Association of COVID-19 Outbreak with Changes in Physical Activity Among Adults with Elevated Risk for Major Adverse Cardiovascular Events

Association of COVID-19 Outbreak with Changes in Physical Activity Among Adults with Elevated Risk for Major Adverse Cardiovascular Events J Gen Intern Med DOI: 10.1007/s11606-021-06725-5 © This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2021 the COVID-19 stay-at-home orders reduced the W hile risk of viral transmission, their impact on preventive health behaviors of high-risk patients is unknown. Greater physical activity is associated with lower cardiovascular disease and mortality rates.1 For individuals at elevated risk for major adverse cardiovascular events (MACE), a short-term reduction in activity could impact longer-term habits.2 The objective of this study was to evaluate the association of the COVID-19 pandemic and the stay-at-home order issued on March 23, 2020, in Metropolitan Philadelphia with changes in physical activity among adults at elevated risk for MACE and examine differences in physical activity changes by sociodemographic characteristics. METHODS This study was approved by the University of Pennsylvania institutional review board and data was obtained from an ongoing randomized clinical trial evaluating the use of gamification and financial incentives to increase physical activity (NCT03911141). Participants were adults with either an atherosclerotic cardiovascular disease (ASCVD) condition or a 10-year ASCVD risk score of ≥ 7.5% who used a Charge 3 (Fitbit) wearable to monitor activity.3 For each participant, daily steps and moderate-to-vigorous physical activity (MVPA) minutes were obtained. Daily MVPA minutes were estimated by totaling the number of minutes with a pace ≥ 100 steps/min.4 We used multiple imputation for step values that were missing or < 1000/day5 (10.1% of data) and model results were pooled using Rubin’s standard rules. Using week 1 (February 1–7) of the pre-COVID-19 period (February 1–March 5, 2020) as reference, weekly changes in Received October 18, 2020 Accepted March 15, 2021 physical activity were estimated using a generalized linear mixed effects model adjusted for participant random effects, pre-trial baseline physical activity, study arm, and participant duration in the trial, in weeks. We then examined variations in physical activity by participant characteristics using a multivariate regression model that compared the period after Pennsylvania’s first COVID-19 case (March 6–May 27, 2020) to the pre-COVID-19 period with interaction terms for time and characteristic. Analyses were conducted in R (version 3.6.1) using 2-sided hypothesis tests (significance level, P < .05). RESULTS The sample comprised 217 adults with mean (SD) age of 69 (6.6) years; 22.6% had an ASCVD condition, and 24.0% were city residents (Table 1). Among citydwelling participants, 21.1% were Black while 9.1% of suburban participants were Black. Participants had a pretrial baseline mean (SD) of 5483 (2039) steps and averaged 7257 (3378) steps during the pre-COVID-19 period (February 1–March 5, 2020). Adjusted results indicate daily steps significantly declined relative to week 1 of the preCOVID-19 period in the 2nd week after the state’s first COVID-19 case (− 281 steps; 95% CI − 509, − 55; P = .01; Fig. 1). The greatest decline occurred in the first week after the stay-at-home order (− 617 steps; 95% CI − 887, − 346; P < .001), but this change was no longer significantly different from week 1 by 4 weeks after the stay-at-home order (week 13). There were no sustained, significant changes in MVPA across the full sample (Fig. 1). After adjusting for sociodemographic characteristics (Table 1), the largest, sustained changes in daily steps in the post-period, relative to the pre-period, were among Black vs. White participants (− 816; 95% CI − 1039, − 594; P < .001) and city vs. suburban residents (− 463, 95% CI − 614, − 311; P < .001). Each group also had significant, sustained declines in MVPA minutes (Table 1). DISCUSSION In a sample of adults at elevated risk for MACE, the COVID-19 pandemic and related stay-at-home order were JGIM Waddell et al.: Association of COVID-19 with Changes in Physical Activity Table 1 Sample Characteristics and Adjusted Changes in Physical Activity Participants (n = 217) Sociodemographics Age, mean (SD), years* Gender, no. (%) Male Female Race/ethnicity White, non-Hispanic Black, non-Hispanic Other Marital status, no. (%) Single Married Other College graduate Annual household income, no. (%) < $50,000 $50,000 to $100,000 > $100,000 City residence, no. (%) Self-reported measures Health status, no. (%) Excellent Very good Good Fair Poor Prior wearable device use, no. (%) Baseline measures Existing ASCVD diagnosis, no. (%) No Yes Body mass index, mean (SD)† Adjusted change in daily steps post-COVID-19 relative to preperiod Adjusted change in MVPA minutes post-COVID-19 relative to pre-period Estimate (95% CI) P value Estimate (95% CI) P value 69 (6.6) − 3 (− 15, 9) 0.66 − 0.2 (− 0.3, − 0.1) <0.001 100 (46.1) 117 (53.9) Ref 63 (− 76, 203) N/A 0.37 Ref 0.3 (− 0.6, 1.3) N/A 0.48 184 (84.8) 26 (12.0) 7 (3.2) Ref − 816 (− 1039, − 594) − 214 (− 586, 157) N/A <0.001 0.26 Ref − 3.5 (− 5.2, − 1.8) − 0.5 (− 2.7, 1.7) N/A <0.001 0.66 23 (10.6) 140 (64.5) 54 (24.9) 172 (79.3) Ref − 103 (− 326, 120) 20 (− 217, 257) − 276 (− 442, − 110) N/A 0.36 0.87 0.001 Ref − 0.6 (− 2.1, 0.9) − 1.2 (− 2.8, 0.3) − 0.1 (− 1.2, 1.0) N/A 0.41 0.12 0.84 45 (20.7) 72 (33.2) 100 (46.1) 52 (24.0) Ref 15 (− 177, 207) − 83 (− 292, 125) − 463 (− 614, − 311) N/A 0.88 0.43 <0.001 Ref − 0.9 (− 2.2, 0.5) − 0.8 (− 2.4, 0.8) − 2.6 (− 3.2, − 1.3) N/A 0.20 0.31 <0.001 17 (7.8) 86 (39.6) 91 (41.9) 23 (10.6) 0 (0.0) 146 (67.3) Ref − 41 (− 286, 204) 9 (− 241, 259) − 24 (− 352, 305) − 239 (− 365, − 112) N/A 0.74 0.94 0.89 <0.001 Ref − 0.8 − 1.7 − 1.7 − 1.0 N/A 0.31 0.04 0.16 0.03 168 (77.4) 49 (22.6) 29.8 (6.2) Ref − 215 (− 372, − 58) − 23 (− 35, − 12) Ref 0.01 <0.001 Ref − 0.1 (− 1.3, 1.0) 0.0 (− 0.1, 0.1) (− 2.3, 0.7) (− 3.2, − 0.1) (− 4.0, 0.7) (− 18, − 0.1) Ref 0.03 0.89 SD, standard deviation; CI, confidence interval; MVPA, moderate-to-vigorous physical activity; ASCVD, atherosclerotic cardiovascular disease; Ref, referent group; N/A, not applicable Multivariate generalized linear model adjusted for pre-trial baseline measure (daily steps or MVPA minutes), study arm, participant week in the clinical trial, each listed participant characteristic, time (before or after the first COVID-19 case on 3/6/20), and an interaction terms for time × participant characteristic. The table presents the estimate for the interaction terms *Variable was grand mean centered. Estimate is for every 1 year increase above the mean value. Here, for every 1 year increase in age, participants took 3 fewer steps in the post-COVID period. For example, participants who were 70 years old took 3 fewer steps, and those who were 71 took 6 fewer steps †Variable was grand mean cen (...truncated)