The COVID-19 pandemic has unquestionably caused many life-changing events. While the impact of the virus on world infection, morbidity and mortality rates are immense, its repercussions on overall human well-being are remarkable. The safety measures imposed during pandemic, especially lockdown, have significantly deranged habitual activities and lifestyles causing adverse consequences on overall health. Although previous studies have shown the relationship between post-pandemic distress, anxiety, stress, and depression during the lockdown and mental health and decreased quality of life among global populations [5, 15, 16], the data from the Malaysian population is still lacking. This study found significant changes in total diet quality, physical activity level, sleep quality, and food insecurity level among the population during the lockdown, and some of these changes were significantly associated with QoL independent of sociodemographic factors.
The total score of diet adherence towards dietary guidelines increased significantly indicating overall diet quality was better (i.e. adequate energy and protein intake with lower salt, fat, and sugar and high in fibre) during lockdown as compared to before lockdown. Bennett et al.  found there are many studies worldwide that have shown to demonstrate changes in dietary habits during lockdowns such as an increase in fresh produce, home cooking, and reduction in comfort foods, and alcohol intake. With the sudden move of local authorities to restrict movement and social interaction, accessing supermarkets to buy fresh produce and consumption of food associated with social occasions have been impacted . Although there might be social and festive eating occasions within the home that are associated with consumption of low-nutritional-quality foods, this was limited as urban Malaysian families live away from their older family members who are the main driver in food preparation during social and festive seasons . With the abundance of time staying at home during the pandemic, more time could be spent preparing home-cooked meals. Preparing home-cooked meals has been shown to increase diet quality as individuals become aware of the quality of ingredients and are able to plan their menu . This disruption due to COVID-19 might be used as a turning point to change their dietary habits to a healthier version [20, 21]. Besides, with the increase of available information on diet and foods through the internet, many have equipped themselves with knowledge of healthy eating practices focusing on foods rich in the healthy microbiome to boost their immune system, antioxidants which are rich in fruits and vegetables as well as higher preference to eat within safe premises especially at home . However, the effect of lockdown also impacted negatively on dietary practices and was associated with other unfavorable lifestyle outcomes including an increase in body weight, mental health issues, and limited physical activity .
In terms of physical activity, Malaysian population has shown an increase in physical activity level by nearly 19% since 2006 to 2019 [23,24,25]. However, METs in walking and total minutes of physical activity decreased significantly during the lockdown whilst METs in moderate activity increased significantly. Inconsistent with findings among adults in China by Wang et al.  where most participants did not perform moderate (jogging and dancing) and vigorous physical activity (rope jumping and weight training). This is possibly because people are not used to home workouts, have limited space, and lack motivation due to the closure of gyms . Despite this, sedentary behavior has increased to 60% and people tend to eat more frequently at home because they are unable to dine in restaurants . Besides, a previous study has shown that home confinement and reduced physical activity during pandemic has increased sugary food intake and levels of food cravings and snack consumptions . However, although there was a decrease in the physical activity level during the lockdown in this study, the reason behind the reduction was not further investigated. Malaysians are encouraged to work from home and restrict outdoor activities since the imposed stay-at-home order which was one of the obvious reasons behind the decrease in physical activity. Our findings were also in line with a study conducted among Brazilians during the pre-pandemic period where less than 5% of participants were inactive and the remaining equally moderately and highly active. However, in the pandemic period, 84% of the sample population was considered inactive . Based on a study by Tison et al. , there was a 5.5% average decrease in daily step count (287 steps) worldwide following a step counter smartphone application within 10 days after the March 11th pandemic started. Furthermore, the inactivity increased to 27.3% (1432 steps) within 30 days. Meanwhile, in China, the average steps per day and the average moderate or vigorous-intensity exercise also declined significantly for both males and females during the semi-lockdown . The restriction of movement due to the pandemic had changed work and transport-related physical activities for a large number of the working population and affected leisure activities by the closure of sports and fitness centers.
The COVID-19 lockdown was also associated with significant changes in other daily activities including sleep schedule. The psychological distress, anxiety, and depression during pandemic and lockdown have disrupted sleeping patterns leading to poor quantity and quality of night-time sleep . This study found that sleep quality has dropped significantly during the lockdown as compared to the pre-lockdown among the Malaysian population. In India, COVID-19 lockdown has shifted the bed- and waking timing, reduced the night-time sleep and increased daytime napping, and caused sleep quality deterioration . Similar findings were also found among populations in European countries including Spain, Italy, and Belgium . In addition to physical health, impaired sleep quality can lead to substantial negative psychological and physiological consequences including increased stress responsivity, somatic pain, emotional distress and mood disorders, and cognitive, memory, and performance deficits which ultimately will lead to reduced QoL .
The longer lockdown has notably impacted food security around the globe due to unemployment, and disruption in food supply and accessibility. The World Food Summit defined that “food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life” . The current study shows a significant increment in food insecurity score during the lockdown period compared to before the lockdown period indicating that people were more food insecure during the lockdown period. Our findings are in line with other surveys from both developed and developing countries [36,37,38]. Undeniably, the COVID-19 pandemic among others had caused economic and psychological vulnerability which had influenced the food security status [36, 39]. Many have turned to food banks or free food distribution to obtain their basic food needs, other than relying on financial aid from the government . This situation if left unattended could worsen and may lead towards more severe health consequences as food insecurity is associated with anxiety and depression as well as psychological distress during the current pandemic [41,42,43].
Across all respondents, this study found that QoL was, in general, at a moderate level during the COVID-19 lockdown period, hence satisfactory. A similar outcome was reported by a study among over 2,000 adults in China who had been isolated at home for an average of 77 days . Approximately 65% of the respondents indicated being satisfied with their QoL. However, the physical domain was comparatively the worse whilst the environmental dimension was the best. This was unsurprising in view of the significant contribution of physical activity (and intensity) to QoL as measured in METs which was proven to be independent of several important socio-demographic variables in our sample. A recent China study also showed the negative impact of the COVID-19 pandemic towards participation in physical activity, which was in turn significantly associated with QoL . The increase in sedentary time and reduction in outdoor physical movement as a consequence of home confinement which has been reported [44,45,46] were the main attributes of such findings. Supporting this, Wang and co-researchers  specifically pointed out that 50% of their stay-home Chinese respondents had diminished time for physical activity while over 60% experienced increased sedentary behavior. It has been contended that people’s engagement with physical activity could stem from one’s motivation and self-efficacy . Moreover, the less active Canadians in their study reported significantly reduced benefit, enjoyment, confidence, support, and opportunities to continue an active lifestyle in the COVID-19 restriction period. Given the protective benefits of physical activity on health and well-being, the government should at any feasible point permit the continuity of this activity at all levels to ensure sustained personal motivation and self-efficacy.
On the other hand, the more favorable outcome on environmental issues was a likely expectation as people generally feel safer at home amid an infectious pandemic such as COVID-19. In addition, the majority were also staying with family members, and spending such interactive time together (cooking, watching tv, chatting, etc.) was naturally a positive surrounding, at least temporarily. The social relationship was also reported to be relatively better when compared to the physical and psychological dimensions, as more time was spent to rest and reconnect with family and friends (via social media, if not physically). Enhanced shared feelings and family care was encouragingly documented . The same picture regarding environmental and social aspects was also depicted by another study among a bigger sample of respondents . Nonetheless, negative changes in weight [49, 50] physical activity level , sleep quality [3, 51, 52], and food insecurity [41, 53] which occurred during lockdown may have introduced psychological distress that lead to significant influence on general QoL. Although the non-significant changes in body weight during lockdown may not reflect the true changes, however every unit change significantly impacted the QoL after controlling for other factors.
This study was the first study to report the impact of lockdown on health-related lifestyles and how it affects QoL among Malaysian adults. The findings of this study nationally represent the Malaysian adults from the major ethnicities, however, the cross-sectional study design cannot be used to infer causality. While the sample sizes may be smaller than we anticipated, our survey was also limited by its online nature and may be biased towards the more educated and technology-savvy population. There was a potential of misreporting errors from the self-reported data especially when both before and during variables were collected in the same survey during lockdown. The number of variables collected were also limited which may had introduced the effect of residual confounding in the associations. The fact that this study used convenient sampling, the percentage of responses was unable to be reported. Nevertheless, the present findings highlighted the importance of lifestyle on QoL and how the lockdown measure during the pandemic had caused significant changes. The government and health authorities should consider appropriate interventions to prevent further disruptions in life and increase wellbeing to increase the QoL of the population, especially during lockdown and post-pandemic. As the world is facing transition to endemic state, creating safe environment while rebuilding the economic and health of the nations is pivotal.