Quality of life and eating habits of patients with obesity during the COVID-19 pandemic

Objective: to verify the quality of life and eating habits of patients with obesity during the COVID-19 pandemic. Method: cross-sectional study with 68 outpatients, candidates for bariatric surgery, at university hospital in the Southern Brazil. Data collection was carried out by telephone, with questions about the profile of the participants and social distancing; questionnaires on quality of life and eating habits were also used. The data analysis, the logistic regression model, Spearman correlation, Mann-Whitney U and Student t-tests were used for independent samples. Results: the general quality of life was 57.03 points and the eating habit with the highest score was cognitive restraint (61.11 points). Most patients (72.1%) were socially distancing themselves and 27.9% had not changed their routine. The chance of isolation was 3.16 times greater for patients who were married. There is a positive correlation between the domains of the Quality of Life questionnaire and cognitive restraint from the questionnaire about eating habits. Conclusion: we found that the participants tended to have a better quality of life as cognitive restraint increased.

health education and clinical monitoring by multiprofessional. The educational group is managed by nursing professionals and has the participation of the entire program team. The strategy of creating and conducting educational groups for patients with obesity contributes to the exchange of experiences and difficulties faced due to the disease, strengthening bonds between the participants, thus becoming an important learning space for health maintenance before and after bariatric surgery. In several studies, researchers have observed that there is a positive relationship between frequent multiprofessional monitoring and the presence of an emotional support network for the mental and physical health of these patients (15,17) .
It is believed that patients who participate in these groups, receiving guidance and continuous monitoring by a multidisciplinary team and developing bonds with other participants and professionals, were more committed to weight loss. Therefore, we proposed to investigate how the quality of life and eating behavior of candidates for bariatric surgery presented themselves during the restriction measures imposed by the pandemic. Thus, the aim of the study is to verify the quality of life and eating habits of patients with obesity during the COVID-19 pandemic.

Type of study
Cross-sectional descriptive study, guided by the STROBE guideline (Strengthening the Reporting of Observational Studies in Epidemiology), which contains items that should be included in observational studies (18) .

Sample
To select the study participants, intentional sampling was used, consisting of patients who were undergoing follow-up in the group entitled "Mudança de Estilo de Vida" (MEV -Change in Lifestyle) before the institution's suspension of group activities, as recommended by the World Health Organization, on March 17, 2020.
Before contingency measures were taken at the hospital, six groups were maintained simultaneously, with a total of 94 patients. To participate in the study, the patient should have participated in the last meeting before the suspension of group activities by the institution.
Patients who had already undergone bariatric surgery and those who did not answer the calls after three attempts, were excluded. The final sample had 68 participants.

Data collection instrument
The WHOQOL-Bref quality of life questionnaire and the Three Factor Eating Questionnaire (TFEQ-21) were translated and adapted to research in Brazil (19)(20) . The first  (20) .

Data collect
Due to the measures implemented to reduce the transmission of COVID-19, data collection took place through telephone contact with the participants. The calls were made by the researchers during business hours, that is, between 8 AM and 6 PM. Patients were asked about their interest in participating in the survey by telephone and whether they were available to answer questions on that call or whether they preferred to schedule another opportunity. The calls were recorded and the participant was asked to say the date and the following sentence: "I, (the person says his name), accepted to participate in the survey on quality of life and eating behavior during the pandemic." The recordings were archived and will be kept for five years in a safe place, by the researchers.   In the comparison analysis of the quality of life questionnaire and the behavior by SD, there was no statistically summarized difference. Table 2 shows the association of this measure with the quality of life questionnaire and behavior associated with eating habits, as well as an association of social distancing with sex and marital status of the 68 participants.

Discussion
In this study, we found that the association between SD, the quality of life and eating behavior of obese individuals, during the pandemic, did not present a statistically significant difference. However, it was observed that as quality of life decreases, emotional eating (EE) and uncontrolled eating (UE) tended to increase.
The data also showed a significant relationship between adherence to social distancing and marital status; the chance of social distance was greater for those who were married or in a stable relationship.
Most participants were female and were in a stable relationship or married, characteristics that are consistent with recent studies, in which researchers assessed the profile of patients awaiting bariatric surgery (21)(22) . Although obesity affects more males, women are the ones who most seek the surgical procedure as a treatment (23) , as there is greater social pressure for a healthy body or within the standards of beauty; additionally, among women, there is better understanding and adherence to health care, which can boost the search for bariatric surgery (21,24) . It is assumed that women have a better understanding of the health risks caused by obesity, are more concerned about their well-being and are more adept at health guidelines, supporting their better adherence to social distancing.
In our study, the most prevalent associated diseases were hypertension, type 2 diabetes mellitus and psychiatric diseases, in agreement with the literature (21,23,25) . This comorbidity profile, commonly seen in obese patients, confers a greater risk of complications when there is a diagnosis of COVID-19. It is estimated that the state of chronic inflammation and the dysregulated immune response increase the chances of these patients presenting severe forms of the disease and dying (26) .
In terms of income, almost a quarter of the participants are in paid employment. However, the variables "Housewife" and "On sick pay" were also prevalent. Discrimination against people with obesity causes absenteeism and dismissal from work, reinforcing social isolation behaviors and aggravating the mental health of workers with obesity (27) . With the pandemic, the distance work modality became necessary to prevent the transmission of the virus, however, it created other factors that can compromise the quality of life of these patients: feeling of isolation and sedentarism (28) . itself in the form of verbal and physical violence against these individuals (32) . People with obesity, especially women, perceive this discrimination and, as a consequence, present feelings of inferiority, embarrassment, sadness, frustration and low self-esteem, which have everlasting repercussions (28) . In the pandemic context, complications of psychiatric illnesses are described, in which the levels of stress, anxiety, and depression were aggravated in individuals with chronic diseases (33) . There is a high incidence of psychiatric illnesses in people with obesity (23,25) ; almost half of the study participants presented some form of it.
Regarding the responses obtained in the social, environmental, and physical domains of the quality of life questionnaire, we found that they corroborate data from studies in which researchers evaluated the quality of life of patients in the pre-and post-bariatric surgery periods. Patients showed dissatisfaction with the physical environment, related to safety and leisure issues (14,29,34) .
It is suggested that the quality of life of candidates for bariatric surgery is impaired, as excess weight negatively affects self-esteem (14) .
Regarding the eating behavior of participants during the pandemic, it was found that cognitive restraint (CR) was the domain with the highest score and that this tends to positively influence quality of life. CR has been shown to be the most prevalent behavior among obese individuals (35) , however, there are contradictions in how it is associated with weight gain. CR is expressed in the understanding that it is necessary to eat less than desired and in a healthier way. However, in obese individuals, it is more difficult to put this into practice when compared to overweight or eutrophic individuals (36)(37) .
The association between CR and other behaviors was not evaluated in this study, but other studies shows that CR may be related to UE, in which the individual needs to eat even after feeling full (38) . In addition, CR can also be associated with UE, as a form of defense against an unpleasant emotion, for example, sadness (15) .
In this relationship, the patient understands that he needs to control or lose weight, but when he finds himself with a negative stimulus or goes through situations of great stress, he ends up eating in an exaggerated and compensatory way, generating a feeling of guilt and frustration (36) .
Participants had higher scores in UE behavior when compared to EE behavior and both tend to negatively influence their quality of life. In recent studies, it was observed that the population, during social distancing measurements, did not show significant changes in CR, but there was a significant increase in UE and EE, resulting in their weight gain, especially in women (38)(39) . In obese people, the risk of worsening symptoms of these behaviors is even greater. However, an assessment of the impact of social isolation on obesity showed that participants did not obtain a significant increase in BMI or worsening of symptoms (40) .
By the end of data collection, no participant had tested positive for COVID-19, with few suspected cases to be confirmed. Most were complying with SD and following hygiene measures. In some of the participants' reports, intense fear of contamination and fear of contaminating their families were observed. Fear, insecurity and negative feelings have been commonly observed in people who adhere to some form of SD during the pandemic (41) . Some