Cardiorespiratory fitness and lifestyle on severe COVID-19 risk in 279,455 adults: a case control study
Elin Ekblom-Bak, Daniel Väisänen, Björn Ekblom, Victoria Blom, Lena V Kallings, Erik Hemmingsson, Gunnar Andersson, Peter Wallin, Jane Salier Eriksson, Tobias Holmlund, Magnus Lindwall, Andreas Stenling, Amanda Lönn
International Journal of Behavioral Nutrition and Physical Activity, doi:10.1186/s12966-021-01198-5
Background: The impact of cardiorespiratory fitness (CRF) and other lifestyle-related factors on severe COVID-19 risk is understudied. The present study aims to investigate lifestyle-related and socioeconomic factors as possible predictors of COVID-19, with special focus on CRF, and to further study whether these factors may attenuate obesity-and hypertension-related risks, as well as mediate associations between socioeconomic factors and severe COVID-19 risk. Methods: Out of initially 407,131 participants who participated in nationwide occupational health service screening between 1992 and 2020, n = 857 cases (70% men, mean age 49.9 years) of severe COVID-19 were identified. CRF was estimated using a sub-maximum cycle test, and other lifestyle variables were self-reported. Analyses were performed including both unmatched, n = 278,598, and sex-and age-matched, n = 3426, controls. Severe COVID-19 included hospitalization, intensive care or death due to COVID-19. Results: Patients with more severe COVID-19 had significantly lower CRF, higher BMI, a greater presence of comorbidities and were more often daily smokers. In matched analyses, there was a graded decrease in odds for severe COVID-19 with each ml in CRF (OR = 0.98, 95% CI 0.970 to 0.998), and a two-fold increase in odds between the lowest and highest (< 32 vs. ≥ 46 ml•min −1 •kg −1 ) CRF group. Higher BMI (per unit increase, OR = 1.09, 1.06 to 1.12), larger waist circumference (per cm, OR = 1.04, 1.02 to 1.06), daily smoking (OR = 0.60, 0.41 to 0.89) and high overall stress (OR = 1.36, 1.001 to 1.84) also remained significantly associated with severe COVID-19 risk. Obesity-and blood pressure-related risks were attenuated by adjustment for CRF and lifestyle variables. Mediation through CRF, BMI and smoking accounted for 9% to 54% of the associations between low education, low income and blue collar/low skilled occupations and severe COVID-19 risk. The results were consistent using either matched or unmatched controls. Conclusions: Both lifestyle-related and socioeconomic factors were associated with risk of severe COVID-19. However, higher CRF attenuated the risk associated with obesity and high blood pressure, and mediated the risk associated with various socioeconomic factors. This emphasises the importance of interventions to maintain or increase CRF in the general population to strengthen the resilience to severe COVID-19, especially in high-risk individuals.
Table 5 Indirect effects of socioeconomic factors on severe COVID-19 in matched analyses Adjusted for sex, age, year HPA was performed, civil status, country of birth, and number of previous diseases as confounders of the exposure-mediator, exposureoutcome, and mediator-outcome relation a Smoking was coded as a binary variable (0 = never/seldom, 1 = daily smoker) ab Indirect effect, HPD CI Highest posterior density credibility interval, BMI Body mass index, CRF Cardiorespiratory fitness, Q Quartile, WCHS White-collar high-skilled, WCLS White-collar low-skilled, BCLS Blue-collar low-skilled, BCHS Blue-collar high-skilled
Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12966-021-01198-5.
Additional file 1:
Authors' information Not applicable. Authors' contributions EEB, AL, VB, LVK, BE, GA, PW contributed to the conception or design of the work. EEB, AL, DV, EH, JSE, ML, AS, TH contributed to the acquisition, analysis, or interpretation of data for the work. EEB, AL, VB, LVK, BE, EH drafted the manuscript. DV, GA, PW, JSE, ML, AS, TH revised it critically for important intellectual content. All authors critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The corresponding author, EEB, is the manuscripts..
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