The COVID-19 pandemic has been the most significant issue in global public health in recent years [1]. The disease both had a direct impact on public health and provoked changes in health-related behaviors, such as lifestyle and healthcare service use [2]. In particular, long-term prevention for other diseases, such as cardiovascular disease (CVD), was less prioritized than this impending health emergency [3]. For instance, there were fewer hospitalizations for myocardial infarction, and cardiac catheterization decreased by 38% in the United States during the pandemic [4]. These changes were attributable to reductions in healthcare service use, resulting from stay-at-home mandates, public hesitation to visit hospitals, and the concentration of health-related resources on COVID-19 [5].

The reduction in CVD hospitalization and treatment did not necessarily indicate a decreased burden of CVD; rather, CVD has continued to be the disease with the largest burden worldwide [6]. In Korea, stroke and ischemic heart diseases were the leading cause of mortality even after 2020, when the pandemic began to sweep through the country [7]. Physical inactivity and excessive body weight, which increased the risk of CVD before COVID-19, remained unmodified during the pandemic [8]. In fact, the containment measures for COVID-19 were likely to hinder the modification of these determinants of CVD. In addition, a considerable body of research reported that patients with underlying CVD showed a higher likelihood of severe respiratory complications and mortality from COVID-19 [2,9]. A study in Louisiana, USA, illustrated the association between cardiometabolic disease and mortality from COVID-19 [2]. As the COVID-19 pandemic is prolonged, an emphasis on CVD prevention may reduce both the harm from this communicable disease and the burden of CVD in the future. Thus, this study sought to examine changes in health-related behaviors during the pandemic and related sociodemographic factors, as part of an investigation exploring public awareness of CVD and its prevention.

We examined self-reported changes in CVD-related health behaviors during the COVID-19 pandemic. Favorable changes were mainly observed in smoking, drinking, and healthcare service use, while unfavorable changes were predominant in diet, exercise, and stress. These negative changes during the pandemic were also significantly associated with age, sex, marital status, and the presence of cardiometabolic disease after adjustment for all socioeconomic factors.

As the world manages the imminent health challenges, COVID-19 has brought about substantial changes in the diagnosis, treatment, and prevention of other diseases such as CVD [1,11]. In particular, growing public interest in health appears to be linked to individual efforts to improve health-related behaviors [12,13]. A study in the United States analyzed online search interest for CVD-related lifestyle factors based on Google Trends and Google Shopping Insights in 2020 [12]. During the pandemic, search terms relating to a healthier diet and physical exercise increased, but searches for smoking-related terms decreased [12]. Our study also documented collateral benefits for healthier lifestyles. Many respondents reported improvements in their smoking and drinking habits during the pandemic (30.6% and 38.1%, respectively). It seems that the decline in smoking and drinking was at least partly due to the restrictions of social gatherings [13]. Earlier reports on COVID-19 also suggested that smoking is a risk factor for the development of more severe cases after being infected [14]. The fear of this novel viral disease seems to have brought about positive changes in health behaviors. However, in dietary habits and physical activity, more people reported negative changes than those who showed positive changes. One possible explanation is that indoor fitness centers were closed, resulting in reduced physical activity, especially in urban settings [15]. Sedentary lifestyles may also have increased as people worked from home and were reluctant to go out [15]. The growing consumption of nonperishable food and delivery food may have led to increased food insecurity and poorer dietary quality after the outbreak of COVID-19 [2,16]. In a survey of college students in Korea, 65% of the respondents answered that they ordered delivery food at least one to two times a week, while reporting a gain of body weight in the past 6 months [16]. Above all, it is alarming that most of the respondents (52.6%) rated their stress as aggravated. Deterioration of mental health during the COVID-19 pandemic has been frequently reported in previous studies. An analysis of 16 studies (113,285 individuals) illustrated a high prevalence of mental distress from December 2019 to June 2020 [17]. Depression was found in 20% of individuals, anxiety in 35%, and psychological stress in 53% [17]. A study in Australia investigated the association between changes in health-related behaviors and psychological distress [18]. Not only was there a high prevalence of negative changes in physical activity (48.9%), sleep (40.7%), drinking (26.6%), and cigarette smoking (6.9%) during the pandemic, but these deteriorations were also associated with greater risks of depression, anxiety, and stress symptoms [18]. Improving both mental health and other health-related behaviors can help reduce psychological distress.

We also confirmed that sociodemographic factors were related to negative changes during the pandemic. While those in their 40s and men were at high risk of deterioration in smoking and drinking, the risks for diet and exercise were higher among those in their 20s and women. This seemed to result from decreases in social smoking and drinking, which were relatively prevalent in middle-aged adults and men. Furthermore, as outdoor activities were canceled after the outbreak and participants spent more time indoors, dietary habits and physical activity may have changed in young adults and women. Educational attainment and monthly household income did not show significant associations with negative changes in health-related behaviors, except for smoking, where lower education and income level put individuals at a higher risk than their counterparts. This finding was not consistent with other studies that presented an association between higher income and engagement in self-protective behaviors during the COVID-19 pandemic [19]. Future studies should investigate the possible effect of income and education on CVD-related health behaviors with a sufficient sample size. After adjusting for all sociodemographic factors in our study, cardiometabolic disease patients were more likely to show aggravation of lifestyle factors, except for smoking and drinking. Similarly, another study reported that patients with diabetes had a higher likelihood of experiencing food insecurity and drug shortages than individuals without diabetes. Patients with diabetes were also more concerned about COVID-19 and perceived the risk as higher, which may lead to greater psychological distress among those with comorbidities [20].

Our study examined changes in CVD-related behaviors that are difficult to investigate with a clinical approach but are nonetheless important for CVD prevention. Despite the possible implications of our study for public health, several limitations should be taken into consideration. First, our findings need to be reaffirmed in future studies with sufficient sample sizes. Although the Cardiovascular Disease Prevention Awareness Survey sought to reflect behavioral changes in the general population in Korea, and consisted of various individuals, the relatively small sample size may limit its implications. Second, our report was based on self-reported data, and the possibility should be considered that the findings resulted from subjective changes without objective indicators or figures. Last, there might have been meaningful differences in characteristics between respondents and nonrespondents. The survey was completed online or on mobile devices, which could result in nonresponsiveness among digitally illiterate subpopulations, which are likely to have a lower socioeconomic status.

COVID-19 caused a reduction in hospital use for CVD patients and those with predisposing factors. This could lead to a higher CVD burden in the near future. Moreover, considerable studies reported more deaths and adverse events from COVID-19 in CVD patients. As the pandemic is prolonged, it is necessary to examine changes in CVD-related health behaviors and establish preventive strategies accordingly. CVD prevention, which has been somewhat postponed, should be further encouraged. Doing so would both relieve the CVD burden that is likely to overload the health system in the near future and reduce the harm from COVID-19.