# Exercise as it relates to Disease/Association of physical activity levels and the prevalence of COVID-19 associated hospitalization

The following critique article is from the research article “ Association of physical activity levels and the prevalence of COVID-19 – associated hospitalisation” by Francis Ribeiro de Souza, Daisy Motta-Santos, Douglas dos Santos Soares, Juliana Beust de Lima, Gustavo Goncalves Cardozo, Luciano Santos Pinto Guimaraes, Carlos Eduardo Negrao, Marcelo Rodrigues dos Santos.

## What is the Background to this research?

Recently, the world is facing an unprecedented pandemic, the new serve acute respiratory syndrome coronavirus (SARS-CoV-2). As the virus spread around the world quickly, it strongly impacted the general population’s daily activities, the prevalence of hospitalization and the burden on public health in Brazil. Till April 2021, there are over 378000 deaths caused by COVID-19 in Brazil. The WHO & government have already promoted and published distinct rules to minimize the spread of the virus, such as self-isolation, social distancing, wearing masks, etc. They are all potential strategies for preventing the disease. Nevertheless, to improve and strengthen the immune system response, exercise training could be an auxiliary tool and strategy against infection. Specifically, it is significant to reduce the number of hospitalizations and advocate faster recovery for the infected patients. This study aimed to assess the link between physical activity and the prevalence of COVID-19 related to hospitalization.

## Where is the research from?

This original research being critiques was published in the journal of Science and Medicine in Sport (JSAMS). The journal is an official journal of Sports Medication Australia (SMA) where covers worldwide aspects of sports science and medicine. Also, it encompassed the publication original research and review papers in relation to the sports science field and public health. With a total of eight authors contributed to this research article whom from Brazil and all of them have their particular professionals in the sports and medicine field. The author’s team declared that there is no conflict of interest.

## What kind of research was this?

This study was a cross-sectional and observational study followed by the STROBE statement checklist. The cross-sectional often used to measure the prevalence of disease, comprehend the determinants of health and attributes of a population. In particular, it was registered on ClincialTrails.gov and acknowledged by the local Human Subject Protection Committee in the Hospital das Clinicas da Faculadade de Medicina da Universida de de Sao Paulo in Brazil. To ensure participants are willing to engage and valid studies, online written informed consent is provided. Therefore, it allows the team to assess and compare different variables from the population of COVID-19 survivors in Brazil.

## What did the research involved?

In this research article, it invited the patient who survived and fully recovered from the SARS-CoV-2 between March and August 2020 in Brazil. During this time period, they designed and conducted online questionnaire for their target population via social media, newscasts, hospitals, medical care providers and disease control centres across the country.
Prior to commencing the first analysis, written consent was obtained and collected with a total of 1597 completed questionnaires. Upon on that, it included the short version of the International Physical Activity Questionnaire. The study separated into two different parts of analysis:
| | First Analysis | Second Analysis |
| Methods | Online questionnaire | Short version of the International Physical Activity Questionnaire (IPAQ) |
| Variables | Clinical outcomes: Symptoms Medications Hospitalisation Length of Hospital Stay Mechanical Ventilation Factors: Age Gender Ethnicity Pre-existing diseases Socioeconomic Educational status | Identify self-report Participant's Physical Activity levels: Athlete, Physical Active or Sedentary Behaviour Sufficient Physical Activity (≥150 min per week of Moderate PA/ ≥75 Vigorous PA) Insufficient Physical Activity (Sedentary Behaviours) |
| Number of Participants | 1200 participants were selected (quality data response) for the second analysis | 938 out of 1200 participants were selected for the final analysis |
After collecting all the qualitative data , there are some sample calculations and tools included for the final analysis.
* G*Power software
* SPSSv.25 software
* Chi-square test
* Winpepi v.11.65 software
* Poisson regression model (prevalence ratio)
The methodology was an accessible that well utilising the internet service and collect data from a big population (research target). Also, it reduced the face to face interview time which is quite valid, faster and cheaper approach to accomplish the analysis. Hence, it facilitated the team to interpret the relationship between PA levels and hospitalisation prevalence.

## What were the basic result?

In the result, 938 participants were selected for the final analysis, but there are only 91 were admitted to the hospital due to COVID-19.To identify the higher prevalence of hospitalization, they mainly relied on four main variables including gender, age, BMI, pre-existing disease and medication.The following tables demonstrated the result of sufficient PA having a LOWER prevalence ratio (PR):

#### Table 1: Factors led Higher Prevalence Ratio (PR)

| Variables | Result (univariate analysis) |
| Gender | Male (p=0.010) |
| Age | >65 years old (p < 0.001) |
| BMI | Obesity I (p =0.001) |
| Pre-existing disease and medication | With disease(p= 0.002) With medication (p < 0.001) |
| Number of symptoms | 3 or more symptoms (p < 0.001) |

#### Table 2: Compare the Insufficient and Sufficient physical activity

| | Mean | Median | PR |
| Insufficient PA | 62.3 ±86 min/week | 25.0 min/week | =0.624 |
| Sufficient PA (PA > 150 min/wk-moderate/ 75 min/wk- vigorous) | 726.9 ±426.7 min/week | 640.0 min/week | =1 (LOWER prevalence) |

#### Table 3: Prevalence Ratio of factors from primary outcome, Multivariate Regression Model

| | Model 1 (age, gender) | Model 2(age, sex, BMI) | Model 3 (age, sex, pre-existing disease) |
| Sufficient PA (150 min/wk moderate or 75 min/wk vigorous) | 0.602 | 0.642 | 0.657 (34.3% Lower prevalence) |

## What conclusions can we take from this research?

In conclusion, the authors found sufficient physical activity (PA) is significant that it could demonstrate a lower prevalence of COVID-19-related hospitalization. In general, WHO recommended individuals should be doing more exercise, as PA has crucial benefits to our hearts, minds and bodies. Also, it improves our overall health and well-being. Individuals who do little or no PA are easy to suffer or diagnose with severe COVID-19, compare with those who are physically active. Within the same year, similar findings can also be found in a study, increasing the PA levels and maintaining a healthy lifestyle could reduce the severity of COVID-19 disease. Although it is not directly related to the hospitalization prevalence, it demonstrated adequate PA benefits to the individuals’ health and well-being, especially to the global disease COVID-19. Overall, governments should encourage and promote more physical exercise to the population, so that it could prevent complications from COVID-19 and burden on the public health system.

## Practical Advice

The study did not provide a complete exercise plan for people to follow, but it mentioned at least 150 min per week of moderate-intensity or 75 min a week of vigorous-intensity as a recommendation. For people who are physically inactive/ sedentary, it is quite challenging and struggling with moderate intensity of exercise. Hence, they have to foster an interest in exercise. Home-based exercise intervention will be the best option , such as yoga workouts which could easily find on the internet, individuals could follow the instructions at home. It benefits for them to stretch their body and avoids injuries after being inactive for a long time. Resistance training and HIIT are also encouraged for the populations to engage, as they could facilitate with better immune system and strength the cardiorespiratory fitness level. However, it is strongly recommended individuals to select an accredited gym coach as the instructor. Apart from the exercise practical advice, it is significant to adhere the COVID-19 rules and restrictions, maintain good respiratory hygiene, so that it could minimize the risk of having COVID-19.

## Further Information

Readings:
* Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study
* Influence of Baseline Physical Activity as a Modifying Factor on COVID-19 Mortality: A Single-Center, Retrospective Study
* Fidelity, tolerability and safety of acute high-intensity interval training after hospitalisation for COVID-19: a randomised cross-over trial
* https://www.who.int/health-topics/coronavirus#tab=tab_1 (Details of COVID -19 from WHO)

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 De Souza, F. R., Motta-Santos, D., Dos Santos Soares, D., De Lima, J. B., Cardozo, G. G., Guimarães, L. S., Negrão, C. E., & Dos Santos, M. R. (2021). Association of physical activity levels and the prevalence of COVID-19-associated hospitalization. Journal of Science and Medicine in Sport, 24(9), 913-918. https://doi.org/10.1016/j.jsams.2021.05.011
* ↑ Da Silveira, M. P., Da Silva Fagundes, K. K., Bizuti, M. R., Starck, É., Rossi, R. C., & De Resende e Silva, D. T. (2020). Physical exercise as a tool to help the immune system against COVID-19: An integrative review of the current literature. Clinical and Experimental Medicine, 21(1), 15-28. https://doi.org/10.1007/s10238-020-00650-3
* ↑ https://www.jsams.org/content/aims
* ↑ Vandenbroucke, J. P., Von Elm, E., Altman, D. G., Gøtzsche, P. C., Mulrow, C. D., Pocock, S. J., Poole, C., Schlesselman, J. J., & Egger, M. (2007). Strengthening the reporting of observational studies in epidemiology (STROBE). Epidemiology, 18(6), 805-835. https://doi.org/10.1097/ede.0b013e3181577511
* ↑ Wang. X. F., Cheng. Z. S (2020). Cross-Sectional Studies: Strengths, Weakness and Recommendations. CHEST, 158(1), s65-s71. https://doi.org/10.1016/j.chest.2020.03.012
* ↑ World Health Organisation. (2020, November 26). Physical activity. WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/physical-activity
* ↑ Tavakol, Z., Ghannadi, S., Tabesh, M. R., Halabchi, F., Noormohammadpour, P., Akbarpour, S., Alizadeh, Z., Nezhad, M. H., & Reyhan, S. K. (2021). Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study. Journal of Public Health. https://doi.org/10.1007/s10389-020-01468-9
* ↑ Borges, L., Moraes, M. M., Arantes, R. M., & Hatanaka, E. (2021). The COVID-19 pandemic: Impact and strategies for sports and exercise medicine researchers during large-scale social restrictions. Journal of Medical Systems, 45(5). https://doi.org/10.1007/s10916-021-01734-7
* ↑ Rasmussen, I. E., Foged, F., Bjørn Budde, J., Rasmussen, R. S., Rasmussen, V., Lyngbæk, M., Jønck, S., Krogh-Madsen, R., Lindegaard, B., Ried-Larsen, M., Jørgensen, P. G., Lund, M. A., Køber, L., Vejlstrup, N., Pedersen, B. K., Berg, R. M., & Christensen, R. H. (2021). Protective potential of high-intensity interval training on cardiac structure and function after COVID-19: Protocol and statistical analysis plan for an investigator-blinded randomised controlled trial. BMJ Open, 11(11), e048281. https://doi.org/10.1136/bmjopen-2020-048281