Small steps, strong shield: directly measured, moderate physical activity in 65 361 adults is associated with significant protective effects from severe COVID-19 outcomes
Lizelle Steenkamp, Robin Terence Saggers, Rossella Bandini, Saverio Stranges, Yun-Hee Choi, Jane S Thornton, Simon Hendrie, Deepak Patel, Shannon Rabinowitz, Professor Jon Patricios
British Journal of Sports Medicine, doi:10.1136/bjsports-2021-105159
Objective To determine the association between directly measured physical activity and hospitalisation, intensive care unit (ICU) admission, ventilation and mortality rates in patients with a confirmed diagnosis of COVID-19. Methods Directly measured physical activity data from 65 361 adult patients with a COVID-19 diagnosis from 19 March 2020 to 30 June 2021, were grouped by activity level: low (<60 min/week), moderate (60-149 min/week) and high activity (≥150 min/week). The association of physical activity levels and the risk of adverse outcomes was analysed using modified Poisson regression. We accounted for demographics and comorbidities including conditions known to influence COVID-19 outcomes, as well as patient complexity as measured by the Johns Hopkins Adjusted Clinical Group system. The regression approach was further validated with a Bayesian network model built off a directed acyclic graph. Results High physical activity was associated with lower rates of hospitalisation (risk ratio, RR 0.66, 95% CI 0.63 to 0.70), ICU admission (RR 0.59, 95% CI 0.52 to 0.66), ventilation (RR 0.55, 95% CI 0.47 to 0.64) and death (RR 0.58, 95% CI 0.50 to 0.68) due to COVID-19 than those who engaged in low physical activity. Moderate physical activity also was associated with lower rates of hospitalisation (RR 0.87, 95% CI 0.82 to 0.91), admission to ICU (RR 0.80, 95% CI 0.71 to 0.89), ventilation (RR 0.73, 95% CI 0.62 to 0.84) and death (RR 0.79, 95% CI 0.69 to 0.91). Conclusions Adults with high and moderate physical activity levels had significantly better outcomes than those with low activity when contracting COVID-19. The apparent protective effects of regular physical activity extended to those with concomitant chronic medical conditions.
Competing interests LS, DP, SR and SH are employed by Discovery Health; JP and JST are editors of BJSM.
Patient consent for publication Not applicable. Ethics approval Permission for use of DHMS anonymised medical and physical activity data was obtained from the Research Governance Committee of Discovery Health. Ethical approval was obtained from the Human Research Ethics Committee of the University of the Witwatersrand, Johannesburg (clearance certificate number M210725.) Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available. Not applicable.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits..
References
Brandenburg, Lesser, Thomson, Does higher self-reported cardiorespiratory fitness reduce the odds of hospitalization from COVID-19?, J Phys Act Health,
doi:10.1123/jpah.2020-0817Cho, Lee, Physical activity and the risk of COVID-19 infection and mortality: a nationwide population-based case-control study, J Clin Med,
doi:10.3390/jcm10071539Christensen, Arneja, Cyr, The association of estimated cardiorespiratory fitness with COVID-19 incidence and mortality: a cohort study, PLoS One,
doi:10.1371/journal.pone.0250508Cunningham, Physical activity and its relationship with COVID-19 cases and deaths: analysis of U.S. counties, J Sport Health Sci,
doi:10.1016/j.jshs.2021.03.008De Souza, Motta-Santos, Soares, Association of physical activity levels and the prevalence of COVID-19-associated hospitalization, J Sci Med Sport,
doi:10.1016/j.jsams.2021.05.011Dunton, Do, Wang, Early effects of the COVID-19 pandemic on physical activity and sedentary behavior in children living in the U, S. BMC Public Health,
doi:10.1186/s12889-020-09429-3Gimati, Alrasheed, Bashir, Effect of a COVID-19 on social, psychological, economic and health conditions in Libya, J App Sci Eng Tech Ed
Greenland, Mansournia, Altman, Sparse data bias: a problem hiding in plain sight, BMJ,
doi:10.1136/bmj.i1981Ledo, Schub, Ziller, Elite athletes on regular training show more pronounced induction of vaccine-specific T-cells and antibodies after tetravalent influenza vaccination than controls, Brain Behav Immun,
doi:10.1016/j.bbi.2019.09.024Lee, Lee, Moon, Physical activity and the risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 related mortality in South Korea: a nationwide cohort study, Br J Sports Med,
doi:10.1136/bjsports-2021-104203Mansournia, Etminan, Danaei, Handling time varying confounding in observational research, BMJ,
doi:10.1136/bmj.j4587Nextstrain, Genomic epidemiology of novel coronavirus -Global subsampling
Patel, Nossel, Patricios, Bright spots, physical activity investments that work: vitality active Rewards-a smartphone APP that incentivises programme members to be physically active, Br J Sports Med,
doi:10.1136/bjsports-2018-099271Sallis, Young, Tartof, Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients, Br J Sports Med,
doi:10.1136/bjsports-2021-104080Simpson, Hussain, Baker, Cardiorespiratory fitness is associated with better control of latent herpesvirus infections in a large ethnically diverse community sample: evidence from the Texas City stress and health study, Brain Behav Immun,
doi:10.1016/j.bbi.2017.07.128Simpson, Kunz, Agha, Exercise and the regulation of immune functions
Stalsberg, Pedersen, Are differences in physical activity across socioeconomic groups associated with choice of physical activity variables to report?, Int J Environ Res Public Health,
doi:10.3390/ijerph15050922Steenkamp, None, Br J Med
Tavakol, Ghannadi, Tabesh, Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study, Z Gesundh Wiss,
doi:10.1007/s10389-020-01468-9Tison, Avram, Kuhar, Worldwide effect of COVID-19 on physical activity: a descriptive study, Ann Intern Med,
doi:10.7326/M20-2665Zbinden-Foncea, Francaux, Deldicque, Does high cardiorespiratory fitness confer some protection against proinflammatory responses after infection by SARS-CoV-2?, Obesity,
doi:10.1002/oby.22849DOI record:
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