Review Article | Iran J Med Microbiol. 2022; 16(3): 178-185
1.

10.30699/ijmm.16.3.178

Iranian Journal of Medical Microbiology | ISSN:2345-4342

Protective Roles of Exercise and Nutritional Factors for Immune System
During Delta Variant-COVID-19 Outbreaks: Evidence Review and Practical
Recommendations
Behzad Taati1

1.
2.
3.
4.
5.
6.
7.

, Seyed Mojtaba Paydar Ardakani2 , Katsuhiko Suzuki3 , Masoumeh Sadat Modaresi4
Majid Taati Moghadam5,6* , Behnam Roozbeh7,

Department of Exercise Physiology, Faculty of Sports Sciences, University of Guilan, Rasht, Iran
Department of Sport Sciences, Ardakan University, Ardakan, Iran
Faculty of Sport Sciences, Waseda Institute of Sports Nutrition, Waseda University, Tokorozawa, Saitama 359-1192, Japan
Department of Exercise Physiology, Ferdowsi University of Mashhad, Mashhad, Iran
Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, IranStudent Research Committee, Iran University of Medical Sciences, Tehran, Iran
Department of sport sciences, Hakim Toos Higher Education Institute, Mashhad, Iran

ABSTRACTThe coronavirus disease 2019 (COVID-19) is a deadly viral infection causing death due to impaired immunity. Therefore, aninvestigation of factors affecting the immune system should be considered. It is well documented that regular sessions ofmoderate-intensity exercise training with up to 1-hour duration boost the immune functions through anti-inflammatory andantioxidant effects. Besides, a diet containing functional and nutritious foods is also needed to aid the immune system.
Herein, we have summarized available data on how exercise and nutritional factors help promote immunity against various
infections. More importantly, this review provides practical and valuable guidance for sedentary adult people and nonprofessional athletes on how to do aerobic and resistance training and stretching exercises at home with no special typesof equipment required during the outbreaks of delta variant-COVID-19. Some significant exercise-related nutritional
considerations regarding carbohydrates, fibers, vitamins, zinc, and omega-3 fatty acids were also supplied that help tocreate better adaptations and improve immune responses.
Keywords: COVID-19 quarantine, Home-based exercise training, Non-functional foods, Pandemic, Professional athletes,
Sedentary people
Received: 2021/08/24;
Corresponding Information:

Accepted: 2022/01/07;

Published Online: 2022/03/20

Majid Taati Moghadam, Department of Microbiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, IranEmail: taatimoghadam.m@tak.iums.ac.ir , Majidtaati1367@yahoo.com

Copyright © 2021, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License which
permits copy and redistribution of the material just in noncommercial usages with proper citation.

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Taati B, Paydar Ardakani S M, Suzuki K, Sadat Modaresi M, Taati Moghadam M, Roozbeh B. Protective
Roles of Exercise and Nutritional Factors for Immune System During Delta Variant-COVID-19
Outbreaks: Evidence Review and Practical Recommendations. Iran J Med Microbiol. 2022; 16 (3) :178185
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1 Introduction
Coronavirus disease 2019 (COVID-19) is a respiretory disease that has created a deadly pandemic that
rapidly spreads worldwide. To date, the virus has
infected 191,000,000 people, including more than
4,100,000 deaths, according to the World HealthOrganization (WHO) (1, 2). Information on the COVID19 can be found on various websites. The WHO
website shows daily reports in all parts of the world.

Year 16, Issue 3 (May-June 2022)

Reports indicate that some countries have reduced
the number of people infected with the virus, butmany other countries create new cases at alarming
rates. Recently, the emergence of different variants
with mutations in COVID-19, especially the deltavariant, is the issue that has multiplied concerns. The
delta variant has affected many countries due to its
rapid transition. It is reportedly increasing in Iraq,

Iranian Journal of Medical Microbiology

Behzad Taati et al., 179
South Korea, Iran, Pakistan, Kazakhstan, Bangladesh,
Japan, Myanmar, Vietnam, Thailand, and Malaysia (3).
Research has shown that most people who gave up
their lives fighting against COVID-19 had underlying
diseases and low immune functions. The findings ofvarious studies have also confirmed that many people
with sufficient immune functions can be infected withviruses without any symptoms (4). Therefore, it has
been suggested that one of the ways to deal with
COVID-19 is to build up the immune system function
and strengthen the body because the immune systeminability causes the defeat of suffering people against
the terrible virus (5-7). Thus, the generalization of allrecommendations by the WHO and various researchers in the field of COVID-19 can be helpful for new
variants of the virus. However, self-isolation andstaying at home during the pandemic may induce
various negative characteristics of sedentary behaveiors, such as decreased physical fitness and immune
functions (6, 8). The present article focuses onpractical exercise training approaches and nutritional
items for sedentary people across the delta variant of
COVID-19 outbreaks.
2. Distinction of Delta Variant of COVID-19
During the SARS-CoV-2 pandemic, mutations of thevirus led to the development of different variants,
including alpha (B.1.1.7), beta (B.1.351), gamma(B.1.1.28.1), and delta (B.1.617.2), which constitute asignificant threat to public health because of theirpotential escape from the immune system and greatertransmissibility (9). The delta variant of COVID-19 was
first identified in India, more prevalent than the alphavariant. The delta variant is more frightening becauseof the increased risk of hospitalization and higher
transfer rates (e.g., 60% faster than the alpha type)and requires more oxygen. It is important to note thatamong patients with delta variant, the number ofpeople hospitalized who have not yet been vaccinatedis higher than those who have not been vaccinated(10-12). Patients with this variant have moderate tosevere cold manifestations. Recently, loss of taste andsmell and shortness of breath cannot be obvious
symptoms because patients' vaccination status andage complicate their diagnosis based on the deltavariant. Hence, the symptoms of the delta variant are
milder than those of the SARS-CoV-2 virus, so patients
may think they have hay fever or a cold and that thesepatients are indistinguishable from others (11).
Mutations in L452R and P681R (splice binding
domain of the SARS-CoV-2 spike protein receptor fromthe delta variant) have been shown to cause hightransmission as well as rapid propagation in heavy
waves in India. In addition, concerns were raised
about the effectiveness of the species and the ability
to escape the vaccine (13, 14). All parameters that playa key role in COVID-19 transmission rate such as
Year 16, Issue 3 (May-June 2022)

production time (interval between primary andsecondary infection), the incubation period (period
from infection to disease onset), and serial interval(interval between onset of symptoms in primary andsecondary cases) were shorter in the delta variant
than previous variants (15). The high number of newly
infected individuals per day leads the Indian
healthcare system to failure as hospitals run out ofbeds, lack oxygen, and cannot serve critically illpatients (13). For that reason, the delta variant is an"improved" virus of the alpha variant, which increases
transmission and anxiety due to some mutations,especially mutations in the spike protein. A major
mutation has occurred at the furin cleavage site,
resulting in greater airway compatibility than the
Wuhan COVID-19. The adaptation of airway cells
increases the virus in infected patients; therefore, theprobability of transmitting the virus from patients to
air is more than its transfer to other people. With this
explanation, the probability of infecting people after
exposure to less viral infection is also high because thisvariant has a higher efficiency in infecting human
airway cells (16). The important thing is that the deltavariant in families and indoor exercises is transmitted(13). In these circumstances, compliance with theprotocols proposed by the WHO, including a distanceof one meter from others, the use of masks, andhandwashing, should be a priority.
Plus, researchers recommend that the proposed
exercises to strengthen the immune system be done
outdoors. Several abnormalities in coagulation andactivation of the complement system also occurred insevere COVID-19 with symptoms containing elevation
on fibrin degradation products, dimero-D, and Creactive protein (CRP). Also cytokine storm wascharacterized by the increase of circulating cytokines
such as interleukin (IL)-6, IL-1β, IL-10, IL-2, IL-8, IL-17,
monocyte chemoattractant protein 1 (MCP-1), tumor
necrosis factor-alpha (TNF-α), interferon-gamma (IFNγ), macrophage inflammatory protein 1 alpha (MIP1α), gamma-induced protein 10 (IP10), granulocytecolony stimulating factor (G-CSF), and othermolecules. In this situation, although in contrast to
increase of inflammation markers such as IL-1β, IP10,
MCP-1, and IFN-γ by T helper lymphocytes 1 response,
increase of IL-4, IL-5, and IL-10 for suppressing the
inflammation via T helper lymphocytes 2 to minimize
inflammatory tissue damage, causes an imbalance inimmune regulation. In COVID-19 patients, cytokine
storm develops an immunological system attack todifferent body organs such as lungs, kidneys, heart,
liver, brain, spleen, and lymph nodes, leading tosignificant lesions (17, 18). Therefore, regular physicalexercise, on the one hand, leads to a decrease of
inflammatory responses and stress hormones; It
increases immature B cells, natural killer (NK) cells,
lymphocytes, and monocytes. Consequen-tly, theIranian Journal of Medical Microbiology

180 Applicable exercises and diet for COVID-19 outbreaks
improvement of the immune system and the
reduction of the systemic inflammatory process
occurring in the body, which confirms the contributionof the immune system by regular physical activity (17),resulting in helping to prevent respiratory diseases
and protecting against infections such as the deltavariant of COVID-19.
3. Exercise Training Approaches
Regimented exercise is considered an importantand effective tool in preventing and managing chronic
non-communicable diseases risk (8, 18-21). Global
recommendations on physical activity for healthsuggest 60 min/day of moderate-to-vigorous physicalactivity for children and youth (5 to 17 years), and 75
min/week of vigorous or 150 min/week of moderate
physical activity for adults and elderly (≥ 18 years) (22).
Nowadays, we know that regular exercise training
combined with proper nutritional strategies would
enhance immune function (23-25). In general, eachsession of moderate-intensity exercise training withthe appropriate duration is an immune systemadjuvant, and when repeated regularly, induces antiinflammatory and antioxidant effects that can protect
against mortality and incidence rates for chronic
diseases, inﬂuenza, and the risk of upper respiratory
tract infection (URTI) (8, 23, 25). There are several
mechanisms related to beneficial effects of regularexercise training, including recirculation of antiinﬂammatory cytokines, immature B cells, cytotoxic T
cells, NK cells, immunoglobulins such as immunoglobulin A (IgA), and immune cells such as neutrophils,
together with improving the functional activity oftissue macrophages against pathogens (8, 23, 26). In
this regard, Klentrou et al. reported that 12 weeks ofmoderate exercise increased salivary IgA in a group of
healthy men and women, compared with sedentary
controls (27). In another study with the same training
period, moderate-intensity exercise modulated
inflammatory cytokines, including TNF-, IL-2, IL-4,
and IL-6, more than low-intensity exercise training inobese type 2 diabetic patients (28). In addition,comparative data from a human study showed that
long-term moderate exercise in sedentary older adults
and women resulted in a significant increase in thenumber of T helper cells. In contrast, non-exercise
control subjects did not show significant changes (29).
Hence, regular moderate exercise seems to be

associated with better immune functions and be
helpful for a decrease in the risk of infections.
It has been concluded that acute exercise stimulates
the continuous exchange of distinct and key immune
cells, such as leukocytes, between the circulation andtissues associated with improved immune functions(23). Increased cardiac output, vascular vasodilation,and blood flow with acute exercise lead to greater
mechanical forces on the endothelium, causing
leukocytes to demarginate and enter the bloodstream. This is accompanied by more shear stresslevels within the capillary structures that containmarginated leukocytes, which can drive moreleukocytes into the peripheral circulation (30).
Additionally, lymph is emptied into the blood via thethoracic duct during exercise, increasing lymphatic
flow (31). In contrast, long-lasting, intense exercise
training may be immunosuppressive. Exposure to thisstressor increases susceptibility to infection and illness
through increased intestinal permeability, oxidative
stress, and induction of muscle damage or fatigue that
leads to acute inﬂammation (8, 25, 26, 32). Therefore,choosing the correct training variables, especially for
sedentary people and amateur athletes, is principal toprevent such adverse effects and maintain or improve
the principal health-related physical ﬁtness components (26, 33).
In that regard, outdoor activities are typically moreavailable, and many types of physical exercises can be
performed, but there are still many possibilities forhome-based exercises during quarantine. Indeed, itshould be emphasized that "doing at least some
exercise is better than nothing" (33, 34). According to
the reasons listed above, we have provided practical
recommendations for speciﬁc home-based exercise
training across the situation of the COVID-19
pandemic (Table 1).
4. Nutritional Recommendations
Sufficient intake of carbohydrates, polyphenols, andvitamins could be helpful (8, 23, 51-53). To improveviral protection and reduce exercise-induced
inﬂammation, a well-balanced diet containing avariety of carbohydrate and protein sources, grains,
fruits, and vegetables is needed to provide sufﬁcientenergy and antioxidants (8, 23, 51, 52, 54). Here, wehave summarized some applicable nutritional items
which may be more important and usable during the
COVID-19 outbreaks (Table 2).

Table 1. Home-based exercise recommendations for sedentary adult people and amateur athletes to do during delta variantCOVID-19 outbreaks.

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Behzad Taati et al., 181

Frequency
At least 3 and preferably 5 days per week
Type
Combined training (60 min) including aerobic (30 min) and resistance (30 min) training regimens
Evidence-based reasons
Aerobic training
1) Continuous or interval training:
Exercises: treadmill running or brisk walking, cycling on a stationary bike (ifavailable), different types of dancing
Duration: 30-min continuously or three 10-min intervals with 1-2 min rest
between them
Intensity: 60%-90% of HRmax (5-10% increases per week)2) Interval training with shorter duration:
Exercises: jogging in place, jumping jacks, jumping rope (visible or invisible,
depending on the individual proficiency), squat thrusts (Burpees), high knees,skaters, and other full-body exercises like these.
Duration: 30 min including 3-4 intervals of each exercise with 10-20 reps
(depend on the type of exercise), and 30-45 s and 1-2 min rest between theintervals and exercises, respectively.
Intensity: 60%-90% of HRmax (5-10% increases per week)↓ TNF- (28, 35-38)↓ CRP (36, 38, 39)↓ HbA1c (28)
↓ IL-2, IL-4 (28)
↓ IL-18 (35, 40)↓ IL-6 (28, 36-39)↑ IL-10 (37)
↑ CD3+ (37)
↑ CD4+ (29, 37)↑ CD8+ (37)
↓ CD4+/CD8+ ratio (37)
↑ CD28+CD4+ (29)↑ salivary IgA (27)
↓ MIP-1γ (35)Resistance training
1) resistance band training:
Exercises: seated row, pull apart, push-ups, decline push-ups, lateral raise,
shoulder press, forward raise, biceps curls, squats, decline triceps extensions,etc.
2) dumbbells (or bottles of water or sand), free weights, or other types ofavailable resistance equipment:
Exercises: reverse fly, bent over row, chest press, shoulder press, forward
raise, biceps curls, overhead triceps extensions, squats, stationary lunges, toeraise, etc.
3) Bodyweight training:
Exercises: sit-ups, push-ups, pull-ups, dips, plank, glute bridge, squats,
Bulgarian split squats, overhead lunges, bicycle crunches, etc.
Duration: 30 min including 3-4 sets of selected exercises with 10-20 reps
(depend on the type of exercise), and 60-90 sec and 2-3 min rest between thesets and exercises, respectively.
Intensity: level 11-16 according to Borg’s scale (i.e., scores 11 and 12 as light,
13 and 14 as somewhat hard, and 15 and 16 as hard exercise).

↓ CRP (41-44)↓ IL-6, TNF- (43, 45)↑ IL-10 (42, 44)↓ IL-18 (35)
↓ NKTNF-, NKTTNF- (46)
↓ HbA1c (47)
↓ LDL-c (47)
↓ TLR2 and TLR4 (44)
↓ MIP-1γ (35)Cool-down
1) static stretching:
Exercises: chest stretch, upper back stretch, shoulder and triceps stretch, wrist
stretch, side stretch, calf stretch against a wall, hip flexor stretch, quadriceps
stretch, seated glute stretch, seated hamstring stretch, low-back stretch on the
ground, abdominal stretch, etc.
Duration: 6-10 sec per limb/muscle.
Intensity: until the onset of pain in the muscle.

↑ salivary IgA (48)↑ testosterone (48)
↓ cortisol (48)↓ neutrophil count (49)
↓ inflammatory lesion thickness(49)↑ IL-2+CD8+ (50)↑ increase, ↓ decrease, HRmax: maximal heart rate, TNF-: tumor necrosis factor-alpha, IL: interleukin, IgA: immunoglobulin
A, NK: natural killer cell, NKT: natural killer T-cell, CRP: C-reactive protein, HbA1c: glycated hemoglobin, TLR: Toll-like receptor,
MIP-1γ: macrophage inflammatory protein 1 gamma.

It should be noted that the recommendations
regarding vitamin D depend on the dietary habits ofYear 16, Issue 3 (May-June 2022)

the country considered. For instance, Iran, emphasizing plant-based diets, has lower 25-hydroxychoIranian Journal of Medical Microbiology

182 Applicable exercises and diet for COVID-19 outbreaks
lecalciferol concentrations than Japan, with highocean fish consumption. It has been suggested thatdaily 3000–5000 IU of vitamin D supplementation (i.e.,cholecalciferol) is needed to maintain serum 25hydroxycholecalciferol concentration during thewinter months when substantial cutaneous production of vitamin D is inadequate (55).

On the other hand, recent clinical trials have also
recommended higher doses of vitamin C (e.g.,
0.000015-0.000024 kg/day) for patients with COVID19 (56). However, research in this field is ongoing, anda more certain conclusion cannot be drawn until
further investigations confirm the results.

Table 2. Exercise-related nutritional recommendations to do across delta variant-COVID-19 outbreaks.
Description
Carbohydrates (57)••

0.3-0.4 kg of carbohydrates such as pasta, rice and bread, 3-4 hours prior to training
0.001-0.0012 kg/kg body weight/hour of carbohydrates such as potatoes and pasta after training

NOTE: RDA for carbohydrates is 0.13 kg/day for adults and children aged ≥ 1 year (58). This is the amount of glucose neededfor optimum brain and nervous system functions. However, carbohydrates can make up 45-65% of a healthy person's daily
diet (59). For instance, this equates to 0.225-0.325 kg/day for a 2,000 kcal diet.
Fruits (23)

• Small portions of fruits such as bananas, dates, and raisins during training• Bigger portions after training

NOTE: Fiber can make up 0.14-0.34 kg/1,000 kcal of a daily diet of everyone aged ≥ 2 years, depending on age-sex groups (59).
For instance, this equates to 2 cups of fruit and 2.5 cups of vegetables per day for a 2,000 kcal diet.
Vitamins (51)• Vitamin C: 0.0002 kg per day• Vitamin D: 2000 IU per day

NOTE: RDA for vitamin C is 0.000015-0.00009 kg/day, and for vitamin D is 600-800 IU/day, for everyone aged ≥ 2 years,
depending on age-sex groups (59).
Others (51)

• Zinc: 0.000008-0.000011 kg per day• Omega-3 fatty acids: 0.00025 kg per day

NOTE: RDA for zinc is 0.000003-0.000011 kg/day, and for omega-3 fatty acids is 0.007-0.017 kg/day, for everyone aged ≥ 2years, depending on age-sex groups (59).
RDA: Recommended Dietary Allowance.

5. Conclusion
Although staying at home will aﬀect peoples'
immune functions and physical fitness due tosignificant decreases in daily physical activity, regularmoderate-intensity home-based exercise programs
provide an opportunity for people to promote theirimmune system and fitness. However, exercise
training without a proper diet, especially sufﬁcientcarbohydrates, vitamins, and polyphenols, will not beeffective and efficient. As a result (60), exercise andproper diet can be key factors in boosting immune
responses and fighting against COVID-19.

Acknowledgment
We gratefully thank all physicians, nurses, midwives,
psychologists, hospital medical staff, and laboratory
technicians who are the guardians of people's health.

Competing Interests
None declared.

Patient Consent
Not required.

Funding
We have not declared a specific grant for thisresearch from any funding agency in public,commercial or not-for-profit sectors.

Conflict of InterestNot required.

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