Impact of COVID-19 on Physical Activity Behavior and Well-Being Outcomes [COVID-19 and Physical Activity Series]

The Impact of COVID-19 on Physical Activity Behavior and Well-Being of Canadians by Drs. Lesser and Nienhuis is an online survey of 1,098 Canadian adults.  Data was collected in April and May 2020 on demographics, physical activity behavior, outdoor physical activity, and measures of well-being.  Participants were categorized as active or inactive using a 150 minutes of moderate to vigorous physical activity per week cutoff, and asked about changes in physical activity since restriction onset, type of physical activity, location of physical activity (indoors, outdoors or both) and whether the location had changed due to social distancing measures, and barriers and facilitators to physical activity.  Drs. Lesser and Nienhuis found significant differences between inactive and active individuals, with a larger portion of inactive individuals reporting less physical activity and a larger portion of active individuals reporting more physical activity since COVID-19.  Specifically, 40.5% of inactive individuals became less active, while only 22.4% of active individuals became less active. In comparison, 33% of inactive individuals became more active while 40.3% of active individuals became more active.   Drs. Lesser and Nienhuis also found that inactive and active individuals that became relatively less active reported significantly less benefit, less enjoyment, less confidence, less support and fewer opportunities to be active.  In contrast, inactive individuals who became more active or maintained their physical activity levels during COVID-19, especially outdoor physical activity, had lower anxiety than those who decreased their physical activity levels. Physical activity was strongly associated with well-being in inactive individuals, suggesting that health-promoting measures directed towards increasing physical activity levels in inactive individuals may be essential to improving well-being.

Lesser, I. A., & Nienhuis, C. P. (2020). The Impact of COVID-19 on Physical Activity Behavior and Well-Being of Canadians. International Journal of Environmental Research and Public Health, 17(11), 3899.

Step #4 Toward Being Trusted Facilities Where Physicians Refer Their Patients [Connecting Health Clubs to Healthcare Series]

Based on the results of a research study conducted at the Harvard School of Public Health between May 2019 and February 2020, physicians surveyed indicate that they write exercise prescriptions/referrals to a variety of professionals, including physical therapists, athletic trainers, health coaches, and exercise professionals.  They also indicate that they may be more likely to refer to a physical therapist than an exercise professional because of insurance reimbursement.  These referrals can be a significant source of new patients for physical therapists.  Yet patients may have a limited number of visits with their physical therapist and may further benefit from a referral to an exercise professional for ongoing assistance.  

Step #4 of a 10-step roadmap for health & fitness centers toward being trusted facilities where physicians refer their patients is:

Explore partnering with physical therapy to secure a pipeline of new members transitioning from physical therapy to regular exercise programs.

Sometimes what I will do is try to tie in their physical therapy evaluation and treatment with the ultimate goal of having them transition to their health club. Physician

Bantham, A. (2020). Perspectives on Exercise Prescriptions/Referrals and Patient Exercise Behavior Change: A Mixed Methods Study of Physicians and Exercise Professionals (Doctoral dissertation).

Impact of COVID-19 Self-Isolation on Physical Activity and Sedentary Behavior [COVID-19 and Physical Activity Series]

Moderate to vigorous physical activity and sedentary behavior change in self-isolating adults during the COVID-19 pandemic in Brazil by Dr. Schuch and co-authors is a cross-sectional survey.  Data was collected between April 11 and May 5, 2020 using self-reported questionnaires.  Participants were self-isolating, defined as staying-at-home and only leaving for essential activities such as visiting the supermarket, the pharmacy, or a health professional.  Dr. Schuch and co-authors found a reduction of 64.28 (95% CI: 36.06 to 83.33) minutes per day spent on moderate to vigorous physical activity, corresponding to a 59.7% reduction (95%CI:35.6 to 82.2).  They also found an additional 152.3 (95% CI: 111.9 to 192.7) minutes per day spent in sedentary behavior, corresponding to a 42.0% increase (95% CI: 31.74 to 52.50).  Greater reductions in moderate to vigorous physical activity and increases in sedentary behavior were seen in younger, unmarried, and employed adults, as well as those with self-reported previous diagnosis of a mental disorder.  Previous studies have shown sufficient evidence to justify making physical activity promotion a global public health priority during the coronavirus pandemic.  These findings highlight the urgent need for the adoption of public health strategies to address the impact of self-isolation during the COVID-19 pandemic on moderate to vigorous physical activity and sedentary behavior.

Schuch, F., Bulzing, R., Meyer, J., Lopez-Sanchez, G., Grabovac, I., Willeit, P., ... & Ward, P. (2020). Moderate to vigorous physical activity and sedentary behavior change in self-isolating adults during the COVID-19 pandemic in Brazil: A cross-sectional survey exploring correlates. medRxiv. 

Lifestyle Risk Factors and COVID-19 Hospitalization [COVID-19 and Physical Activity Series]

Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization by Dr. Hamer and co-authors is a prospective cohort study of 387,109 adults in the United Kingdom.  Physical activity, smoking, and alcohol intake were assessed by questionnaire, and baseline data collection took place between 2006 and 2010.  Specifically, physical activity was assessed using the International Physical Activity Questionnaire that measures duration and frequency of moderate-to-vigorous physical activity, and meeting physical activity guidelines was defined as ≥150 min/week moderate-to-vigorous physical activity or ≥75 min/week vigorous physical activity. Dr. Hamer and co-authors found a dose-dependent association between the risk of COVID-19 with worsening lifestyle scores, such that participants in the most adverse category had 4-fold higher risk (RR = 4.41; 95% CI, 2.52, 7.71) compared to people with the most optimal lifestyle.  Approximately 0.2% (N = 760) of the sample were hospitalized with a COVID-19 infection between March 16 and April 26, 2020, and their risk profile was characterized as being male, older age, smokers, physically inactive, less highly educated, non-white ethnicity, and higher prevalence of cardiometabolic comorbidities.  Based on risk factor prevalence estimates, unhealthy behaviors in combination accounted for 51.4% of the population attributable fraction of severe COVID-19.  Individually, smoking contributed to 13.3%, physical inactivity contributed to 8.6%, and overweight and obesity contributed to 29.5% of hospitalized cases of COVID-19.  After adjustment for age, sex and mutually for each lifestyle factor, physical inactivity (relative risk, 1.32; 95% confidence interval, 1.10, 1.58), smoking (1.42;1.12, 1.79) and obesity (2.05;1.68, 2.49)—but not heavy alcohol consumption (1.12; 0.93, 1.35)—were all related to COVID-19.  Protective associations of physical activity on COVID-19 were observed even at relatively low levels of activity below the current guidelines (i.e., < 150 min moderate to vigorous activity) and no dose-response effect was observed for higher levels. Dr. Hamer and co-authors concluded that adopting simple lifestyle changes could lower the risk of severe COVID-19 infection. 

Hamer, M., Kivimäki, M., Gale, C. R., & Batty, G. D. (2020). Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain, Behavior, and Immunity.

Risk Factors Linked with Increased Risk for Dying from COVID-19 [COVID-19 and Physical Activity Series]

OpenSAFELY: Factors Associated with COVID-19 Death in 17 Million Patients is a cohort study of the risk factors linked with increased risk for dying from COVID-19.  Dr. Williamson and co-authors examined the health records of over 17 million adults, or about 40% of England’s population, using a secure health analytics platform called OpenSAFELY.  They found that patients older than 80 were more than 20 times more likely to die from COVID-19 than people in their 50s (fully adjusted HR 20.61; 95% CI 18.72-22.70) and that men were more likely to die than women of the same age (fully adjusted HR 1.59, 1.53-1.65).  Dr. Williamson and co-authors also found that people with underlying medical conditions like obesity (obesity class I fully adjusted HR 1.05, 95% CI 1.00-1.11, obesity class II fully adjusted HR 1.40, 95% CI 1.30-1.52, obesity class III fully adjusted HR 1.92, 95% CI 1.72-2.13), diabetes, severe asthma, and cardiovascular disease were at higher risk. They found that Black and South Asian people, as well as those from other ethnic minority groups, were more likely to die than white patients (fully adjusted HR 1.43-1.48).  Evaluating the association between pre-existing medical conditions (e.g., obesity, diabetes, severe asthma, and cardiovascular disease) and death from COVID-19, we confirmed increased mortality risks, supporting the targeted use of additional protection measures for people in these groups. 

Williamson, E. J., Walker, A. J., Bhaskaran, K., Bacon, S., Bates, C., Morton, C. E., ... & Cockburn, J. (2020). OpenSAFELY: factors associated with COVID-19 death in 17 million patients. Nature, 1-11.

Effects of COVID-19 Home Confinement on Eating Behavior and Physical Activity [COVID-19 and Physical Activity Series]

Effects of COVID-19 Home Confinement on Eating Behavior and Physical Activity by Dr. Ammar and co-authors is an international online survey of the behavioral and lifestyle consequences of COVID-19 restrictions.  Launched in April 2020 in seven languages and disseminated in Europe, Africa, Asia, and the Americas, the survey captured results from the first thousand respondents.  It included 64 questions on health, mental well-being, mood, life satisfaction and multi-dimensional lifestyle behaviors (physical activity, diet, social participation, sleep, technology use, need of psychosocial support).  The validated questionnaire for physical activity was the International Physical Activity Questionnaire Short Form (IPAQ-SF).  Dr. Ammar and co-authors found that COVID-19 restrictions had a negative effect on all physical activity intensity levels (vigorous, moderate, walking and overall):

• The number of days/week and minutes/day of vigorous intensity physical activity decreased by 22.7% (t = 7.75, p < 0.001, d = 0.374) and 33.1% (t = 9.75 p < 0.001, d = 0.542), respectively. 

• The number of days/week and minutes/day of moderate intensity physical activity decreased by 24% (t = 7.89, p < 0.001, d = 0.396) and 33.4% (t = 7.85, p < 0.001, d = 0.343), respectively. 

• The number of days/week and minutes/day of walking decreased by 35% (t = 15.80, p < 0.001, d = 0.677) and 34% (t = 9.34, p < 0.001, d = 0.389), respectively.

• The number of days/week and minutes/day of all physical activity decreased by 24% (t = 15.61, p < 0.001, d = 0.482) and 33.5% (t = 12.51, p < 0.001, d = 0.387), respectively.

• The number of hours/day of sitting increased by 28.6% (t = −25.61, p < 0.001, d = 1.130).

They call for further research that addresses improved interventions for specific subpopulations and identifies conditions for successfully maintaining a healthy lifestyle before, as well as during, isolation.  While COVID-19 restrictions help to abate the rate of infection, the results of this survey show that the restrictions have reduced overall physical activity (number of days and number of hours) and access to exercise, and that the decline in physical activity was accompanied by increased sedentary (sitting) behavior.  

Ammar, A., Brach, M., Trabelsi, K., Chtourou, H., Boukhris, O., Masmoudi, L., ... & Müller, P. (2020). Effects of COVID-19 Home Confinement on Eating Behaviour and Physical Activity: Results of the ECLB-COVID19 International Online Survey. Nutrients, 12(6), 1583.

Step #3 Toward Being Trusted Facilities Where Physicians Refer Their Patients [Connecting Health Clubs to Healthcare Series]

Twenty-two percent of physicians surveyed note patient cost concerns as a barrier to their referring patients to health & fitness centers.  How can more health & fitness centers and exercise professionals overcome this barrier to work with patients referred by their physicians?  

Step #3 of a 10-step roadmap for health & fitness centers toward being trusted facilities where physicians refer their patients is:

 Communicate the value proposition for exercise programs and professionals and reframe referrals as a cost-saver for patients.

Other research studies also find that patient cost concerns are one of the most cited barriers to physicians writing exercise prescriptions/referrals.  However, physicians also note affordable offers as a facilitator to their referring patients to local health & fitness centers.  Many health & fitness center programs are available to referred patients at a reduced rate, and when participants complete the programs they can convert to membership at regular prices.  Physicians also recognize that surgeries and medications can be more expensive than lifestyle management.  Research shows that exercise prescription/referral in the primary care setting is considered a “best buy,” a cost-effective intervention.

But if you consider the cost of medications and other healthcare-related costs, I think exercise programs are on the cheap side. Physician

Bantham, A. (2020). Perspectives on Exercise Prescriptions/Referrals and Patient Exercise Behavior Change: A Mixed Methods Study of Physicians and Exercise Professionals (Doctoral dissertation).

Impact of COVID-19 on Childhood Obesity in the United States [COVID-19 and Physical Activity Series]

Projecting the Impact of COVID-19 on Childhood Obesity in the United States by Dr. An is a microsimulation model with four scenarios.  The four scenarios are: 1) a 2-month nationwide school closure in April and May 2020; 2) scenario 1 followed by a 10% reduction in  daily physical activity in the summer from June to August; 3) scenario 2 followed by 2-month school closure in September and October; and 4) scenario 3 followed by an additional 2-month school closure in November and December.  Previous studies show that U.S. elementary school children participate, on average, in 88 minutes of physical activity per day.  The model accounts for decreased physical activity due to lost physical activity opportunities at school (i.e., cancelled physical education classes), which are not made up for at home due to nationwide stay-at-home orders.  It relies on BMI and obesity data collected in a nationally representative longitudinal study tracking weight patterns of 15,631 children from kindergarten through 5th grade.  Dr. An found that, relative to the control scenario without COVID-19, scenarios 1, 2, 3, and 4 were associated with an increase in the mean BMI by 0.056, 0.084, 0.141, and 0.198 units, respectively, and an increase in childhood obesity prevalence by 0.640, 0.972, 1.676, and 2.373 percentage points, respectively.  This means that even a 2-month school closure alone could result in an increase in the childhood obesity rate by 0.640 percentage points, and a further increase by 2.377 percentage points if school closures continue to the end of 2020.  By March 2021, approximately 1.27 million new childhood obesity cases could develop during the COVID-19 pandemic due to lost physical activity opportunities at school. Public health interventions are urgently called for to promote active lifestyles and to mitigate the adverse impact of COVID-19 on unhealthy weight gains and childhood obesity. 

An, R. (2020). Projecting the impact of COVID-19 pandemic on childhood obesity in the US: A microsimulation model. Journal of Sport and Health Science.

Step #2 Toward Being Trusted Facilities Where Physicians Refer Their Patients [Connecting Health Clubs to Healthcare Series]

North Carolina gyms are still closed, but the NC Attorney General announced that indoor gyms can reopen to members who have prescriptions from their physicians saying that they need to exercise for their health.  My research study conducted at the Harvard School of Public Health between May 2019 and February 2020 did not anticipate COVID, but did compile data from physicians about characteristics of health & fitness centers/exercise professionals that they trust to refer their patients.  Step #2 of a 10-step roadmap for health & fitness centers toward being trusted facilities where physicians refer their patients is:

Reframe working with trusted exercise professionals who can develop exercise programs for their patients as a time-saver for physicians.

Thirty-eight percent of physicians surveyed mention “limited time” as a barrier to their counseling on physical activity and writing exercise prescriptions.  Physicians often do not have enough time in their office visit to do an assessment and find out what exercise their patients need.  Yes, it can take time on both sides to connect health clubs to healthcare.  But if physicians know how exercise professionals can develop exercise programs or plans for their patients, they may view exercise professionals as trusted experts who can save them hours of time compiling information handouts on exercise.  

Bantham, A. (2020). Perspectives on Exercise Prescriptions/Referrals and Patient Exercise Behavior Change: A Mixed Methods Study of Physicians and Exercise Professionals (Doctoral dissertation).

Changes in Physical Activity due to COVID-19 and Associations with Mental Health [COVID-19 and Physical Activity Series]

Changes in Physical activity and Sedentary Behavior due to the COVID-19 Outbreak and Associations with Mental Health by Dr. Meyer and co-authors is a cross-sectional study of 3,052 U.S. adults.  Previous studies have indicated average decreases in step counts as a result of COVID-related public health restrictions, as well as high levels of depressive and anxiety symptoms likely associated with the pandemic.  Dr. Meyer and co-authors recruited participants through convenience sampling from Iowa State University faculty, staff, students and alumni, and additional snowball sampling resulting in responses from all 50 states and the District of Columbia.  They assessed mental health using Perceived Stress Scale-4, 3-item Loneliness, Short Warwick-Edinburgh Mental Wellbeing Scale, Lubben Social Network Scale, and Beck Depression and Anxiety Inventories.  Dr. Meyer and co-authors found that weekly physical activity was reduced after COVID-19-related restrictions among previously active participants (mean change: -32.3% [95% CI: -36.3%, -28.1%]) but largely unchanged among previously inactive participants (+2.3% [-3.5%, +8.1%]); sitting time was increased (previously active: +26.4% [+22.6%, +30.1%]; inactive: +16.0% [+13.2%, +18.8%]) and screen time was increased (previously active: +37.8% [+32.7%, +43.0%]; inactive: +25.3% [+21.6%, +29.1%]).  They also found that no longer meeting physical activity guidelines and increased screen time following COVID-19-related restrictions were consistently associated with worse mental health (i.e., higher depressive symptoms, loneliness, stress, lower positive mental health; all p<0.001).  Previously active participants who were no longer active following COVID-19-related public health restrictions reported worse mental health compared to those who maintained their activity level.  The findings strongly support the need to implement and support measures that promote physical activity while limiting screen time throughout the duration of COVID-19 restrictions to mitigate short- and likely long-term mental health consequences. 

Meyer, J., McDowell, C., Lansing, J., Brower, C., Smith, L., Tully, M. & Herring, M. (2020). Changes in physical activity and sedentary behaviour due to the COVID-19 outbreak and associations with mental health in 3,052 US adults. 10.33774/coe-2020-h0b8g.

Step #1 Toward Being Trusted Facilities Where Physicians Refer Their Patients [Connecting Health Clubs to Healthcare Series]

Here is the first in a series on Connecting Health Clubs to Healthcare Through Exercise Referrals.  

During the COVID-19 gym closures, there are a few health & fitness centers that have remained open.  They applied for and received special dispensation because they are working with patients referred by their physicians for a particular exercise program as part of their course of treatment.  How can more health & fitness centers and exercise professionals work with patients referred by their physicians? 

Step #1 toward being trusted facilities where physicians refer their patients: Ensure physicians get feedback that measures and quantifies patients’ progress and outcomes.

When asked to what extent their patients adhere to the written exercise prescriptions/referrals that they make, 28% of physicians surveyed respond “I don’t know.” They want to know their patients are successful and tend to refer to health & fitness centers where previously referred patients have reported back good success. 

“So if they start seeing the outcomes sent back to them, and their patients are continually getting better, losing weight, have less pain, that starts building trust with them.” Exercise Professional

This is step #1 in a 10-step roadmap for health & fitness centers.  It is based on the results of a research study conducted at the Harvard School of Public Health between May 2019 and February 2020.  Physicians and exercise professionals were surveyed and interviewed, including questions like: what are characteristics of a health & fitness center/exercise professional that you trust to refer your patients?

Bantham, A. (2020). Perspectives on Exercise Prescriptions/Referrals and Patient Exercise Behavior Change: A Mixed Methods Study of Physicians and Exercise Professionals (Doctoral dissertation).

Obesity as a COVID-19 Risk Factor [COVID-19 and Physical Activity Series]

Obesity in Patients Younger than 60 years as a Risk Factor for COVID-19 Hospital Admission is a retrospective analysis of BMI, by age, in positive, symptomatic hospital patients.  Previous studies have demonstrated that the risk factors associated with COVID-19 disease severity include increased age, diabetes, immunosuppression and organ failure.  Dr. Lighter and co-authors found a significant difference in admission to acute and critical care in patients younger than 60 years with varying BMIs.  Patients with a BMI over 30 were 2.0 (95% 1.6-2.6, p<0.0001) and 1.8 (95% CI 1.2-2.7, p=0.006) times more likely to be admitted to acute and critical care, respectively, compared to patients with a BMI under 30.  Dr. Lighter and co-authors conclude that obesity in people younger than 60 years is a newly identified epidemiologic risk factor which may contribute to increased morbidity rates experienced in the United States. Though patients aged <60 years are generally considered a lower risk group of Covid-19 disease severity, obesity appears to be a previously unrecognized risk factor for hospital admission and need for critical care. This has important and practical implications, where nearly 40% of adults in the US are obese with a BMI >30.

Lighter, J., Phillips, M., Hochman, S., Sterling, S., Johnson, D., Francois, F., & Stachel, A. (2020). Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission. Clin Infect Dis, 9 (10.1093).

Physical Activity for Immunity Protection [COVID-19 and Physical Activity Series]

Physical Activity for Immunity Protection by Dr. Laddu and co-authors is a commentary on the role that physical activity plays in immune health and reducing the risk, duration, or severity of viral infection.  Previous studies have shown physical activity to dramatically reduce the risk for developing systemic inflammation, excess body mass and non-communicable diseases known to compromise immune function.  Dr. Laddu and co-authors note that the immune system is responsive to exercise, dependent on the intensity and duration of effort and type of exercise.  Specifically, moderate-intensity physical activity enhances immunosurveillance against infectious pathogens and protects against infectious disease symptoms.  Dr. Laddu and co-authors focus their attention on exercise and immune health in older adults, who are the most sensitive to developing infectious disease, including the most recent coronavirus outbreak.  They find that moderate-intensity physical activity may moderate the effects of aging on the immune system and reduce the risk of infection.  Dr. Laddu and co-authors conclude that daily physical activity is an important strategy for optimizing the immune system function to prevent or attenuate severity of infection, especially among vulnerable populations with immune-compromised conditions.  In the face of this novel coronavirus pandemic, public health advisory organizations are encouraging individuals to initiate or continue regular engagement in physical activity to maintain physical and mental health and wellbeing when not contraindicated and while abiding to public health and community safety. 

Laddu, D. R., Lavie, C. J., Phillips, S. A., & Arena, R. (2020). Physical activity for immunity protection: Inoculating populations with healthy living medicine in preparation for the next pandemic. Progress in Cardiovascular Diseases.

Effects of COVID-19 Lockdown on Lifestyle Behaviors in Children with Obesity [COVID-19 and Physical Activity Series]

The Effects of COVID-19 Lockdown on Lifestyle Behaviors in Children with Obesity Living in Verona, Italy by Dr. Angelo Pietrobelli and co-authors is a longitudinal study of trends in lifestyle behaviors among children confined to their homes during the COVID-19 pandemic.  Previous studies have found more rapid weight gain in children during summer vacations, without the structure and routine around mealtimes, physical activity, and sleep schedule provided by school environments.  Dr. Pietrobelli and co-authors hypothesize that factors contributing to weight gain in children with overweight and obesity are exacerbated during a pandemic-associated lockdown.  Interviews were conducted with 41 parents at baseline (May-July 2019) and three weeks after the quarantine began on March 10, 2020.  They were asked 12 questions about their children’s lifestyle behaviors, including sports activity participation, screen time, sleep behavior, and eating habits.  The results revealed that children spent 2.30 (-2.30±4.60 hrs/week, p=0.003) fewer hours per week on sports activities, where any physical activity (e.g., jogging, playing in the backyard, etc.) was considered sports during the lockdown.  Children also spent 4.85 (4.85±2.40 hrs/day, p<0.001) more hours per day on screen time, slept .65 (0.65±1.29 hrs/day, p=0.003) more hours per day, and drank .50 (0.50±1.08 #/day, p=.005) more sugary drinks per day.  Dr. Pietrobelli and co-authors conclude that there is a critical need for preventive measures during periods of lockdown, including telemedicine lifestyle programs, supplemental guidance for families by clinicians to maintain healthy lifestyle choices, and exercise programs that minimize viral transmission.  The tragic COVID-19 pandemic has collateral effects extending beyond those of direct viral infection. Children and adolescents struggling with obesity are placed in an unfortunate position of isolation that appears to create an unfavorable environment for maintaining healthy lifestyle behaviors.

Pietrobelli, A., Pecoraro, L., Ferruzzi, A., Heo, M., Faith, M., Zoller, T., ... & Heymsfield, S. B. (2020). Effects of COVID‐19 Lockdown on Lifestyle Behaviors in Children with Obesity Living in Verona, Italy: A Longitudinal Study. Obesity.

A Tale of Two Pandemics [COVID-19 and Physical Activity Series]

A Tale of Two Pandemics by Dr. Grenita Hall and co-authors is a commentary on the interrelationship between the COVID-19 pandemic and the physical inactivity/sedentary behavior pandemics.  Physical inactivity was defined as a pandemic in 2012, and today 31% of people aged 15 and older are physically inactive, according to the World Health Organization.  Dr. Hall and co-authors hypothesize that the COVID-10 pandemic has the potential to accelerate the physical inactivity/sedentary behavior pandemic even further.  With the suspension of physical activity opportunities in school-based physical education and athletic programs, fitness centers and public parks and social distancing and shelter in place directives, they believe it is likely that COVID-19 is making the world move even less than before.  Dr. Hall and co-authors cite research on natural disasters and physical activity indicating a lasting significant decrease in physical activity in children and adolescents. They recommend that similar research must be conducted to determine the lasting impact of the COVID-19 pandemic on physical activity patterns and sedentary time.  Dr. Hall and co-authors also examine the intersection between current risks for health complications and mortality rates associated with COVID-19 and the current state of physical inactivity and sedentary behavior.  They highlight the risk for a vicious cycle where current and potentially accelerated physical inactivity patterns and sedentary behaviors may worsen the impact of future pandemics.  The world will recover from the COVID-19 pandemic and so-called normal activities will resume. However, the physical inactivity/sedentary behavior pandemic will continue and, more troublingly, we may be at risk for this pandemic to worsen as a result of COVID-19.

Hall, G., Laddu, D. R., Phillips, S. A., Lavie, C. J., & Arena, R. (2020). A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?. Progress in Cardiovascular Diseases.