% 8

mobile

Table 2

FIG-1 Fig-2
 Time taken to fall
time taken to fall asleep asleep
3 23
23
1
2 16 2
3

1 61 61
16

0 10 20 30 40 50 60 70

Fig-3 Fig-4

Fig-5 Fig-6

Fig-7 Fig-8
Fig-9 Fig-10

Fig-11 Fig-12

Table 2:

diseases Familial On Frequent Need to No answer

medication attacks increase
medication
during LD

Diagnosed 31.61% 6.32% 52.30% 9.77% 312

case of
depression

Diagnosed 58.33% 17.26% 21.43% 2.98% 318

case of
asthma or
 allergy

Table 3:

Habits during No Occasional daily No answer

lockdown

Smoking 90.04% 7.14% 2.18% 23

habits

Alcohol 89.78% 10% 0.22% 25

consumption

Sleep inducing 93.06% 6.05% 0.86% 25

medication

Table 4:

Natural habits Regular Irregular No answer

during lockdown

Bowel habits 78.62% 21.28% 23

Menstrual cycle 82.14% 17.86% 290

DISCUSSION:

A decrease in mental and physical wellbeing, which likely resulted from the exceptional situation
due to the pandemic and was associated with decreased sleep quality and sleep duration. In
table1, the sleep profile was affected a lot . The strength of these effects may even have masked a
link between reduced social jetlag and positive effects on sleep quality, which has previously
been reported [8]. According to table 1, 61% students took longer time to fall asleep and 69% of
students had longer duration of sleep. Around 6.05% took medication to induce sleep as
lockdown hampered their routine of life. On a more positive note, we were also able to identify
factors that limited the decline in sleep quality during the lockdown. These included a reduction
in social sleep restriction, that is, the harmonisation of sleep duration across work and free days,
as well as a reduction in working hours. Moreover, increases in daylight exposure and exercise
may have buffered the negative effects of the lockdown and were associated with less decreased
sleep quality and increased sleep duration. Possibly, these factors were able to reduce lockdown-
induced stress [9]. In the three European countries included in the study, the COVID-19
lockdown, during which public life came to a standstill and many people experienced increased
flexibility regarding social schedules, led to improved individual sleep–wake timing and overall
more sleep. At the same time, however, many people suffered from a decrease in sleep quality in
this burdening and exceptional situation. Potential strategies to mitigate the adverse effects of the
lockdown on sleep quality may include exposure to natural daylight and exercise.[10]

It was seen that most of the students stayed with parents[89.16]% as hostels were
closed down due to lockdown. Physical distancing and self-isolation strongly impacted citizens’
lives, affecting in particular eating habits and everyday behaviours. There are two major
influences: staying at home (which includes digital-education, smart working, limitation of
outdoors and in-gym physical activity) and stockpiling food, due to the restriction in grocery
shopping. In addition, the interruption of the work routine caused by the quarantine could result
in boredom, which in turn is associated with a greater energy intake [10]. Moreover in this study
there is increase in the use of mobile phones [82.40%], among the students, this may have a
relation with online classes which are organized by the college in order to carry out the
academics and to relieve themselves from the boredom of lockdown.
In this study, there is increase in the intake of water [49.25%], fruit intake [49.46%], Vegetable
intake [57.63%] among the students. It is likely as the diet is supervised by the parents. In
addition to boredom, hearing or reading continuously about the COVID-19 from media can be
stressful. Stress leads subjects toward overeating, especially ‘comfort foods’ rich in sugar,
defined as “food craving” [11]]. Those foods, mainly rich in simple carbohydrates, can reduce
stress as they encourage serotonin production with a positive effect on mood 12]. However, this
food craving effect of carbohydrates is proportional to the glycemic index of foods that is
associated with the increased risk of developing obesity and cardiovascular diseases, beyond a
chronic state of inflammation that has been demonstrated to increase the risk for more severe
complications of COVID-19 [13]. This new condition may compromise maintaining a healthy
and varied diet, as well as a regular physical activity. For example, limited access to daily
grocery shopping may lead to reduce the consumption of fresh foods, especially fruit, vegetables
and fish, in favour of highly processed ones, such as convenience foods, junk foods, snacks, and
ready-to-eat cereals, which tend to be high in fats, sugars, and salt. Moreover, psychological and
emotional responses to the COVID-19 outbreak [12,], may increase the risk of developing
dysfunctional eating behaviors. It is well known how the experience of negative emotions can
lead to overeating, the so-called “emotional eating” [13]. In this study it is seen that physical
activity of the students decreased by [32.80%] leading to gain in body weight [52.15%]. In table
2, we see frequent [52.30%] of diagnosed case of depression [21.43%] diagnosed case of allergy
or asthma. According to table 3, smoking habit and alcohol consumption was found to be
minimal. According to table 4, bowel habit and menstural cycle of female students were found to
be regular In order to contrast and respond to the negative experience of self-isolation, people
could be more prone to look for reward and gratification physiologically associated with food
consumption, even overriding other signals of satiety and hunger [14]. In addition, boredom
feelings, which may arise from staying home for an extended period, are often related to
overeating as a means to escape monotony [15]. On the other hand, negative experiences may
lead to eating restriction, due to the physiological stress reactions that mimic the internal
sensations associated with feeding-induced satiety.[16]
Finally, lifestyle may be substantially changed due to the containment measures, with the
consequent risk of sedentary behaviours, modification in smoking and sleeping habits[17]. Of
interest, different studies reported an association between sleep disturbances and obesity due to
increase the secretion of pro-inflammatory cytokines by the increased visceral adipose that could
contribute to alter the sleep–wake rhythm [18]. In addition, alsodiet seems to influence the
quality of sleep, in fact very recently in a cross-sectional study included 172 middle-aged adults
it has been reported that good sleepers had higher adherence to the Mediterranean diet (MD) and
lower body mass index (BMI) compared to poor sleepers [19].
Considering the smoking, there are a significant association exists between SARS-CoV-2
infection and air pollution, and in this context in smokers, more severe COVID-19 symptoms
occur [20].Low physical activity levels have been suggested to interact both with body fat and
appetite dysregulation [21].

In table 2 we see frequent attacks [52.30%] of diagnosed case of depression [21.43%] diagnosed
case of allergy Or asthma. According to table 3, smoking habit and alcohol consumption was
minimal among the students.
The COVID-19 outbreak has prompted most countries opt for population confinement and social
distancing measures as a way to control the spread of the virus. However, important
psychological effects have been pointed out in previous confinement experiences
(Hawryluck et al., 2004). The current pandemic has already shown significant psychological
symptoms related to anxiety, stress and depression Wang et al., 2020Bao et al., 2020,
Xiang et al., 2020Yang et al., 2020 [24]. A higher prevalence of high scores on psychological
impact measured by IES was observed compared to the prevalence of large scores on depression,
anxiety and stress measured by DASS-21. Similar results were also recently found in China
by Wang et al. (2020)[25]. As these authors point out, this difference in prevalence may be due
to the specific evaluation of the impact of the event by IES versus a non-specific evaluation by
DASS-21. Regarding the different groups at the university, significantly higher depression,
anxiety and stress scores were observed in students compared to the different groups of
employees[26]. The high prevalence of psychological symptoms in university students has been
frequently pointed out (Auerbach et al., 2016; Bayram and Bilgel, 2008; Bruffaerts et al., 2018)
[27]. While there is evidence from several studies in which students from the HS or Engineering
area were found to present higher symptomatology scores than those in the Humanities area
(Elias et al., 2011; Posselt and Lipson, 2016), our results show precisely the opposite.[28]
In fact, the lowest scores are shown by E&A students and workers on all three
subscales. In line with our results, the study of Lipson et al. (2016) showed that A&H students
have a greater tendency to develop mental illnesses compared to the other areas, such as the
Engineering and Business students, who also seem to undergo treatment less frequently29].
A study with a large sample size performed in China obtained similar percentage
oIES scores with respect to our study (Wang et al., 2020). Furthermore, that study also highlights
the high levels of symptomatology in students, indicating that the uncertainty and the potential
negative impact on academic progress may have motivated the impact on students’ mental
health.[30]
However, results from another study in the general population of China, evaluated using the
same instrument (IES), seem to show a much lower percentage of moderate or severe scores on
the impact of the event, 7.6% (Zhang and Ma, 2020). The reasons for the difference between that
study and our results may perhaps be related to the considerable age difference between the
respondents of both studies, with younger respondents in our case, and a significantly smaller
sample size in the study on the Chinese general population..[31]
This study has some strengths and limitations. Among the strengths, the large sample size (2530
respondents) allowed us to perform a robust analysis and extract solid tendencies and
associations. Also, this is an early study that offers a unique opportunity to investigate the
emotional impact of the COVID-19 pandemic in a university environment. It provides valuable
information about the current situation useful to gain some insight about the situation in other
universities or in possible future global crises.
It is important to explore why younger students are suffering a greater psychological
impact, which could be related to factors such as their perception of the future, their way of
consuming information media, etc.
CONCLUSION-. This study suggests that mental health of students and should be carefully
monitored during this crisis, and authorities should provide psychological services oriented and
adapted to these circumstances to mitigate the emotional impact on medical students

.
REFERENCES
1. Wittmann M., Dinich J., Merrow M., Roenneberg T. Social jetlag: misalignment of biological
and social time. Chronobiol. Int. 2006;23:497–509. [PubMed] [Google Scholar]
2. Wong P.M., Hasler B.P., Kamarck T.W., Muldoon M.F., Manuck S.B. Social jetlag,
chronotype, and cardiometabolic risk. J. Clin. Endocrinol. Metab. 2015;100:4612–4620. [PMC
free article] [PubMed] [Google Scholar]
3. Levandovski R., Dantas G., Fernandes L.C., Caumo W., Torres I., Roenneberg T., Hidalgo
M.P.L., Allebrandt K.V. Depression of respondents with moderate or severe
scores associate with chronotype and social jetlag in a rural population. Chronobiol.
Int. 2011;28:771–778. [PubMed] [Google Scholar]
4. Depner C.M., Melanson E.L., Eckel R.H., Snell-Bergeon J.K., Perreault L., Bergman B.C.,
Higgins J.A., Guerin M.K., Stothard E.R., Morton S.J. Ad libitum weekend recovery sleep fails
to prevent metabolic dysregulation during a repeating pattern of insufficient sleep and weekend
recovery sleep. Curr. Biol. 2019;29:957–967.e4. [PubMed] [Google Scholar]
5. Ghotbi N., Pilz L.K., Winnebeck E.C., Vetter C., Zerbini G., Lenssen D., Frighetto G.,
Salamanca M., Costa R., Montagnese S., Roenneberg T. The μMCTQ: an ultra-short version of
the Munich ChronoType
Questionnaire. J. Biol. Rhythms. 2019;35:98–110. [PubMed] [Google Scholar]
6. Blume C., Schmidt M., Cajochen C. Sleep and social jetlag during COVID-19. Open Science
Framework. 2020 doi: 10.17605/osf.io/mhsw8. [CrossRef] [Google Scholar]
7. Roepke S.E., Duffy J.F. Differential impact of chronotype on weekday and weekend sleep
timing and duration. Nat. Sci. Sleep. 2010;2010:213–220. [PMC free article] [PubMed] [Google
Scholar]
8. Raman S., Coogan A.N. A cross-sectional study of the associations between chronotype,
social jetlag and subjective sleep quality in healthy adults. Clocks Sleep. 2020;2:1–6. [Google
Scholar]
9. de Quervain D., Aerni A., Amini E., Bentz D., Coynel D., Gerhards C., Fehlmann B., Freytag
V., Papassotiropoulos A., Schicktanz N. The Swiss Corona Stress Study. Open Science
Framework. 2020 doi: 10.31219/osf.io/jqw6a. [CrossRef] [Google Scholar]
11. Muscogiuri G, Pugliese G, Barrea L, Savastano S, Colao A. Obesity: the “Achilles heel” for
COVID-19? Metabolism. 2020;108:154251. doi: 10.1016/j.metabol.2020.154251. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]

12. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and
associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic
among the general population in China. Int J Environ Res Public Health. 2020;17:1729. doi:
10.3390/ijerph17051729. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
13. Montemurro N. The emotional impact of COVID-19: from medical staff to common
people. Brain Behav Immun. 2020 doi: 10.1016/j.bbi.2020.03.032. [PMC free article] [PubMed]
[CrossRef] [Google Scholar]
14. van Strien T. Causes of emotional eating and matched treatment of obesity. Rep: Curr Diab;
2018. [PMC free article] [PubMed] [Google Scholar]
15. Evers C, Dingemans A, Junghans AF, Boevé A. Feeling bad or feeling good, does emotion
affect your consumption of food? A meta-analysis of the experimental evidence. Rev: Neurosci.
Biobehav; 2018. [PubMed] [Google Scholar]
16. Singh M. Mood, food and obesity. Front Psychol. 2014;5:1–35. doi:
10.3389/fpsyg.2014.00925. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
17. Havermans RC, Vancleef L, Kalamatianos A, Nederkoorn C. Eating and inflicting pain out
of boredom. Appetite. 2015;85:52–57. doi: 10.1016/j.appet.2014.11.007. [PubMed]
[CrossRef] [Google Scholar]
18. Crockett AC, Myhre SK, Rokke PD. Boredom proneness and emotion regulation predict
emotional eating. J Health Psychol. 2015;20:670–680. doi:
10.1177/1359105315573439. [PubMed] [CrossRef] [Google Scholar]
19. Muscogiuri G, Barrea L, Annunziata G, Di Somma C, Laudisio D, Colao A, et al. Obesity
and sleep disturbance: the chicken or the egg? Crit Rev Food Sci Nutr. 2019;59:2158–2165. doi:
10.1080/10408398.2018.1506979. [PubMed] [CrossRef] [Google Scholar]
20. Pugliese G, Barrea L, Laudisio D, Salzano C, Aprano S, Colao A, et al. Sleep apnea, obesity,
and disturbed glucose homeostasis: epidemiologic evidence, biologic insights, and therapeutic
strategies. Curr Obes Rep. 2020;9:30–38. doi: 10.1007/s13679-020-00369-y. [PubMed]
[CrossRef] [Google Scholar]
21. Muscogiuri G, Barrea L, Aprano S, Framondi L, Di Matteo R, Laudisio D, et al. Sleep
quality in obesity: does adherence to the mediterranean diet matter? Nutrients. 2020;12:1364.
doi: 10.3390/nu12051364. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
22. Engin AB, Engin ED, Engin A. Two important controversial risk factors in SARS-CoV-2
infection: obesity and smoking. Environ Toxicol Pharmacol. 2020 doi:
10.1016/j.etap.2020.103411. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
23. Panahi S, Tremblay A. Sedentariness and health: is sedentary behavior more than just
physical inactivity? Front Public Heal. 2018;6:258. doi: 10.3389/fpubh.2018.00258. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]
24. People Who Are at Higher Risk for Severe Illness | Coronavirus | COVID-19 |
CDC. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-
risk.html. Accessed 7 May 2020.
25. Hauner H. Secretory factors from human adipose tissue and their functional role. Proc Nutr
Soc. 2005;64:163–169. doi: 10.1079/PNS2005428. [PubMed] [CrossRef] [Google Scholar]
26. Dietz W, Santos-Burgoa C. Obesity and its implications for COVID-19
mortality. Obesity. 2020 doi: 10.1002/oby.22818. [PubMed] [CrossRef] [Google Scholar]
27. Di Renzo L, Gualtieri P, Romano L, Marrone G, Noce A, Pujia A, et al. Role of personalized
nutrition in chronic-degenerative diseases. Nutrients. 2019;11(8):1707. doi:
10.3390/nu11081707. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
28. De Lorenzo A, Bernardini S, Gualtieri P, Cabibbo A, Perrone MA, Giambini I, et al.
Mediterranean meal versus Western meal effects on postprandial ox-LDL, oxidative and
inflammatory gene expression in healthy subjects: a randomized controlled trial for nutrigenomic
approach in cardiometabolic risk. Acta Diabetol. 2017;54:141–149. doi: 10.1007/s00592-016-
0917-2. [PubMed] [CrossRef] [Google Scholar]
29. Soldati L, Di Renzo L, Jirillo E, Ascierto PA, Marincola FM, De Lorenzo A. The influence
of diet on anti-cancer immune responsiveness. J Transl Med. 2018;16(1):75. doi:
10.1186/s12967-018-1448-0. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
30. Cani PD, Van Hul M. Mediterranean diet, gut microbiota and health: when age and calories
do not add up! Gut. 2020 doi: 10.1136/gutjnl-2020-320781. [PMC free article] [PubMed]
[CrossRef] [Google Scholar]
31. PATTO in cucina Magazine. https://www.pattoincucina.it/. Accessed 7 May 2020.
32. We Are Social & Hootsuite. Digital 2020. Data Reportal. 2020.
33. Schröder H, Fitó M, Estruch R, Martínez-González MA, Corella D, Salas-Salvadó J, et al. A
short screener is valid for assessing Mediterranean diet adherence among older Spanish men and
women. J Nutr. 2011;141:1140–1145. doi: 10.3945/jn.110.135566. [PubMed]
[CrossRef] [Google Scholar]
34. http://old.iss.it/binary/ofad/cont/questionariogiovaniinforma.1225957648.pdf. Accessed 26
May 2020.
35. Istat.it | Multiscopo sulle famiglie: aspetti della vita quotidiana - parte
generale. https://www.istat.it/it/archivio/217037. Accessed 7 May 2020.
36. COVID-19 ITALIA -
Desktop. http://opendatadpc.maps.arcgis.com/apps/opsdashboard/index.html#/
b0c68bce2cce478eaac82fe38d4138b1. Accessed 7 May 2020.
37. Jayawardena R, Sooriyaarachchi P, Chourdakis M, Jeewandara C, Ranasinghe P. Enhancing
immunity in viral infections, with special emphasis on COVID-19: a review. Diabetes Metab
Syndr Clin Res Rev. 2020;14:367–382. doi: 10.1016/j.dsx.2020.04.015. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]
38. Brake SJ, Barnsley K, Lu W, McAlinden KD, Eapen MS, Sohal SS. Smoking upregulates
angiotensin-converting enzyme-2 receptor: a potential adhesion site for novel coronavirus
SARS-CoV-2 (Covid-19) J Clin Med. 2020;9:841. doi: 10.3390/jcm9030841. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]
39. García OP, Long KZ, Rosado JL. Impact of micronutrient deficiencies on obesity. Nutr
Rev. 2009;67:559–572. doi: 10.1111/j.1753-4887.2009.00228.x. [PubMed] [CrossRef] [Google
Scholar]
40. Childs CE, Calder PC, Miles EA. Diet and immune function. MDPI AG: Nutrients;
2019. [Google Scholar]
41. Costa de Miranda R, Di Renzo L, Cupertino V, Romano L, De Lorenzo A, Salimei C, et al.
Secular trend of childhood nutritional status in Calabria (Italy) and the United States: the spread
of obesity. Nutr Res. 2019;62:23–31. doi: 10.1016/j.nutres.2018.10.008. [PubMed]
[CrossRef] [Google Scholar]
42. De Lorenzo A, Gratteri S, Gualtieri P, Cammarano A, Bertucci P, Di Renzo L. Why primary
obesity is a disease? J Transl Med. 2019;17:169. doi: 10.1186/s12967-019-1919-y. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]
43. Dhurandhar NV, Bailey D, Thomas D. Interaction of obesity and infections. Obes
Rev. 2015;16:1017–1029. doi: 10.1111/obr.12320. [PubMed] [CrossRef] [Google Scholar]
44. De Lorenzo A, Romano L, Di Renzo L, Di Lorenzo N, Cenname G, Gualtieri P. Obesity: a
preventable, treatable, but relapsing disease. Nutrition. 2020;71:110615. doi:
10.1016/j.nut.2019.110615. [PubMed] [CrossRef] [Google Scholar]
45. Nappi F, Barrea L, Di Somma C, Savanelli MC, Muscogiuri G, Orio F, et al. Endocrine
aspects of environmental “obesogen” pollutants. MDPI AG: Int J Environ Res Public Health;
2016. [PMC free article] [PubMed] [Google Scholar]
46. Denoth F, Scalese M, Siciliano V, Di Renzo L, De Lorenzo A, Molinaro S. Clustering eating
habits: frequent consumption of different dietary patterns among the Italian general population in
the association with obesity, physical activity, sociocultural characteristics and psychological
factors. Eat Weight Disord. 2016;21:257–268. doi: 10.1007/s40519-015-0225-9. [PubMed]
[CrossRef] [Google Scholar]
47. Beck MA, Handy J, Levander OA. Host nutritional status: The neglected virulence
factor. Trends Microbiol. 2004;12:417–423. doi: 10.1016/j.tim.2004.07.007. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]
48. Romano L, Bilotta F, Dauri M, Macheda S, Pujia A, De Santis GL, et al. Short report—
medical nutrition therapy for critically ill patients with COVID-19. Sci: Eur Rev Med
Pharmacol; 2020. [PubMed] [Google Scholar]
49. Muscogiuri G, Barrea L, Savastano S, Colao A. Nutritional recommendations for CoVID-19
quarantine. Eur J Clin Nutr. 2020 doi: 10.1038/s41430-020-0635-2. [PMC free article] [PubMed]
[CrossRef] [Google Scholar]
50. Di Renzo L, Merra G, Botta R, Gualtieri P, Manzo A, Perrone MA, et al. Post-prandial
effects of hazelnut-enriched high fat meal on LDL oxidative status, oxidative and inflammatory
gene expression of healthy subjects: a randomized trial. Eur Rev Med Pharmacol
Sci. 2017;21:1610–1626. [PubMed] [Google Scholar]
51. Ministero della Sanità Classificazione statistica internazionale delle malattie e dei problemi
sanitari correlati DECIMA
REVISIONE. http://www.salute.gov.it/imgs/C_17_pubblicazioni_1929_allegato.pdf.