{'fraction_non_alphanumeric': 0.031051677243880325, 'fraction_numerical': 0.010275007555152614, 'mean_word_length': 5.133920296570899, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 5, 'lorem ipsum': 0, 'www.': 4, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Collateral Damage of the COVID‐19 Pandemic on Nutritional Quality and Physical Activity: Perspective from South Korea

A novel coronavirus (SARS-CoV-2), that emerged in the city of Wuhan, China in December 2019, has now spread worldwide.


Introduction
A novel coronavirus (severe acute respiratory syndrome-coronavirus 2) that emerged in the city of Wuhan, China, in December 2019 has now spread worldwide. As of June 2, 2020, more than 6,200,000 people had been infected with this virus, and its mortality is around 6% (see https:// coron avirus.jhu.edu/map.html for real-time tracking of cases).
According to initial reports, old age, obesity, hypertension, and preexisting cardiovascular diseases, as well as diabetes mellitus, are considered risk factors for the severity of the coronavirus disease 2019 . During the COVID-19 pandemic, the potential reduction in physical activity in general, as well as an increase in sedentary time caused by many social distancing protocols and government lockdowns and regulations present in many countries, should be a source of concern. Access to a healthy diet for all is also an issue, and these factors, in turn, are likely to contribute to weight gain and related cardiometabolic consequences. Here, we provide a South Korean perspective that may provide some explanations for these behavioral changes and related health consequences. Some solutions are also proposed.

Changes in Dietary Patterns Toward Unhealthy Foods and Increase in Sedentary Time
During the COVID-19 pandemic, dietary patterns have been changing, and access to healthy food options has diminished (1). In countries such as South Korea and other Asian countries, where the food delivery network is highly developed, dependence on such services has seen a substantial increase. According to Statistics Korea data, online food shopping has increased by 66 Delivered foods are mostly fast foods, such as pizza, hamburgers, fried chicken, and carbonated soda or sugar-sweetened beverages (2), and are probably more obesogenic than home-cooked foods (3,4). The increased consumption of fast food has been shown to be associated with increased energy density (5), excessive portion sizes, high glycemic load (6), and low intakes of vegetables, fruits, and milk (7). Some previous studies have shown that increased consumption of fast food and sugar-sweetened beverages is associated with increased risk of obesity (6,8), fatty liver (9), metabolic syndrome, and type 2 diabetes (6,10,11).
Among the many types of fast foods being delivered in South Korea, Korean-style fast foods are much more popular because they are less expensive and easier to access across various income levels and residence regions (12). Of particular concern in the Korean-style fast foods are high-carbohydrate foods such as white flour, white rice, and cornstarch. In addition, because of the recent COVID-19 economic disruption, many households are likely to be suffering from financial difficulties, limiting their ability to buy and consume more expensive, healthier, and fresh foods. In addition, a decrease in outdoor activities and an increase in time spent on smartphones, online games, and TV viewing may have also contributed to a negative impact on eating behaviors. During such sedentary screen time, people habitually tend to consume energy-dense snacks and alcohol or sugar-sweetened beverages (13,14). Thus, increased screen time not only may have contributed to increased sedentary behaviors but also may have indirectly influenced overall nutritional quality in a negative way during these times of confinement. Studies are currently underway in some countries to document these phenomena, and results are expected to be reported in the near future.
Another important issue is nutrition in students. Schools in many countries, including South Korea, have been closed for several months, and the future is uncertain regarding their reopening in some countries. In this context, children confined at home will be more dependent upon the family environment. Whereas some popular surveys have suggested that some families may cook more at home (which could contribute to increases in their nutritional quality), socioeconomic status may be an important factor explaining why some other families may rather be more likely to choose unhealthy fast foods, instead of the healthier and Perspective COVID-19 AND OBESITY more balanced lunches provided by schools. Lack of supervision from teachers and parents (who are often working) for their food choices and dietary habits is another factor to consider (15). Food security is another issue for children from low-income families, who may get their best meal daily from school programs.
Many authorities such as the Centers for Disease Control and Prevention and the World Health Organization are recommending general quarantine principles, such as wearing a mask, washing hands thoroughly, and keeping a social distance. Based on social distancing, people are recommended not to get together at work and public places as well as in restaurants. Naturally, the likelihood of eating alone is increasing during this COVID-19 pandemic, and this is also likely to affect dietary habits in a negative way. According to a previous study using Korean national data, diet quality and eating behaviors of people who eat alone were poor (16). The social aspect of eating together helps us control or limit how much and what we eat because of socially determined norms, expectations, and even judgments. In the absence of these, people are more likely to overindulge. The psychological stress of dealing with the pandemic may also contribute to the overconsumption of low-nutritional-quality/energy-dense "comfort food." Again, data on these issues are forthcoming.
One of the most important strategies to stop the spread of severe acute respiratory syndrome-coronavirus 2 is to reduce close interpersonal contact. On the basis of this strategy, public as well as private facilities, such as community health centers, gyms, swimming pools, and parks, have been closed by law in many countries. In many cases, people who have come in contact with infected people or who have spent time at locations that were visited by infected individuals have been requested to stay at home for 2 weeks as a form of "self-quarantine." Many countries have put in place confinement policies, and economic activities have been shut down for several weeks. In these aspects, South Korea is similar to the rest of the world.
Persons with obesity or overweight are reported to be less active, and sedentary behaviors are relatively prevalent among these individuals all over the world (17,18). Thus, developing solutions to increase physical activity is a challenge, particularly when individuals are confined. For example, for people with obesity, group exercise with peers or exercise under supervision have been reported to be effective compared with absence of support (19,20). But policies prohibiting public gatherings in confined spaces or going to a local gym leave persons living with obesity with limited options. This situation could be an obstacle for some individuals to exercise, not only among people with obesity but also for the general public. In a study of more than 400,000 middle-aged adults, a lower density of physical activity facilities was associated with higher adiposity levels (21). Overcoming such hurdles and trying to navigate across government policies in order to remain physically active or to exercise for 150 minutes per week take commitment and may require some creativity, even for the most motivated and health-conscious person.
In addition, most school systems have been shut down, which poses the problem of lack of physical activity that children would generally undertake on a daily basis from interaction with friends and, more importantly, from physical education classes and academic sports programs. For these reasons, adults or children with obesity may be deprived of opportunities to engage in physical activity and may become demotivated. Overall, the impact of South Korea's pandemic response on sedentary behaviors and levels of physical activity may mirror the rest of the world. Again, data to document these phenomena are needed and are expected in the coming months.

Recommendations
It has been well documented that the development of chronic societal diseases such as diabetes mellitus and obesity is affected by behaviors such as lack of physical activity and an energy-dense diet of poor nutritional quality (https://www.who.int/healt h-topic s/nonco mmuni cable -disea ses#tab=tab_1). It is proposed that the COVID-19 pandemic is likely to have a negative influence on behaviors associated with obesity and cardiometabolic health.
Here, we propose that the COVID-19 pandemic has produced negative influences on behaviors associated with obesity and cardiometabolic health, and we suggest some actions to limit the impact on health during the current viral crisis (Table 1). Social network services and internet platforms such as YouTube could be used to create a sense of community between people during times of lockdown such as this (22). Social media or Web-based programs could create some ludic and friendly physical activity challenges among users, and good examples of this are the many exercise challenges that have "gone viral" (23,24). Indeed, YouTube could be a useful tool for home training if the educational videos were provided by trained health professionals or kinesiologists, who adjust their "educational products" to the user (e.g., a young, active mother who wants to stay fit has different goals compared with a frail, elderly person who needs to move and reduce sitting time). Thus, the credibility and quality of the tools provided on the Web are important. We also propose that medical societies could take more leadership in this area. Of note, several medical societies have started several actions to help people at high risk of COVID-19. The American Diabetes Association has asked Congress to help people living with diabetes mellitus by keeping insurance coverage going, eliminating co-pays for antidiabetic medications, and getting testing into underserved communities (https://www.diabe tes.org/advoc acy/ platform). The American Society for Nutrition has released three steps to stay healthy during the COVID-19 pandemic: (1) minimize trips to the supermarket during the pandemic and eat healthy, (2) eat out safely during the COVID-19 pandemic with restaurant curfews, and (3) think positive! Mind-set is vital to getting through this pandemic physically and mentally healthy (https://nutri tion.org/makin g-healt h-andnutri tion-a-prior ity-durin g-the-coron aviru s-covid -19-pande mic/). The Korean Endocrine Society has also released a special report, recommending sharing scientific knowledge with patients and educating them to fight this crisis together (25). This report suggests several actions, such as strict self-hygiene, self-monitoring, and lifestyle modifications in patients with chronic societal diseases to protect them from COVID-19. In particular, the Society suggests using telemedicine and digital health, because many comorbid patients, such as people with obesity, have difficulty visiting clinics during the COVID-19 pandemic.
Concerning nutritional quality, there are several possibilities to be explored. First, a public health campaign could be developed to encourage providers to produce and deliver healthier foods (with a reward system). Fortunately, in South Korea, many companies are now offering precooked, balanced, and nutritional meals, which are a good alternative to fast food. An electronic commerce firm (Coupang, Seoul, South Korea) has launched a same-day delivery service for fresh food, allowing customers to order in the morning and receive their products in the evening (https://www.korea times.co.kr/www/ tech/2020/05/694_288830.html). Same-day fresh food delivery service is an innovation that can change the whole paradigm of eating. However, the establishment of infrastructure, such as transportation or information technology, is required for this. Second, being confined is an opportunity to promote family cooking at home provided that, once again, credible public health educational material becomes available on the Web. This is particularly important for children with weight issues, to help them learn how to cook healthy foods from a young age. As families share food habits, these programs should also be attractive for low-socioeconomic-class families. For instance, public health authorities could offer meal coupons redeemable with preapproved healthy food suppliers.
Finally, we would like to propose that all international medical societies should get involved in developing a list of recommended open sources for the promotion of physical activity/exercise and healthy eating during the COVID-19 pandemic. More active counseling is needed to help people with obesity address their issues and deal with their barriers to adopting a healthier lifestyle (26). It is the responsibility of health providers to promote healthy living in these challenging times.O