Int J Infect
Int J Infect

article information

International Journal of Infection: Vol.9, issue 2; e118853
published online: April 10, 2022
article type: Research Article
received: August 24, 2021
revised: December 24, 2021
accepted: February 21, 2022
DOI: https://doi.org/10.5812/iji.118853
Crossmark

The Association Between Physical Activity Level of CVD Patients and Rate of Covid-19 Incidence

authors:

avatar Rastegar Hoseini ORCID 1 , * , avatar Zahra Hoseini ORCID 1 , avatar Elahe Bahmani ORCID 1 , avatar Mahsa Ahmadi Darmian ORCID 1

Department of Exercise Physiology, Faculty of Sport Sciences, Razi University, Kermanshah, Iran

how to cite: Hoseini R, Hoseini Z, Bahmani E, Ahmadi Darmian M. The Association Between Physical Activity Level of CVD Patients and Rate of Covid-19 Incidence. Int J Infect. 2022;9(2):e118853. https://doi.org/10.5812/iji.118853.

Abstract

Background:

Decreased physical activity level (PAL) and consequent lifestyle alterations might induce cardiovascular diseases (CVDs). Like many other chronic diseases, CVD attenuates the immune system, which in turn can affect the rate of COVID-19 infection and its severity.

Objectives:

This study aims to investigate the association between PAL and the rate of COVID-19 incidence in CVD patients.

Methods:

The statistical population of this descriptive cross-sectional study included all CVD patients in Kermanshah, among which 727 individuals (371 men and 356 women) were randomly selected as the statistical sample. The International Physical Activity Questionnaire (IPAQ-SF) was used to assess the PAL. The independent t-test was used to compare men and women. Also, the association between variables was evaluated by the Pearson correlation coefficient test (using SPSS 24 at the significance level of P < 0.05).

Results:

No significant differences were observed in the PAL and the incidence of COVID-19 between men and women. There is also a significant positive association between low and severe PAL and the incidence of COVID-19 in men and women suffering from CVD. However, there was a significant inverse association between moderate PAL and the incidence of COVID-19.

Conclusions:

This study demonstrated that moderate PAL might prevent or reduce the severity of COVID-19 in CVD patients by strengthening the immune system.

1. Background

Cardiovascular diseases (CVDs), like many other chronic diseases, are closely related to lifestyle, mental health, and quality of life, which can lead to other diseases if not controlled (1). In 2016, according to the World Health Organization (WHO), CVDs accounted for 56.9% of 15.2 million deaths, i.e., almost one in three (2). Also, the prevalence of CVDs is higher in the Middle East than in other parts of the world (3). Epidemiological studies in Iran and the United Arab Emirates indicated that the prevalence of CVDs will reach 5.9% (4). Lifestyle alteration has led to the widespread prevalence of obesity and overweight, which is the most important risk factor for CVDs (5, 6). According to the literature, physical activity level (PAL) and exercise are simple and low-cost non-pharmacological interventions to prevent risk factors for CVD and improve the quality of life of CVD patients (7). Studies have shown that increased PAL reduces the inflammatory biomarkers and CVD risk factors (8, 9). On the other hand, in late December 2019, the first variant of the new coronavirus, COVID-19, was identified (10). According to the literature, age and underlying diseases, including hypertension, diabetes, CVD, etc., are closely related to the severity of COVID-19 and the occurrence of the acute respiratory syndrome (11, 12). The low PAL induced by COVID-19 quarantine increases the risk factors for CVDs (13). Until finding a definitive cure, strengthening the immune system is one way to prevent or minimize the adverse effects of COVID-19, which can be achieved by promoting PAL (14). Exercise has positive effects on the immune system and has been shown to decrease the negative effects of COVID-19 quarantine on the immune system. Regular exercise not only increases the ability to perform daily tasks and functional capacity but also strengthens the immune system of CVD patients (15, 16). Due to the novelty of the coronavirus, so far, limited scientific studies have evaluated the effect of exercise on COVID-19, particularly in CVD patients.

2. Objectives

Considering the importance and role of PAL in preventing or minimizing the risk of infectious diseases in CVD patients, this study aimed to investigate the association between the COVID-19 incidence and PAL in CVD patients during the COVID-19 outbreak.

3. Methods

3.1. Study Design

The statistical population of this cross-sectional-descriptive study consisted of all patients with CVD in Kermanshah. Using Cochran's sample size formula, with a 95% confidence level and 99% test power, the sample size was determined as 384 subjects. The questionnaire was sent to 870 available samples, of which 727 individuals filled the questionnaire (371 men and 356 women).

3.2. Population

Inclusion criteria included: Men or women aged ≥ 30 years and ≤ 70 years, diagnosis of hypertension (i.e., systolic and diastolic blood pressure over 140 and 90 mmHg) or using blood pressure-lowering medications, stable typical or atypical symptoms consisting of jaw pain, chest pain, shoulder pain, palpitations, chest tightness, chest burning, non-chest pain symptoms (e.g., dyspnea or worsening effort tolerance), atherosclerosis diagnosis, and angina diagnosis using computerized tomography (CT) scan or magnetic resonance angiography (MRA). Also, the exclusion criteria were: Partially filled questionnaires, smoking, having other cardiac problems such as arrhythmia and valvular disease. The objectives and importance of the research were explained to the participants before answering the questionnaires; observing ethical considerations was also assured (Figure 1).

Flow chart of the study population
Flow chart of the study population
Figure 1.

Flow chart of the study population

3.3. International Physical Activity Questionnaire

International Physical Activity Questionnaire (IPAQ-SF) is designed to collect information on the time spent being physically active during the last week in four categories: Vigorous-intensity, moderate-intensity, walking, and sitting (17, 18). The activity patterns in each category should be multiplied by their estimated value in Metabolic Equivalent of Tasks (METs). Then, the scores of four categories were summed to estimate the overall physical activity in a week. The MET intensity values were 8 METs in vigorous, 4 METs in moderate, 3.3 METs in walking, and 1 METs in sitting (19). PAL scores > 3000 were considered as high, between 600 - 3000 as moderate, and < 600 as low (20). Kelishadi et al. confirmed the validity and reliability of the questionnaire in a sample of Iranians (21).

3.4. Statistical Analysis

Data analysis was administered using SPSS version 24. Statistical significance was considered when the P-value < 0.05. The Pearson correlation coefficient and independent t-test were used to evaluate the association between variables and to compare the mean value of variables between men and women, respectively.

4. Results

Table 1 shows the demographic characteristics, PAL, and the incidence of COVID-19. The results show that women have lower PAL than men; women also had a higher incidence of COVID-19 (Table 1).

Table 1.

Demographic Characteristics of Participants

VariablesMen (n = 356)Women (n = 371)
Age (y)43.70 ± 8.3446.18 ± 6.32
Height (cm)171.03 ± 11.14160.23 ± 7.17
Weight (kg)83.24 ± 8.1676.44 ± 5.23
BMI (kg/m2)28.46 ± 6.2429.85 ± 4.46
PAL (MET) 1023.11 ± 23.12982.32 ± 29.15
Incidence of COVID-19 (%)52.0252.52

The results indicate that most CVD patients with COVID-19 had low PAL, while a lower percentage of them had moderate PAL. Interestingly, most non-infected CVD men and women had moderate PAL (Figure 2).

The rate of COVID-19 incidence based on PAL
The rate of COVID-19 incidence based on PAL
Figure 2.

The rate of COVID-19 incidence based on PAL

Also, there was a significant positive association between low and high PALs and the incidence of COVID-19 in men and women with CVDs. There was a significant inverse association between moderate PAL and the incidence of COVID-19 (Table 2).

Table 2.

The Relationship Between the PALs and the Incidence of COVID-19

Incidence of COVID-19PALs
MenWomen
LowModerateHighLowModerateHigh
r0.723-0.7840.4350.626-0.8210.491
P0.024 a0.016 a0.042 a0.031 a0.001 a0.039 a

aSignificant association with the incidence of COVID-19

5. Discussion

The overall mean physical activity level (PAL) of the subjects was moderate. Although not statistically significant, the PAL was higher in men than women. According to results of previous studies, various exercise activities (e.g., resistance, aerobic, and combined) increase the cardiovascular fitness of men and women at all ages (from childhood to elderly age), which indicates a direct association between physical activity and risk factors for CVDs (22, 23). Physical activity, on the one hand, strengthens the autonomic system (sympathetic/parasympathetic imbalance) function and, on the other hand, reduces the disturbance of ventricular repolarization, leading to attenuated ventricular function and sudden death (22, 24). Also, physical activity reduces the risk of cardiac arrhythmias by improving endothelial function, reducing platelet adhesion, and modifying the autonomic system (24). The findings showed that most CVD patients (both men and women) with COVID-19 had low PAL. However, a lower percentage of CVD patients with moderate PAL were infected with COVID-19.

In other words, the present study showed that most non-COVID-19 CVD patients had moderate PAL. According to previous studies, moderate PAL reduces the risk of infectious diseases, including viral and bacterial infections (25, 26). Moderate PAL also affects the immune system by invoking lymphoid from the tissue stores of myokines, glucocorticoids, and hormones (e.g., enkephalin) (27). This evidence demonstrates the ability of moderate PAL in improving the immune responses to infections and cancer and maintaining the immune system (28, 29). Interestingly, our results also show a significantly positive relationship between the incidence of COVID-19 with low and high (vigorous) PAL in both men and women with CVD. According to previous studies, high PAL leads to inadequate recovery and may cause temporal immunosuppression (attenuating the immune system) state (30). Vigorous exercise can alter or suppress some immune parameters, such as circulating leukocytes, plasma cytokine concentrations, salivary immunoglobulin A secretion, macrophage, and neutrophil xenophobia. Therefore, high PAL is associated with an increased risk of infection (30, 31). Previous studies indicate decreased immune system parameters (e.g., serum immunoglobulin) and antibody production following vigorous exercise (32). There are different mechanisms associated with the effect of PAL on antibodies and serum immunoglobulins. The difference in the ratio of antibody secretion and degradation might be due to the change in the concentration of serum antibodies that could be due to vascular abnormalities. On the other hand, exercise increases the lymph flow, leading to altered protein entrance to the bloodstream (33). Also, the half-life of serum immunoglobulins is affected by the exercise variables (including severity and duration), resulting in a difference in the number of antibodies and serum immunoglobulins (34).

5.1. Conclusions

In general, moderate PAL is associated with a lower incidence of COVID-19, probably by strengthening the immune system. Thus, it is recommended that individuals with underlying diseases (e.g., CVD) have moderate PAL during COVID-19 quarantine while observing COVID-19 restriction protocols.

Acknowledgements

References

  • 1.

    Didem A, Unal A, Alaettin U, Mustafa T. Prevalence of hypertension among individuals aged 50 years and over and its impact on health related quality of life in a semi-rural area of western Turkey. Chin Med J. 2008;121(16):1524-31. https://doi.org/10.1097/00029330-200808020-00005.

  • 2.

    Kaptoge S, Pennells L, De Bacquer D, Cooney MT, Kavousi M, Stevens G, et al. World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions. Lancet Glob Health. 2019;7(10):e1332-45. https://doi.org/10.1016/s2214-109x(19)30318-3.

  • 3.

    Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol. 2018;17(1):83. [PubMed ID: 29884191]. [PubMed Central ID: PMC5994068]. https://doi.org/10.1186/s12933-018-0728-6.

  • 4.

    Teo K, Lear S, Islam S, Mony P, Dehghan M, Li W, et al. Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. JAMA. 2013;309(15):1613-21. [PubMed ID: 23592106]. https://doi.org/10.1001/jama.2013.3519.

  • 5.

    Forman D, Bulwer BE. Cardiovascular disease: optimal approaches to risk factor modification of diet and lifestyle. Curr Treat Options Cardiovasc Med. 2006;8(1):47-57. [PubMed ID: 16401383]. https://doi.org/10.1007/s11936-006-0025-7.

  • 6.

    Gupta BP, Murad MH, Clifton MM, Prokop L, Nehra A, Kopecky SL. The effect of lifestyle modification and cardiovascular risk factor reduction on erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med. 2011;171(20):1797-803. [PubMed ID: 21911624]. https://doi.org/10.1001/archinternmed.2011.440.

  • 7.

    Elagizi A, Kachur S, Lavie CJ, Carbone S, Pandey A, Ortega FB, et al. An Overview and Update on Obesity and the Obesity Paradox in Cardiovascular Diseases. Prog Cardiovasc Dis. 2018;61(2):142-50. [PubMed ID: 29981771]. https://doi.org/10.1016/j.pcad.2018.07.003.

  • 8.

    Beavers KM, Ambrosius WT, Nicklas BJ, Rejeski WJ. Independent and combined effects of physical activity and weight loss on inflammatory biomarkers in overweight and obese older adults. J Am Geriatr Soc. 2013;61(7):1089-94. [PubMed ID: 23772804]. [PubMed Central ID: PMC3714323]. https://doi.org/10.1111/jgs.12321.

  • 9.

    Hamer M, Ingle L, Carroll S, Stamatakis E. Physical activity and cardiovascular mortality risk: possible protective mechanisms? Med Sci Sports Exerc. 2012;44(1):84-8. [PubMed ID: 21659902]. https://doi.org/10.1249/MSS.0b013e3182251077.

  • 10.

    Wu JT, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet. 2020;395(10225):689-97. [PubMed ID: 32014114]. [PubMed Central ID: PMC7159271]. https://doi.org/10.1016/S0140-6736(20)30260-9.

  • 11.

    Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-13. [PubMed ID: 32007143]. [PubMed Central ID: PMC7135076]. https://doi.org/10.1016/S0140-6736(20)30211-7.

  • 12.

    Huang X, Wei F, Hu L, Wen L, Chen K. Epidemiology and Clinical Characteristics of COVID-19. Arch Iran Med. 2020;23(4):268-71. [PubMed ID: 32271601]. https://doi.org/10.34172/aim.2020.09.

  • 13.

    Ceriello A, Standl E, Catrinoiu D, Itzhak B, Lalic NM, Rahelic D, et al. Issues of Cardiovascular Risk Management in People With Diabetes in the COVID-19 Era. Diabetes Care. 2020;43(7):1427-32. [PubMed ID: 32409501]. https://doi.org/10.2337/dc20-0941.

  • 14.

    Carter SJ, Baranauskas MN, Fly AD. Considerations for Obesity, Vitamin D, and Physical Activity Amid the COVID-19 Pandemic. Obesity (Silver Spring). 2020;28(7):1176-7. [PubMed ID: 32299148]. [PubMed Central ID: PMC7311254]. https://doi.org/10.1002/oby.22838.

  • 15.

    Metsios GS, Stavropoulos-Kalinoglou A, Veldhuijzen van Zanten JJ, Treharne GJ, Panoulas VF, Douglas KM, et al. Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review. Rheumatology (Oxford). 2008;47(3):239-48. [PubMed ID: 18045810]. https://doi.org/10.1093/rheumatology/kem260.

  • 16.

    Federighi Baisi Chagas E, Biteli P, Moreira Candeloro B, Angelo Rodrigues M, Henrique Rodrigues P. Physical exercise and COVID-19: a summary of the recommendations. AIMS Bioengineering. 2020;7(4):236-41. https://doi.org/10.3934/bioeng.2020020.

  • 17.

    Acs P, Betlehem J, Olah A, Bergier J, Melczer C, Premusz V, et al. Measurement of public health benefits of physical activity: validity and reliability study of the international physical activity questionnaire in Hungary. BMC Public Health. 2020;20(Suppl 1):1198. [PubMed ID: 32799846]. [PubMed Central ID: PMC7429907]. https://doi.org/10.1186/s12889-020-08508-9.

  • 18.

    Lavelle G, Noorkoiv M, Theis N, Korff T, Kilbride C, Baltzopoulos V, et al. Validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF) as a measure of physical activity (PA) in young people with cerebral palsy: A cross-sectional study. Physiotherapy. 2020;107:209-15. [PubMed ID: 32026822]. https://doi.org/10.1016/j.physio.2019.08.013.

  • 19.

    Tran VD, Do VV, Pham NM, Nguyen CT, Xuong NT, Jancey J, et al. Validity of the International Physical Activity Questionnaire-Short Form for Application in Asian Countries: A Study in Vietnam. Eval Health Prof. 2020;43(2):105-9. [PubMed ID: 32383410]. https://doi.org/10.1177/0163278718819708.

  • 20.

    Damirchi A, Mehrabani J, Mousavi F. The Relationship between Obesity, Overweight and Demographic Factors with Physical Activity in 18-69 Year-Old Adults in Rasht City. Iran J Endocrinol Metab. 2013;15(4):378-86. eng.

  • 21.

    Kelishadi R, Ardalan G, Gheiratmand R, Gouya MM, Razaghi EM, Delavari A, et al. Association of physical activity and dietary behaviours in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN Study. Bull World Health Organ. 2007;85(1):19-26. [PubMed ID: 17242754]. [PubMed Central ID: PMC2636217]. https://doi.org/10.2471/blt.06.030783.

  • 22.

    Pollock ML, Franklin BA, Balady GJ, Chaitman BL, Fleg JL, Fletcher B, et al. AHA Science Advisory. Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription: An advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association; Position paper endorsed by the American College of Sports Medicine. Circulation. 2000;101(7):828-33. [PubMed ID: 10683360]. https://doi.org/10.1161/01.cir.101.7.828.

  • 23.

    Grossman DC, Bibbins-Domingo K, Curry SJ, Barry MJ, Davidson KW; U. S. Preventive Services Task Force, et al. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Risk Factors: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;318(2):167-74. [PubMed ID: 28697260]. https://doi.org/10.1001/jama.2017.7171.

  • 24.

    Lavie CJ, Milani RV. Cardiac rehabilitation and exercise training in secondary coronary heart disease prevention. Prog Cardiovasc Dis. 2011;53(6):397-403. [PubMed ID: 21545925]. https://doi.org/10.1016/j.pcad.2011.02.008.

  • 25.

    Warburton DER, Bredin SSD. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol. 2017;32(5):541-56. [PubMed ID: 28708630]. https://doi.org/10.1097/HCO.0000000000000437.

  • 26.

    Pape K, Ryttergaard L, Rotevatn TA, Nielsen BJ, Torp-Pedersen C, Overgaard C, et al. Leisure-Time Physical Activity and the Risk of Suspected Bacterial Infections. Med Sci Sports Exerc. 2016;48(9):1737-44. [PubMed ID: 27187103]. https://doi.org/10.1249/MSS.0000000000000953.

  • 27.

    Drela N, Kozdron E, Szczypiorski P. Moderate exercise may attenuate some aspects of immunosenescence. BMC Geriatr. 2004;4:8. [PubMed ID: 15456521]. [PubMed Central ID: PMC524506]. https://doi.org/10.1186/1471-2318-4-8.

  • 28.

    Lowder T, Padgett DA, Woods JA. Moderate exercise protects mice from death due to influenza virus. Brain Behav Immun. 2005;19(5):377-80. [PubMed ID: 15922557]. https://doi.org/10.1016/j.bbi.2005.04.002.

  • 29.

    Hojman P, Dethlefsen C, Brandt C, Hansen J, Pedersen L, Pedersen BK. Exercise-induced muscle-derived cytokines inhibit mammary cancer cell growth. Am J Physiol Endocrinol Metab. 2011;301(3):E504-10. [PubMed ID: 21653222]. https://doi.org/10.1152/ajpendo.00520.2010.

  • 30.

    Mohammadi M, Siavoshi H, Naderi A, Panah Abadi M, Maleki M. A review of cardiac rehabilitation and exercise in cardiovascular disease. J Crit Rev. 2020;7(1). https://doi.org/10.31838/jcr.07.01.32.

  • 31.

    Shirvani H, Nikbakht H, Ebrahim Kh GA. The effects of soccer specific exercise and Taurine supplementation on serum cytokine response in male elite soccer players. Ann Biol Res. 2012;3(9):4420-6.

  • 32.

    Ghaderi M, Azarbayjani M, Atashak S, Molanouri-Shamsi M, Mokari-Saei S, Sharafi H. The Effect of maximal progressive exercise on serum cortisol & immunoglobulin a responses in young elite athletes. Ann Biol Res. 2011;2(6):456-63.

  • 33.

    Thomas NE, Leyshon A, Hughes MG, Jasper MA, Davies B, Graham MR, et al. Concentrations of salivary testosterone, cortisol, and immunoglobulin A after supra-maximal exercise in female adolescents. J Sports Sci. 2010;28(12):1361-8. [PubMed ID: 20853205]. https://doi.org/10.1080/02640414.2010.510144.

  • 34.

    Sun H, Wang M, Dang R, Qin P, Zhou L, Zhang Y. Effects of comprehensive treatment of aerobic exercise and medicine on levels of serum immunoglobulins and cytokines in rats with chronic abacterial prostatitis. Chongqing Medicine. 2017;46(27):3767-9.