Keywords
Exercise, COVID-19, SARS-CoV-2, Systematic Review, Meta-Analysis
Abstract
Objective: Nowadays, the COVID-19 pandemic has caused serious consequences for global health and economy. The important question is whether the level of physical activity might influence the risk of COVID-19 incidence or clinical outcomes, including the severity or mortality of infected patients. The objective of this systematic review and meta-analysis is to evaluate the association between sufficient physical activity and incidence, hospitalization, severity, recovery, and mortality of COVID-19.
Methods: A systematic search of Web of Sciences, PubMed, and Scopus between December 2019 and November 2021 in English language was conducted. Studies were screened based on the inclusion criteria, i.e. observational studies (case-control, prospective or retrospective longitudinal designs, and cross-sectional studies) which have determined the association of physical activity, exercise, sports participation, or sedentary behavior with COVID-19 incidence or outcomes, including mortality, severity, recovery and hospitalization in healthy population or population with any specific comorbidity.
Results: Based on eligibility criteria, 27 articles were finally included in the qualitative synthesis. The meta-analysis of five studies evaluating association of physical activity and COVID-19 mortality showed weighted OR of OR of 0.61 (CI 95%: 0.50- 0.75) with heterogeneity (I2= 45.8%, P<0.001) and in seven studies regarding physical activity and COVID-19 hospitalization, weighted OR was 0.541 (CI 95% :0.491 -0.595) with heterogeneity (I2=81.7%, P<0.001).
Conclusion: Participating in sufficient physical activity might decrease COVID-19 related hospitalization and mortality. Developing programs to increase physical activity during the COVID-19 pandemic might be an appropriate health strategy.
References
[1] Stockwell S, Trott M, Tully M, Shin J, Barnett Y, Butler L, McDermott D, Schuch F, Smith L. Changes in physical activity and sedentary behaviours from before to during the COVID-19 pandemic lockdown: a systematic review. BMJ Open Sport & Exercise Medicine 2021;7(1):e000960.
[2] Mattioli AV, Ballerini Puviani M, Nasi M, Farinetti A. COVID-19 pandemic: the effects of quarantine on cardiovascular risk. Eur J Clin Nutr 2020;74(6):852-5.
[3] Reiner M, Niermann C, Jekauc D, Woll A. Long-term health benefits of physical activity–a systematic review of longitudinal studies. BMC public health. 2013;13(1):1-9.
[4] Zbinden‐Foncea H, Francaux M, Deldicque L, Hawley JA. Does high cardiorespiratory fitness confer some protection against proinflammatory responses after infection by SARS‐CoV‐2? Obesity 2020;28(8):1378-81.
[5] da Silveira MP, da Silva Fagundes KK, Bizuti MR, Starck É, Rossi RC, e Silva DTdR. Physical exercise as a tool to help the immune system against COVID-19: an integrative review of the current literature. Clin Exp Med 2021;21(1):15-28.
[6] Halabchi F, Ahmadinejad Z, Selk-Ghaffari M. COVID-19 epidemic: exercise or not to exercise; that is the question. Asian J Sports Med. 2020;11(1):e102630.
[7] Sallis R, Young DR, Tartof SY, Sallis JF, Sall J, Li Q, Smith GN, Cohen DA. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: A study in 48 440 adult patients. Br J Sports Med 2021;55(19):1099-1105.
[8] Halabchi F, Mazaheri R, Sabeti K, Yunesian M, Alizadeh Z, Ahmadinejad Z, Aghili SM, Tavakol Z. Regular Sports Participation as a Potential Predictor of Better Clinical Outcome in Adult Patients With COVID-19: A Large Cross-Sectional Study. J Phys Act Health 2020;18(1):8-12.
[9] Tavakol Z, Ghannadi S, Tabesh MR, Halabchi F, Noormohammadpour P, Akbarpour S, Alizadeh Z, Nezhad MH, Reyhan SK. Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study. Journal of Public Health (Z Gesundh Wiss) 2021;1-9.
[10] Memari A-H, Selk-Ghaffari M, Khosravi A, Kordi R. Action plan to increase physical activity during COVID-19 pandemic. Sultan Qaboos Univ Med J 2021. PMID: 34888068
[11] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097.
[12] Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis 12.P, Lisy K, Mu P-F. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017. Available from https://reviewersmanual.joannabriggs.org/
[13] Ahmadi MN, Huang BH, Inan-Eroglu E, Hamer M, Stamatakis E. Lifestyle risk factors and infectious disease mortality, including COVID-19, among middle aged and older adults: Evidence from a community-based cohort study in the United Kingdom. Brain Behav Immun 2021;96:18-27.
[14] Boukelia B, Alataibi AS. The effect of bmi and physical activity levels on the duration of symptomatic days with covid-19 infection. medRxiv [Preprint] 2020.08.21.20179499[cited 2021 Dec 19] doi: https://doi.org/10.1101/2020.08.21.20179499
[15] Bielik V, Grendar M, Kolisek M. A Possible Preventive Role of Physically Active Lifestyle during the SARS-CoV-2 Pandemic; Might Regular Cold-Water Swimming and Exercise Reduce the Symptom Severity of COVID-19? Int J Environ Res Public Health 2021;18(13).
[16] Cho D-H, Lee SJ, Jae SY, Kim WJ, Ha SJ, Gwon JG, Choi J, Kim DW, Kim JY. Physical Activity and the Risk of COVID-19 Infection and Mortality: A Nationwide Population-Based Case-Control Study. J Clin Med 2021;10(7):1539.
[17] Cunningham GB. Physical activity and its relationship with COVID-19 cases and deaths: Analysis of US counties. J Sport Health Sci 2021; 10(5)
:570-576.
[18] de Souza FR, Motta-Santos D, dos Santos Soares D, de Lima JB, Cardozo GG, Guimarães LSP, Negrão CE, Dos Santos MR. Association of physical activity levels and the prevalence of COVID-19-associated hospitalization. J Sci Med Sport 2021;24(9): 913-918
[19] Gao C, Zhao Z, Li F, Liu JL, Xu H, Zeng Y, et al. The impact of individual lifestyle and status on the acquisition of COVID-19: A case-Control study. PloS one 2020;15(11):e0241540.
[20] Hamer M, Kivimäki M, Gale CR, Batty GD. Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain Behav Immun 2020;87:184-7.
[21] Hamrouni M, Roberts MJ, Thackray A, Stensel DJ, Bishop N. Associations of obesity, physical activity level, inflammation and cardiometabolic health with COVID-19 mortality: a prospective analysis of the UK Biobank cohort. BMJ open 2021;11(11):e055003.
[22] Huang B, Zhang S, Gong J, Niu Y, Zhang F, Jiang L, Wang M, Cui J, Li W, Jin C, Bao P. Impact of physical activity and lifestyle in pre-infection on the susceptibility and prognosis of infects with COVID-19. RESEARCH SQUARE [Preprint].23 Jul, 2020 [cited 2021 Dec 19] DOI: 10.21203/rs.3.rs-46730/v1
[23] Latorre-Román PÁ, Guzmán-Guzmán IP, Delgado-Floody P, Herrador Sanchez J, Aragón-Vela J, García Pinillos F, Párraga Montilla JA. Protective role of physical activity patterns prior to COVID-19 confinement with the severity/duration of respiratory pathologies consistent with COVID-19 symptoms in Spanish populations. Res Sports Med 2021:1-12.
[24] Lee SW, Lee J, Moon SY, Jin HY, Yang JM, Ogino S, Song M, Hong SH, Abou Ghayda R, Kronbichler A, Koyanagi A. 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 [published online ahead of print, 2021 Jul 22]. Br J Sports Med. 2021;bjsports-2021-104203. doi:10.1136/bjsports-2021-104203
[25] Li S, Hua X. Modifiable lifestyle factors and severe COVID-19 risk: a Mendelian randomisation study. BMC Med Genomics 2021;14(1):38.
[26] Lobelo F, Bienvenida A, Leung S, Mbanya A, Leslie E, Koplan K, Shin SR. Clinical, behavioural and social factors associated with racial disparities in COVID-19 patients from an integrated healthcare system in Georgia: a retrospective cohort study. BMJ open 2021;11(5):e044052.
[27] Marcus GM, Olgin JE, Peyser ND, Vittinghoff E, Yang V, Joyce S, Avram R, Tison GH, Wen D, Butcher X, Eitel H. Predictors of incident viral symptoms ascertained in the era of COVID-19. PloS one 2021;16(6):e0253120.
[28] Nguyen MH, Pham TTM, Vu DN, Do BN, Nguyen HC, Duong TH, Pham KM, Pham LV, Nguyen TT, Tran CQ, Nguyen QH. Single and Combinative Impacts of Healthy Eating Behavior and Physical Activity on COVID-19-like Symptoms among Outpatients: A Multi-Hospital and Health Center Survey. Nutrients 2021;13(9).
[29] Okeahalam C, Williams V, Otwombe K. Factors associated with COVID-19 infections and mortality in Africa: a cross-sectional study using publicly available data. BMJ open 2020;10(11):e042750.
[30] Pinto AJ, Goessler KF, Fernandes AL, Murai IH, Sales LP, Reis BZ, Santos MD, Roschel H, Pereira RM, Gualano B. No associations between physical activity and clinical outcomes among hospitalized patients with severe COVID-19. medRxiv [Preprint]. November 30, 2020. [cited 2021 Dec 19] doi: https://doi.org/10.1101/2020.11.25.20237925
[31] Pitanga FJG, Beck CC, Pitanga CPS, Pinho CS, Cortez ACL, Guedes DP, Matsudo, V K R. Association between leisure time physical activity and mortality by C0VID-19 in the Brazilian capitals: an ecological analysis. SCIELO.1912 [Preprint].1 March, 2021 [cited 2021 Dec 19] https://doi.org/10.1590/SciELOPreprints.1912
[32] Rowlands AV, Kloecker DE, Chudasama Y, Davies MJ, Dawkins NP, Edwardson CL, Gillies C, Khunti K, Razieh C, Islam N, Zaccardi F. Association of timing and balance of physical activity and rest/sleep with risk of COVID-19: a UK Biobank Study. Mayo Clin Proc 2021;26(1): 156-164.
[33] Salgado-Aranda R, Perez-Castellano N, Nunez-Gil I, Orozco AJ, Torres-Esquivel N, Flores-Soler J, et al. Influence of Baseline Physical Activity as a Modifying Factor on COVID-19 Mortality: A Single-Center, Retrospective Study. Infect Dis Ther 2021;10(2):801-14.
[34] Wang J, Sato T, Sakuraba A. Worldwide association of lifestyle-related factors and COVID-19 mortality. Ann Med 2021;53(1):1528-33.
[35] Webber BJ, Lang MA, Stuever DM, Escobar JD, Bylsma VFH, Wolff GG. Health-Related Behaviors and Odds of COVID-19 Hospitalization in a Military Population. Prev Chronic Dis 2021;18:E96.
[36] Zhang XM, Li X, Sun ZW, He YZ, Xu W, Campbell H, Dunlop MG, Timofeeva M, Theodoratou E. Physical activity and COVID-19: an observational and Mendelian randomisation study. J Glob Health 2020;10(2).
[37] Song Y, Ren F, Sun D, Wang M, Baker JS, István B, Gu Y
. Benefits of exercise on influenza or pneumonia in older adults: a systematic review. Int J Environ Res Public Health 2020;17(8):2655.
[38] Laddu DR, Lavie CJ, Phillips SA, Arena R. Physical activity for immunity protection: Inoculating populations with healthy living medicine in preparation for the next pandemic. Prog Cardiovasc Dis 2021;64:102-4.
[39] Mohamed AA, Alawna M. Role of increasing the aerobic capacity on improving the function of immune and respiratory systems in patients with coronavirus (COVID-19): A review. Diabetes Metab Syndr 2020;14(4):489-96.
[40] Lancaster GI, Febbraio MA. The immunomodulating role of exercise in metabolic disease. Trends Immunol 2014;35(6):262-9.
[41] Pedersen BK, Febbraio MA. Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol Rev 2008;88(4):1379-406.
[42] Zadow EK, Wundersitz DWT, Hughes DL, Adams MJ, Kingsley MIC, Blacklock HA, et al. Coronavirus (COVID-19), Coagulation, and Exercise: Interactions That May Influence Health Outcomes. Semin Thromb Hemos 2020;46(7):807-14.
[2] Mattioli AV, Ballerini Puviani M, Nasi M, Farinetti A. COVID-19 pandemic: the effects of quarantine on cardiovascular risk. Eur J Clin Nutr 2020;74(6):852-5.
[3] Reiner M, Niermann C, Jekauc D, Woll A. Long-term health benefits of physical activity–a systematic review of longitudinal studies. BMC public health. 2013;13(1):1-9.
[4] Zbinden‐Foncea H, Francaux M, Deldicque L, Hawley JA. Does high cardiorespiratory fitness confer some protection against proinflammatory responses after infection by SARS‐CoV‐2? Obesity 2020;28(8):1378-81.
[5] da Silveira MP, da Silva Fagundes KK, Bizuti MR, Starck É, Rossi RC, e Silva DTdR. Physical exercise as a tool to help the immune system against COVID-19: an integrative review of the current literature. Clin Exp Med 2021;21(1):15-28.
[6] Halabchi F, Ahmadinejad Z, Selk-Ghaffari M. COVID-19 epidemic: exercise or not to exercise; that is the question. Asian J Sports Med. 2020;11(1):e102630.
[7] Sallis R, Young DR, Tartof SY, Sallis JF, Sall J, Li Q, Smith GN, Cohen DA. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: A study in 48 440 adult patients. Br J Sports Med 2021;55(19):1099-1105.
[8] Halabchi F, Mazaheri R, Sabeti K, Yunesian M, Alizadeh Z, Ahmadinejad Z, Aghili SM, Tavakol Z. Regular Sports Participation as a Potential Predictor of Better Clinical Outcome in Adult Patients With COVID-19: A Large Cross-Sectional Study. J Phys Act Health 2020;18(1):8-12.
[9] Tavakol Z, Ghannadi S, Tabesh MR, Halabchi F, Noormohammadpour P, Akbarpour S, Alizadeh Z, Nezhad MH, Reyhan SK. Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study. Journal of Public Health (Z Gesundh Wiss) 2021;1-9.
[10] Memari A-H, Selk-Ghaffari M, Khosravi A, Kordi R. Action plan to increase physical activity during COVID-19 pandemic. Sultan Qaboos Univ Med J 2021. PMID: 34888068
[11] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6(7):e1000097.
[12] Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis 12.P, Lisy K, Mu P-F. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017. Available from https://reviewersmanual.joannabriggs.org/
[13] Ahmadi MN, Huang BH, Inan-Eroglu E, Hamer M, Stamatakis E. Lifestyle risk factors and infectious disease mortality, including COVID-19, among middle aged and older adults: Evidence from a community-based cohort study in the United Kingdom. Brain Behav Immun 2021;96:18-27.
[14] Boukelia B, Alataibi AS. The effect of bmi and physical activity levels on the duration of symptomatic days with covid-19 infection. medRxiv [Preprint] 2020.08.21.20179499[cited 2021 Dec 19] doi: https://doi.org/10.1101/2020.08.21.20179499
[15] Bielik V, Grendar M, Kolisek M. A Possible Preventive Role of Physically Active Lifestyle during the SARS-CoV-2 Pandemic; Might Regular Cold-Water Swimming and Exercise Reduce the Symptom Severity of COVID-19? Int J Environ Res Public Health 2021;18(13).
[16] Cho D-H, Lee SJ, Jae SY, Kim WJ, Ha SJ, Gwon JG, Choi J, Kim DW, Kim JY. Physical Activity and the Risk of COVID-19 Infection and Mortality: A Nationwide Population-Based Case-Control Study. J Clin Med 2021;10(7):1539.
[17] Cunningham GB. Physical activity and its relationship with COVID-19 cases and deaths: Analysis of US counties. J Sport Health Sci 2021; 10(5)
:570-576.
[18] de Souza FR, Motta-Santos D, dos Santos Soares D, de Lima JB, Cardozo GG, Guimarães LSP, Negrão CE, Dos Santos MR. Association of physical activity levels and the prevalence of COVID-19-associated hospitalization. J Sci Med Sport 2021;24(9): 913-918
[19] Gao C, Zhao Z, Li F, Liu JL, Xu H, Zeng Y, et al. The impact of individual lifestyle and status on the acquisition of COVID-19: A case-Control study. PloS one 2020;15(11):e0241540.
[20] Hamer M, Kivimäki M, Gale CR, Batty GD. Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain Behav Immun 2020;87:184-7.
[21] Hamrouni M, Roberts MJ, Thackray A, Stensel DJ, Bishop N. Associations of obesity, physical activity level, inflammation and cardiometabolic health with COVID-19 mortality: a prospective analysis of the UK Biobank cohort. BMJ open 2021;11(11):e055003.
[22] Huang B, Zhang S, Gong J, Niu Y, Zhang F, Jiang L, Wang M, Cui J, Li W, Jin C, Bao P. Impact of physical activity and lifestyle in pre-infection on the susceptibility and prognosis of infects with COVID-19. RESEARCH SQUARE [Preprint].23 Jul, 2020 [cited 2021 Dec 19] DOI: 10.21203/rs.3.rs-46730/v1
[23] Latorre-Román PÁ, Guzmán-Guzmán IP, Delgado-Floody P, Herrador Sanchez J, Aragón-Vela J, García Pinillos F, Párraga Montilla JA. Protective role of physical activity patterns prior to COVID-19 confinement with the severity/duration of respiratory pathologies consistent with COVID-19 symptoms in Spanish populations. Res Sports Med 2021:1-12.
[24] Lee SW, Lee J, Moon SY, Jin HY, Yang JM, Ogino S, Song M, Hong SH, Abou Ghayda R, Kronbichler A, Koyanagi A. 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 [published online ahead of print, 2021 Jul 22]. Br J Sports Med. 2021;bjsports-2021-104203. doi:10.1136/bjsports-2021-104203
[25] Li S, Hua X. Modifiable lifestyle factors and severe COVID-19 risk: a Mendelian randomisation study. BMC Med Genomics 2021;14(1):38.
[26] Lobelo F, Bienvenida A, Leung S, Mbanya A, Leslie E, Koplan K, Shin SR. Clinical, behavioural and social factors associated with racial disparities in COVID-19 patients from an integrated healthcare system in Georgia: a retrospective cohort study. BMJ open 2021;11(5):e044052.
[27] Marcus GM, Olgin JE, Peyser ND, Vittinghoff E, Yang V, Joyce S, Avram R, Tison GH, Wen D, Butcher X, Eitel H. Predictors of incident viral symptoms ascertained in the era of COVID-19. PloS one 2021;16(6):e0253120.
[28] Nguyen MH, Pham TTM, Vu DN, Do BN, Nguyen HC, Duong TH, Pham KM, Pham LV, Nguyen TT, Tran CQ, Nguyen QH. Single and Combinative Impacts of Healthy Eating Behavior and Physical Activity on COVID-19-like Symptoms among Outpatients: A Multi-Hospital and Health Center Survey. Nutrients 2021;13(9).
[29] Okeahalam C, Williams V, Otwombe K. Factors associated with COVID-19 infections and mortality in Africa: a cross-sectional study using publicly available data. BMJ open 2020;10(11):e042750.
[30] Pinto AJ, Goessler KF, Fernandes AL, Murai IH, Sales LP, Reis BZ, Santos MD, Roschel H, Pereira RM, Gualano B. No associations between physical activity and clinical outcomes among hospitalized patients with severe COVID-19. medRxiv [Preprint]. November 30, 2020. [cited 2021 Dec 19] doi: https://doi.org/10.1101/2020.11.25.20237925
[31] Pitanga FJG, Beck CC, Pitanga CPS, Pinho CS, Cortez ACL, Guedes DP, Matsudo, V K R. Association between leisure time physical activity and mortality by C0VID-19 in the Brazilian capitals: an ecological analysis. SCIELO.1912 [Preprint].1 March, 2021 [cited 2021 Dec 19] https://doi.org/10.1590/SciELOPreprints.1912
[32] Rowlands AV, Kloecker DE, Chudasama Y, Davies MJ, Dawkins NP, Edwardson CL, Gillies C, Khunti K, Razieh C, Islam N, Zaccardi F. Association of timing and balance of physical activity and rest/sleep with risk of COVID-19: a UK Biobank Study. Mayo Clin Proc 2021;26(1): 156-164.
[33] Salgado-Aranda R, Perez-Castellano N, Nunez-Gil I, Orozco AJ, Torres-Esquivel N, Flores-Soler J, et al. Influence of Baseline Physical Activity as a Modifying Factor on COVID-19 Mortality: A Single-Center, Retrospective Study. Infect Dis Ther 2021;10(2):801-14.
[34] Wang J, Sato T, Sakuraba A. Worldwide association of lifestyle-related factors and COVID-19 mortality. Ann Med 2021;53(1):1528-33.
[35] Webber BJ, Lang MA, Stuever DM, Escobar JD, Bylsma VFH, Wolff GG. Health-Related Behaviors and Odds of COVID-19 Hospitalization in a Military Population. Prev Chronic Dis 2021;18:E96.
[36] Zhang XM, Li X, Sun ZW, He YZ, Xu W, Campbell H, Dunlop MG, Timofeeva M, Theodoratou E. Physical activity and COVID-19: an observational and Mendelian randomisation study. J Glob Health 2020;10(2).
[37] Song Y, Ren F, Sun D, Wang M, Baker JS, István B, Gu Y
. Benefits of exercise on influenza or pneumonia in older adults: a systematic review. Int J Environ Res Public Health 2020;17(8):2655.
[38] Laddu DR, Lavie CJ, Phillips SA, Arena R. Physical activity for immunity protection: Inoculating populations with healthy living medicine in preparation for the next pandemic. Prog Cardiovasc Dis 2021;64:102-4.
[39] Mohamed AA, Alawna M. Role of increasing the aerobic capacity on improving the function of immune and respiratory systems in patients with coronavirus (COVID-19): A review. Diabetes Metab Syndr 2020;14(4):489-96.
[40] Lancaster GI, Febbraio MA. The immunomodulating role of exercise in metabolic disease. Trends Immunol 2014;35(6):262-9.
[41] Pedersen BK, Febbraio MA. Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol Rev 2008;88(4):1379-406.
[42] Zadow EK, Wundersitz DWT, Hughes DL, Adams MJ, Kingsley MIC, Blacklock HA, et al. Coronavirus (COVID-19), Coagulation, and Exercise: Interactions That May Influence Health Outcomes. Semin Thromb Hemos 2020;46(7):807-14.