Fit Is It in COVID-19, Future Pandemics, and Overall Healthy Living

Abstract

Substantial evidence supports the importance of fitness, especially cardiorespiratory fitness (CRF) and muscular fitness, to prevent and to treat cardiovascular disease (CVD).1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar In fact, patients with various chronic diseases including obesity, dyslipidemia, and diabetes mellitus (DM) who present with a higher CRF often have a more favorable short- and long-term prognosis compared with individuals without these conditions but with low levels of CRF. This observation supports the importance of CRF as one of the strongest CVD risk factors or risk markers. In fact, through an American Heart Association Scientific Statement, we have called on clinicians to consider CRF a health status “vital sign.”2Ross R. Blair S.N. Arena R. et al.Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.Circulation. 2016; 134: e653-e699Crossref PubMed Scopus (1070) Google Scholar In this issue of Mayo Clinic Proceedings, Brawner et al3Brawner C.A. Ehrman J.K. Bole S. et al.Maximal exercise capacity is inversely related to hospitalization secondary to coronavirus disease 2019.Mayo Clin Proc. 2021; 96: 32-39Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar from the Henry Ford Medical Group in Detroit, Michigan, described 246 patients in their health care system who had a previous exercise treadmill test to determine CRF as indicated by peak metabolic equivalents (METs) and who tested positive for severe acute respiratory syndrome coronavirus 2 infection. The purpose of this study by Brawner et al was to determine the impact of CRF on hospitalization risk due to coronavirus disease 2019 (COVID-19). Importantly, their population was 75% African American (AA) with a mean body mass index of 32.7 kg/m2. They demonstrated that in their population (mean age, 59 years; 42% male), peak METs were considerably lower (6.7±2.8 METs) in those hospitalized compared with those not hospitalized (8.0±2.4 METs; P < .001). In addition, peak METs were inversely associated with a 17% lower risk of hospitalization in an unadjusted analysis and 13% lower risk in an adjusted analysis for every 1 unit increase in METs, once again supporting the importance of CRF on major health outcomes, including risk for hospitalization due to COVID-19. Very recently, we suggested that physical activity (PA) may be important for immunity protection4Laddu D.R. Lavie C.J. Phillips S.A. Arena R. Physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (121) Google Scholar as evidence suggests that higher PA, such as running, is associated with significant reductions in mortality risk attributed to respiratory diseases, pneumonia, and aspiration pneumonia, including in those with DM.4Laddu D.R. Lavie C.J. Phillips S.A. Arena R. Physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (121) Google Scholar,5Lavie C.J. Lee D.C. Sui X. et al.Effects of running on chronic diseases and cardiovascular and all-cause mortality.Mayo Clin Proc. 2015; 90: 1541-1552Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar However, considering the low level of PA in our society,1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar,6Ozemek C. Lavie C.J. Rognmo O. Global physical activity levels—need for intervention.Prog Cardiovasc Dis. 2019; 62: 102-107Crossref PubMed Scopus (96) Google Scholar resulting in low levels of CRF, we recently suggested that the current state of physical inactivity and COVID-19 is a tale of 2 pandemics, highlighting how COVID-19 and global trends in physical inactivity and sedentary behavior are affected by one another.7Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (359) Google Scholar Indeed, regular PA and exercise have been shown to improve health and may be effective in reducing the occurrence, severity, and duration of respiratory tract infections.8Grande A.J. Keogh J. Silva V. Scott A.M. Exercise versus no exercise for the occurrence, severity, and duration of acute respiratory infections.Cochrane Database Syst Rev. 2020; 4: CD010596PubMed Google Scholar Also, we recently formed an organization for the global path forward, Healthy Living for Pandemic Event Protection (HL-PIVOT), whose overarching goal is to improve global health and to protect individuals from the risks associated with chronic disease and viral infections.9Arena R. Lavie C.J. HL-PIVOT NetworkThe global path forward—Healthy Living for Pandemic Event Protection (HL-PIVOT).Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (33) Google Scholar Improving exercise capacity, namely, CRF, is an important target to reduce CVD risk as lower CRF levels are clearly associated with increased incidence of CVD.1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar The severity of COVID-19 is also considerably worse in those individuals with a history of CVD or DM.10Aggarwal G. Cheruiyot I. Aggarwal S. et al.Association of cardiovascular disease with coronavirus disease 2019 (COVID-19) severity: a meta-analysis.Curr Probl Cardiol. 2020; 45: 100617Crossref PubMed Scopus (83) Google Scholar,11Aggarwal G. Lippi G. Lavie C.J. Henry B.M. Sanchis-Gomar F. Diabetes mellitus association with coronavirus disease 2019 (COVID-19) severity and mortality: a pooled analysis.J Diabetes. 2020; 12: 851-855Crossref PubMed Scopus (40) Google Scholar In this context, increasing PA and CRF may reduce CVD and DM risk and improve prognosis in these conditions,1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar,4Laddu D.R. Lavie C.J. Phillips S.A. Arena R. Physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (121) Google Scholar,5Lavie C.J. Lee D.C. Sui X. et al.Effects of running on chronic diseases and cardiovascular and all-cause mortality.Mayo Clin Proc. 2015; 90: 1541-1552Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar,7Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (359) Google Scholar, 8Grande A.J. Keogh J. Silva V. Scott A.M. Exercise versus no exercise for the occurrence, severity, and duration of acute respiratory infections.Cochrane Database Syst Rev. 2020; 4: CD010596PubMed Google Scholar, 9Arena R. Lavie C.J. HL-PIVOT NetworkThe global path forward—Healthy Living for Pandemic Event Protection (HL-PIVOT).Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (33) Google Scholar including during COVID-19 and future pandemics. We have recently discussed in Mayo Clinic Proceedings that patients with obesity have a considerably worse prognosis during COVID-19.12Sanchis-Gomar F. Lavie C.J. Mehra M.R. Henry B.M. Lippi G. Obesity and outcomes in COVID-19: When an epidemic and pandemic collide.Mayo Clin Proc. 2020; 95: 1445-1453Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar,13Sharma A. Garg A. Rout A. Lavie C.J. Obesity is associated with more critical illness in COVID-19.Mayo Clin Proc. 2020; 95: 2040-2042Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar This Henry Ford COVID-19 population was quite obese, having a mean body mass index well into the obesity range.3Brawner C.A. Ehrman J.K. Bole S. et al.Maximal exercise capacity is inversely related to hospitalization secondary to coronavirus disease 2019.Mayo Clin Proc. 2021; 96: 32-39Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Improving PA and CRF may go a long way to reduce, to prevent, and to treat obesity in the first place as well as to prevent progression to more severe degrees14Lavie C.J. Laddu D. Arena R. Ortega F.B. Alpert M.A. Kushner R.F. Healthy weight and obesity prevention: JACC Health Promotion Series.J Am Coll Cardiol. 2018; 72: 1506-1531Crossref PubMed Scopus (223) Google Scholar and to improve prognosis in patients with obesity during COVID-19 and future pandemics.12Sanchis-Gomar F. Lavie C.J. Mehra M.R. Henry B.M. Lippi G. Obesity and outcomes in COVID-19: When an epidemic and pandemic collide.Mayo Clin Proc. 2020; 95: 1445-1453Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar,13Sharma A. Garg A. Rout A. Lavie C.J. Obesity is associated with more critical illness in COVID-19.Mayo Clin Proc. 2020; 95: 2040-2042Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar We have recently discussed the higher risk for the AA population during COVID-19,15Sanchis-Gomar F. Lippi G. Lavie C.J. Why is COVID-19 especially impacting the African American population?.Ann Med. 2020; 52: 331-333Crossref PubMed Scopus (5) Google Scholar partly explained by a higher risk of untreated or undertreated hypertension and DM as well as a much higher prevalence of obesity. In addition, we have recently discussed that the AA population often has lower levels of CRF compared with White individuals.16Swift D.L. Staiano A.E. Johannsen N.M. et al.Low cardiorespiratory fitness in African Americans: a health disparity risk factor?.Sports Med. 2013; 43: 1301-1313Crossref PubMed Scopus (35) Google Scholar, 17Swift D.L. Johannsen N.M. Earnest C.P. Newton Jr., R.L. McGee J.E. Church T.S. Cardiorespiratory fitness and exercise training in African Americans.Prog Cardiovasc Dis. 2017; 60: 96-102Crossref PubMed Scopus (18) Google Scholar, 18Lavie C.J. Kuruvanka T. Milani R.V. Prasad A. Ventura H.O. Exercise capacity in adult African-Americans referred for exercise stress testing: is fitness affected by race?.Chest. 2004; 126: 1962-1968Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Moreover, we have demonstrated that AA individuals may have a lower improvement in CRF after participation in an exercise training program compared with White individuals.17Swift D.L. Johannsen N.M. Earnest C.P. Newton Jr., R.L. McGee J.E. Church T.S. Cardiorespiratory fitness and exercise training in African Americans.Prog Cardiovasc Dis. 2017; 60: 96-102Crossref PubMed Scopus (18) Google Scholar,19Swift D.L. Johannsen N.M. Lavie C.J. et al.Racial differences in the response of cardiorespiratory fitness to aerobic exercise training in Caucasian and African American postmenopausal women.J Appl Physiol (1985). 2013; 114: 1375-1382Crossref PubMed Scopus (31) Google Scholar In this Henry Ford population, which was 75% AA, overall levels of CRF were low, only 7.5 METs, for a relatively young population in the mid to upper 50s at the time of the exercise assessment. Therefore, increasing levels of CRF, possibly with high-intensity interval training, could help reduce obesity, DM, and CVD in the AA population and improve prognosis in future pandemics.1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar,4Laddu D.R. Lavie C.J. Phillips S.A. Arena R. Physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (121) Google Scholar,5Lavie C.J. Lee D.C. Sui X. et al.Effects of running on chronic diseases and cardiovascular and all-cause mortality.Mayo Clin Proc. 2015; 90: 1541-1552Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar,7Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (359) Google Scholar, 8Grande A.J. Keogh J. Silva V. Scott A.M. Exercise versus no exercise for the occurrence, severity, and duration of acute respiratory infections.Cochrane Database Syst Rev. 2020; 4: CD010596PubMed Google Scholar, 9Arena R. Lavie C.J. HL-PIVOT NetworkThe global path forward—Healthy Living for Pandemic Event Protection (HL-PIVOT).Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (33) Google Scholar,12Sanchis-Gomar F. Lavie C.J. Mehra M.R. Henry B.M. Lippi G. Obesity and outcomes in COVID-19: When an epidemic and pandemic collide.Mayo Clin Proc. 2020; 95: 1445-1453Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar,14Lavie C.J. Laddu D. Arena R. Ortega F.B. Alpert M.A. Kushner R.F. Healthy weight and obesity prevention: JACC Health Promotion Series.J Am Coll Cardiol. 2018; 72: 1506-1531Crossref PubMed Scopus (223) Google Scholar In this context, we think that taking urgent measures to improve CRF in the AA population is needed to improve health in AAs, including for future pandemics. We applaud this Henry Ford group for undertaking this study and demonstrating the impact of CRF in COVID-19 prognosis. Clearly, this group and others may later study much larger cohorts to determine the impact of CRF on severe COVID-19 conditions, such as intensive care unit admissions, need for mechanical ventilators, and death, as well as the relative impact of fitness vs fatness in COVID-19 prognosis.3Brawner C.A. Ehrman J.K. Bole S. et al.Maximal exercise capacity is inversely related to hospitalization secondary to coronavirus disease 2019.Mayo Clin Proc. 2021; 96: 32-39Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Clearly, greater efforts are needed to improve PA as recent statistics demonstrate low levels of PA and high levels of sedentary behavior and physical inactivity in both adults and children worldwide.6Ozemek C. Lavie C.J. Rognmo O. Global physical activity levels—need for intervention.Prog Cardiovasc Dis. 2019; 62: 102-107Crossref PubMed Scopus (96) Google Scholar Increasing PA and overall fitness, both CRF and muscular fitness,1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar,20Martinez-Gomez D. Ortega F.B. Hamer M. et al.Physical activity and risk of metabolic phenotypes of obesity: a prospective Taiwanese cohort study in more than 200,000 adults.Mayo Clin Proc. 2019; 94: 2209-2219Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 21Bonikowske A.R. Lopez-Jimenez F. Physical activity: the secret—not so secret—to prevent and revert metabolic dysregulation in people of all sizes.Mayo Clin Proc. 2019; 94: 2164-2165Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 22Lavie C.J. Lee D. Ortega F.B. UK Biobank contributes to aerobic and muscle fitness research.Mayo Clin Proc. 2020; 95: 840-842Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 23Wang Y. Lee D.C. Brellenthin A.G. et al.Association of muscular strength and incidence of type 2 diabetes.Mayo Clin Proc. 2019; 94: 643-651Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 24Jimenez-Pavon D. Brellenthin A.G. Lee D.C. Sui X. Blair S.N. Lavie C.J. Role of muscular strength on the risk of sudden cardiac death in men.Mayo Clin Proc. 2019; 94: 2589-2591Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar is an essential approach to preventing CVD and adverse CVD outcomes1Lavie C.J. Ozemek C. Carbone S. Katzmarzyk P.T. Blair S.N. Sedentary behavior, exercise, and cardiovascular health.Circ Res. 2019; 124: 799-815Crossref PubMed Scopus (487) Google Scholar,20Martinez-Gomez D. Ortega F.B. Hamer M. et al.Physical activity and risk of metabolic phenotypes of obesity: a prospective Taiwanese cohort study in more than 200,000 adults.Mayo Clin Proc. 2019; 94: 2209-2219Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,21Bonikowske A.R. Lopez-Jimenez F. Physical activity: the secret—not so secret—to prevent and revert metabolic dysregulation in people of all sizes.Mayo Clin Proc. 2019; 94: 2164-2165Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,23Wang Y. Lee D.C. Brellenthin A.G. et al.Association of muscular strength and incidence of type 2 diabetes.Mayo Clin Proc. 2019; 94: 643-651Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar,24Jimenez-Pavon D. Brellenthin A.G. Lee D.C. Sui X. Blair S.N. Lavie C.J. Role of muscular strength on the risk of sudden cardiac death in men.Mayo Clin Proc. 2019; 94: 2589-2591Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar as well as probably improving prognosis in future pandemics,4Laddu D.R. Lavie C.J. Phillips S.A. Arena R. Physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (121) Google Scholar,7Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (359) Google Scholar, 8Grande A.J. Keogh J. Silva V. Scott A.M. Exercise versus no exercise for the occurrence, severity, and duration of acute respiratory infections.Cochrane Database Syst Rev. 2020; 4: CD010596PubMed Google Scholar, 9Arena R. Lavie C.J. HL-PIVOT NetworkThe global path forward—Healthy Living for Pandemic Event Protection (HL-PIVOT).Prog Cardiovasc Dis. 2020; ([Online ahead of print])Crossref Scopus (33) Google Scholar supporting our assertion that “fit is it!” Inverse Relationship of Maximal Exercise Capacity to Hospitalization Secondary to Coronavirus Disease 2019Mayo Clinic ProceedingsVol. 96Issue 1PreviewTo investigate the relationship between maximal exercise capacity measured before severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalization due to coronavirus disease 2019 (COVID-19). Full-Text PDF Cardiorespiratory Fitness Attenuates the Impact of Risk Factors Associated With COVID-19 HospitalizationMayo Clinic ProceedingsVol. 96Issue 3PreviewAs highlighted in the editorial “Fit Is It in COVID-19, Future Pandemics, and Overall Healthy Living,” published in the January 2021 issue of the Mayo Clinic Proceedings, it is important to bring more awareness to cardiorespiratory fitness (CRF) as an independent predictor of morbidity and mortality.1 To that end, we present additional data regarding the interaction of CRF with the traditional risk factors often associated with increased illness severity from coronavirus disease 2019 (COVID-19). Full-Text PDF In Reply — Cardiorespiratory Fitness Attenuates the Impact of Risk Factors Associated With COVID-19 HospitalizationMayo Clinic ProceedingsVol. 96Issue 3PreviewWe appreciate the interest by Kerrigan et al1 regarding the cardiorespiratory fitness (CRF) editorial that we wrote about their Henry Ford Hospital CRF and coronavirus disease 2019 (COVID -19) study.2 This small study of only 246 patients did not show increased risk of obesity for hospitalizations in their univariate analysis, and in the multivariate analysis, there was an obesity paradox, with the obese having a 43% lower risk of requiring hospitalizations. Full-Text PDF