COVID-19 versus phys

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Rece ved / Gel ş: 21.10.2020 · Accepted / Kabul: 15.12.2020 · Publ shed / Yayın Tar h : 27.01.2021

Correspondence / Yazışma: Muhammed Atakan · Hacettepe Ün vers tes , Spor B l mler Fakültes , Ankara, Turkey · muhammed.atakan@hacettepe.edu.tr

Research Art cle / Araştırma Makales

COVID-19 versus phys cal nact v ty – a self-reported quest onna re study COVID-19 pandem sürec n n f z ksel nakt v teye etk s

Muhammed M. Atakan¹ , Sel n Akt t z¹ , Mert Kayhan²

1Faculty of Sport Sc ences, Hacettepe Un vers ty, Ankara, Turkey 2Faculty of Sport Sc ences, Dumlupınar Un vers ty, Kütahya, Turkey

ABSTRACT

Object ve: COVID-19 is linked with signiﬁcant mortality and morbidity. To curb the spread of the pandemic, curfews and lockdowns were imposed in many countries, leading to reduced physical activity (PA) irrespective of race, ethnicity, or income level. Although some papers documented how PA level was affected by COVID-19 in children and elderly in some countries, no similar data is available in Turkey during the pandemic. Therefore, we aimed to document the changes in step count in Turkey following the ﬁrst reported case.

Mater als and Methods: A total of 1427 participants were included in the study (male: n=242, female: n=1185), and were asked to ﬁll out an online survey with questions on demographic information, working conditions, medical history, and average daily step count for two months before (January- February) and after (March-April) the outbreak of COVID-19 (10 March) in Turkey. Two-way repeated measure variance analysis and independent- sample t-tests were used to analyze the data.

Results: Data revealed that step count/day decreased by 43.5% (pre: 6564 ± 3615 steps/day vs. during: 3707 ± 3006 steps/day; p<0.05) during the pandemic compared to the pre-pandemic, with no difference between males (32.9%) and females (45.9%) (p>0.05). A similar signiﬁcant reduction (p>0.05) in step count was observed in the working (pre: 6795 ± 3832 steps/day vs. post: 4027 ± 3223 steps/day) and unemployed adults (pre:

6337 ± 3374 steps/day vs. post: 3390 ± 2742 steps/day) (p<0.001).

Conclus on: Compared with the pre-pandemic, step count markedly decreased in all groups during the pandemic in Turkey, regardless of gender and medical condition. This study provides preliminary data on how the COVID-19 pandemic has impacted step count in Turkey.

Keywords: COVID-19, step count, physical activity, pandemic ÖZ

Amaç: COVID-19, mortalite ve morbidite ile önemli ölçüde ilişkilidir. Bu ölümcül salgının yayılmasını engellemek için getirilen sokağa çıkma yasakları ve kısıtlamalar, ırk, etnik köken veya gelir düzeyine bakılmaksızın çeşitli ülkelerde ﬁziksel aktivitenin (FA) azalmasına yol açmıştır. Bazı ülkelerde çocukların ve yaşlıların FA düzeyinin COVID-19'dan nasıl etkilendiğini gösteren makaleler olmasına karşın, pandemi sırasında Türkiye'deki adım sayılarındaki deği‐

şikliği bildiren veri yoktur. Bu nedenle, bu çalışmada Türkiye'deki bildirilen ilk COVID-19 vakasından sonra adım sayısındaki değişikliklerin gösterilmesi amaçlandı.

Gereç ve Yöntemler: Toplamda 1427 gönüllünün (Erkek: n=242, Kadın: n=1185) yer aldığı çalışmada katılımcıların demograﬁk bilgileri, çalışma koşulları, tıbbi geçmişleri ve Türkiye'de COVID-19 (10 Mart) salgınından iki ay önce (Ocak -Şubat) ve iki ay sonraki (Mart-Nisan) adım sayıları sorgulandı. Verilerin analizinde iki yönlü tekrarlı ölçüm varyans analizi ve bağımsız örneklerde t-testi kullanıldı.

Bulgular: Elde edilen veriler, pandemi sırasında COVID-19 salgını öncesine kıyasla günlük adım sayılarının %43.5 azaldığını (ön: 6564 ± 3615 adım/gün, son: 3707 ± 3006 adım/gün; p<0.05) gösterdi. Bu farklılık erkek (%32.9) ve kadın (%45.9) arasında benzerdir (p>0.05). Hem çalışanlarda (ön: 6795 ± 3832 adım/gün, son: 4027 ± 3223 adım/gün) hem işsizlerde (ön: 6337 ± 3374 adım/gün, son: 3390 ± 2742 adım/gün) pandemi sırasında adım sayısında önemli bir azalma (p<0.001) gözlendi. Bu azalış gruplar arasında benzerdir (p>0.05).

Sonuç: Elde edilen bulgular, Türkiye'de, pandemi öncesine kıyasla pandemide çalışma koşulları ve cinsiyete bakılmaksızın tüm gruplarda adım sayısının önemli ölçüde azaldığını göstermektedir. Bu çalışma, Türkiye'de COVID-19 pandemisinden adım sayılarının nasıl etkilendiğine dair ilk ön verileri sağlamaktadır.

Anahtar Sözcükler: COVID-19, adım sayısı, ﬁziksel aktivite, pandemi

INTRODUCTION

The globally pandem c coronav rus d sease 2019 (COVID-19) s an emerg ng resp ratory nfect ous d sease caused by severe acute resp ratory syndrome coronav rus 2 (SARS-CoV- 2). S nce the f rst case reported n early December 2019 n Wuhan, Ch na, th s deadly v rus rap dly spread to the majo-

r ty of countr es worldw de, a ect ng more than n nety-four m ll on nd v duals, and caus ng 2034527 deaths as of Janu- ary 20, 2021 (1), w despread su er ng, pan c, soc al unrest, and econom c nstab l ty. A pandem c of th s scale has alre- ady created dramat c challenges all over the world n terms

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of economy, soc al nteract ons, and nd v dual l festyles and caused var ous d seases rang ng from asymptomat c to fatal ones (2-4). In the nfected people, the ma n symptoms concern the lower resp ratory tract w th the potent al of le- ad ng to fatal pneumon a, hypoxem a, d culty n breat- h ng and acute resp ratory d stress syndrome (5). Although some remed es and v able vacc nes may prov de comfort and allev ate symptoms of th s unprecedented v rus, t appears that the best way to curb the spread of COVID-19 n th s per od s st ll self- solat on, wear ng masks, avo d ng close soc al contact w th people (6).

Bes des, phys cal nact v ty (PI) or sedentar sm s cons dered a major r sk factor for a range of adverse outcomes (7- 11), caus ng over three m ll on deaths annually even pr or to COVID-19 (7) due to ts deleter ous e ects on health. Ho- wever, desp te the pos t ve e ects of phys cal act v ty (PA) on phys cal and mental health (12-15), t s more challen- g ng than usual to cont nue normal PA patterns dur ng the COVID-19 pandem c because of publ c health orders, recommendat ons to stay at home, school and park closures, and self- solat on (16). Bes des, the poss ble expected outcome of these l festyle changes dur ng the COVID-19 pande- m c s markedly reduced da ly PA level and ncreased sedentary behav ors due to the lockdown and curfew mposed to curb th s deadly pandem c (17). Cons der ng a recently publ shed study report ng that even one wk of reduced PA substant ally lowered myof br llar prote n synthes s rates (18) and caused the loss of muscle mass and strength, mpa red nsul n sens t v ty, as well as an ncreased syste- m c n ammat on (19), one can assume that lockdowns and curfews mposed for months may be more or as harmful for health as the COVID-19 pandem c. To address the mpact of the COVID-19 on PA, Hemph ll et al. measured step count n ch ldren w th congen tal heart d sease, and reported cons - derably reduced PA level a er March 11, when the COVID-19 outbreak pandem c was declared by the World Health Orga- n sat on (WHO), compared w th before the pandem c (20).

A descr pt ve study support ng Hemph ll’s f nd ngs showed rap d worldw de step count decreases dur ng the COVID-19 pandem c n 189 countr es (21). However, there s no data ava lable that presents how da ly step count was a ected by the COVID-19 pandem c n Turkey. Therefore, we a med to compare the changes n step count two months before and a er 10 March, when the f rst case of COVID-19 was reported n Turkey.

MATERIALS and METHODS

We conducted a self-reported quest onna re study. The nc- lus on cr ter a covered all age groups w th/w thout pre- ex st ng med cal cond t ons. Out of 1481 part c pants (female: n=1185, male: n=242) who f lled out the onl ne survey

bu lt us ng Google Forms, the data of 54 people (3.6% of the part c pants) who stated that they d d not record the number of steps was not ncluded n the f nal analys s. In add t - on, 46 part c pants were m nors for whom parental consent was not obta ned, as the study was based on voluntary par- t c pat on and d d not nvolve any ntervent on. The part c - pants cons sted of healthy, unhealthy, young, m ddle age, old, work ng, unemployed populat ons w th d erent edu- cat on levels nclud ng un vers ty (65.4%), h gh school (19.3%), graduate (13.3%) and pr mary school (2.0%) gradu- at on. Part c pants were nformed about the purpose and method of the study. Inst tut onal approved consent ncluded n the quest onna re was obta ned from part c pants who declared that they voluntar ly part c pated n the study. The study protocol was approved by the Inst tut onal non- ntervent onal cl n cal research eth cs board and was conducted n accordance w th the Hels nk Declarat on.

Data collect on

The collect on nstrument was bu lt on the Google Forms platform and was d ssem nated v a the nternet through appl cat ons and soc al networks: WhatsApp groups, Instag- ram, and Facebook, from May 15 to June 1, 2020. Each part - c pant had the r ght to complete the quest onna re once.

The quest onna re bu lt was l nked to a spec f c Google user’s account whereby data secur ty was ensured. An n- format ve text appeared at the top of the quest onna re by wh ch the part c pants were nformed n deta l about the study. The quest onna re cons sted of seventeen quest ons nclud ng demograph c nformat on, work ng cond t on n- dependent of phys cal work, med cal h story, method of measur ng step count and the average step count. A er- wards, the collected data was converted nto an excel spre- adsheet, where a reﬁnement of analys s was performed to exclude nadm ss ble data such as 50000 to 60000 steps per day. In add t on, step count data that s m lar for all the cons dered months were excluded from the study. In add t - on, the answers g ven to the quest on about chron c d sease were exam ned and those part c pants who reported hav ng at least one of the chron c d seases class f ed by the WHO (22) were accepted as part c pant w th chron c d sease.

The answers to the quest ons about the part c pants’ step count were based on two months before (January-February) and two months a er (March-Apr l) 10 March, when the f rst COVID-19 case was reported n Turkey. Step counts were cons dered from January 10 to February 10, February 10 to March 10, March 10 to Apr l 10, Apr l 10 to May 10, and accord ngly, the average step count per month was calculated. Part c pants were asked to f ll n the number of steps on the forms by wr t ng the average step count for January, February, March and Apr l 2020; recorded us ng a smartp‑

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hone, smartwatch or pedometer. Self-reported body we ght and he ght f gures were used, and body mass ndex (BMI) scores were calculated [we ght (kg)/he ght (m)²] (Table 1).

Table 1. Characteristics of the participants

Variables Female

(n=1185)

Male (n=242)

Age (years) 26.7 ± 7.5 28.6 ± 10.0

Height (cm) 164.8 ± 5.8 177.7 ± 7.3

Body mass (kg) 61.5 ± 10.8 79.8 ± 12.9

BMI (kg/m²) 22.6 ± 3.7 25.2 ± 3.6

Figures as mean ± SD; BMI: body mass index

Stat st cal Analys s

A two-way repeated-measures analys s of var ance (t me x gender) was used to determ ne whether ma n e ects ex sted between the groups and over t me, followed by a Bonferro- n post hoc test. Independent sample t-test was used to determ ne f d erences between the pre- and post-pandem c months ex sted across outcome var ables. Stat st cal analy- ses were performed us ng SPSS Stat st cs for W ndows, Ver- s on 21.0 (IBM Corp., Armonk, NY, USA), and the level of s gn f cance was set at p<0.05. All data are presented as me- ans ± standard dev at on.

RESULTS

The character st cs of the part c pants are presented n Tab- le 1. Of the total of 1427 val d responses n the sample, 83%

of the people were female, wh le 17% were male. The majo- r ty of the part c pants (about 97%) were between the ages of 18 and 59 (Table 2). Unsurpr s ngly, the work ng cond t - ons of the part c pants recru ted were cons derably a ected by the pandem c (p<0.05), y eld ng an ncreased work-from- home trend and markedly decreased work ng from o ce (F g. 1). There was a strong trend toward decreas ng step count from February through Apr l for all the class f ed groups (F g. 2).

Table 2. Age distribution of participants

Gender Female (n=1185) Male (n=242)

<18 yrs 46 (3.9) 6 (2.5)

18-29 yrs 859 (72.5) 166 (68.6)

30-59 yrs 276 (23.3) 64 (26.4)

≥60 yrs 4 (0.3) 6 (2.5)

Figures as n (%)

Figure 1. Changes in working condition before and during the pandemic

Figure 2. Changes in step count by gender (A), pre- existing medical condition (B), work status (C) and working condition (D) before and during the pandemic The recorded step count (step/day) were markedly decreased by 43.5% (pre: 6564 ± 3615 steps/day vs. dur ng: 3707 ± 3006 steps/day; p<0.05) dur ng the pandem c compared w th before the COVID-19 outbreak (10 March) for both se- xes (F g. 2A, F g. 3), w th no d erence (p>0.05) between males (32.9%) and females (45.9%). There were s m larly s gn f cant reduct ons n step count n healthy adults (pre:

6539 ± 3529 steps/day vs. dur ng: 3717 ± 2978 steps/day;

p<0.001) and adults w th chron c d sease (pre: 6782 ± 4289 steps/day vs. dur ng: 3622 ± 3621 steps/day; p<0.001) between the pre- and post- pandem c months (p<0.05) (F g. 2B, F g. 4), show ng that pre-ex st ng med cal cond t on d d not a ect step count.

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Figure 3. Changes in step count by gender (*: p<0.05).

Figure 4. Changes in step count by health status (*:

p<0.05)

Step count was s m lar n pre-pandem c months (January and February) for adults w th chron c d seases (F g. 2B) and n workers (F g. 2C), yet there were s gn f cant d erences n healthy adults (January: 6449 ± 3646 steps/day vs. Febru- ary: 6630 ± 3658 steps/day; p=0.001; F g. 2B), and n unemployed adults (January: 6204 ± 3518 steps/day vs. Feb- ruary: 6471 ± 3526 steps/day; p<0.001; F g. 2C). S gn f cant reduct ons n step count occurred n the work ng (pre: 6795

± 3832 steps/day vs. post: 4027 ± 3223 steps/day) and unemployed adults (pre: 6337 ± 3374 steps/day vs. post:

3390 ± 2742 steps/day; p<0.001) from before to dur ng the pandem c months, and th s was s m lar between groups (p>0.05; F g. 2C, F g. 5).

Figure 5. Changes in step count in workers and unemployed (*: p<0.05)

There was no d erence n step count by work ng cond t on before the pandem c months (p>0.05), yet dur ng the pandem c months those who worked from o ce had h gher step count n March (5450 ± 3795 steps/day vs. 4419 ± 3138 steps/day; p=0.058) and n Apr l (4550 ± 4244 steps/day vs.

2519 ± 3110 steps/day; p<0.001) than those who worked from home (F g. 2D).

DISCUSSION

The ma n f nd ng of the current study was that the PA level of Turk sh populat on ncluded was markedly decreased a er the outbreak of COVID-19. Th s s the f rst study to report changes n step count n the Turk sh populat on follo- w ng the outbreak of COVID-19 and the f nd ngs of the current study unve l substant al changes n the work ng cond - t ons follow ng th s challeng ng pandem c.

It has recently been suggested that there are two s multane- ous mportant pandem cs: the f rst one s the COVID-19 pandem c and second one w th a d erent nature s PI (2,23). Unfortunately, all the data ava lable conv nc ngly warns that the PI pandem c w ll pers st a er the world reco- vers from the COVID-19 v rus, and the health and econom c mpacts of the PI pandem c w ll cont nue to be severe (24).

Accord ng to the WHO, 31% of nd v duals 15 years or older are phys cally nact ve. Cons der ng the h gh levels of global PI assoc ated w th numerous adverse health outcomes (13,21,25) nclud ng dysl p daem a (26), m crovascular dys- funct on and per pheral nsul n res stance (27), card ovascular d sorders and metabol c syndrome (28), t s est ma- ted that approx mately 3.2 m ll on deaths each year are att- r buted to th s unhealthy l festyle behav ors (12). D ng et al.

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tely globally $53.8 b ll on, contr but ng to $13.7 b ll on n product v ty loses and resulted n 13.4 m ll on d sab l ty-ad- justed l fe-years (29).

It appears that the ongo ng global cr s s caused by the spread of COVID-19 d sease exerts profound e ects on human health and soc al l fe n many commun t es all over the world. Lockdowns and solat on mposed to curb the CO- VID-19 pandem c run the r sk of reduced PA w th potent al long-term consequences (6), and these unfavourable e ects of short- and long-term PI before or dur ng the pandem c l kely occur rap dly (30). A study support ng th s not on by Krogh-Madsen et al. (31) reported that decreased da ly act - v ty levels n healthy young males from 10501 to 1344 steps/day for just two weeks led to a 17% decl ne n skeletal muscle nsul n sens t v ty, 7% n card ovascular f tness, and 3% n lean leg mass.

Shad et al. (18) also determ ned that only a week of reduct - on n step count caused substant al decl ne n da ly myof b- r llar prote n synthes s rates, and decl ne n whole-body n- sul n sens t v ty. Therefore, cons der ng the second and even th rd wave of the pandem c, t w ll be mportant to understand the long-term mpact of reduced PA on health. Mo- reover, s nce regular exerc se s known to modulate the m- mune system and to prov de protect on aga nst some d seases such as obes ty, d abetes and hypertens on that cause severe COVID-19 d sease (2,32), regular exerc se and PA m ght be cons dered as mportant strateg es to cope w th d srupt ons caused by COVID-19.

Cytok nes released by cells play major role n the mmune system. Among these cytok nes, nterleuk n (IL)-6, IL-10, and tumor necros s factor-alpha (TNFα) assoc ated w th adverse cl n cal symptoms (23) were found to be markedly h gh n COVID-19 nfected ntens ve care un t pat ents (33).

Also, cons der ng the pos t ve mpacts of regular exerc se on lung funct on and resp ratory nfect on/ llness nclud ng COVID-19 by nduc ng ant - n ammatory cytok nes (34), reduc ng system c n ammat on (35) and ox dat ve stress markers (36), PA strateg es should be undertaken to enco- urage people to part c pate n phys cal act v t es that are appropr ate for the r age and med cal cond t on to avo d short- and long-term negat ve health mpacts of reduced PA and to rel eve the symptoms of the d sease. Furthermore, to attenuate the negat ve health outcomes of the mposed curfews and lockdowns on da ly PA, people should also mplement pract cal l festyle strateg es that w ll ncrease energy expend ture, to be less sedentary dur ng lockdowns (25,37,38).

Our study had some l m tat ons. For example, we used an onl ne survey method to determ ne the PA level determ ned by step count. As the data s based on answers g ven to th s

survey, t m ght not re ect PA level. Therefore, further stu- d es that are capable of measur ng PA level, depend ng on the mode and ntens ty us ng appropr ate dev ces are ne- eded and w ll help to nterpret changes n PA patterns du- r ng the pandem c. In add t on, the major ty of part c pants (83%) of th s study were women, wh ch makes t d cult to apply the results to soc ety. Lastly, the survey used was f l- led out by the part c pants onl ne. Instead, a face-to-face survey method m ght allow researchers for more n-depth data collect on and comprehens ve understand ng.

CONCLUSION

The present study prov des prel m nary data on the changes n step count before and dur ng the COVID-19 pandem c n Turkey. The mpact of reduced PA caused by COVID-19 ma nly depends on the magn tude of reduct on, so careful mon tor ng of PA levels n d erent populat ons s requ red.

Regular PA s a v tal f rst step to ma nta n card ometabol c- health, and may also be a protect ve factor to cope pos t - vely w th solat on-related challenges. These approaches a m ng to ncrease PA levels should be ma nta ned for months. By mplement ng support ve l festyle strateg es for the necess ty and e ect veness of PA, long-term negat ve health e ects due to reduced PA can be avo ded. Therefore, t s necessary to mon tor changes n PA levels due to CO- VID-19. Also, promot ng appropr ate phys cal act v t es w ll help to overcome nact v ty dur ng the outbreak of COVID- 19. Cont nuous PA mon tor ng data w ll also prov de un que ns ght about the mpact of COVID-19, wh ch w ll nform sc ent sts about potent al health consequences, and help n develop ng ntervent ons, both dur ng the pandem c and n the future.

Acknowledgements / Teşekkür

The authors would l ke to thank all part c pants nvolved for the r part c - pat on n f ll ng out the survey.

Conﬂict of Interest / Çıkar Çatışması

The authors declared no con cts of nterest w th respect to authorsh p and/or publ cat on of the art cle.

Financial Disclosure / Finansal Destek

The authors rece ved no f nanc al support for the research and/or publ - cat on of th s art cle.

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