Exercise for COVID-19: real-time analysis of all 39 studies

Exercise for COVID-19: real-time meta analysis of 33 studies

Covid Analysis (Preprint) (meta analysis)

• Statistically significant improvements are seen for mortality, ventilation, ICU admission, hospitalization, recovery, and cases. 26 studies from 26 independent teams in 14 different countries show statistically significant improvements in isolation (19 for the most serious outcome).

• Meta analysis using the most serious outcome reported shows 39% [31‑46%] improvement. Results are similar after exclusions and similar for peer-reviewed studies.

• Results are robust — in exclusion sensitivity analysis 28 of 33 studies must be excluded to avoid finding statistically significant efficacy in pooled analysis.

• Results are consistent with the overall risk of all cause mortality based on cardiorespiratory fitness — [Laukkanen] show RR 0.55 [0.50-0.61] for the top vs. bottom tertiles.

• Studies analyze exercise/physical activity levels before infection, comparing regular/moderate exercise vs. lower/no exercise. Note that risk may increase with more extreme activity levels.

• No treatment, vaccine, or intervention is 100% available and effective for all variants. All practical, effective, and safe means should be used. Denying the efficacy of treatments increases mortality, morbidity, collateral damage, and endemic risk.

• All data to reproduce this paper and sources are in the appendix. [Rahmati] present another meta analysis for exercise, showing significant improvements for mortality, ICU admission, and hospitalization.

Covid Analysis et al., 5/20/2022, preprint, 1 author.

Causal relationship between physical activity, leisure sedentary behaviors and COVID-19 risk: a Mendelian randomization study

Chen et al., Journal of Translational Medicine, doi:10.1186/s12967-022-03407-6

UK Biobank Mendelian randomization study showing decreased risk of COVID-19 hospitalization with genetically predicted accelerometer-assessed physical activity, and increased risk with television watching.

Chen et al., 5/13/2022, United Kingdom, Europe, peer-reviewed, 7 authors.

Exercise Preferences and Benefits in Patients Hospitalized with COVID-19

Kontopoulou et al., Journal of Personalized Medicine, doi:10.3390/jpm12040645

Retrospective 66 hospitalized COVID-19 patients in Greece, showing significantly improved recovery with a history of exercise in unadjusted results. Exercise after hospitalization was also associated with lower levels of dyspnea one month post hospitalization.

recovery time, 66.2% lower, relative time 0.34, p < 0.001, high activity levels mean 22.0 (±14.0) n=42, low activity levels mean 65.0 (±32.0) n=24.

relative dyspnea after hospitalization, 66.7% better, RR 0.33, p < 0.001, high activity levels mean 1.0 (±1.0) n=42, low activity levels mean 3.0 (±1.0) n=24.

Excluded in after exclusion results of meta analysis: unadjusted results with no group details.

Kontopoulou et al., 4/17/2022, retrospective, Greece, Europe, peer-reviewed, survey, 4 authors, study period November 2020 - December 2020.

Health behaviours the month prior to COVID-19 infection and the development of self-reported long COVID and specific long COVID symptoms: A longitudinal analysis of 1,811 UK adults

Paul et al., medRxiv, doi:10.1101/2022.04.12.22273792 (Preprint)

Retrospective 1,811 COVID-19 patients in the UK, showing lower risk of self-reported long COVID with 3+ hours of exercise per week in the month before infection, without statistical significance (p=0.16).

risk of long COVID, 38.1% lower, RR 0.62, p = 0.16, adjusted, OR converted to RR, 3+ hours per week vs. none, multivariable, model 4, control prevalance approximated with overall prevalence.

risk of long COVID, 4.1% lower, RR 0.96, p = 0.89, adjusted, OR converted to RR, ≤2 hours per week vs. none, multivariable, model 4, control prevalance approximated with overall prevalence.

Paul et al., 4/13/2022, retrospective, United Kingdom, Europe, preprint, survey, 2 authors.

Baseline physical activity is associated with reduced mortality and disease outcomes in COVID‐19: A systematic review and meta‐analysis

Rahmati et al., Reviews in Medical Virology, doi:10.1002/rmv.2349 (meta analysis)

Meta analysis of 12 physical activity and COVID-19 studies, showing lower mortality, ICU admission, and hospitalization with physical activity.

risk of death, 53.0% lower, RR 0.47, p = 0.001.

risk of ICU admission, 35.0% lower, RR 0.65, p = 0.001.

risk of hospitalization, 42.0% lower, RR 0.58, p = 0.001.

Rahmati et al., 4/13/2022, peer-reviewed, 10 authors.

Influence of Baseline Physical Activity as a Modifying Factor on COVID-19 Mortality: A Single-Center, Retrospective Study

Salgado-Aranda et al., Infectious Diseases and Therapy, doi:10.1007/s40121-021-00418-6

Retrospective 520 COVID-19 patients in Spain, showing significantly lower mortality with a history of physical activity.

risk of death, 83.1% lower, HR 0.17, p = 0.003, high activity levels 4 of 223 (1.8%), low activity levels 41 of 297 (13.8%), NNT 8.3, active vs. sedentary, Cox proportional hazards.

Salgado-Aranda et al., 3/14/2022, retrospective, Spain, Europe, peer-reviewed, 15 authors, study period 15 February, 2020 - 15 April, 2020.

Socio-demographic, lifestyle and health characteristics as predictors of self-reported Covid-19 history among older adults: 2006-2020 Health and Retirement Study

Beydoun et al., American Journal of Infection Control, doi:10.1016/j.ajic.2022.02.021

Retrospective 2,830 people in the USA, showing lower risk of COVID-19 with a history of moderate/vigorous exercise.

risk of case, 43.0% lower, OR 0.57, p = 0.05, high activity levels 1,710, low activity levels 448, adjusted, multivariable, >1/week vs. none, model 2, RR approximated with OR.

risk of case, 62.0% lower, OR 0.38, p = 0.010, high activity levels 672, low activity levels 448, adjusted, multivariable, 1-4/mon vs. none, model 2, RR approximated with OR.

Beydoun et al., 3/12/2022, retrospective, USA, North America, peer-reviewed, survey, 7 authors.

Risk Factors for COVID-19 in College Students Identified by Physical, Mental, and Social Health Reported During the Fall 2020 Semester: Observational Study Using the Roadmap App and Fitbit Wearable Sensors

Gilley et al., JMIR Mental Health, doi:10.2196/34645

Retrospective survey of 1,997 college students in the USA, showing no significant difference in COVID-19 cases with exercise in unadjusted results.

risk of case, 41.8% higher, RR 1.42, p = 0.55, high activity levels 172 of 1,917 (9.0%), low activity levels 5 of 79 (6.3%), unadjusted.

Gilley et al., 2/10/2022, retrospective, USA, North America, peer-reviewed, survey, 21 authors, study period September 2020 - December 2020, trial NCT04766788.

Small steps, strong shield: directly measured, moderate physical activity in 65 361 adults is associated with significant protective effects from severe COVID-19 outcomes

Steenkamp et al., British Journal of Sports Medicine, doi:10.1136/bjsports-2021-105159

Retrospective 65,361 COVID-19 patients in South Africa, showing significantly lower ICU admission, ventilation, and mortality with exercise.

risk of death, 42.0% lower, RR 0.58, p < 0.001, high activity levels 29,469, low activity levels 13,366, adjusted, high activity vs. low activity, poisson regression, multivariable.

risk of mechanical ventilation, 45.0% lower, RR 0.55, p < 0.001, high activity levels 29,469, low activity levels 13,366, adjusted, high activity vs. low activity, poisson regression, multivariable.

risk of ICU admission, 41.0% lower, RR 0.59, p < 0.001, high activity levels 29,469, low activity levels 13,366, adjusted, high activity vs. low activity, poisson regression, multivariable.

Steenkamp et al., 2/9/2022, retrospective, South Africa, Africa, peer-reviewed, 10 authors, study period 19 March, 2020 - 30 June, 2021.

Reduced Sleep in the Week Prior to Diagnosis of COVID-19 is Associated with the Severity of COVID-19

Huang et al., Nature and Science of Sleep, doi:10.2147/NSS.S263488

Retrospective 164 COVID-19 patients and 188 controls in China, showing lower risk of cases with regular exercise.

risk of severe case, 46.8% lower, RR 0.53, p = 0.18, high activity levels 7 of 74 (9.5%), low activity levels 16 of 90 (17.8%), NNT 12, unadjusted, exercise habit, ≥1 time per week, excluded in exclusion analyses: unadjusted results with no group details.

risk of severe case, 8.0% lower, RR 0.92, p = 1.00, high activity levels 3 of 23 (13.0%), low activity levels 20 of 141 (14.2%), NNT 88, unadjusted, ≥30 minutes ≥3 times per week, excluded in exclusion analyses: unadjusted results with no group details.

risk of case, 65.9% lower, OR 0.34, p = 0.004, adjusted, case control OR, regular exercise, multivariable.

Huang et al., 11/30/2021, retrospective, China, Asia, peer-reviewed, survey, 5 authors, study period 10 February, 2020 - 28 March, 2020.

Associations of obesity, physical activity level, inflammation and cardiometabolic health with COVID-19 mortality: a prospective analysis of the UK Biobank cohort

Hamrouni et al., BMJ Open, doi:10.1136/bmjopen-2021-055003

Prospective UK Biobank analysis, showing a history of low physical activity associated with COVID-19 mortality.

risk of death, 29.0% lower, RR 0.71, p = 0.009, high activity levels 138 of 106,006 (0.1%), low activity levels 109 of 47,827 (0.2%), adjusted, OR converted to RR, high vs. low physical activity, multivariable.

Hamrouni et al., 11/3/2021, prospective, United Kingdom, Europe, peer-reviewed, 5 authors.

Associations of pre-pandemic levels of physical function and physical activity with COVID-19-like symptoms during the outbreak

Saadeh et al., Aging Clinical and Experimental Research, doi:10.1007/s40520-021-02006-7

Retrospective 904 patients in Sweden, showing higher risk of COVID-19-like symptoms with poor muscle strength. Risk was slightly higher for physical inactivity, without statistical significance.

risk of symptomatic case, 9.1% lower, OR 0.91, p = 0.71, high activity levels 362, low activity levels 225, adjusted, 2+ symptoms, Table 8, physically active vs. inactive, multivariable, RR approximated with OR.

risk of symptomatic case, 3.8% lower, OR 0.96, p = 0.85, high activity levels 362, low activity levels 225, adjusted, 1+ symptoms, Table 2, model 2, physically active vs. inactive, multivariable, RR approximated with OR.

Saadeh et al., 10/30/2021, retrospective, Sweden, Europe, peer-reviewed, 6 authors, study period March 2020 - June 2020.

Frailty but not sarcopenia nor malnutrition increases the risk of developing COVID-19 in older community-dwelling adults

Lengelé et al., Aging Clinical and Experimental Research, doi:10.1007/s40520-021-01991-z

Analysis of 241 adults >65yo in Belgium, showing lower risk of COVID-19 with a history of physical activity.

risk of case, 73.6% lower, RR 0.26, p = 0.03, high activity levels 23 of 229 (10.0%), low activity levels 4 of 12 (33.3%), NNT 4.3, OR converted to RR.

Lengelé et al., 10/23/2021, prospective, Belgium, Europe, peer-reviewed, median age 75.6, 8 authors, study period March 2020 - April 2021.

Cardiorespiratory fitness and lifestyle on severe COVID-19 risk in 279,455 adults: a case control study

Ekblom-Bak et al., International Journal of Behavioral Nutrition and Physical Activity, doi:10.1186/s12966-021-01198-5

Retrospective 857 severe COVID-19 cases and matched controls in Sweden, showing lower risk of severe COVID-19 with higher cardiorespiratory fitness.

risk of severe case, 47.6% lower, OR 0.52, p = 0.02, case control OR, model 3, high vs. very low CRF.

Ekblom-Bak et al., 10/19/2021, retrospective, Sweden, Europe, peer-reviewed, 13 authors.

Lifestyle and Comorbidity-Related Risk Factors of Severe and Critical COVID-19 Infection: A Comparative Study Among Survived COVID-19 Patients in Bangladesh

Mohsin et al., Infection and Drug Resistance, doi:10.2147/IDR.S331470

Retrospective 1,500 COVID+ patients in Bangladesh, showing lower risk of severe cases with regular exercise in unadjusted results.

risk of severe case, 19.0% lower, RR 0.81, p = 0.04, high activity levels 86 of 258 (33.3%), low activity levels 224 of 544 (41.2%), NNT 13, exercise >30 minutes.

risk of severe case, 0.9% higher, RR 1.01, p = 0.91, high activity levels 290 of 698 (41.5%), low activity levels 224 of 544 (41.2%), exercise <30 minutes.

Excluded in after exclusion results of meta analysis: unadjusted results with no group details.

Mohsin et al., 9/30/2021, retrospective, Bangladesh, South Asia, peer-reviewed, survey, 10 authors, study period November 2020 - April 2021.

Association of physical activity levels and the prevalence of COVID-19-associated hospitalization

de Souza et al., Journal of Science and Medicine in Sport, doi:10.1016/j.jsams.2021.05.011

Retrospective survey of 938 COVID-19 recovered patients in Brazil, showing lower hospitalization with physical activity. NCT04396353.

risk of mechanical ventilation, 73.2% lower, RR 0.27, p = 0.07, high activity levels 3 of 611 (0.5%), low activity levels 6 of 327 (1.8%), NNT 74, unadjusted, excluded in exclusion analyses: unadjusted results with no group details.

risk of hospitalization, 34.3% lower, RR 0.66, p = 0.046, high activity levels 49 of 611 (8.0%), low activity levels 42 of 327 (12.8%), NNT 21, adjusted, sufficient vs. insufficient, model 3, multivariable.

de Souza et al., 9/30/2021, retrospective, Brazil, South America, peer-reviewed, 8 authors, study period June 2020 - August 2020, trial NCT04396353.

Evaluation of the Relationship Between Daily Physical Activity Level and Laboratory Factors and the Length of Hospitalization in Patients with COVID-19

Ehsani et al., Middle East Journal of Rehabilitation and Health Studies, doi:10.5812/mejrh.114607

Retrospective 71 hospitalized COVID-19 patients in Iran, showing faster recovery with a history of moderate to high physical exercise.

Exercise was assessed during the last seven days when patients may already have had COVID-19 symptoms. Patients with higher severity may have been less likely to exercise, leading to confounding by indication.

recovery time, 61.1% lower, relative time 0.39, p < 0.001, high activity levels mean 8.03 (±2.79) n=33, low activity levels mean 20.62 (±3.25) n=38.

Excluded in meta analysis: exercise was assessed during the last seven days when patients may already have had COVID-19 symptoms. Patients with higher severity may have been less likely to exercise, leading to confounding by indication.

Ehsani et al., 9/22/2021, retrospective, Iran, Middle East, peer-reviewed, survey, 4 authors.

Predictors of incident SARS-CoV-2 infections in an international prospective cohort study

Lin et al., BMJ Open, doi:10.1136/bmjopen-2021-052025

Prospective survey analysis of 28,575 people in 99 countries, showing a lower risk of COVID-19 with a exercise, without statistical signifcance.

risk of case, 47.4% lower, OR 0.53, p = 0.40, exercise ≥1/month vs. exercise <1/month, RR approximated with OR.

Lin et al., 9/21/2021, prospective, multiple countries, multiple regions, peer-reviewed, survey, 19 authors, study period 26 March, 2020 - 8 October, 2020.

Single and Combinative Impacts of Healthy Eating Behavior and Physical Activity on COVID-19-like Symptoms among Outpatients: A Multi-Hospital and Health Center Survey

Nguyen et al., Nutrients, doi:10.3390/nu13093258

Analysis of 3,947 participants in Vietnam, showing significantly lower risk of COVID-19-like symptoms with physical activity and with a healthy diet. The combination of being physically active and eating healthy reduced risk further compared to either alone. The analyzed period was Feb 14 to Mar 2, 2020, which may have been before testing was widely available.

risk of symptomatic case, 20.3% lower, RR 0.80, p < 0.001, high activity levels 904 of 2,836 (31.9%), low activity levels 483 of 1,111 (43.5%), NNT 8.6, adjusted, OR converted to RR, active vs. inactive, COVID-19-like symptoms, multivariable.

risk of symptomatic case, 42.0% lower, OR 0.58, p < 0.001, adjusted, high HES and physically active, COVID-19-like symptoms, multivariable, RR approximated with OR.

Nguyen et al., 9/18/2021, retrospective, Vietnam, South Asia, peer-reviewed, survey, 17 authors, study period 14 February, 2020 - 2 March, 2020.

Lifestyle risk factors and infectious disease mortality, including COVID-19, among middle aged and older adults: Evidence from a community-based cohort study in the United Kingdom

Ahmadi et al., Brain, Behavior, and Immunity, doi:10.1016/j.bbi.2021.04.022

Retrospective 468,569 adults in the UK, showing no significant difference in COVID-19 mortality based on diet quality, however significantly lower mortality was seen with higher diet quality for pneumonia and infectious diseases.

risk of death, 30.0% lower, RR 0.70, p = 0.005, adjusted, sufficient vs. inactive, model 2, multivariable.

Ahmadi et al., 8/31/2021, retrospective, United Kingdom, Europe, peer-reviewed, 5 authors.

Risk Factors for SARS-CoV-2 Infection Severity in Abu Dhabi

Baynouna AlKetbi et al., Journal of Epidemiology and Global Health, doi:10.1007/s44197-021-00006-4

Retrospective 234 COVID-19 cases in the United Arab Emirates, showing lower risk of mortality with increased physical activity.

risk of death, 98.5% lower, OR 0.01, p = 0.049, adjusted, multivariable, RR approximated with OR.

Baynouna AlKetbi et al., 8/23/2021, retrospective, United Arab Emirates, Middle East, peer-reviewed, 16 authors.

Muscle strength explains the protective effect of physical activity against COVID-19 hospitalization among adults aged 50 years and older

Maltagliati et al., Journal of Sports Sciences, doi:10.1080/02640414.2021.1964721

Retrospective 3,139 adults >50 in Europe, with 66 COVID-19 hospitalizations, showing lower risk of hospitalization with higher physical activity and with higher muscle strength. Note that model 2 includes muscle strength which is correlated with physical activity [eurapa.biomedcentral.com].

1. eurapa.biomedcentral.com, https://eurapa.biomedcentral.com/articles/10.1186/s11556-021-00260-2.

risk of hospitalization, 52.0% lower, OR 0.48, p = 0.02, adjusted, model 1, more than once a week vs. hardly ever or never, multivariable, RR approximated with OR.

Maltagliati et al., 8/11/2021, retrospective, multiple countries, multiple regions, peer-reviewed, survey, 8 authors.

Physical activity and the risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 related mortality in South Korea: a nationwide cohort study

Lee et al., British Journal of Sports Medicine, doi:10.1136/bjsports-2021-104203

Retrospective 212,768 adults in South Korea, showing lower risk of COVID-19 cases, severity, and mortality with physical activity. Notably, results for aerobic and muscle strengthening activities combined were much better than results for either one in isolation.

risk of death, 74.0% lower, RR 0.26, p = 0.046, high activity levels 2 of 11,072 (0.0%), low activity levels 32 of 41,293 (0.1%), NNT 1683, adjusted, OR converted to RR, model 2,aerobic and muscle strengthening vs. insufficient aerobic and muscle strengthening, multivariable.

risk of severe case, 57.8% lower, RR 0.42, p = 0.03, high activity levels 39 of 11,072 (0.4%), low activity levels 273 of 41,293 (0.7%), adjusted, OR converted to RR, model 2,aerobic and muscle strengthening vs. insufficient aerobic and muscle strengthening, multivariable.

risk of case, 15.6% lower, RR 0.84, p = 0.03, high activity levels 291 of 11,072 (2.6%), low activity levels 1,293 of 41,293 (3.1%), NNT 199, adjusted, OR converted to RR, model 2,aerobic and muscle strengthening vs. insufficient aerobic and muscle strengthening, multivariable.

Lee et al., 7/22/2021, retrospective, South Korea, Asia, peer-reviewed, 25 authors, study period 1 January, 2020 - 31 July, 2020.

Nutritional and lifestyle changes required for minimizing the recovery period in home quarantined COVID-19 patients of Punjab, Pakistan

Rabail et al., Food Science & Nutrition, doi:10.1002/fsn3.2458

Survey of 80 recovered COVID-19 patients in Pakistan, showing faster recovery with higher physical activity before infection.

Rabail et al., 7/9/2021, Pakistan, South Asia, peer-reviewed, survey, 11 authors, study period November 2020 - February 2021.

Exercise rehabilitation associates with lower mortality and hospitalisation in cardiovascular disease patients with COVID-19

Buckley et al., European Journal of Preventive Cardiology, doi:10.1093/eurjpc/zwaa135

PSM retrospective 643 COVID-19 patients with cardiovascular disease undergoing exercise rehabilitation within 3 months of diagnosis, showing significantly lower re-hospitalization and mortality with exercise rehabilitation.

risk of death, 75.8% lower, RR 0.24, p < 0.001, high activity levels 10 of 639 (1.6%), low activity levels 41 of 638 (6.4%), NNT 21, OR converted to RR.

risk of hospitalization, 50.9% lower, RR 0.49, p < 0.001, high activity levels 97 of 643 (15.1%), low activity levels 198 of 643 (30.8%), NNT 6.4, OR converted to RR.

Buckley et al., 7/5/2021, retrospective, USA, North America, peer-reviewed, 7 authors.

A Possible Preventive Role of Physically Active Lifestyle during the SARS-CoV-2 Pandemic; Might Regular Cold-Water Swimming and Exercise Reduce the Symptom Severity of COVID-19?

Bielik et al., International Journal of Environmental Research and Public Health, doi:10.3390/ijerph18137158

Retrospective 1,544 participants in Slovakia, showing a lower risk of more severe COVID-19 for physically active participants, without statistical significance.

risk of moderate case, 30.4% lower, RR 0.70, p = 0.10, high activity levels 775, low activity levels 365, adjusted, physically active group.

risk of case, 9.1% higher, RR 1.09, p = 0.36, high activity levels 775, low activity levels 365, adjusted, physically active group.

Bielik et al., 7/4/2021, retrospective, Slovakia, Europe, peer-reviewed, survey, 3 authors, study period 7 December, 2020 - 12 December, 2020.

Does Higher Self-Reported Cardiorespiratory Fitness Reduce the Odds of Hospitalization From COVID-19?

Brandenburg et al., Journal of Physical Activity and Health, doi:10.1123/jpah.2020-0817

Retrospective 263 COVID+ patients, showing lower hospitalization with higher self-reported cardiorespiratory fitness, but no significant differences for physical activity. Participants in the study were healthier and more fit than the general population.

risk of hospitalization, 6.0% higher, OR 1.06, p = 0.60, high activity levels 102, low activity levels 39, adjusted, multivariable, PA, >1h vigorous vs. no/low, RR approximated with OR.

risk of hospitalization, 78.0% lower, OR 0.22, p = 0.05, high activity levels 177, low activity levels 34, adjusted, multivariable, CRF, 6.2-8.7 vs. >10, RR approximated with OR.

risk of hospitalization, 64.0% lower, OR 0.36, p = 0.04, high activity levels 97, low activity levels 34, adjusted, multivariable, CRF, 8.7-10 vs. >10, RR approximated with OR.

risk of severe case, 35.0% lower, OR 0.65, p = 0.30, high activity levels 102, low activity levels 39, adjusted, multivariable, PA, >1h vigorous vs. no/low, RR approximated with OR.

risk of severe case, 24.0% lower, OR 0.76, p = 0.60, high activity levels 52, low activity levels 34, adjusted, multivariable, CRF, 4.4-6.2 vs. >10, RR approximated with OR.

Brandenburg et al., 7/1/2021, retrospective, multiple countries, multiple regions, peer-reviewed, survey, 4 authors.

Does pre-existent physical inactivity have a role in the severity of COVID-19?

Yuan et al., Therapeutic Advances in Respiratory Disease, doi:10.1177/17534666211025221

Retrospective 164 COVID-19 patients in China, showing physical inactivity associated with an increased risk of severe COVID-19.

risk of death, 90.5% lower, RR 0.09, p = 0.09, high activity levels 0 of 61 (0.0%), low activity levels 6 of 103 (5.8%), NNT 17, relative risk is not 0 because of continuity correction due to zero events, excluded in exclusion analyses: excessive unadjusted differences between groups.

risk of severe case, 70.0% lower, RR 0.30, p = 0.03, high activity levels 3 of 61 (4.9%), low activity levels 26 of 103 (25.2%), NNT 4.9, adjusted, OR converted to RR, multivariable.

Yuan et al., 6/20/2021, retrospective, China, Asia, peer-reviewed, 9 authors, study period 15 February, 2020 - 14 March, 2020.

Predictors of incident viral symptoms ascertained in the era of COVID-19

Marcus et al., PLOS ONE, doi:10.1371/journal.pone.0253120

Prospective survey based study with 14,335 participants, showing lower risk of viral symptoms with regular exercise.

risk of symptomatic case, 42.1% lower, RR 0.58, p < 0.001, high activity levels 240 of 10,627 (2.3%), low activity levels 134 of 3,708 (3.6%), NNT 74, adjusted, OR converted to RR, multivariable.

Marcus et al., 6/17/2021, prospective, multiple countries, multiple regions, peer-reviewed, survey, 12 authors, study period 26 March, 2020 - 3 May, 2020.

Protective role of physical activity patterns prior to COVID-19 confinement with the severity/duration of respiratory pathologies consistent with COVID-19 symptoms in Spanish populations

Latorre-Román et al., Research in Sports Medicine, doi:10.1080/15438627.2021.1937166

Retrospective 420 people in Spain, showing lower risk of COVID-19 hospitalization with a history of physical activity.

risk of hospitalization, 76.0% lower, OR 0.24, p = 0.05, moderate physical activity, >150 min per week, RR approximated with OR.

risk of hospitalization, 87.0% lower, OR 0.13, p = 0.07, moderate physical activity, 30-150 min per week, RR approximated with OR.

Latorre-Román et al., 6/15/2021, retrospective, Spain, Europe, peer-reviewed, survey, 7 authors.

The association of estimated cardiorespiratory fitness with COVID-19 incidence and mortality: A cohort study

Christensen et al., PLOS ONE, doi:10.1371/journal.pone.0250508

Prospective study of 2,690 adults in the UK Biobank showing lower cardiorespiritory fitness associated with COVID-19 mortality.

risk of death, 63.0% lower, RR 0.37, p = 0.02, high activity levels 543, low activity levels 529, adjusted, high fitness vs. low fitness, multivariable.

risk of case, 23.0% lower, RR 0.77, p = 0.20, high activity levels 55 of 543 (10.1%), low activity levels 77 of 529 (14.6%), NNT 23, adjusted, high fitness vs. low fitness, multivariable.

Christensen et al., 5/5/2021, prospective, United Kingdom, Europe, peer-reviewed, 5 authors, study period 16 March, 2020 - 26 July, 2020.

Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients

Sallis et al., British Journal of Sports Medicine, doi:10.1136/bjsports-2021-104080

Retrospective 48,440 COVID-19 patients in the USA, showing significantly lower mortality, ICU admission, and hospitalization with exercise.

risk of death, 59.2% lower, RR 0.41, p = 0.005, high activity levels 11 of 3,118 (0.4%), low activity levels 170 of 6,984 (2.4%), adjusted, OR converted to RR, consistently active vs. consistently inactive, multivariable.

risk of ICU admission, 41.5% lower, RR 0.58, p = 0.006, high activity levels 32 of 3,118 (1.0%), low activity levels 195 of 6,984 (2.8%), adjusted, OR converted to RR, consistently active vs. consistently inactive, multivariable.

risk of hospitalization, 53.0% lower, RR 0.47, p < 0.001, high activity levels 99 of 3,118 (3.2%), low activity levels 732 of 6,984 (10.5%), adjusted, OR converted to RR, consistently active vs. consistently inactive, multivariable.

Sallis et al., 4/13/2021, retrospective, USA, North America, peer-reviewed, 8 authors.

Physical Activity and the Risk of COVID-19 Infection and Mortality: A Nationwide Population-Based Case-Control Study

Cho et al., Journal of Clinical Medicine, doi:10.3390/jcm10071539

Retrospective 6,288 COVID+ patients and 125,772 matched controls in South Korea, showing significantly lower risk of COVID-19 infection and mortality with higher physical activity.

risk of death, 53.0% lower, OR 0.47, p = 0.01, high activity levels 17 of 48 (35.4%) cases, 3,223 of 4,536 (71.1%) controls, case control OR, moderate to vigorous vs. inactive.

risk of case, 10.0% lower, OR 0.90, p < 0.001, high activity levels 3,223 of 4,536 (71.1%) cases, 68,609 of 92,587 (74.1%) controls, NNT 142, case control OR, moderate to vigorous vs. inactive.

Cho et al., 4/6/2021, retrospective, South Korea, Asia, peer-reviewed, 9 authors.

Risk factors for developing COVID-19: a population-based longitudinal study (COVIDENCE UK)

Holt et al., Thorax, doi:10.1136/thoraxjnl-2021-217487

Prospective survey-based study with 15,227 people in the UK, showing reduced risk of COVID-19 cases with lower impact physical activity. NCT04330599. COVIDENCE UK.

risk of case, 17.0% lower, OR 0.83, p = 0.18, adjusted, fully adjusted, ≥2 hours lower impact physical activity vs. 0 hours, RR approximated with OR.

Holt et al., 3/30/2021, prospective, United Kingdom, Europe, peer-reviewed, 34 authors, study period 1 May, 2020 - 5 February, 2021, trial NCT04330599.

Obesity, walking pace and risk of severe COVID-19 and mortality: analysis of UK Biobank

Yates et al., International Journal of Obesity, doi:10.1038/s41366-021-00771-z

UK Biobank retrospective 412,596 people, showing severe COVID-19 and COVID-19 mortality inversely associated with self-reported walking pace.

risk of death, 45.3% lower, RR 0.55, p = 0.001, high activity levels 72 of 163,912 (0.0%), low activity levels 62 of 30,119 (0.2%), adjusted, OR converted to RR, multivariable.

risk of severe case, 46.7% lower, RR 0.53, p < 0.001, high activity levels 291 of 163,912 (0.2%), low activity levels 180 of 30,119 (0.6%), adjusted, OR converted to RR, multivariable.

Yates et al., 2/26/2021, retrospective, United Kingdom, Europe, peer-reviewed, 7 authors.

Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study

Tavakol et al., Journal of Public Health, doi:10.1007/s10389-020-01468-9

Retrospective 206 patients in Iran, showing COVID-19 disease severity associated with lower physical activity.

risk of severe case, 68.5% lower, RR 0.31, p = 0.05, high activity levels 3 of 64 (4.7%), low activity levels 19 of 124 (15.3%), NNT 9.4, adjusted, OR converted to RR, moderate to high activity versus low activity, multivariable.

Tavakol et al., 2/4/2021, retrospective, Iran, Middle East, peer-reviewed, 9 authors, study period 20 March, 2020 - 24 April, 2020.

Physical activity and COVID-19: an observational and Mendelian randomisation study

Zhang et al., J. Glob. Health, doi:10.7189/jogh-10-020514

UK Biobank retrospective showing significantly lower COVID-19 cases with objectively measured physical activity.

risk of death, 26.0% lower, OR 0.74, p = 0.17, adjusted, AMPA, per SD increase, multivariable, RR approximated with OR.

risk of case, 18.0% lower, OR 0.82, p = 0.01, adjusted, AMPA, per SD increase, multivariable, RR approximated with OR.

Zhang et al., 12/6/2020, retrospective, United Kingdom, Europe, peer-reviewed, 9 authors.

The effect of aerobic exercise on immune biomarkers and symptoms severity and progression in patients with COVID-19: A randomized control trial

Mohamed et al., Journal of Bodywork and Movement Therapies, doi:10.1016/j.jbmt.2021.07.012

Small RCT with 30 mild/moderate COVID-19 patients, 15 performing 2 weeks of moderate-intensity aerobic exercise, showing decreased severity (WURSS) and improved immune markers with exercise.

Mohamed et al., 10/31/2020, Turkey, Europe, peer-reviewed, 2 authors, study period April 2020 - June 2020.

Inverse Relationship of Maximal Exercise Capacity to Hospitalization Secondary to Coronavirus Disease 2019

Brawner et al., Mayo Clinic Proceedings, doi:10.1016/j.mayocp.2020.10.003

Retrospective 246 COVID-19 patients in the USA, showing the risk of hospitalization inversely associated with maximal exercise capacity. Adjusted results are only provided for MET as a continuous variable.

risk of hospitalization, 74.2% lower, OR 0.26, p = 0.001, unadjusted, highest fitness quartile vs. lowest fitness quartile, RR approximated with OR, excluded in exclusion analyses: unadjusted results with no group details.

Brawner et al., 10/10/2020, retrospective, USA, North America, peer-reviewed, 10 authors, study period 29 February, 2020 - 30 May, 2020.

Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK

Hamer et al., Brain, Behavior, and Immunity, doi:10.1016/j.bbi.2020.05.059

UK Biobank retrospective analysis of 387,109 people, showing lower risk of COVID-19 hospitalization with physical activity.

risk of hospitalization, 27.5% lower, RR 0.72, p < 0.001, adjusted, model 2, sufficient vs. no activity, multivariable.

risk of hospitalization, 33.8% lower, RR 0.66, p < 0.001, adjusted, model 1, sufficient vs. no activity, multivariable.

Hamer et al., 7/31/2020, retrospective, United Kingdom, Europe, peer-reviewed, 4 authors.

Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants

Guthold et al., The Lancet Global Health, doi:10.1016/S2214-109X(18)30357-7

Meta analysis of 358 surveys showing the prevalence of insufficient physical activity around the world. Prevalence in high-income countries was over twice as high, and has increased over time.

Guthold et al., 10/31/2018, peer-reviewed, 4 authors.

Antiandrogens	(meta)	Lactoferrin	(meta)
Aspirin	(meta)	Melatonin	(meta)
Bamlaniv../e..	(meta)	Metformin	(meta)
Bebtelovimab	(meta)	Molnupiravir	(meta)
Bromhexine	(meta)	N-acetylcys..	(meta)
Budesonide	(meta)	Nigella Sativa	(meta)
Cannabidiol	(meta)	Nitazoxanide	(meta)
Casirivimab/i..	(meta)	Paxlovid	(meta)
Colchicine	(meta)	Peg.. Lambda	(meta)
Conv. Plasma	(meta)	Povidone-Iod..	(meta)
Curcumin	(meta)	Probiotics	(meta)
Diet	(meta)	Proxalutamide	(meta)
Ensitrelvir	(meta)	Quercetin	(meta)
Ensovibep	(meta)	Remdesivir	(meta)
Exercise	(meta)	Sleep	(meta)
Famotidine	(meta)	Sotrovimab	(meta)
Favipiravir	(meta)	Tixagev../c..	(meta)
Fluvoxamine	(meta)	Vitamin A	(meta)
Hydroxychlor..	(meta)	Vitamin C	(meta)
Iota-carragee..	(meta)	Vitamin D	(meta)
Ivermectin	(meta)	Zinc	(meta)

Other Treatments		Global Adoption