Appetite 163 (2021) 105220

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Appetite
journal homepage: www.elsevier.com/locate/appet

Factors associated with diet changes during the COVID-19 pandemic period
in Brazilian adults: Time, skills, habits, feelings and beliefs
Alline Artigiani Lima Tribst, Ph.D, Research Scientist *, Cláudia Raulino Tramontt, Ph.D,
Research Collaborator, Larissa Galastri Baraldi, Ph.D, Research Scientist
Center for Food Studies and Research at University of Campinas. R. Albert Einstein 291, Campinas, SP, 13083-852, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: This study aimed to identify individual, household and sociodemographic factors associated with changes in food
Food habits consumption that lead to changes in the diet quality, in the context of the COVID-19 pandemic concerning
Cooking organization and administration Brazilian adults. Improvements or worsening in diet quality (IDQ or WDQ) were verified using an exploratory
Healthy diets
online survey which investigated whether participants (n = 4780) increased or decreased their consumption of
Risk factors
Surveys and questionnaires
food subgroups that mark positive or negative food patterns. Respondents also agreed or disagreed with their
beliefs about food safety, cooking skills, family support, home characterization, feelings and behaviors. All
factors of influence on the IDQ or WDQ groups were always compared against the general participants (who did
not change their diet sufficiently to be classified into these groups). Individuals from the IDQ group spent more
time on food (81.4% versus 62.0%), started to cook more often (91.4%), were more confident with their cooking
skills (p < 0.01) and positive feelings were at least 2.5 times more prevalent. Adjusted analysis showed the
chance to improve diet was 1.39 higher among those who did not feel overworked and increased 1.07 in each
additional cooking chore shared between household members. For each additional positive feeling, the odds
were 1.41 to IDQ and 0.67 to WDQ. Moreover, for each additional negative feeling the chances for WDQ were
1.21 and 0.90 for IDQ. Those in the WDQ group were more unaware of issues related to contagion during meals,
they were not afraid of eating food prepared outside their home and agreed that industrialized food is safer (OR
= 1.85). These results highlight the associated factors in improving or worsening diet patterns as a consequence
of the COVID-19 pandemic, supporting messages presented in Dietary Guidelines.

1. Introduction pressures) could be an aggravating factor for changes on appetite during

The new way of life imposed by COVID-19 world pandemic has been
changing the possibilities of food choice (Béné, 2020) and influencing
dietary habits. The state of lockdown and mobility restrictions have
direct effects on people’s lifestyle and could lead to disordered eating
(Naja & Hamadeh, 2020), like frequent snacking, skipping meals, rigid
rituals and routines surrounding food, and loss of control around food
(Anderson, 2020).
In addition, negative psychological conditions and feelings - condi­
tions of stress, distress, and emotions like fear and sadness, in turn, can
feed back into the cycle of dietary habits as a “natural” response through
both psychological and physiological mechanisms (Anton & Miller,
2005; Macht, 1999). Since the appetite is influenced by a broad factors
internal and external, previous stress-causing conditions like being
exposed to chronic psychological stressors (e.g. overworking or job
the COVID-19 pandemic context (Torres & Nowson, 2007). Depending
on the individual background, the food pattern may also be modified in
positive or negative directions (Macht, 1999, 2008).
A food pattern based on hyperpalatable (marked by the use of some
food additives, like artificial sweeteners, flavors, dyes, and flavor en­
hancers) and low nutrient profile food products (high in energy density,
free sugars or salt) is considered unhealthy and can lead to excessive
consumption (WHO, 2003). As a consequence, worsening in diet quality
is marked by inadequate fiber, vitamin, and mineral profile while
increasing total calories (Hall et al., 2019; Shan et al., 2019).
Salty-snacks, candies, fast-food dishes, and sweetened beverages are
mentioned as common items found in this kind of food pattern (WHO,
2013), which, in the long term, is correlated with several
non-communicable diseases including obesity, cardiovascular and
metabolic diseases, all types of cancer, depression, gastrointestinal

* Corresponding author.
E-mail addresses: tribst@unicamp.br (A.A.L. Tribst), claudiartramontt@gmail.com (C.R. Tramontt), lbaraldi@unicamp.br (L.G. Baraldi).

https://doi.org/10.1016/j.appet.2021.105220
Received 11 November 2020; Received in revised form 26 February 2021; Accepted 14 March 2021
Available online 27 March 2021
0195-6663/© 2021 Elsevier Ltd. All rights reserved.
A.A.L. Tribst et al.
disorders and premature mortality (Monteiro et al., 2019; Pagliai, 2020;
Popkin, 2020).
On the other hand, adequate food patterns have been considered one
of the main pillars to enhance the body immune system (Abbas & Kamel,
2020), which can be decisive for individuals to increase the consump­
tion of healthy food (Naja & Hamadeh, 2020). Optimal nutrition,
namely the ingestion of fruits, vegetables, whole grains, plants, and
adequate content of protein and healthy fats, is considered the best way
to get essential nutrients and guarantee the normal function of the im­
mune system, playing an important role on defense against COVID-19
(Abbas & Kamel, 2020; Dauchet, 2006; Faria Coelho-Ravagnani et al.,
2020; WHO, 2003).
One of the main drivers of healthy eating patterns is the time
available to organize eating activities, including time spent cooking,
learning new recipes, improving cooking skills, and sharing meals with
family members (Bhutani et al., 2020; Scarmozzino & Visioli, 2020). The
improvement on familiar interaction and increased time at home
derived from COVID-19 pandemic seemed to cause positive outcomes on
the food patterns of some population’s strata in Italy, Spain, Chile, and
Colombia (Bhutani et al., 2020; Rodríguez-Pérez et al., 2020; Scar­
mozzino & Visioli, 2020).
In Brazil, recent studies are divergent about the patterns in food
consumption during the pandemic period raising questions about how
the quality of the population’s diet is. While a national survey showed a
decrease in the usual frequency of consumption of fresh foods and an
increase in the frequency of consumption of ready-to-eat or heat dishes,
salty snacks, chocolate, and biscuits, two other studies point to an
opposite direction, with improvements in food pattern. It has been
demonstrated that, during confinement, Brazilian adolescents presented
a higher average legume intake compared with adolescents from other
countries (Ruiz-Roso et al., 2020). Likewise, the adult population also
increased the consumption of healthy food markers, including higher
average legume intake, while the consumption of unhealthy food
markers remained unchanged (Steele, 2020).
Considering the multifactorial aspects that can influence dietary
patterns and the need to better comprehend these changes under the
pandemic context, this exploratory study aims to identify factors asso­
ciated with positive and negative changes on food patterns, in the
context of the COVID-19 pandemic concerning Brazilian adults. The
hypothesis was that people with different backgrounds on cooking skills
and family support, combined with their beliefs and new emotional
conditions, could modify their diet in different ways.
2. Materials and methods
2.1. Study design, participant recruitment and data collection
This was an exploratory cross-sectional study consisting of an online
consumer behavior survey applied in Brazil (May 12th to June 26th,
2020) through a convenience sample. This period was established in 45
days, aiming to guarantee response in a similar scenario of COVID-19
pandemic in Brazil (the most restricted phase of quarantine in the
country and 881–990 deaths daily). Voluntary participants were
recruited using social media (Facebook), researchers’ professional con­
tacts from the five regions of the country, and personal ones (ques­
tionnaire link was sent by WhatsApp). They received a web link of
Google survey (Google Forms) that redirected them to 50 mandatory
questions. Considering the difficulties to call volunteers during the
pandemic period, an adapted snowball sampling strategy was used,
including posting information about the research study on social
networking sites and on University websites (Lee & Spratling, 2019).
Additionally, volunteers were stimulated to spread the questionnaire
link into their personal network to increase the total and diversity of
participants, as carried out by Faber et al. (2020). The questionnaire was
answered by 4817 individuals and the final sample achieved was 4780
eligible participants (over 18 years old).
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Appetite 163 (2021) 105220
The informed consent form was presented before the questions and it
was necessary to read and agree with the terms before answering the
survey. Ethical approval was obtained from the human ethics committee
at the University of Campinas (UNICAMP) (CAAE
30650220.0000.5404).
2.2. Conceptual background and questionnaire planning
This study adopted food pattern definition according to theoretical
frameworks widely spread in many Dietary Guidelines (especially the
Brazilian Guideline) and backgrounds regarding dietary diversity pre­
sented originally by The Food and Agriculture Organization (Brazil,
2014; FAO, 2011; FAO, 2016; Herforth et al., 2019). Thus, a healthy
food pattern is those which include a traditional and diverse diet. The
key factors to achieve this food pattern is given preference to in natura,
fresh meals prepared mainly with plant-based options (fruit, vegetables,
legumes, whole or ground cereals and beans) and moderate consump­
tion of animal protein (meat, eggs and milk) (Willett et al., 2019).
Moreover, a healthy food pattern must avoid the consumption of food
products that do not belong to traditional diets, with inadequate
nutrient profile and with ingredients in their formula that are only for
industrial use (PAHO, 2016). Conversely, the opposite food pattern was
named unhealthy.
Thereby, this survey was structured in two sections, one aimed at
evaluating changes in diet quality and the other investigating individual
and family factors that may influence the quality of the diet. Those
sessions are presented below. Additional questions of sociodemographic
profile were included to characterize the study population.
To evaluate the clarity and relevance of each question included, the
instrument was sent to a group of five experts in the areas of nutrition
and public health and food science, which gave positive feedback to the
authors (Rubio et al., 2003). In addition, a face validity was conducted
through a sample of the target population (ten adults among mal­
e/female, from 30 to 70 years, graduated or not – covering the variety
profile of targeted respondents) to estimate the time of completion and
evaluate the clarity of the introductory text, introductory question and
proposed format answer options. Few adjustments were based on the
respondent feedbacks (e.g., inclusion of “retired” as option in the
question about “permanent job”, inclusion of “none” as options about
feelings during the pandemic) and the time to answer the survey was
estimated in 5–10 min.
In order to evaluate the internal consistency of the items regarding
changes in the consumption of food subgroups, alpha Cronbach test was
carried out. Its result (alpha = 0.706) showed adequate reliability,
allowing to group those items and creating the outcomes of this study.
The other section of the questionnaire (beliefs about food safety and risk
of contracting COVID-19 by food; cooking skills and family support;
feelings and behaviors) were equally tested and had poor internal con­
sistency (alpha = 0.627), thus, these questions were treated as indi­
vidual items on the statistical analysis.
2.3. Assessment of changes in the consumption of food subgroups during
the COVID-19 pandemic
The first section of the survey included 12 items that focused on
assessing changes on the two dimensions (healthy and unhealthy) of diet
quality in Brazil. Its content was based on an instrument presented by
Sattamini in 2019, which was modified to be applied quickly, consid­
ering the Covid-19 pandemic scenario. Therefore, the items included
were also chosen based on food markers pointed by the Brazilian
Household Budget Survey, especially to investigate individuals’ changes
on food pattern (Brazil, 2019). Starting from the original 13 food sub­
groups presented to evaluate the unhealthy dimension of the diet (Sat­
tamini, 2019), the sweetened drinks were grouped into a single group
and items that were not consumed by itself (such as sauces and
margarine) were excluded, resulting in 6 items to evaluate this
A.A.L. Tribst et al.
dimension of the diet. The healthy dimension of the diet was represented
by six other items presented as the main subgroups of traditionally
consumed foods and recommended in Chapter 3 “From foods to meals”
of the “Brazilian Dietary Guidelines” (Brazil, 2014).
Summing up, respondents were asked to indicate the changes in their
consumption answering the question “Please, identify whether the
COVID-19 pandemic has changed your consumption habit of following
food”. The food items included in the questionnaire were: (i) beef/
chicken/pork, (ii) eggs, (iii) milk/cheese/yogurt, (iv) rice/beans, (v)
fruits (vi) vegetables/greens, (vii) “French bread” (most usual bread sold
in Brazilian’s bakeries), (viii) soda/fruit drinks (ix) candies, (x) salty
snacks, (xi) sweet snacks and (xii) ready-to-eat frozen food. The response
options were: (1) I never ate this food, (2) It was greatly reduced, (3) It
was a little reduced, (4) It had not changed, (5) It increased a little and
(6) It greatly increased.
2.4. Assessment of beliefs about food safety and risk of contracting
COVID-19 by food; cooking skills and family support; feelings and
behaviors
In this section, participants were asked about their agreement level
with the statements: (i) “I’m afraid of being contaminated by corona­
virus from food or food packages”, (ii) “A healthy diet can help to
improve my immunity”, (iii) “I’m keeping food clean and safe (using
soap, alcohol or chlorine)”, (iv) “I’m afraid of eating food prepared
outside my home”, (v) “I think Industrialized food is safer to eat”, (vi) “I
think that smallholder food is safer to eat”, (vii) “I have no family/friend
support to cook”, (viii) “I am facing difficulties because I don’t know
how to cook”, (ix) “I’m overworked, so I can’t cook”, (x) “I am worried
that the food will run out at my house”, (xi) “I have no money to pur­
chase healthy and diverse foods, and (xii) I am eating less because of
monetary difficulties. Statements (i)-(vi) were based on information
disclosed about the risks of contracting COVID-19 through food (Eric,
2020) and about the relationship between diet and immunity (Abbas &
Kamel, 2020). Statements (vii)-(ix) were based on cooking skills and
cooking support (Lam & Adams, 2017; Martins, 2020). Finally, the last
three were extracted from a questionnaire with determinants of food
security (Bickel, 2000). Together with the socio-demographic data, the
last three statements presented here were used as a proxy of income
(Bickel, 2000). For this block of questions, the response options were
based on a 5-point Likert scale ranging from “totally disagree” to “totally
agree” (Lu et al., 2018).
To investigate the adults’ cooking practices, some questions were
added based on an instrument developed to evaluate domestic cooking
practices considered relevant in Brazil, according to recommendations
of the Dietary Guidelines for the Brazilian (Martins et al., 2021). Re­
spondents were also asked about if: (i) they or somebody in home spent
more time cooking (yes/no), (ii) they changed the time dedicated to
eating practices (no/yes, it decreased/yes, it increased), (iii) the main
person responsible for cooking at home received more assistance with
food preparation (yes/no) and (iv) which kind of assistance (on food
purchase/dish washing and kitchen cleaning/pre-preparation, including
cleaning, cutting, peeling ingredients like vegetables).
Finally, they answered about personal feelings experienced during
the pandemic period that could affect their dietary habits: anxiety/peace
of mind/fear/mental exhaustion/faith/stress/confidence/none (Macht,
2008).
2.5. Assessment of socio-demographic characteristics and pandemic
exposure
Participants were asked about their age group (<18 years/18–35/
36-60/60–75/more than 75 years), gender (male/female), educational
level (Not graduated – grouping elementary, adult education program,
secondary and high school –, superior and post-graduation). Addition­
ally, they answered about how many people they were living with
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Appetite 163 (2021) 105220
during the pandemic period (0/1/2/3/4 or more), who these people are
(parents/partner/children/friends/alone/other) and how many of them
cooks at home (0/1/2/3 or more). For proxy of income evaluation,
participants answered whether they had a permanent job just before the
beginning of the pandemic (yes/no/no, I am retired), how many hours
they used to work (0/up to 10/10–20/20–30/30–40/more than 40 h)
and also whether their family had income reduction due to the pandemic
(yes/no).
Surrounding the pandemic period, participants answered whether:
(i) they are socially isolated (yes/partially/no), (ii) they are or live with
someone from the risk group for COVID-19 (yes/no) - including people
with over 60 years and/or with comorbidities (diabetes, high blood
pressure, obesity, breath diseases).
2.6. Data management
Firstly, each food subgroup consumption was categorized into 1 for
the answer options “It increased a little” and “It greatly increased” and
− 1 for the answer options “It was a little reduced” and “It was greatly
reduced”, in the case of the answers “It had not changed” or “I never ate
this food”, the value 0 was assumed. Two new variables were created,
one that corresponded to the sum of all food subgroups considered
healthy (according to the theoretical framework) and another to the sum
of all food subgroups that should be avoided or restricted (unhealthy
pattern).
Thus, the main outcome was named “Improved diet quality”,
configuring healthy changes in food pattern. This outcome was cate­
gorized as “1” when participants reached the following conditions: a)
have increased the consumption of at least on one of the food markers of
diverse and healthy diets (fruits/vegetables), b) had a positive result in
the final sum of the group previously identified as healthy, c) the sum of
the score for the unhealthy group was zero or negative. Otherwise, the
outcome was categorized as “zero”, grouping respondents who did not
achieve all conditions necessary to be classified into “Improved diet
quality” group during quarantine.
The secondary outcome that sets negative modifications on food
pattern was named as “Worsened diet quality”. It was categorized as
“zero” on the same rationale, when the individual was not belonging to
this pattern, and as “1” if the sum score of items for the unhealthy food
group was positive (≥1) while the sum of the group identified as healthy
was zero or negative.
2.7. Data analysis
The software Win-Pepi was used to determine the minimum sample
size for regression analysis. The parameters considered were a) model
with ten predictors b) number required to attain a power of 80%, C) with
a significance level of 0.05 to detect a “small effect”, and the result was a
sample of between 878 individuals which were achieved in the study.
Both outcomes “improved diet quality” (IDQ) or “worsened diet
quality” (WDQ) were analyzed individually against their counterfactual
group (named as general population), which means those individuals
that did not change their diet added by those who changed their diet in
the opposite way. The crude associations of exposure factors with each
outcome were tested with Pearson chi-square test or nonlinear equiva­
lent (Fisher exact test), Bonferroni test was applied to explore on which
categories the difference was significant. Logistic regressions were used
to select the variables to be tested in the adjusted model, a univariate
model with a cut-off point of p < 0.20 was used, and in the multiple
associations Likelihood-ratio test after estimation were considered to
obtain the final model. A significance level <0.05 was considered for all
estimates. All statistical analysis was performed using software Stata
16.0 MP.
A.A.L. Tribst et al. Appetite 163 (2021) 105220

3. Results
The changes in the consumption of food makers observed during the
beginning of the COVID-19 pandemic showed an improvement of diet
quality for 21.1% (n = 1008) of the interviewees and worsening for
12.5% (n = 596).
Sociodemographic characteristics of the sample that improved their
diet quality did not differ from the rest of the entire sample, except for
social isolation that was more frequently in this group (p < 0.001). They
were mostly women (around 80%) and had a permanent job before the
pandemic (66.2%), half of them were post-graduated, middle-aged
adults (36–60 y. o.) and were living with one or two persons (mainly
parents, children and partners), with no statistical difference to the
others participants. (Table 1).
Those who worsened their diet quality were younger and graduated,
and the proportion of participants partially isolated and unemployed
before the pandemic was slightly higher when compared with the rest of
the participants (p < 0.05 for Bonferroni test). In addition, they were
living with more people – except considering partners - at the moment of
the research (Table 1).
For the other evaluated parameters, no differences were observed
between those who improved, worsened, or maintained the diet quality
(data not shown). These parameters showed that around sixty percent of
the respondents were living with somebody that belongs to the risk
group for covid-19, half of them used to work more than 30 h per week,
while 15.6% were not working just before the study (they were retired or
unemployed), and 46.8% had an income reduction as consequence of
the pandemic.
3.1. Management of time demand, cooking skills, and family support
The pandemic affected the time spent on eating activities (p < 0.05).
Comparing with the sample that not improved their diet, the majority of
individuals that improved their diet (81.4% versus 62.0%) spent more
time on food; while those who worsened their diet quality decreased
twice the time spent on eating activities (14.3% versus 7.8%) (p < 0.001
for Bonferroni’s multiple tests and between groups) (Table 2). This
behavior remained significant on the adjusted analysis, with odds ratios
of 2.24 (improved diet quality) and 0.77 (worsened diet quality)
compared to the group that did not change their diet (Table 4).
In addition, the crude analysis of other parameters linked to home
time dedicated to food and cooking skills (Table 2) showed that in­
dividuals who improved their diet started to cook more often (91.4%)
and were also more confident with their cooking skills: 81.7% disagreed
with the sentence “I do not know how to cook” (p < 0.01). They also did
not feel overworked with other tasks than cook (63.5%) and the division
of cooking and household chores between the members of the house was
higher among this group, especially for pre-preparing and cooking tasks

Table 1
Characteristics of the study population according to the pattern of changes in diet quality.
IDW (n = 1008) General Population a A (n = WDQ (n = 596) General Population a B (n = Study population (N =
3772) 3884) 4480)

n (%) n (%) n (%) n (%) N (%)

Social-isolated?
No 14 (1.4) 110 (2.9) 17 (2.9) 107 (2.56) 124 (2.6)
Partially 221 (21.9) 1119 (29.7) 193 (32.4) 1147 (27.4) 1340 (28.0)
Yes 773 (76.7) 2543 (67.4) 386 (64.8) 2930 (70.0) 3316 (69.4)
Significance of the test (p-value) 0.033 0.001
Gender
Female 797 (79.1) 2926 (77.6) 479 (80.4) 3244 (77.5) 3723 (77,9)
Male 210 (20.8) 839 (22.2) 114 (19.1) 935 (22.4) 1049 (21,9)
Not declared 1 (0.1) 7 (0.2) 3 (0.5) 5 (0.1) 8 (0,2)
Significance of the test (p-value) 0.521 0.022
Formal employment during or immediately before the Pandemic
Retired 60 (5.9) 244 (6.5) 24 (4.0) 280 (6.7) 124 (2.6)
No 281 (27.9) 1064 (28.2) 179 (30.0) 1166 (27.9) 1340 (28.0)
Yes 667 (66.2) 2464 (65.3) 393 (65.9) 2738 (65.4) 3316 (69.4)
Significance of the test (p-value) 0.798 0.035
Age group
18–35 422 (41.9) 1710 (45.3) 332 (55.7) 1800 (43.0) 3723 (77,9)
36–60 494 (49.0) 1744 (46.2) 237 (39.8) 2001 (47.8) 1049 (21,9)
>60 92 (9.1) 318 (8.4) 27 (4.5) 383 (9.2) 8 (0,2)
Significance of the test (p-value) 0.142 0.000
Education
High school or less 100 (9.9) 387 (10.3) 46 (7.7) 441 (10.5) 304 (6.4)
Graduation 396 (39.3) 1521 (40.3) 261 (43.8) 1656 (39.6) 1345 (28.1)
Post-Graduation 512 (50.8) 1864 (49.4) 289 (48.5) 2087 (49.9) 3131 (65.5)
Significance of the test (p value) 0.738 0.037
Number of individuals at home
Alone 144 (14.3) 520 (13.8) 66 (11.1) 598 (14.3) 2132 (44.6)
1 to 2 531 (52.7) 1900 (50.4) 296 (49.7) 2135 (51) 2238 (46.8)
≥3 333 (33.0) 1352 (35.8) 234 (39.3) 1451 (34.7) 410 (8.6)
Significance of the test (p-value) 0.252 0.027
Whom do you live with?
Alone 106 (10.5) 379 (10.1) 50 (8.4) 435 (10.4) 487 (10.2)
Partners 250 (24.8) 831 (22.0) 113 (19.0) 968 (23.1) 1917 (40.1)
Relatives (children or/and 552 (54.8) 2154 (57.1) 368 (61.7) 2338 (55.9) 2376 (49,7)
parents)
Other 100 (9.9) 408 (10.8) 65 (10.9) 443 (10.6)
Significance of the test (p-value) 0.230 0.020

IDQ: improved diet quality.

WDQ: worsened diet quality.
a
General Population: groups those individuals that not changed their diet added of those who changed their diet in the opposite way of the reference group (IDQ or
WDQ).

4
A.A.L. Tribst et al. Appetite 163 (2021) 105220

Table 2 Table 3
Time and social support to cook for the study population during the covid-19 Feelings and beliefs of the study population during the covid-19 pandemic in
pandemic in Brazil according to the pattern of changes in diet quality. Brazil according to the pattern of changes in diet quality.
IDQ General WDQ General IDQ General WDQ General
Population a A Population Population a A Population a B
a
B
N (%) N (%) N (%) N (%)
N (%) N (%) N (%) N (%)
I’m afraid of being contaminated by coronavirus from food/food packages
Have you changed the time spent on eating activities? Indifferent 82 (8.1) 378 (10.0) 71 389 (9.3)
No 154 1055 (28.0) 161 1048 (11.9)
(15.3) (27.0) (25.0) I agree (76.7) 2703 (71.7) 413 3063 (73.2)
Yes, it increased 821 2340 (62.0) 350 2811 (69.3)
(81.4) (58.7) (67.2) I disagree 153 691 (18.3) 112 732 (17.5)
Yes, it decreased 33 (3.3) 377 (10.0) 85 325 (7.8) (15.2) (18.8)
(14.3) Significance of the P < 0.05 P = 0.071
Significance of the test P < 0.001 P < 0.001 test (p value)
(p value) I’m afraid of eating food prepared outside my home
Has the frequency of cooking increased at home? Indifferent 167 620 (16.4) 107
No 87 (8.6) 603 (16.0) 105 585 (14.0) (16.6) (18.0)
(17.6) I agree 516 1747 (46.3) 232 2031 (48.5)
Yes 921 3169 (84.0) 491 3599 (51.2) (38.9)
(91.4) (82.4) (86.0) I disagree 325 1405 (37.3) 257 1473 (35.2)
Significance of the test P < 0.001 P < 0.05 (32.2) (43.1)
(p value) Significance of the P < 0.05 P < 0.001
I’m overworked, so I can’t cook test (p value)
Indifferent 101 531 (14.1) 94 538 (12.9) Industrialized food is safer to eat
(10.0) (15.8) Indifferent 119 570 (15.1) 91 598 (14.3)
I Agree 267 1158 (30.7) 217 1208 (11.8) (15.3)
(26.5) (36.4) (28.9) I agree 101 503 (13.3) 112 492 (11.8)
I disagree 640 2083 (55.2) 285 2438 (10.0) (18.8)
(63.5) (47.8) (58.2) I disagree 788 2699 (71.6) 393 3094 (73.9)
Significance of the test P < 0.001 P < 0.001 (78.2) (65.9)
(p value) Significance of the P < 0.001 P < 0.001
I don’t know how to cook test (p value)
Indifferent 108 555 (14.7) 103 560 (13.4) Smallholder food is safer to eat
(10.7) (17.3) Indifferent 278 1125 (29.8) 198 1205 (28.8)
I Agree 77 (7.6) 444 (11.8) 96 425 (10.1) (27.6) (33.2)
(16.1) I agree 456 1446 (38.4) 201 1701 (40.7)
I disagree 823 2773 (73.5) 397 3199 (45.2) (33.7)
(81.7) (66.6) (76.5) I disagree 274 1201 (31.8) 1979 1278 (30.5)
Significance of the test P < 0.001 P < 0.001 (27.2) (33.1)
(p value) Significance of the P < 0.001 P < 0.05
I have no family/friend support to cook test (p value)
Indifferent 126 643 (17.0) 129 640 (15.3)
(12.5) (21.6) IDQ: improved diet quality.
I Agree 64 (6.1) 362 (9.6) 70 356 (8.5) WDQ: worsened diet quality.
a
(11.7) General Population: groups those individuals that not changed their diet
I disagree 818 2767 (73.4) 397 3188 added of those who changed their diet in the opposite way of the reference group
(81.2) (66.7) (76.2) (IDQ or WDQ).
Significance of the test P < 0.001 P < 0.001
(p value)
3.2. Feelings and beliefs about food safety and risk of contracting COVID-
IDQ: improved diet quality. 19 with food
WDQ: worsened diet quality.
a
General Population: groups those individuals that not changed their diet
Positive feelings (peace of mind, confidence, and faith) were at least
added of those who changed their diet in the opposite way of the reference group
2.5 times more prevalent among those who improved their diet quality
(IDQ or WDQ).
than among those who worsened it (Fig. 2). Compared to the general
participants, for each additional positive feeling reported, the odds of
(Fig. 1). The impact of these parameters was explained in the adjusted
improving diet quality increased by 1.41 and there was a 33% less
analysis, which showed that the chance to improve the diet was 1.39
chance of worsening it (Table 4). The opposite was also true, negative
higher among those who did not feel overworked and increased 1.07 for
feelings (anxiety, stress, mental exhaustion, and fear) were more prev­
each additional cooking chore shared between household members
alent in the group that worsened the diet quality. Compared to the
(Table 4).
general population, each additional negative feeling resulted in an odd
The group who worsened their diet quality also showed that most
1.21 upper of this outcome and 10% less chance of improving the diet
individuals had cooking skills and described an increase of home time
(Table 4).
devoted to food (Table 2). Even so, this group was characterized by
People who improved their diet quality were more afraid of being
having the highest percentages of individuals (p < 0.05) who did not
infected by coronavirus from food, therefore, they are sanitizing food
increase the frequency of cooking at home (17.6%), who were over­
packages and surfaces and mostly agreed with the sentence “I’m afraid
worked (36.4%), who did not know how to cook or were indifferent to it
of food prepared outside my home” (Table 3), having these two pa­
(34.4%) and had no family/friend support to cook (11.7%). Thus, the
rameters positive role (41% and 31%, respectively) in the improvements
adjusted analysis showed that those who disagreed with the sentence “I
of the diet quality in the adjusted model (Table 4). Whereas, those who
have no family/friend support to cook” were 35% less likely to worsen
worsened their diet quality were more unaware (are indifferent or
their diet, compared to those who were indifferent to these statements
disagree) to issues related to contagion during meals, they are not being
(Table 4).
afraid to eat food prepared outside their home (Table 3) and this

5
A.A.L. Tribst et al. Appetite 163 (2021) 105220

Table 4
Adjusted chance to improve or worsen the diet quality of the study population
during the covid-19 pandemic in Brazil for all individual and family
determinants.
Changes on diet

Improved diet qualitya Worsened diet qualityb

OR CI (95%) OR CI (95%)

Have you changed the time spent on eating activities?

No 1.00
yes, it increased 2.24*** (1.85–2.72) 0.77*** (0.63–0.95)
Yes, it decreased 0.70 (0.47–1.06) 1.21 (0.89.-
1.65)
I have no family/friend support to cook
Indifferent – – 1.00
I Agree – – 0.84 (0.60–1.18)
I disagree – – 0.65*** (0.52–0.81)
I’m overworked, so I can’t cook
Indifferent 1.00 – –
I Agree 1.18 (0.9–1.53) – – Fig. 2. - Experienced feelings of the study population during the covid-19
I disagree 1.39*** (1.09–1.78) – – pandemic in Brazil according to the pattern of changes in diet quality.
Number of shared cooking 1.07* (1.02–1.13) – –
and household chores
Number of positive feelings 1.41*** (1.26–1.57) 0.67* (0.54–0.84) boosting immunity (96.0%), and this percentage was slightly higher (at
Number of negative 0.90*** (0.85–0.95) 1.21*** (1.12–1.29) 1%, P < 0.005) among those who improved their diet (data not shown).
feelings
Industrialized food is safer
Indifferent – – 1.00 4. Discussion
I Agree – – 1.85*** (1.35–2.54)
I disagree – – 0.97 (0.75–1.24) This study aimed to describe changes in diet quality of Brazilians,
I’m afraid of eating food prepared outside my home estimated by changes in dietary pattern, during the confinement of the
I disagree 1.00 1.00
COVID-19 pandemic. Hence, to understand the different pathways of
– –
Indifferent 1.31* (1.04–1.63) 0.82 (0.64–1.06)
I agree 1.17 (0.99–1.38) 0.58* (0.47–0.7) change in the diet, all possible associated factors studied went through
I’m keeping food clean and safe multiple analyzes with each outcome (improvement or worsened diet
Indifferent 1.00 – – quality). Around twenty percent of the studied population improved
I Agree 1.47* (1.01–2.14) – –
their diet pattern while nearly ten percent worsened their diet quality.
I disagree 1.33 (0.87–2.03) – –
The main drivers for changing the participants’ eating pattern, either to
a
Adjusted for current income proxy and being in social isolation. improve or worsen diet quality, were related to time and house cooking
b
Education, gender, age group. administration and organization, followed by feelings, beliefs, and
family support experienced during the most restricted phase of quar­
antine in Brazil.
Time availability is an important driver for a healthy diet allowing
individuals planning and preparing adequate meals (Davis & You, 2011;
Lavelle et al., 2016; Smith et al., 2013; Yang et al., 2015) from raw in­
gredients instead of only finishing or using read-to-eat meals (Lam &
Adams, 2017). In the light of this concept, spending more time on eating
activities has been stimulated in national food policies, particularly in
the Brazilian Dietary Guideline (Brazil, 2014; FAO, 2020). Thus, the
results of our research seem to corroborate with this policy approach
since the individuals increase in time spent on food was the main pro­
tective factor for the improvements of the diet quality.
In fact, quarantine allowed/imposed the increase in time spent on
food for some population groups, bearing in mind it has forced some
people to stay at home (Burki, 2020; Chung et al., 2020; Craig &
Churchill, 2020, Cucinotta & Vanelli, 2020). That is, for some families,
the possibility to work at home, avoiding hours lost in traffic, or the
reduction of the working hours, increased their free time, allowing
changes in time organization and work-family balance. This new family
context was confirmed by data from Australia in which restrictions of
Fig. 1. Division of cooking and household chores on the study population
during the covid-19 pandemic in Brazil according to the pattern of changes in
quarantine increased men’s participation on household work in the
diet quality. country (Craig & Churchill, 2020).
Additional positive outcomes during quarantine were also found in
many countries, where it was observed an increase of fruits and vege­
perception was confirmed in the adjusted model in which individuals
tables intake or other healthy items like olive oil (Bhutani et al., 2020;
who were afraid to eat food outside the home were 62% less likely to
Ruiz-Roso et al., 2020, Scarmozzino & Visioli, 2020). Positive changes in
worsen their diet than general study population (Table 4). Furthermore,
the diet quality seems to be more likely in countries with culinary tra­
the chance of those who agreed that industrialized food is safer was 1.85
ditions such as Spain and Italy, whereas so far these changes were mostly
to worsen diet quality than the chance of those who are indifferent to
observed in these countries (Scarmozzino & Visioli, 2020). The changes
this issue (Table 4).
in food consumption in Italy, markedly increase in flour and yeast
Virtually the entire sample agrees that healthy eating is important to
consumption, suggested the tendency to replace ready-to-eat meals by

6
A.A.L. Tribst et al.
handmade dishes (Scarmozzino & Visioli, 2020), rediscovering family
ties in a culture in which food preparation plays a vital role in the
dimension of care (Bracale & Vaccaro, 2020). This phenomenon can also
be illustrated by the observed exponential increase in Google search of
“traditional recipes” in Spain (Rodriguez-Pérez et al., 2020).
We believe that a similar process may occur in many families in
Brazil, being a country of culinary tradition and food diversity (Cascudo,
2017; Poulain, 2017), which explains a major proportion of individuals
improving their diet quality rather than decreasing it during the
research period. However, the maintenance of the habit of homemade
meals after the end of quarantine can be a challenge (Rodríguez-Pérez
et al., 2020) depending on new transitions and requirements on the
balance of paid-unpaid tasks (job, home and family demand) (Craig &
Churchill, 2020).
For others social contexts, especially for underprivileged income and
parents with children, they have been overloaded by the accumulation
of tasks like child care and monitoring of their school activities and extra
household work (Chung et al., 2020; Craig & Churchill, 2020; Kha­
latbari-Soltani et al., 2020), which could negatively affect the time on
food. As noted, the COVID-19 pandemic affected the time available for
cooking unevenly in different contexts, and this especially applies for
countries such as Brazil where inequalities and diverse social and cul­
tural realities co-exist (Andrade et al., 2018). In our study population,
the division of cooking chores among all residents was quite relevant for
changes in the outcomes, and when this did not happen, people became
more vulnerable to worsening their eating pattern.
In the last decades, little and slow positive changes have been found
in some populations regarding the division between house members on
meal preparation and responsibilities linked to food (Flagg et al., 2014;
Harnack et al., 1998; Méjean et al., 2017). To accomplish this, people
must be empowered for healthy nutrition to promote autonomy in food
choice (Brandstetter et al., 2015), understanding the relevance of each
individual contribution on decisions and actions on routine and their
role on health self-care. Thereby, diet interventions and public policies
should include and dialogue with both genders for the greatest impact
(Crane et al., 2018). The results of our study reinforce the idea that the
achievement of adequate eating patterns should be considered an issue
for all individuals and the share of household and cooking chores must
be considered an assignment of all the residents of the house (Brazil,
2014; Flagget et al., 2014; Méjean et al., 2017). Considering the majority
of the respondents were women and division of cooking and household
chores was pointed by less than 50% on most of the asked items, it is
assumed that the female role in unpaid work is still quite relevant even
in the most privileged strata, such as the population of this study.
In addition to these issues, individual attitudes related to protection
against COVID-19 exposure (including self-isolation, clean-up food
packages and surfaces, and fear of eating out or eating delivered food)
favored the quality of the diet. This could be attributed to the benefits of
home cooking, as opposed to eating out, which is commonly associated
with better diet quality and lower food costs (Claro et al., 2014, 2016;
Tiwari et al., 2017). This can be explained considering people that
usually eat out of home had higher intake of saturated fats, sweets, soft
drinks, and meat products and a low consumption of fruits and vege­
tables (Andrade et al., 2018; Rodríguez-Pérez et al., 2020). In the
pandemic scenario, this difference of quality of meals prepared inside
and outside the home was aggravated in Brazil, since the sanitary re­
strictions regarding the disallowance of food consumption in the local
temporarily closed most of traditional restaurants. Considering those
places that sold traditional healthy meals are usually less structured to
sell food on the drive thru or delivery system, compared with interna­
tional fast food chain restaurants, the competition in sales became even
more uneven (Hawkes et al., 2015). Consequently, individuals that were
not isolated may were more exposed to worsening diet quality than
those who weren’t (Haris et al., 2020). Similarly, results from Spanish
COVIDiet Study showed that survey participants who were not used to
having any daily meal out of home increased their adherence to the
7
Appetite 163 (2021) 105220
Mediterranean diet during the pandemic (Rodríguez-Pérez et al., 2020).
Moreover, self-isolation probably increased the time devoted for
eating activities (Chung et al., 2020; Cucinotta & Vanelli, 2020) and the
number of meals shared with other residents of the house, which is
recognized as a protective factor for the diet quality (Robson et al., 2020;
Verhage et al., 2018). Thus, family meals probably help to explain the
reported increase of legume intake of Brazilian adolescents during the
Pandemic (Ruiz-Roso, 2020) and the improvement of diet quality
observed for part of participants in our research. On the other hand, our
results showed that beliefs about industrialized food as safer and no
afraid of food prepared outside home threaten the quality of diet
pattern, since this idea can stimulate the consumption of snacks,
fast-foods, ready-to-eat meals and sweetened beverages (Andrade and
Mehta, 2018; Bezerra et al., 2015).
As expected, the results of this study showed a higher proportion of
young people in the WDQ. It is well known that young people tend to be
less concerned with the negative impacts of unhealthy food and their
eating habits tend to be similar to those of the social group which they
belong (Powell et al., 2019). In Brazil, the National Survey showed that
the greater percentage of industrialized food was consumed among
younger age strata compared to the older ones (Brazilian Budget Survey,
acronymous in Portuguese: POF) (Brazil, 2019). Furthermore, younger
individuals are less likely to develop cooking skills compared to mature
adults (McGowan et al., 2016). Thus, this strata tends to be more
vulnerable to worsening the diet quality.
The last, but not least, factor associated with changes in diet during
the pandemic was personal feelings. Those with positive feelings
(tranquility, faith, and confidence) improved their diet quality, whereas
those with negative feelings (anxiety, fear, mental exhaustion, and
stress) worsened it. Similarly with our results, negative feelings are
being strongly linked to the increase of unhealthy food markers in many
countries, notably with the increase of “comfort food” (chocolate, ice-
cream, and desserts) (Ammar et al., 2020; Bhutani et al., 2020; Reye­
s-Ollivarría et al., 2020; Romeo-Arroyo et al., 2020; Scarmozzino &
Visioli, 2020) as an attempt to cope with the stress produced by
confinement (Muscogiuri et al., 2020; Reyes-Ollivarría et al., 2020) and
by the expected terrible consequences of pandemic in economy and
people lifestyle (Laguna et al., 2020; Muscogiuri et al., 2020).
Moreover, negative feelings can increase the hunger sensation,
leading individuals to look for more caloric food options (Romeo-Arroyo
et al., 2020; Yılmaz & Gökmen, 2020), which would increase the intake
of macronutrients and can be accompanied by micronutrients deficiency
(Muscogiuri et al., 2020). Considering that micronutrients have a
fundamental role in the serotonine production and thus in the humor of
people (Scarmozzino & Visioli, 2020), their intake reduction as a
consequence of the impact of negative feelings in the diet pattern tends
to result in a vicious cycle (Muscogiuri et al., 2020). Complementarily, it
is possible that those people that improved their diet pattern had
increased micronutrients ingestion, which helps to explain their domi­
nant positive feelings and their vigilance behavior regarding to
COVID-19 (Jovančević & Milićević, 2020).
This study has some limitations. Our sample, although large enough
to conduct statistics tests, was non-probabilistic. As a consequence of
this, participants were majority female, had high education level and
80% were from the Southeast region, limiting the generalizability of
results to the other sociodemographic groups of Brazil. Female response
bias is well known in health surveys (Cull et al., 2005), and in our study
this may have been favored by the network contact list of most people
that helped to spread the survey. Regarding the instrument applied, it
did not allow analyzing quantitative indicators of diet quality and re­
spondent’s previous consumption, which is an expected limitation due
the cross-sectional design of the study. Although the questions around
changes on food markers consumption and food safety, cooking skills
and family support had been validate in previous research, the survey
was not pilot tested or enough validated among a subsample of the
target population. To ensure all survey indicators had strong internal
A.A.L. Tribst et al.
consistency among the entire Brazilian population, it is highly recom­
mended additional validation tests to reproduce this questionnaire. In
spite of changes in diet quality were assessed in this survey, additional
questions about correlated outcomes were not included, such as physical
activity and body weight, but it would be relevant to be explored in
future research. Attention is drawn to the need of long-term studies with
representative populations to better understand the real changes on diet
and its effects on health outcomes after the COVID-19 pandemic.
Despite these drawbacks, we present the strengths of the study: the
questions were written objectively for the interviewee to assess which of
their changes in healthy and unhealthy food markers consumption was
affected by the pandemic of covid-19, considering the present moment
and avoiding memory bias. The study was innovative since it was the
first in raising associated factors that could favor and impair the diet
quality in the Brazilian population based on the determinants outlined in
the Dietary Guidelines showing the possibility of whether or not these
factors are modifiable according to different contexts (Brazil, 2014;
Herforth et al., 2019).
The overall evaluation of the results suggests that in face of a drastic
and unexpected changes in the living context – imposed by the pandemic
of covid-19 – most of participants maintained their previously estab­
lished food pattern (which could be healthy or unhealthy), showing that
even an extreme event cannot easily change that. Thus, this study em­
phasizes the importance of building good eating habits throughout life,
especially in childhood and adolescence (Marcone et al., 2020; UNICEF,
2019). Furthermore, we observed that the associated factors with
changes in diet pattern were correlated in a network, highlighting that
determinants of eating pattern are complex. However, it is possible to
change them in favor of healthy diet if the context and the food system
are built to overcome individual and environmental barriers (Hawkes,
2015; Swinburn, 2011).
5. Conclusion
The novelty of this exploratory study comprises the associated fac­
tors of improvement or worsening diet pattern as a consequence of
COVID-19 pandemic in Brazil, given support to the messages presented
in the Dietary Guidelines. This knowledge could support future in­
terventions to promote healthy eating habits, considering that important
associations regarding cooking skills, family support and available time
to cooking tasks were pointed to reach positive changes in diet. Further,
long-term longitudinal studies, applying a validated instrument and
with a representative sample are recommended, especially focusing on
individual and family organization and time used for different eating
activities.
Ethical statement
1) This material is the authors’ own original work, which has not been
previously published elsewhere.
2) The paper is not currently being considered for publication
elsewhere.
3) The paper reflects the authors’ own research and analysis in a
truthful and complete manner.
4) The paper properly credits the meaningful contributions of co-
authors and co-researchers.
5) The results are appropriately placed in the context of prior and
existing research.
6) All sources used are properly disclosed (correct citation). Literally
copying of text must be indicated as such by using quotation marks
and giving proper reference.
7) All authors have been personally and actively involved in substantial
work leading to the paper, and will take public responsibility for its
content.
An online questionnaire was distributed through the Google Forms
8
Appetite 163 (2021) 105220
platform from May 12th to June 26th, 2020. The participants read the
informed consent form to participate in the study before answering the
questionnaire, and ethical approval was obtained from the ethics com­
mittee at the University of Campinas (UNICAMP) (CAAE
30650220.0000.5404).
Authors contributions
AALT and LGB designed the research; LGB and CRT took care of data
management and analyses; AALT and LGB interpreted the data; AALT
wrote the first draft of the manuscript, LGB and CRT contributed
significantly to the intellectual content of this first draft; AALT, CRT and
LGB revised each draft for important intellectual content. All authors
read and approved the final manuscript.
Funding/financial disclosures
Nothing to declare.
Declaration of competing interest
None.
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