COVID-19 Lockdown Inactivity May Spell Trouble for CVD Prevention

With the world locked down in the fight against COVID-19, experts are reminding people that daily physical activity is as important as ever for the primary and secondary prevention of cardiovascular disease, especially since this coronavirus is more lethal for those with underlying health conditions.

And while there is no published evidence that exercise habits have dropped off with the self-isolation and quarantine protocols now in place, some preliminary data suggests people might be moving less in these worrisome times.

Fitbit, the company that manufacturers activity trackers and smartwatches, reports that the COVID-19 pandemic has affected physical activity levels for its 30 million or so active users. Data from late March show that compared with the same time last year, step counts around the globe went down—ranging from a 7% drop in Germany to a 38% decline in Spain, one of the countries hardest hit by the pandemic. In Italy, another country devastated by the coronavirus, step count activity is down 25%. In the United States and Canada, activity levels as measured by step count are down 12% and 14%, respectively.  

These data aren’t peer-reviewed nor are they published in a scientific journal, but the trends are worrisome, according to Salim Virani, MD, PhD (Baylor College of Medicine, Houston, TX).

“There is quite a bit of concern in the prevention community,” said Virani, chair of the American College of Cardiology (ACC) Prevention Council. The Fitbit population differs from the general population in terms of affluence and inclination toward daily exercise, but the US data reflect a period before the tighter lockdown restrictions went into place. “It’s even more of a concern now,” he said. “If you’ve been following the science behind physical activity, people who are very sedentary get the most benefit when they go from sedentary to just a little bit of activity because they’re on the steepest part of the curve. The reverse can also be true.”

For people who were mildly active at baseline, becoming completely sedentary because of a lockdown can have a detrimental effect. Vascular function is impacted even when an individual is immobile for 3 to 6 hours, said Virani, and atrophy of the cardiac muscle can occur after 2 weeks. “Now we’re talking about a month-long lockdown in the US and some of the other countries,” he said.

While we’re still in the early days of the pandemic, which is both a medical and financial crisis, there will be a need to study its long-term impact on lifestyle disruptions and chronic disease, said Virani.  

People who are very sedentary get the most benefit when they go from sedentary to just a little bit of activity because they’re on the steepest part of the curve. The reverse can also be true. Salim Virani

“Behavior has changed for the worse, and we now have a huge financial crisis, with quite a few people having lost their jobs or their wages having gone down, so how is that going to affect how active people are going to be long-term?” he asked. “How adherent are they going to be to their medication, to a healthy lifestyle? We know that most natural disasters lead to about a 5-mm Hg increase in systolic blood pressure. So, based on these data points, there is quite a bit of concern about how we’re going to deal with the prevention side of this pandemic.” 

Marginalizing Exercise in Face of Global Crisis

This week in a perspective published online in Circulation, Eamon Duffy, MD, Miguel Cainzos-Achirica, MD, PhD, and Erin Michos, MD (all Johns Hopkins University School of Medicine, Baltimore, MD), warn that with the public health crisis comes pressing challenges for cardiovascular disease prevention: “health interventions that provide long-term benefit may seem counterintuitive and be marginalized,” amid the more immediate risk of viral infection, they write. Still, despite COVID-19 being an impending global emergency, cardiovascular disease remains the leading cause of mortality, accounting for nearly 18 million deaths in 2017.

“Even though COVID-19 is a disease related to a viral infection, it’s absolutely entwined with cardiovascular disease,” Michos told TCTMD. Patients with underlying risk factors, such as obesity, hypertension, diabetes, and preexisting cardiovascular disease, have more severe COVID-19 disease and have worse mortality than healthier individuals. “They’re more vulnerable and more at risk so we can’t forget about cardiovascular prevention even in the midst of this crisis.”

Eduardo Sanchez, MD, the chief medical officer for prevention at the American Heart Association (AHA), acknowledged that daily life and its accompanying routines, such as going to the gym, pool, or yoga studio, have been disrupted by COVID-19. Nonetheless, the AHA has been trying to convey the importance of daily physical activity even now and continues to recommend that people get in at least 150-300 minutes of moderate-intensity or 75-100 minutes of vigorous-intensity physical activity each week

“If anything, we’re doubling down on just how important it is to get that physical activity in,” Sanchez told TCTMD. “We have increased stress, are sometimes feeling sad, maybe have a little bit of depression, and physical activity helps with physical and mental health. . . . Right now, physical activity maybe has more value than [it did] before COVID-19.”

From a practical perspective, daily exercise can also break up the day and provide time with family. “Days can seem almost like an endless series of phone calls,” said Sanchez. “For folks to get out into their backyard, or into the neighborhood, there’s value in that.”

The AHA is currently partnering with fitness trainers and leading virtual workouts on their website as part of their “Move More” campaign. Throughout the week, sometimes twice per day, the AHA offers free 30-minute Pilates, yoga, and Tabata workouts, as well as some lighter weight-based sessions. Anecdotally, Sanchez said he is aware that people are struggling with how to be active given the current restrictions, but the flip side is that others are sharing what they’re doing to stay healthy.

We have increased stress, are sometimes feeling sad, maybe have a little bit of depression, and physical activity helps with physical and mental health . . . Right now, physical activity maybe has more value than [it did] before COVID-19. Eduardo Sanchez

“There is interest,” he said, “but what I can’t tell you is whether that cuts across all swaths. There are some who are going to have much less ability to find free time because they’re trying to manage work, children, or live-at-home parents, all of whom are in the same space at the same time. One of the things [the AHA] is suggesting is negotiating some time to engage in physical activity. I would bet that all things being what they are, people are less physically active now than they were.”

The World Health Organization (WHO) recommendations for daily exercise line up with the AHA, and it recently developed a guide to help people stay active in confined or limited space. 

Michos also pointed to the swelling online community of fitness enthusiasts, noting that finding a “virtual workout buddy” might help people stay engaged and accountable. In major cities it can be difficult to safely go outdoors, but heading to parks or even driving to a more walkable neighborhood might be options for some people, she said, adding that we will all need to adapt to a changed environment because the pandemic will take time to abate. 

“I would love to think that this crisis will disappear and go away, but there are a lot of projections that we might not go back to the way things were on New Year’s Day,” said Michos. “There might be a second wave this fall and maybe another round next winter. We may have to rethink the way we do a lot of things.”

Social Isolation ≠ Inactivity

For patients with high blood pressure, hypercholesterolemia, prior MI, stroke, or heart failure, Sanchez stressed that it’s even more critical to maintain physical activity as part of a secondary-prevention treatment regimen.

Michos agreed, noting that preventive cardiology is well suited to telemedicine since a physical exam isn’t typically required, but rather relies on a review of patient history and prior laboratory and imaging studies (and ambulatory blood-pressure monitoring, if patients have their own device). At present, she’s enjoying the emergence of telemedicine, and noted that patients find it convenient, too. Telemedicine and remote monitoring make it easier for physicians to frequently reach patients to emphasize physical activity and diet, as well as optimize risk factor control and titrate medications, she said.

Earlier this month, Giuseppi Lippi, MD (University of Verona, Italy), and colleagues published a perspective in the European Journal of Preventive Cardiology, highlighting the myriad ways exercise lowers the risk of morbidity and mortality. In Italy, all citizens are required to stay home unless they have to leave the house for approved reasons, such as work, unavoidable health issues, purchasing groceries, or picking up medications, they explain. While there have been more than 25,000 deaths in Italy from COVID-19, the authorities still allow people to exercise outside for 1 hour per day, provided a minimum interpersonal distance of 1 m is kept.

There might be a second wave this fall and maybe another round next winter. We may have to rethink the way we do a lot of things. Erin Michos

“This seems a reasonable compromise between the unfavorable health consequences associated with physical inactivity and the compelling need to contain the COVID-19 outbreak,” Lippi and colleagues write.

Virani said that “social isolation” has been interpreted in different ways in different countries, but it doesn’t mean not being active. “Even today, there are a lot of activities that are available online,” he said. “The guidelines aren’t saying don’t go out [at all]. You can go out and do your regular walk within the community as long as you can maintain a safe distance. Not all of us have that luxury, I admit, but a large proportion of the population can go out and maintain a safe distance with others. We have to think about it a little more actively than before, but the messaging needs to be that [physical activity] is as important as ever for physical and mental health.”

Michos made a similar comment, saying that the early recommendations to stay home really lacked guidance about the importance of maintaining a healthy lifestyle.

“Everyone is glued to their computers and phones with efforts to stay connected to the outside world,” she said. “We have screen use skyrocketing and unfortunately people are much more sedentary. Of course, this is a very stressful time and patients might be more likely to have unhealthy coping mechanisms, such as unhealthy eating patterns. Not only that, but it’s harder to get access to good nutrition because most of the healthy foods are perishable and have a shorter half-life.”

On the other hand, the public is highly engaged at the moment with medical information so health experts and physicians need to emphasize the importance of maintaining healthy lifestyle behaviors in the face of the pandemic, Michos concluded.