Please critique the results section of the paper (including the Tables and Figures). You will take the role of a peer reviewer for a journal. In your review back to the editor, please comment on 1) those items you think the authors did well (i.e., strengths), 2) those items where the authors could have improved (i.e., weaknesses, limitations), and 3) questions you might have for the authors.

ARTICLE TITLE: Effects of COVID-19 Home Confinement on Eating Behavior and Physical Activity: Results of the ECLB-COVID19 International Online Survey

6 > of 13 0 - ZOOM + 3. Results 3.1. Sample Description The present study focused on the first thousand responses (i.e., 1047 participants), which were reached on 11 April 2020. Overall, 54% of the participants were female and the participants were from Asian (36%, mostly from Western Asia), African (40%, mostly from North Africa), European (21%) and other (3%) countries. Age, health status, employment status, level of education and marital status are presented in Table 1. Table 1. Demographic characteristics of the participants. Variables (%) Gender Male 484 (46.2%) Female 563 53.8% Continent North Africa 419 (40%) Western Asia 377 (36%) Europe 220 (21%) Other 31 (3%) Age (years) 18-35 577 (55.1%) 36-55 367 (35.1%) 255 103 (9.8%) Nutrients 2020, 12, 1583 7 of 13 Table 1. Cont. Variables (%) Level of education Master/doctorate degree 527 (50.3%) Bachelor's degree 397 37.9% Professional degree 28 (2.7%) High school graduate, diploma or the equivalent 69 (6.6%) No schooling completed 26 (2.5%0) Marital status Single 455 (43.5% Married/Living as couple 562 (53.7%) Widowed/Divorced/Separated 30 (2.9%) Employment status Employed for wages 538 (51.4% Self-employed 74 (7.1%) Out of work/Unemployed (7.2%) A student 259 (24.7%) Retired 23 (2.2%) Unable to work (0.9%) Problem caused by COVID-19 59 (5.6%) Other 10 (1%) Health state Healthy 956 (91.3%) With risk factors for cardiovascular disease 81 With cardiovascular disease 10 (7.7%) (1%)7 > of 13 0 - ZOOM + 3.2. Physical Activity before and during the Confinement Period Responses to the physical activity questionnaire recorded before and during home confinement are presented in Table 2. Table 2. Responses to the physical activity questionnaire recorded before and during home confinement before during A (4% ) t Test Confinement Confinement p Value Cohen's d Vigorous Days/week 1.97 + 2.11 1.52 + 2.03 0.45 (22.7%) 7.751 of 13 0 - ZOOM + 3.2.5. Sitting Statistical analysis reported that the number of hours/day of sitting increased by 28.6% during home confinement (t = -25.61, p of 13 0 - ZOOM + 3.3.5. Question 4 (Q4): Alcohol Binge Drinking The score of Q4 (binge alcohol drink; Figure 1) decreased significantly during home confinement (t = -12.16, p of 13 0 - ZOOM + Nutrients 2020, 12, 1583 10 of 13 a result of COVID-19. There were 1047 replies (54% women) from Western Asia (36%), North Africa (40%), Europe (21%) and other countries (3%), which revealed that the COVID-19 home confinement has had a negative effect on all levels of PA (vigorous, moderate, walking and overall) and an increase in daily sitting time by more than 28%. Additionally, an unhealthy pattern of food consumption (the type of food, eating out of control, snacks between meals and number of main meals) was exhibited Only alcohol binge drinking decreased significantly. Despite recommendations that home confinement should not hinder people from being physically active [25], present results show that there has been a decline in all PA levels during the COVID-19 home confinement period. While the effect size is small to medium for most parameters, the 35% reduction in number of days per week walking is medium to large. In fact, 2.45 days is a serious change, independent from the number of walking days before confinement. However, the most prominent change was in sitting behaviour, which increased more than a full standard deviation (very large effect size: d = 1.13), most likely due to the increased time that people were required to stay within their quarantine location. Indeed, 29% of the sample reported sitting for 6-8 h a day during confinement (vs. 24% before), a threshold area which Patterson et al. [26] suggested causes an increase in disease and mortality risks. Far more serious was the proportion of individuals who sat for more than 8 h a day, which increased from 16% to 40% during confinement. Preliminary data indicate that 41% of the sample increased their sitting behaviour by only 1 h or less, but this increased by five hours or more for 27% of the sample The results of this survey concur with recent studies demonstrating that the current COVID-19 home confinement could dramatically impact lifestyle activities globally, including participation in sports and PA engagement [12,27]. The restrictions have reduced overall PA (number of days and number of hours) and access to exercise. In spite of an increased offering of PA guidance and classes available on social media, present results indicate that it has not been possible for individuals to adequately maintain their normal PA patterns with home activities. The decline in PA was accompanied by increased sedentary (sitting) behaviour. However, the extent to which PA participation is impacted by the current COVID-19 pandemic will be linked to the stringency of individual government confinement policies. It is already shown in China that different regional policies and socio-economic factors were associated with differences in PA [1]. These factors need to be considered when designing and promoting PA interventions for the COVID-19 pandemic. It was recently demonstrated that individuals demonstrate a greater use (15%) of Information and Communications Technology (ICT) during the confinement period [11]. Therefore, future PA intervention to foster an Active and Healthy Confinement Lifestyle (AHCL) during pandemic can be based on ICT solutions, such as home-based exergames and fitness apps. The results of this survey also found that, in contrast to the guidance of the World Health Organization [6,7], people changed their eating behaviours, with increased consumption of unhealthy food, eating out of control, more snacking between meals and an overall higher number of main meals [28]. Regarding dietary behaviours, there seems to be no single behavioural problem. While a medium effect size (d = 0.5) was recorded for total score, a small effect size was registered for the type of food, number of main meals and eating out of control. The effect size for snacks between meals was medium. Binge drinking of alcohol showed the largest effect size (d = 0.58) but, conversely, in a healthy direction. This may be due to the fact that younger individuals are less likely to be surrounded by other drinking peers [29]. The negative changes in the majority of eating behaviours could be attributed to eating out of anxiety or boredom [9], a dip in motivation to participate in PA or maintain healthy eating [30] or an increase in mood-driven eating [9]. Alternative support for motivation during home confinement may be sourced from assistive technologies such as apps, streaming services and social media in order to counteract poor dietary behaviours, meal planning and controlling food composition and meals' caloric content using ICT-based solutions such as mhealth and nutrition apps may be the best pproach to combating unhealthy eating habits while in confinement [9,11].Page of 13 0 - ZOOM + Nutrients 2020, 12, 1583 11 of 13 The results reported in this report should be utilised for further research and development in public health promotion during the COVID-19 pandemic. Motivating people to stand up can be a first step of health promotion against sedentary behaviour. It was recently suggested that in times of restrictions due to the COVID19 pandemic, breaking up prolonged sitting with simple measures, such as alternating between sitting and standing for 30 min periods, may result in meaningful increases in energy expenditure, thus promoting metabolic health in terms of glycaemia control for both healthy and diseased individuals [31,32]. Individuals may have improved metabolism and other health outcomes during the COVID-19 home confinement by adhering to the following dietary behaviours: (i) reducing meal frequency, (ii) consuming regular (i.e., breakfast (about 40% of daily total energy), (iii) lunch (30% of daily total energy) and (iv) dinner (30% of daily total energy)) and (v) good quality meals e.g., more fresh vegetables, good quality protein source, avoiding refined and high glycaemia foods), and (vi) adapting intermittent or a long fasting period (i.e., more than 12 h) [7,31]. Further research should address (i) insight into subpopulations for the development of interventions to address their needs, (ii) interference of diet and PA behaviours, for improving interventions, and (iii) identification of conditions for successfully maintaining a healthy lifestyle before as well as during isolation. Although many ideas and recommendations already exist [7,27,31-33], individuals seem to need more support to effectively use the ser offered and to underst sequences of inaction. Technology and social media allow for innovative health behaviour support via fitness applications and video streaming and motivation and gamification support; adding the beneficial social aspect is also very important to encourage maintenance of physical activity behaviours. 5. Strengths and Limitations The strengths of this research project include a survey provided in multiple languages, which has been widely distributed in several continents. Scientists from different disciplines and many countries cooperated to make this possible. However, there were also limitations of the low-threshold strategy in that it did not allow for narrow target groups with defined inclusion and exclusion criteria Thus, a collection from a representative sample cannot be expected. Only during post hoc studies can criteria-based subsamples be analysed. The validity of answers is a general problem of online surveys and we attempted to address this by the differential approach described in the methods section. 6. Conclusions and Future Perspectives The preliminary results of the survey indicate a negative effect of home confinement on PA and diet behaviour with a significant increase in sitting time and unhealthy diet, indicative of a more sedentary lifestyle. These observations have potential implications that could aid the development of PA and nutritional recommendations to maintain health during the COVID-19 pandemic. The major perspectives of the ECLB-COVID 19 multicentre study are to target more affected countries and to collect more responses, allowing a between-country comparison and also separate analysis of each country's data. Indeed, identifying exact behavioural changes in each country will provide better-informed decisions during the reopening process. Supplementary Materials: The following are available online at http://www.mdpi.com/2072-6643/12/6/1583/s1, Table S1: Distribution of responses (%) in each item of the diet behaviour questionnaire Author Contributions: Name of the guarantor: A.A.; Drafting the work: A.A., M.B.; Analysis and interpretation of data for the work: A.A., M.B., K.T., O.B., L.M., B.B.; Revising the work critically for important intellectual content: K.T., H.C., S.J.B., J.M.G., S.V.W.S., P.M., N.M., A.J., J.M.S., T.D., A.H.; Substantial contributions to the conception or design of the work or the acquisition of data for the work: A.A., M.B., K.T., H.C., O.B., L.W., B.B., E.B., D.H., M.A., P.M., N.M., A.A., O. M., A.A., O.H., L.L.P.-D., A.B.-j., C.W., S.B., C.S.P., L.M., M.T., K.I., A.K., N.L.B., K.C., J.M.G., N.B., F.G., L.C., H.B., G.M.A., O.A., M.J., K.E.A., O.A., M.J., K.E.A., N.S., L.V.G.-P., B.L.R., L.R., W.M., J.G.-R., M.E., R.S., S.V.W.S., A.J., R.A.-H., T.M., M.J., F.B., F.F.-S., B.S., R.P., A.G., S.J.B., J.M.S., T.D., A.A; Final approval of the version to be published: A.A., M.B., K.T., H.C., O.B., L.W., B.B., E.B., D.H., M.A., P.M., N.M., A.A., O.H., L.L.P.-D., A.B.-j., C.W., S.B., C.S.P., L.M., M.T., K.I., A.K., N.L.B., K.C., J.M.G., N.B., F.G., L.C., H.B., G.M.A., O.A., M.J., K.E.A., N.S., L.V.G.-P., B.L.R., L.R., W.M., J.G.-R., M.E., R.S., S.V.W.S., A.J., R.A.-H., T.M., M.J., F.B., F.F.-S., B.S., R.P., A.G., S.J.B., J.M.S., T.D., A.A., E.C. All authors have read and agreed to the published version of the manuscript.12 > of 13 0 - ZOOM + Nutrients 2020, 12, 1583 12 of 13 Funding: Research is urgently needed to help understand the impacts of the COVID-19 pandemic on peoples' lifestyle. However, normal funding mechanisms to support scientific research are too slow. The authors received no specific funding for this work. Acknowledgments: We thank our consortium's colleagues who provided insight and expertise that greatly assisted the research. We thank all colleagues and people who believed in this initiative and helped to distribute the anonymous survey worldwide. We are also immensely grateful to all participants who #StayHome and #BoostResearch by voluntarily taking the #ECLB-COVID19 survey. We would like to acknowledge the recent addition to our team of Dr. Bill Mcilroy and Dr. Donald Cowan, both from the University of Waterloo in Canada, who will be participating in the development of information technologies that will support our technology-driven solutions to alleviate some of the serio effects of the COVID-19 pandemic and subsequent quarantine. This manuscript has been released as a pre-print at https://www.medrxiv.org/content/10.1101/2020.05. 04.20072447v1, [14]. Conflicts of Interest: The authors report no conflicts of interest. References 1. Hossain, M.M.; Sultana, A.; Purohit, N. Mental health outcomes of quarantine and isolation for infection prevention: A systematic umbrella review of the global evidence. SSRN Electron. J. 2020. [CrossRef] 2. Bloch, W.; Halle, M.; Steinacker, J.M. Sport in times of Corona (Sport in Zeiten von Corona). Ger. J. Sports Med. 2020, 71, 83-84. [CrossRef] 3. 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