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Differential Effects of the COVID-19 Pandemic on Physical Activity Involvements and Exercise Habits in People With and Without Chronic Diseases: A Systematic Review and Meta-analysis
Corresponding author Arnold Y.L. Wong, PT, MPhil, PhD, Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China.
To conduct a systematic review and meta-analysis to summarize evidence regarding differential changes in physical activity (PA) involvements and exercise habits in people with and without chronic diseases during the COVID-19 outbreak.
Data Sources
MEDLINE, Embase, SPORTDiscus, Cumulative Index to Nursing and Allied Health, PsycINFO, Cochrane Library, and Physiotherapy Evidence Database were searched from November 2019 to May 2021.
Study Selection
Two reviewers independently screened cross-sectional and longitudinal studies that investigated changes in PA-related outcomes in people with and without chronic diseases during the pandemic.
Data Extraction
PA-related outcomes and sedentary time were extracted from the included studies. Relevant risk of bias were assessed. Meta-analyses were conducted for each PA-related outcome, if applicable. Quality of evidence of each PA-related outcome was evaluated by Grading of Recommendations Assessment, Development, and Evaluation.
Data Synthesis
Of 1226 identified citations, 36 articles (28 with and 8 without chronic diseases) with 800,256 participants were included. Moderate evidence from wearable sensors supported a significant reduction in pooled estimates of step count (standardized mean differences [SMD]=−2.79, P<.01). Very limited to limited evidence substantiated significant decreases in self-reported PA-related outcomes and significant increases in sedentary behaviors among people with and without chronic diseases. Specifically, pooled estimates of metabolic equivalent-minute per week (SMD=−0.16, P=.02) and PA duration (SMD=−0.07, P<.01) were significantly decreased, while sedentary time (SMD=0.09, P=.04) showed significant increases in the general population (small to large effects). Very limited evidence suggested no significant PA changes among people in a country without lockdown.
Conclusions
During the pandemic, objective and self-reported assessments showed significant reductions in PA in people with and without chronic diseases globally. This mainly occurred in countries with lockdowns. Although many countries have adopted the “live with the coronavirus” policy, authorities should implement population-based strategies to revert the potential lockdown-related long-term deleterious effects on people's health.
the disease has rapidly plagued the globe, inflicting unprecedented negative effects on the global socioeconomic and health care systems. As of September 2021, a total of 221 countries had been struck by COVID-19, resulting in more than 248 million infected cases and over 5 million deaths.
Countries with lower national income and suboptimal medical services are more vulnerable to the negative consequences of the COVID-19 pandemic, including changes in health behaviors such as physical activity (PA) participation.
Given the escalating number of confirmed COVID-19 cases and overburdened health care systems, the World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic.
Most governments implemented stringent measures, including travel ban, nationwide quarantine, social distancing, and lockdowns to suppress the outbreak.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
may be more susceptible to the adverse effect of reduced PA. Reduced PA in these patients not only may affect their disease progression but also increases their risk of developing additional inactivity-related diseases. Regular moderate to vigorous PA (MVPA) can boost immunity against community-acquired infectious diseases and increase potency of vaccination. Although an earlier systematic review has summarized the preliminary effects of the COVID-19 pandemic lockdown on PA changes of the public,
it was limited by small representative samples and lack of assessments of evidence or meta-analyses regarding the effects of the pandemic on various PA-related outcomes among people with and without chronic diseases in countries with or without lockdowns. Because PA changes measured by wearable sensors may differ from those collected from self-reported PA questionnaires, comprehensive meta-analyses of various PA-related outcomes can better inform policy makers in developing tailored strategies to revert the adverse effects of physical inactivity in vulnerable subgroups during and after the pandemic. The current systematic review and meta-analysis addressed this gap to summarize the evidence regarding effects of the COVID-19 pandemic on PA-related outcomes in the people with and without chronic diseases who did not contract COVID-19.
Methods
The study protocol was registered on PROSPERO (CRD42021234936). The Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines
A systematic literature search was conducted on 7 databases (MEDLINE, EMBASE, SPORTDiscus, Cumulative Index to Nursing and Allied Health, PsycINFO, Cochrane Libraries, Physiotherapy Evidence Database) to identify articles published between November 1, 2019, and May 31, 2021, without any language restrictions. We searched these databases using a combination of 2 sets of keywords: [‘COVID’ OR ‘cov*’ OR ‘corona*’ OR ‘severe acute respiratory syndrome coronavirus 2’ OR ‘SARS*’] AND [‘physical activit*’ OR ‘activity level’ OR ‘exercise habit*’ OR ‘exercise routine*’ OR ‘lifestyle’] (appendix 1). Additional relevant articles were searched from the reference lists of the included studies. Forward citation tracking was conducted using Scopus. The corresponding authors of the included articles were contacted by emails to identify any additional relevant publications.
Selection criteria
Cross-sectional and longitudinal studies that investigated PA-related outcomes during the COVID-19 pandemic were included. Articles were excluded if the participants were actively or previously infected with COVID-19. Commentaries, letters to editors, reviews, conference proceedings, and qualitative studies were also excluded.
Study selection
All citations identified from database searches were exported to EndNote X9 (Clarivate).a After removing duplicates, 2 reviewers (K.Y.N., K.H.W.) independently screened the titles and abstracts following the selection criteria. They piloted on 100 abstracts to align discrepancy. They then independently screened the remaining references. Abstracts deemed relevant were included for full-text screening. The process was repeated for the full-text screening. Reviewers met to reach a consensus about the eligible articles. If disagreements persisted, a third reviewer (K.C.K.) arbitrated the disagreements. The interrater agreement was calculated using Cohen's κ.
Two independent reviewers (K.Y.N., K.H.W.) used a standardized form to extract data related to authors, year of publication, study location, study design, data collection methods, response and attrition rate, participants’ demographics, definitions of PA and sedentary behaviors, changes in PA-related outcomes, and the corresponding statistics.
Risk of bias assessments
Two independent reviewers (K.Y.N., K.H.W.) used 2 separate tools to assess the quality of the included studies. Specifically, the methodological quality of cross-sectional studies was assessed by the 20-item Appraisal Tool for Cross-Sectional Studies.
The tool only provides descriptive assessments without numeric scores. It is flexible for researchers to use it based on their priorities. Therefore, we rearranged the items into 6 domains: objectives and design, study participation, handling of nonrespondents, outcome measures, statistical analysis, and reporting.
Prevalence, incidence, and factors associated with non-specific chronic low back pain in community-dwelling older adults aged 60 years and older: a systematic review and meta-analysis.
Prevalence, incidence, and factors associated with non-specific chronic low back pain in community-dwelling older adults aged 60 years and older: a systematic review and meta-analysis.
each domain was ranked as low, moderate, or high based on the criteria listed in appendix 2. The Quality in Prognosis Studies tool was used to assess the methodological quality of longitudinal studies.
The Quality in Prognosis Studies tool comprises 6 domains: study participation, study attrition, prognostic factor measurement, outcome measurement, study confounding, and statistical analysis and reporting.
PA-related outcomes extracted from the included studies were categorized into 2 pairs of subgroups: (1) the people with and without chronic diseases and (2) countries with and without lockdown. If 2 or more included studies reported changes in a particular PA-related outcome during the pandemic in a given subgroup, the respective standardized mean differences (SMDs) were pooled for a meta-analysis using a random-effects model. All meta-analyses were performed using the Comprehensive Meta-analysis Version 3.3 software.b Statistical heterogeneity of the included studies was assessed by I² statistics and classified as low (I²<40%), moderate (I²=40%-59%), substantial (I²=60%-74%), and considerable (I²>75%) heterogeneity.
The Grading of Recommendations Assessment, Development, and Evaluation framework consists of 7 domains, 5 of which could downgrade the quality of evidence regarding the estimated effect size, while the other 2 domains could increase the confidence in the estimated effect size. The synthesized data was ranked as very limited, limited, moderate, or high quality of evidence regarding how the true effect lays close to the estimated effect (see appendix 2).
The literature search identified 1226 publications, while 13 records were identified through other sources (fig 1). After removing 103 duplicates, 1136 studies were eligible for the title and abstract screening. Of the 95 screened full-text articles, 36 articles were included.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Fifty-nine full-text articles were excluded because they did not investigate PA changes (n=40); they included confirmed COVID-19 cases (n=6); or they were commentaries, letters or reviews (n=13). Our κ coefficients showed substantial (κ=0.75) and almost perfect (κ =0.93) agreements between the 2 reviewers (K.Y.N., K.H.W.) during the title/abstract screening and full-text screening, respectively.
The 36 included studies recruited 800,256 participants from Asia, Africa, Australia, Europe, and North and South America. Thirty-five studies were conducted in countries or regions with lockdowns,
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
The participants’ mean ages ranged from 7.3-74.0 years. Table 1 summarizes participants’ demographics in the included studies. Twenty-three studies adopted a cross-sectional design,
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Proportion of participants reported change in PA levels Proportion of participants reported change in exercise Proportion of participants reported change in sedentary time
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
Association of web-based physical education with mental health of college students in Wuhan during the COVID-19 outbreak: cross-sectional survey study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
Changes in lifestyle, behaviors, and risk factors for cognitive impairment in older persons during the first wave of the coronavirus disease 2019 pandemic in Finland: results from the FINGER Study.
Changes of physical activity and ultra-processed food consumption in adolescents from different countries during COVID-19 pandemic: an observational study.
(appendix 3). All the 13 retrospective studies did not provide information regarding the dropout participants nor accounted for potential confounders (appendix 4).
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
The included studies used diverse definitions of PA (appendices 5-7, table 2). Five studies used accelerometers and/or pedometers to quantify PA levels.
Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
Impact of the COVID-19 epidemic on lifestyle behaviors and their association with subjective well-being among the general population in mainland China: cross-sectional study.
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Definition of PA according to IPAQ: refer to appendix 3.