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Biomedical Research Theme, School of Human Sciences, University of Derby, Derby, United KingdomDepartment of Physical Therapy, College of Applied Sciences, the University of Illinois, Chicago, Illinois, USAHealthy Living for Pandemic Event Protection Network, Chicago, Illinois, USA
Biomedical Research Theme, School of Human Sciences, University of Derby, Derby, United KingdomHealthy Living for Pandemic Event Protection Network, Chicago, Illinois, USA
Human Performance and Health Group, Centre for Life and Sport Sciences, School of Health Sciences, Birmingham City University, Birmingham, United Kingdom
Biomedical Research Theme, School of Human Sciences, University of Derby, Derby, United KingdomDepartment of Physical Therapy, College of Applied Sciences, the University of Illinois, Chicago, Illinois, USAHealthy Living for Pandemic Event Protection Network, Chicago, Illinois, USA
Healthy Living for Pandemic Event Protection Network, Chicago, Illinois, USADepartment of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School–University of Queensland School of Medicine, New Orleans, Louisiana, USA
Department of Physical Therapy, College of Applied Sciences, the University of Illinois, Chicago, Illinois, USAHealthy Living for Pandemic Event Protection Network, Chicago, Illinois, USA
Cardiovascular disease is the leading noncommunicable disease and cause of premature mortality globally. Despite well established evidence of a cause-effect relationship between modifiable lifestyle behaviours and the onset of risk of chronic disease, preventive approaches to curtail increasing prevalence have been ineffective. This has undoubtedly been exacerbated by the response to COVID-19, which saw widespread national lockdowns implemented to reduce transmission and alleviate pressure on strained health care systems. A consequence of these approaches was a well documented negative impact on population health in the context of both physical and mental well-being. Although the true extent of the impact of the COVID-19 response on global health has yet to be fully realised or understood, it seems prudent to review effective preventative and management strategies that have yielded positive outcomes across the spectrum (ie, from individual to society). There is also a clear need to heed lessons learned from the COVID-19 experience in the power of collaboration and how this can be used in the design, development, and implementation of future approaches to address the longstanding burden of cardiovascular disease.
Résumé
Les maladies cardiovasculaires sont la principale maladie non transmissible et la première cause de mortalité prématurée dans le monde. Malgré la preuve bien établie d’une relation de cause à effet entre les comportements modifiables liés au mode de vie et l’apparition du risque de maladie chronique, les approches préventives visant à freiner l’augmentation de la prévalence ont été inefficaces. Cette situation a sans aucun doute été exacerbée par la réaction à la COVID-19, qui a entraîné la mise en place de vastes mesures de confinement à l’échelle nationale afin d’en réduire la transmission et d’alléger la pression sur les systèmes de soins de santé déjà mis à rude épreuve. Ces approches ont eu pour conséquence un impact négatif bien documenté sur la santé de la population dans le contexte du bien-être physique et mental. Bien que l’ampleur réelle de l’impact de la réponse à la COVID-19 sur la santé mondiale n’a pas encore été pleinement réalisée ou comprise, il semble prudent d’examiner les stratégies de prévention et de gestion efficaces qui ont donné des résultats positifs à tous les niveaux (c’est-à-dire de l’individu à la société). Il est également nécessaire de tenir compte des leçons tirées de l’expérience COVID-19 en ce qui concerne le pouvoir de la collaboration et la manière dont elle peut être utilisée dans la conception, le développement et la mise en œuvre de futures approches visant à lutter contre le fardeau de longue date que représentent les maladies cardiovasculaires.
Cardiovascular disease (CVD) is a prominent noncommunicable disease phenotype that may be characterised as a group of interacting disorders that includes coronary heart disease, cerebrovascular disease, and stroke. Collectively, CVD is the leading cause of morbidity and premature mortality on a global scale,
Decades of research have established a cause-effect relationship that exists between modifiable lifestyle behaviours and the onset of risk of premature chronic disease.
Healthy lifestyle interventions to combat noncommunicable disease—a novel nonhierarchical connectivity model for key stakeholders: a policy statement from the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine.
Arguably, the most effective public health strategy is primary prevention, where modifying lifestyle choices can reduce the risk of developing CVD by up to 80%.
Despite a plethora of evidence to support the relationship between lifestyle behaviours and chronic disease, previous and universal approaches to counter increasing prevalence and the subsequent impact on health care providers are confounded by the complex and interactive nature of chronic disease.
Previous attempts by international governments and health agencies to influence healthy lifestyle choices have been confounded by poor adherence, accessibility, and scalability.
In addition, the broad nature of interacting factors is often neglected and considered in the design, development, and implementation of prevention and optimal management efforts to achieve population-level effectiveness. To add further complexity, the response to COVID-19 precipitated an unprecedented global health care challenge.
During this time, unhealthy lifestyle behaviours were exacerbated and once again thrust into the forefront of public attention. Unhealthy lifestyle behaviours (eg, poor quality diet, lack of physical inactivity, and tobacco/alcohol use) are major contributors to the global burden of disease.
GBD 2017 Risk Factor Collaborators Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
Although the longstanding impact of the COVID-19 response on lifestyle behaviours and chronic disease is yet to be realised, it has almost certainly contributed to a worsening in trends of population-level cardiometabolic risk factors.
Although empirical methodologies lack consistency, reports clearly demonstrate important changes in lifestyle behaviours and well-being due to imposed social distancing measures and other preventative restrictions meant to curtail transmission.
Influence of the Covid-19 lockdown on the physical and psychosocial well-being and work productivity of remote workers: cross-sectional correlational study.
Of significant interest is the impact of a persisting symptom profile beyond an acute infection, now referred to as post-COVID syndrome or long COVID. This presents a rapidly evolving global health crisis
As the world begins its recovery from the COVID-19 experience, there is a significant opportunity to improve public health and well-being that should not be squandered; this opportunity includes combatting the long-standing noncommunicable disease crisis. In this review, we provide a summary of effective prevention and management strategies that can be implemented to address the growing burden that will continue to impact global health and well-being.
The Role of Health and Fitness as a Primary Marker of Cardiovascular Health
Cardiorespiratory fitness (CRF) is a primary marker of health, resiliency, and longevity.
It is established that individuals who are genetically predisposed to developing chronic diseases but maintain a healthy lifestyle and have a preserved CRF across the lifespan have a lower level of risk for developing CVD.
An update on the role of cardiorespiratory fitness, structured exercise and lifestyle physical activity in preventing cardiovascular disease and health risk.
Figure 1 highlights the role and importance of CRF and other key behavioural characteristics that can be targeted in individuals who lead unhealthy lifestyles and are subsequently diagnosed with a chronic disease, but then make dramatic changes that emulate a healthy lifestyle can reverse and limit the longstanding implications associated with chronic disease.
demonstrated that those individuals with positive lifestyle behaviours (defined as behaviours that promote improved health outcomes) and characteristics had a lower incidence of hospitalisation due to COVID-19 infection after adjustment for chronic conditions (ie, CVD and hypertension), supporting the assertion that healthy lifestyle behaviours provide a protective mechanism despite a previous chronic disease diagnosis. In addition, Sallis et al.
reported an increased risk of adverse outcomes when infected with COVID-19 in those who were physically inactive. Although data during the acute stages highlight the protective benefits of healthy lifestyle behaviours, more surveillance research into the effects this has on the development of long COVID and chronic disease is needed. Although more research is needed to scale up this finding and to stratify it relative to comorbidities and other healthy living behaviours, initial findings indicate a further complexity in the global response to chronic disease.
Figure 1Modifiable lifestyle behaviours that affect the prevalence of cardiovascular disease, which has been affected by COVID-19.
Effective Strategies to Maintain and Improve Cardiovascular Health
The primary prevention strategy for improving cardiovascular (CV) health is through modifying lifestyle behaviours. Higher CV health is also associated with less susceptibility to COVID-19 infection and a reduction in severe outcomes and symptomology.
These lifestyle behaviours primarily consist of following good nutritional behaviours and being physically active, as these two modifiable factors can nourish the immune system and reduce the inflammatory response following infection.
This is important because of an elevated inflammatory response that comes to light during COVID-19, characterised as a “cytokine storm” (ie, a cascade of cytokine [and chemokine] production resulting in leukocyte infiltration and activation that can cause tissue damage and organ dysfunction).
Reducing the incidence of this phenomenon is therefore vital to protect CV health and reduce the chances of severe outcomes for patients with COVID-19.
Adequate and balanced nutrition is imperative to optimise immune system function and our body’s response to infections.
Observational studies demonstrate that individuals with a “normal” body mass are less likely to experience COVID-19 hospitalisations and more likely to experience reduced symptomology.
recently observed obesity to have an association with mortality from COVID-19 (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.10-4.34). This could be linked to chronic low-grade inflammation and higher antiinflammatory cytokines from poor nutrition. In contrast, a healthy diet may offer protective effects for CV health and thus against the severity of COVID-19. Moreover, the nutritional status of individuals has also been associated with vaccination effectiveness, whereby low intake of micronutrients (particularly malnourishment) seemed to impair the protection gained from vaccines.
Given that both a lack of nutrients and being obese negatively affect CV health, leading potentially to metabolic syndrome, it is clear from this evidence that nutrition is a modifiable factor that could help sustain CV health and reduce the severe consequences of COVID-19. This is an area of great concern given the sharp increase in the rates of obesity, particularly in the Western world,
which may have been magnified by reduced access to recreational facilities and an increase in sedentary behaviour (SB) throughout the pandemic. The lasting impacts that the COVID-19 response will have on lifestyle behaviours and the influence of CV risk factors have yet to be established; initial trends are not certainly troubling for the future. As such, the promotion of healthy lifestyle behaviours is a critical area of consideration for the development of strategies to improve CV outcomes, from both primary and secondary prevention perspectives.
A healthy diet can work synergistically with appropriate levels of physical activity (PA) to improve CV health and reduce negative COVID-19 outcomes. Participating in exercise improves mitochondrial function by initially increasing the acute levels of reactive oxygen species that up-regulate mitochondrial biogenesis, as well as superoxide dismutase, catalase, and glutathione peroxidase.
These effects reinforce our antioxidant defence systems and improve immunity, which is critical to a cell’s ability to respond to viral infections such as COVID-19.
demonstrated that those demonstrating low PA levels (P = 0.05) or low metabolic equivalent (P = 0.03) were more likely to experience increased disease severity. It is well established that avoiding SB or conversely engaging in regular PA is a key factor of CV health,
as outlined in more detail below. It is important to note that the intensity of exercise is a modifiable factor and that moderate exercise is preferable to intense exercise, because the latter can lead to immunosuppression of anti-inflammatory cytokines and thus to greater susceptibility to infection.
Further strategies to improve CV health and COVID-19 complications are to avoid behaviours such as those that can damage the liver (eg, alcohol) or the respiratory system (eg, smoking), because these have also been associated with a higher risk of mortality (liver disease: OR 2.81, 95% CI 1.31-6.01; smoking: OR 1.46, 95% CI 0.83-2.60) and severity of symptoms (liver disease: OR 0.81, 95% CI 0.47-1.4; smoking: OR 1.80, 95% CI 1.14-2.85).
Several modifiable factors can function as preventative tools to help individuals protect their CV health and susceptibility to a severe or life-threatening response to a COVID-19 infection. Equally, through improved immunity, behavioural changes could reduce the impact of the cytokine storm that is apparent with a COVID-19 infection. Adhering to healthy lifestyle behaviours that include healthy nutrition and PA is critical in the response moving forward to weaken the grip the virus has on the global population.
Key points
•
The response to a COVID-19 infection is malleable, and individuals should attempt to change the subsequent risk of serious symptoms by reducing the impact of the cytokine storm.
•
The response to infection is influenced by behaviour changes in nutrition and exercise that help promote improved immunity.
•
Avoiding unhealthy lifestyle behaviours such as smoking and SB reduces the severity of COVID-19 infection.
Strategies to Manage or Mitigate the Implications of Reduced CV Health
Before the emergence of COVID-19, the protective effects of PA in the management of chronic conditions were already well established.
The mechanisms of action are multifactorial and include improved or normalised vascular function and blood pressure, weight loss, glycemic regulation, lipid profile, mitochondrial function, stress reduction, and improved quality of life.
The benefits of accumulating 150 to 300 minutes of moderate-intensity PA and performing 2 days of muscle-strengthening activities, and the benefits for sleep quality, are associated with reduced anxiety, improving cognition, and improving insulin sensitivity.
Previous recommendations highlight that bouts of at least 10 minutes of aerobic PA were needed to count toward the weekly allotment of PA, but bouts of less than 10 minutes also provide positive health benefits and reduce mortality risk.
This is meaningful when promoting PA to individuals living sedentary and/or physically inactive lives who may perceive planning for structured activities lasting 10 or more minutes to be untenable. Alternatively, high-volume, high-intensity exercise emerged as a key strategy for improving CRF in all participants completing 1,800 and 3,000 kcal/wk for men and women, respectively. High-intensity interval training along with time-efficient forms of training has gained traction. Interventions such as vigourously climbing 3 flights of stairs 3 times per day, separated by a 4-hour recovery period, 3 days/wk for at least 6 weeks contributed to improved CRF and presented potential real-world application in the workplace,
Even more efficient was performing five 4-second all-out sprints with 45-second rest periods every hour over 8 hours on a cycle ergometer that decreased postprandial plasma triglyceride metabolism and increased whole-body fat oxidation.
Despite recognition of the health-related benefits of physically activity, only one-fourth of adults reported meeting the aerobic and strengthening components of the PA guidelines before the COVID-19 era.
Reduced recreational activities, active travel time and daily activities were significantly associated with lower PA levels. Although PA levels were reduced across all age groups, the already low levels of PA in older adults were exacerbated during the lockdown. Browne et al.
reported PA and SB data in a group of hypertensive older adults before and during the pandemic. On average, participants took 5,809 steps per day, accumulated 303 min/d of light PA, 15.5 min/d of moderate to vigourous PA, and 653 min/d of sedentary time. When measured during the pandemic, there were decreases of 900 steps per day, 2.8 min/d of moderate to vigourous PA, and 26.6 min/d of light activity, and a 30-min increase in sedentary time.
These data are sobering when considering that SB significantly increases the risk of developing CVD. In a previous investigation, sedentary time in healthy older adults was associated with a 22% and 27% better likelihood of having a cluster of traditional CVD risk factors in women and men, respectively.
It is important to recognise that those with an established management plan during the pandemic likely lost contact with physicians due to a reprioritisation of clinical staff to address the challenges of COVID-19.
Clinical and organisational framework of repurposing paediatric intensive care unit to adult critical care in a resource-limited setting: lessons from the response of an urban general hospital to the Covid-19 pandemic.
Contact with care providers is an effective strategy to maintain engagement with lifestyle interventions, and a reduction in contact or access during the pandemic may have led to attrition and a worsening of patient outcomes.
Though challenging and representing a major change, one positive response was to move the delivery of effective cardiac rehabilitation (CR) services to a virtual platform.
A multiprofessional face-to-face and remote real-time hybrid mode of exercise-based cardiac rehabilitation: an innovative proposal during the Covid-19 pandemic.
Early data demonstrate that remote synchronous (live virtual CR monitoring or hybrid, ie, virtual CR as well as in-person CR sessions) models of CR delivery are potential ways to improve access and increase capacity for underserved patients who could benefit from CR participation.
Comparison of home-based vs center-based cardiac rehabilitation in hospitalisation, medication adherence, and risk factor control among patients with cardiovascular disease.
The impact of lockdowns on PA is not disputed, but favourable trends began to emerge once it became clear that a quick resolution to the pandemic was not plausible. With enrollment and membership in health and fitness centres reduced owing to imposed capacity limits or member hesitancy, individuals turned to spending more time being physically active outside, finding creative ways of increasing PA indoors, and investing in home fitness equipment. The development of fitness phone applications outpaced previous years’ rates,
Although there are many contributing reasons, it is likely that those that were able to work remotely effectively eliminated or decreased weekly automotive commutes to and from work.
Key point
•
A substantial proportion of the population does not meet minimal activity levels, which has been exacerbated by COVID-19 policies. Many forms of exercise can improve CRF and lower the risk of CVD, and the use of virtual platforms and synchronous contact might help improve access and capacity to assist with getting individuals to be active.
A Global Call to Action
Notwithstanding the well documented benefits of healthy living behaviours, availability of knowledge and advancements in medicine and technology, and an array of global initiatives over several decades, there has been little change in public health outcomes. Despite a plethora of initiative-taking models and global strategies to promote healthy living behaviours, these approaches have been ineffective, with CVD prevalence data not showing any signs of improvement and but a burden to health care for decades to come.
these approaches have been hindered by a lack of integration, differentiation, acceptability, and scalability beyond a local or national level. Given the urgency, it is appropriate to establish global health policies that are enriched with behavioural, implementation, and systems science approaches to coordinate a holistic approach to addressing the current and future global health threats.
Although the health threats of ever-evolving circumstances are an immediate concern to global health and well-being, the ongoing and widespread prevalence of CV health issues seen globally is itself a pre-existing pandemic. Exercise and PA that is effective and accessible via consistent and equitable approaches across nations will seek to address CV health issues. Therefore, international policymakers and decision makers should prioritise and instil an “exercise/healthy living is medicine” message across the lifespan, including education on PA and literacy to embed habitual exercise in the global population.
Initiatives by leading organisations such as the World Health Organisation and the U.S. National Institutes of Health to address public health challenges have raised awareness of CVD and the associated risk factors. However, their attempts to address global health suffer from a lack of compelling evidence of effectiveness in thwarting the trajectory and prevalence of CVD and chronic disease more broadly. Indeed, recent reports from the U.K. House of Commons Report on Grassroots Participation in Sport and Physical Activity identified that despite a mission statement and promised legacy to increase the number of adults participating in recreational and competitive sports and an £8.8 billion investment, the 2012 Olympic Games in London entirely failed to influence participation levels.
It is conceivable that all interested parties share the ambition to improve population health, but there is a lack of global representation and widespread opportunity to engage with such agencies to inform decision making, implementation, and reporting processes. What is most evident is a lack of consideration and global thinking from established health agencies to adopt and implement unified health agendas that could be effective in improving global public health.
Unhealthy lifestyle behaviours and chronic disease have been with society throughout history, but what was a pre-existing and sizeable challenge to public health has undoubtedly been accelerated and even synergized in the wake of COVID-19.
The key to successfully addressing the chronic disease burden can be achieved first via formal recognition from international governments and nongovernment agencies. Global attempts can then be implemented within health authorities, international governments, and academic researchers working collaboratively with deep interdisciplinary practice. Under the remit of healthy living medicine, holistic approaches to improving access and widespread adoption of healthy living behaviours should be devised in a manner that will benefit the population’s health and well-being for years to come.
Conclusion
With rising prevalence of CVD and the impact on health care, there is a need to develop cohesive interventions that are accessible and can be implemented at a scale to instil healthy living behaviours globally. This might appear idealistic, but there is a need for a global health infrastructure that is supported with appropriate investment. This could also include data modernisation and improved surveillance mechanisms that are transient and reflected by mass media coverage to make this panacea a reality. COVID-19 has served as a stark reminder to those with an interest in public health that adopting reactive approaches to public health challenges may not be in the public’s best interests. We must therefore work collaboratively to establish effective, scalable, and sustainable approaches and increase the recognition and implementation of precision public health.
Funding Sources
The authors have no funding sources to declare.
Disclosures
The authors have no conflicts of interest to disclose.
Healthy lifestyle interventions to combat noncommunicable disease—a novel nonhierarchical connectivity model for key stakeholders: a policy statement from the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine.
Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
Influence of the Covid-19 lockdown on the physical and psychosocial well-being and work productivity of remote workers: cross-sectional correlational study.
An update on the role of cardiorespiratory fitness, structured exercise and lifestyle physical activity in preventing cardiovascular disease and health risk.
Clinical and organisational framework of repurposing paediatric intensive care unit to adult critical care in a resource-limited setting: lessons from the response of an urban general hospital to the Covid-19 pandemic.
A multiprofessional face-to-face and remote real-time hybrid mode of exercise-based cardiac rehabilitation: an innovative proposal during the Covid-19 pandemic.
Comparison of home-based vs center-based cardiac rehabilitation in hospitalisation, medication adherence, and risk factor control among patients with cardiovascular disease.
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