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E.R. Tuttiett1, B.M. Corfe2, E.A. Williams1


1. Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, S10 2RX, England; 2. Human Nutrition Research Centre, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle NE2 4HH, UK

Corresponding Author: Esme Tuttiett, University of Sheffield Medical School, Beech Hill Road, S10 2RX, email: ertuttiett1@sheffield.ac.uk, ORCID ID: https://orcid.org/0000-0002-7591-4099, phone: 0114 222 5522

J Aging Res & Lifestyle 2021;10:50-53
Published online September 23, 2021, http://dx.doi.org/10.14283/jarlife.2021.9



The lockdown restrictions imposed as a result of COVID-19 impacted on many areas of daily life including dietary behaviours. A cohort of middle-older age adults (n=17), who had previously provided 3-day food diaries in May 2019 were asked to record their 3 day dietary intake in May 2020 when the UK was under lockdown restrictions. Mean (SD) energy intakes were significantly higher by ~750kilojoules in 2020 (8587kJ (1466.9)) compared to 2019 (7837 kJ (1388.9)). This energy increase is equivalent to ~170kcal; approximately 2 slices of bread. Furthermore, recorded meat/meat products, riboflavin, vitamin B6/B12 and iron intakes were all greater in 2020. No other dietary differences were observed between the two timepoints. This was a small, homogenous but well controlled sample, who exhibited a relatively stable diet during lockdown compared with pre-pandemic intakes 12 months earlier. It can be concluded that there was little evidence of food insecurity in this cohort.

Key words: COVID-19, lockdown, diet, food groups.




In December 2019, a novel coronavirus (COVID-19), induced by the SARS-CoV-2, emerged. Following its rapid spread, a global pandemic was announced by the World Health Organisation on 11th March 2020 (1) and resulted in a UK national lockdown on 23rd March 2020 (2). Lockdown restrictions consequentially led to lifestyle modifications, including disrupting eating habits, leading to research being undertaken to investigate such changes (3–8).
A cross-national survey was used to compare food dynamics in 1,732 Chinese and 1,547 U.S. households (4). Similar behaviours were recorded by both nationalities and included favouring online shopping and purchasing extra amounts of food when shopping, so fewer trips to buy groceries needed to be made. On the contrary, responses to web-based surveys revealed differing eating behaviours between Spanish and Greek residents (8). Lower restraint eating was reported in Spain, where lockdown regulations were more stringent.
Themes that have emerged globally in the literature regarding changes in diet include the increase in purchasing of: tinned goods, “comfort” foods/confectionary, and baking ingredients (4, 9, 10). More home cooking, including homemade desserts, has been reported during lockdown, mirrored by a decrease in takeaway and ready meal consumption (4, 9, 10). The impact of pre-pandemic health status (11) and socioeconomic status (4) have been implicated as factors that influence dietary behaviours observed during lockdown periods. It is difficult to decipher a common pattern of dietary habits in relation to health emerging as respondents to surveys have often reported a split array of lifestyle behaviours (12).
The majority of the evidence has used web based food frequency questionnaires or surveys that do not always capture accurate dietary intake due to recall bias and missing food items. Furthermore, pre-pandemic dietary intakes in the same population are lacking. In light of this, it was the aim of this research to re-sample a small group of middle-older aged adults who had reported dietary intake using estimated food diaries exactly 12 months before the 1st UK lockdown (13). This demographic is often understudied and there are growing obesity rates in the middle-older adult age group so assessing dietary habits during the lockdown period is of interest. It was hypothesised that lockdown restrictions would have led to changes in dietary behaviours observed in this cohort.


Materials and Methods

Study population and ethics

Twenty-four healthy participants, aged 50-75, who had provided detailed 3-day food diaries in May–July 2019 as part of an unrelated study (13) were re-contacted in May 2020, during UK-wide COVID-19-lockdown restrictions and invited to provide a further 3-day food diary. Prior permission was obtained from all participants in 2019 to be recontacted. Participants were sent a study information sheet, alongside study documents, and implied consent was assumed if documents were returned.
Ethical approval for this study was granted by the University of Sheffield’s ethics committee (ethical approval number: 034260)


This study was a repeated dietary analysis of a convenience sample. The eligibility criteria utilised in the 2019 study (13) dictated participant characteristics. In 2020, participants could either complete the study documentation electronically, and receive it via email, or in paper-version, and receive the documentation in the post. The protocol for completing the 3-day food diary collection (as described elsewhere, (13)) was replicated from the 2019 sampling. In short, participants were asked to record everything they ate and drank during a 24-hour period on 3 occasions during the same week (Monday, Wednesday and Friday). Participants had received previous training for this methodology and utilised a food portion booklet, containing photographs from the Ministry of Agriculture, Food and Fisheries (MAFF) food atlas (Nelson, 1997) to aid with completing this.
Guidance to aid with the return of study documentation was provided and a follow-up discussion between the researcher and the participants was arranged, via a video/telephone call, to check the data for clarity and to obtain further qualitative information about dietary behaviour habits during lockdown. Following completion of all tasks, participants received a £20 voucher to thank them for their participation.

Data analysis

Food diary data was inputted into Dietplan7 nutritional analysis software (Forestfield Software Ltd). This software was used to generate a full report for each participant, containing averages across the three days for energy, macronutrient and micronutrient data, based on UK Composition of Foods tables (14). The report also classified the data into food groups. All statistical analyses were undertaken using SPSS software (version 26.) Data was checked for normality using the Shapiro-Wilk test. Related-Samples Wilcoxon Signed Rank Test analysis was used to assess differences between 2019 (pre-pandemic) and 2020 (lockdown) dietary intakes. A p-value of <0.05 was used to indicate significance.

Table 1
Comparison of energy, macro- and micro-nutrient intakes in the study sample (n=17) on two consecutive years; 2019 vs 2020

Data is presented as average mean (SD) values for all participants (n=17.); p-values denoted Wilcoxon analysis using data collected in 2019 compared to data collected in 2020. Significance was set at p=0.05; kJ= kilojoules; g=grams; mg=milligrams, µg=micrograms



Participant Characteristics

All twenty-four original participants were contacted; twenty agreed to provide a further food diary and four did not respond to the follow up email. One participant dropped out of the research due to time limitations. Two participants (both male) were also removed from the analysis, one who displayed irregular eating behaviour, due to shift working, and one for an incomplete food diary, leaving only female participants remaining (n=17). The mean (SD) age and BMI of the included participants was 61.5 (7.4) years and 23.8 (3.8) kg/m2 respectively.

Energy, Macronutrient and Micronutrient Intakes (table 2)

Mean (SD) energy intakes were 9.6% higher in 2020, compared to 2019; 8587kJ (1466.9) vs 7837 kJ (1388.9). No difference was observed in the dietary intakes of protein, carbohydrate and fat at the two timepoints. In 2020, riboflavin, vitamin B6, Vitamin B12 and iron intakes were significantly higher by an average of 0.5mg, 0.3mg, 3.8µg and 3.5mg respectively. No differences were observed in any other micronutrient.

Table 2
Percentage energy provided by food groups, for all participants (n=17), on two consecutive years; 2019 vs 2020

In this table all participant data has been collated together and averages are presented for all 17 participants, based on their food diary recordings. The information demonstrates the average total amount of energy (kJ) consumed by participants in each food group, per day. Further analysis also demonstrates the percentage of energy each food group contributes to overall energy intakes. p-values are Wilcoxon analysis comparing data collected in 2019 to data collected in 2020. Significance was set at p=0.05. kJ= kilojoules.


Food group analysis (table 2)

No differences were observed at a food group level other than for meat and meat products, which significantly contributed more to the average energy provided as a food group in 2020, compared to 2019 (p=0.003).



This research investigated dietary intakes both prior to and during lockdown restrictions in a healthy cohort aged 50-71 years. This study revealed, on average, more kilojoules of energy were consumed by participants in May 2020, compared to the previous year. Intakes of riboflavin, vitamins B6 common B12 and iron were greater in 2020 than 2019. These micronutrients are particularly abundant in meat and exploration of the data at a food group level revealed that meat intakes were significantly greater in 2020.
Overall, the dietary data remained fairly stable across 2019 and 2020, in this population. This would suggest that food security was not an issue for the participants, but caution should be paid to the demographic sampled. Survey analysis revealed that the greatest food insecurity were amongst households in the lowest income categories or had family members who had lost income during the pandemic (4). Overall, from the literature, a split picture has emerged in relation to dietary behaviours as a result of lockdown measures (6, 12), and personal circumstances are likely to be an explanation for these disparities (4).
Analysis of food basket data in Spain suggested that energy intakes rose by an average of 6% (15), a similar finding also observed in this sample. Possible explanations for increased energy consumption could be related to greater intakes of nutritionally sparse but energy-dense foods being consumed, often associated with snacking behaviours. Trends of increased consumption of snacks during lockdown, have also been reported by those responding to surveys (11).
Anecdotally, participants in this research reported more home-cooking in 2020. The evening mealtime was described as an event/social occasion, during lockdown, and even referred to as the “highlight of the day” (data not presented). Similarly, it was reported by individuals in Poland that their consumption of homemade meals increased (3), as did U.S. and Chinese citizens (4). Following further investigation of the food diaries to observe the type of food being documented, it was noted that home-cooked meals were often meat-dominated including casseroles and mince-based dishes, such as bolognaise.
The limitations of this study include the small, homogenous sample. This was a convenience based sample, meaning power calculations were not possible. Collection of further demographic and lifestyle information, including physical activity levels, would have made adjustments for confounding variables possible. A critical strength of this research is that the assessments were undertaken on the same individuals at exactly the same time of year. Furthermore, estimated food diaries were obtained, which provide good estimates of energy, nutrient and food intakes. In contrast, a large proportion of research investigating dietary habits during lockdown have relied upon questionnaires and surveys. These are highly subject to recall bias, consequentially deeming them an inadequate method of dietary assessment. This research should be replicated with larger samples who have provided reliable dietary intake information prior to and during lockdown.



• Diet remained generally stable prior to and during lockdown at nutrient and food group level for this small but well controlled population.
• Capturing information from a variety of backgrounds/SES is an important consideration for future work in order to ascertain the overall implications of lockdown on dietary habits.


Disclosure/conflict of interest: No conflicts of interest.

Ethical standards: Ethical approval for this study was granted by the University of Sheffield’s ethics committee (ethical approval number: 034260).

Acknowledgments: The authors would like to thank the Medical Research Council (MRC) and Versus Arthritis for funding this work. Thanks also go to the participants who engaged with this research.

Funding sources: This work was supported by the Medical Research Council (MRC) and Versus Arthritis as part of the Medical Research Council Versus Arthritis Centre for Integrated Research into Musculoskeletal Ageing (CIMA) [MR/R502182/1]. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.



1. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020 https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020 Accessed 14 Decemeber 2020
2. Prime Minister’s statement on coronavirus (COVID-19): 23 March 2020 – GOV.UK https://www.gov.uk/government/speeches/pm-address-to-the-nation-on-coronavirus-23-march-2020 Accessed 14 Decemeber 2020
3. Górnicka M, Drywień ME, Zielinska MA, Hamułka J Dietary and Lifestyle Changes During COVID-19 and the Subsequent Lockdowns among Polish Adults: A Cross-Sectional Online Survey PLifeCOVID-19 Study. Nutrients 2020; 12(8):2324.
4. Dou Z, Stefanovski D, Galligan D, Lindem M, Rozin P, Chen T, et al The COVID-19 Pandemic Impacting Household Food Dynamics: A Cross-National Comparison of China and the U.S. SocArXiv (2020) https://osf.io/preprints/socarxiv/64jwy/
5. Di Renzo L, Gualtieri P, Pivari F, Soldati L, Attinà A, Cinelli G, et al Eating habits and lifestyle changes during COVID-19 lockdown: An Italian survey. J Transl Med 2020; 18(1):229.
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K. Dervan1, G. Mulkerrin2, T. McDonnell1, E.C. Mulkerrin1


1. Department of Geriatric Medicine, University Hospital Galway, Republic of Ireland; 2. Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen’s Square, London, United Kingdom

Corresponding Author: Dr. K Dervan, Department of Geriatric Medicine, University Hospital Galway, Republic of Ireland- killiandervan@gmail.com

J Aging Res & Lifestyle 2020;9:35-39
Published online October 22, 2020, http://dx.doi.org/10.14283/jarlife.2020.8



The COVID-19 pandemic poses a major challenge to delivering multi-disciplinary complex care for older patients. Modern technology can assist in providing such care. This article highlights efforts to bridge the “digital divide” between generations and addresses the beneficial impact telemedicine has on older people’s lifestyles. Novel triage models for accessing emergency care which were successful for patients of all age groups including those over 65 years are described. Moreover, innovative successful approaches to the outpatient assessment of older patients with complex chronic health conditions using telemedicine are highlighted. Furthermore, innovative solutions piloted in remote areas of Australia offer promise for telemedicine-lead remote assessment of older patients, and the results are encouraging compared to in-person consultations. The experience with a General Practitioner (GP)/specialist online real-time interaction model for remote management of HF in mainly older people has also been encouraging. The use of telemedicine in falls prevention has produced impressive results in high-risk older patients albeit with some ambivalence from older participants. Virtual reality rehabilitation programmes have produced better physical outcomes than traditional rehabilitation programmes. Furthermore, telerehabilitation for chronic obstructive pulmonary disease (COPD) and HF have shown to be both feasible and effective. To maximise their benefits in the difficult post-COVID-19 period, technologies must be embraced by both physicians and older patients. Online community care platforms discussed have demonstrated a positive, tangible impact on the lifestyle of the older generation. Furthermore, educational guidelines can assist in implementing the fundamentals of telemedicine, but for the widespread successful and safe integration of these services, adoption of regulatory frameworks with a focus on ethical issues of telehealth is imperative.

Key words: COVID-19, aging, technology, virtual assessment, telemedecine.



Since January 2020, a seismic shift has occurred in the way in which healthcare providers, patients, and the wider community interact with one another and the world around them. The outbreak of novel coronavirus-associated acute respiratory disease, known as COVID-19 is a “once-in-a-century pandemic” (1). Older patients, especially those with significant co-morbidities are at increased risk of severe disease and the cascade of associated complications, including disability and death (2). Strict social distancing measures have been implemented, while hospitals minimise in-person office visits in a bid to decrease the potential risk of cross-contamination. Dr. Marjory Warren the mother of British geriatric medicine formulated the early principles of Geriatric Medicine and, almost 70 years on, her teachings remain valid today (3). The importance of multidisciplinary teams, attention to diverse issues (medical, social, and functional), and active involvement of the older person in their clinical progress is paramount. The recent measures implemented in response to COVID-19 have added significant strain to these services (4), whilst also having a negative knock-on effect on older people’s livelihood. Below strategies enabling technology to assist in the provision of specialist care to older patients in the post-COVID-19 pandemic era are discussed.


Bridging the “Digital-Divide”

Despite barriers to technology for older people, the current pandemic may act as a catalyst for bridging the digital divide, as older people have become more digitally connected, with many partaking in “Zoom” calls to see family and friends. Interestingly, the proportion of people using the internet aged 65 years or older has been rapidly increasing in recent years, with 80% of people aged 65-74 having used the internet in the previous 3 months (5). While a level of ambivalence amongst the older population regarding new technologies is understandable, numerous studies have reported high satisfaction rates with telemedicine (6). Older patients have reported a positive impact on their livelihoods, with an increased sense of well-being and safety, along with improvements in social cohesion thanks to online community care platforms (7). Furthermore, a study focussing on barriers to interacting with technology noted apprehension about the lack of clarity in the support and instructions provided. Despite this, most participants were eager to adopt new technology and willing to learn (8). To bridge the digital divide, EU initiatives like the “Grandparents & Grandchildren Project”, aim to encourage the younger generation to help and provide reassurance, in an attempt to improve digital literacy amongst older people (9). Whilst further research is necessary to successfully negotiate the “bridge”, the above findings suggest significant progress and a positive attitude towards new technologies with a beneficial impact on lifestyle in the older population.


Role of Telemedicine

The unprecedented emergence of COVID-19 has transformed current clinical practice and now more than ever it is imperative to explore alternative options for providing specialist care in the future. Of particular importance in the case of older patients is ensuring that the person consents to their involvement in the virtual assessment process. Indeed a strong regulatory framework for digital health applications, processes, and software such as that of the US Food and Drug Administration should be adopted internationally. (10)

Acute Care

A “Forward Triage Model” – whereby patients are stratified before arrival in the Emergency Department (ED) with the use of smart devices or webcam-enabled computers, can act as a central strategy for surge control amidst a global pandemic. It focuses on efficient screening, is patient-centred, and conducive to self-quarantine measures, thus protecting patients, clinicians, and the community from exposure (11). An example of a similar successful system is the “ETHAN Project” in Houston, Texas (12). This initiative incorporates telecommunications technology to triage patients with non-life-threatening illnesses, who were being attended by emergency medical services (EMS) via telemedicine with an ED Physician. Whilst this study primarily focussed on EMS utilization and outcomes, patients in the study reported an 88% overall satisfaction rate with telemedicine-enabled EMS response. Furthermore, there was a significant reduction in ED ambulance transfers from 74% to only 18% and there was a 44-minute reduction for the EMS unit back in-service time, resulting in two-fold greater productivity (12). Although further research is needed, it is worthwhile noting that patients >65 years old were included in the above study, an important factor for consideration when determining how clinicians can help provide specialist care with the use of technology to older patients during and post-COVID-19.

Outpatient Assessments

Providing outpatient services to an older cohort of patients is often difficult due to the complexity of their healthcare needs and adverse outcomes are common after discharge from ED (13). Some benefits of telemedicine for older patients are already documented (14). Early studies found that video conference-enabled telemedicine was as accurate as in-patient clinical examination for establishing a diagnosis of dementia (15). Additionally, patients reported a high degree of satisfaction and a willingness to participate in telemedicine-enabled clinical care in the future (15). Furthermore, at-home telemonitoring of chronically ill patients has been shown to have a positive impact on healthcare expenditure, the number of hospital admissions, reduction in length of stay(LOS) in hospital, and most importantly a reduction in mortality (16). Similarly, a 2015 Cochrane Systematic Review demonstrated similar health outcomes for patients with chronic health conditions including HF and DM when comparing telehealth-enabled remote monitoring and videoconferencing to in-person or telephone visits (17). Remaining independent and living in one’s own home is often a key desire of older patients; outpatient virtual assessments facilitate this and could positively influence an older person’s manner of living.
A recent pilot study in Western Australia compared the effectiveness of two alternative geriatrician models of care; the tele-geriatric service (TGS) and visiting geriatrician (VG) (18). In this study, GPs were encouraged to refer patients early during the course of symptom evolution, which subsequently translated into improved care coordination and slower disease progression. Furthermore, whilst both TGS and VG had similarly reduced rates of health service use, a higher volume of patients across a broader geographical area and improved waiting list management occurred using TGS. Consequently, TGS reduced avoidable hospitalisations and subsequent health deterioration (18).
Another key area where technology is applicable to healthcare is in the role of virtual consultations (VC), multidisciplinary meetings, and rehabilitation, with VC having been rapidly deployed in response to COVID-19 (19). The success of VC has also been demonstrated with the implementation of a GP-specialist on-line, real-time interaction for optimal management of outpatients with HF. Analysis of outcomes of this innovative approach shows a very positive impact on the provision of HF care in the community with high acceptability of its (mainly older) users, with only 17% requiring subsequent review in OPD (20).

Table 1
Potential technological modalities for older patient assessments



Falls are a common presenting complaint of older people both from the community and NH, occurring in up to 30% of that population. Recent studies have shown that a telerehabilitation home-based programme, with integrated tele-surveillance, is feasible and effective in preventing falls in older patients with a high risk of falling (21), yet there remains a level of ambivalence among older participants around the utility of technology and their capacity to adapt it to address falls prevention (22).
After hospitalisation in an acute geriatric ward, over 11% of older patients are referred to rehabilitation facilities (23). A recent meta-analysis and systematic literature review of virtual reality rehabilitation (VRR) programmes, demonstrated that VRR programmes are more effective than traditional rehabilitation programmes for physical outcomes (24). Furthermore, other studies have shown that home-based telerehabilitation in older patients with COPD and HF was both feasible and effective (25).


Potential Barriers

The COVID-19 pandemic has catalysed the rapid adoption of telehealth, and whether healthcare providers are ready or not, the new reality is that virtual care has arrived (26). The advantages of telemedicine can be summarised as the 5 C’s: accessible care, increased convenience, enhanced comfort, greater confidentiality, and now reduced risk of contagion (27). Despite this telemedicine has its limitations, including the inability to perform a physical examination and inequitable access to the internet and related technologies for older people which again highlights the need to bridge the “digital divide”. Furthermore, effective and efficient integration of telemedicine programmes require extensive staff and patient education, and accessory platforms to facilitate video and audio communications. Comprehensive guides and toolkits can help rapidly integrate telemedicine into practice (28), but for our older patients embracing new technologies it can be a steep learning curve and one could argue are we attempting to “sow a seed and reap a harvest simultaneously?”
For successful implementation of telemedicine globally, it needs to be included in the essential levels of care granted to all citizens and countries must adopt the necessary framework of regulations for supporting the wide integration of telemedicine into current health care systems (29). In addition, in the growing age of information technologies, it is imperative patient’s information is kept confidential and secure, and that informed consent is obtained. Abiding by guidelines and attention to ethical issues in telemedicine helps to ensure safer use of these services.(30).
If such a remote, tele-healthcare management approach is successful, it should impact positively on health, promote active involvement in decision making, help older patients adopt a healthy lifestyle and outlook, reduce unplanned hospitalisations, and may also herald other novel approaches to managing this vulnerable population.



In summary, COVID-19 has resulted in a dramatic change in the way in which we as clinicians provide specialist care which will endure. The aftermath of this pandemic will present an unprecedented challenge in adapting to new modalities for delivering healthcare. Dr. Marjory Warren’s identification of the need for interdisciplinary care to older frail people remains relevant today. Addressing the optimal role of technology in the provision of specialist care for older patients can have a positive impact on the future delivery of care to older patients and one’s livelihood.


Learning Points

• The COVID-19 pandemic should act as a catalyst to advance the use of digital technologies for older people.
• Successful remote telemedicine-enhanced initiatives for emergency management of patients, including older ones, have emerged during the pandemic.
• Online community care platforms have been shown to impact positively on the livelihood of older patients, providing an increased sense of well-being and safety whilst improving social cohesion.
• Initiatives such as “tele-geriatric services” should be evaluated as mechanisms to enhance community access to specialist geriatric assessment.
• Existing and experimental models of remote technologically enhanced care in rehabilitation, outpatient (many chronic disease-specific) and residential settings should be trialed for generic older patients.
• Adopting necessary regulatory frameworks for implementing telemedicine services, with attention to ethical issues is imperative for safe use of these services.


Ethical standards: Adhered to high ethical standards.

Conflicts of Interest: No conflict of interest.



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