The COVID-19 pandemic has dominated nearly every aspect of our lives during the past 18 months. Early on, studies showed the elderly and patients who suffer from non-communicable diseases (NCDs) were at greatest risk for severe COVID-19 outcomes, defined as being hospitalized, admitted to the intensive care unit and dying. Yet we know that regular exercise has been shown to significantly reduce the incidence and improve the management of NCDs and enhance immune function.

As a long-time family medicine physician, I have observed firsthand the benefits of exercise for the health and well-being of my patients. In fact, with virtually every disease I encounter in my practice, I have found that exercise is the most powerful medication I can prescribe. For that reason, I felt it was likely that regular exercise would dramatically reduce the risk of severe COVID-19 outcomes.

Therefore, I led a group of colleagues in a study to test the hypothesis that consistently meeting physical activity (PA) guidelines (>150 minutes per week of moderate-to-vigorous PA) prior to a diagnosis of COVID-19 would lead to more favorable outcomes among adults. The study was conducted at Kaiser Permanente in Southern California, which is an integrated health care system serving some 4.7 million residents at 15 medical centers. All Kaiser patients have their exercise habits assessed at every outpatient visit using an Exercise Vital Sign (EVS). The EVS is assessed by the medical assistant who asks each patient two questions about their exercise habits (frequency and duration) during the intake at each outpatient visit.

Our analytic cohort consisted of 48,440 COVID-19 patients with a mean age of 47.5 years; 62% were female and 65% were Hispanic. Mean body mass index was 31.2 kg/m² and almost half the patients had at least one co-morbidity. In terms of their COVID-19 outcomes, 8.6% were hospitalized, 2.4% were admitted to the intensive care unit and 1.6% died. With unadjusted data, we found that patients who were consistently meeting PA guidelines prior to their COVID-19 diagnosis were about 70% less likely to be hospitalized and about 80% less likely to die.

After adjusting for the CDC defined risk factors for severe COVID-19, those who were consistently meeting PA guidelines prior to their COVID-19 diagnosis were 2.26 times less likely to be admitted to the hospital and almost 2.5 times less likely to die compared to patients who were consistently inactive. The only bigger risk factors were older age (> 60 yrs.) and a history of organ transplant. We also found that patients who were doing just “some activity” (>10 mins. but <150 mins. per week) were also at a lower risk of both hospitalization and dying than those who are consistently inactive. Interestingly, race and obesity (unless severe [body mass index >40 kg/m²]) were not found to be risks for severe COVID-19 after controlling for PA and other COVID-19 risk factors.

The strengths of our study were the large sample of COVID-19 patients who had a measure of their PA habits before they were diagnosed. Also, the COVID-19 risk factors and outcomes in our study population were objectively measured, having been taken directly from each patient’s electronic medical record. Limitations of the study included the fact that PA was self-reported using the EVS. However, the EVS has been in use at Kaiser for more than 10 years and has been validated in previous studies.

In my opinion, the evidence for the benefit of regular PA in terms of COVID-19 outcomes shown in our study dramatically contrasts with public health efforts to promote PA during the pandemic. We should be informing the public that short of a vaccination, regular PA is perhaps the most important thing one can do to reduce their risk for severe COVID-19. The results of this study define a clear and actionable guideline to reduce the risk for severe COVID-19 outcomes and suggest that PA should be prioritized by public health officials and incorporated into routine medical care. We all know that exercise is medicine, and we can now add COVID-19 to the long list of conditions it should be prescribed to treat!


Robert Sallis, M.D., FACSM, is a family medicine and sports medicine physician at Kaiser Permanente Medical Center in Fontana, California. He is director of the Kaiser Sports Medicine Fellowship Training program and on the administrative faculty for the Family Medicine Residency. Dr. Sallis also serves as a clinical professor of Family Medicine at UC Riverside School of Medicine and serves at chief medical officer for the Los Angeles Football Club (Major League Soccer). He is a past president of ACSM and founded the Exercise is Medicine^® global health initiative during his term as ACSM president.

^{Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent positions or policies of ACSM. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.}

Diet Manipulation for Healthy Living – Importance of 16-Hour Fasting

Social media commonly offers a variety of healthy living solutions, presenting a perfect mix of speculation, firm belief, a bit of scientific evidence and personal experience. Nutrition tends to be a popular topic on social media. Often, a seemingly convincing case is made that encourages people that a dietary approach is miraculous. One such topic is prolonged fasting. As health practitioners, we often have clients mention this “new” approach to healthy living. However, the approach often has little-to-no scientific evidence.

Our group recently completed a project studying prolonged fasting. Our study, published in the December 2021 issue of Medicine & Science in Sports & Exercise_®, evaluated the effects of daily diet manipulation and resistance training on health benefits. We hypothesized that 12 months of time-restricted eating would lead to lower fat body mass and a reduction of inflammatory and metabolic markers compared to a regular dietary pattern. This diet manipulation experiment was conducted in a group of expert resistance trainers. The time-restricted eating group consumed their energy needs in three meals during eight hours each day. Subjects in the normal diet group also had three meals, which were consumed over 16 hours. This approach provided fasting times of 16 and eight hours, respectively. The time-restricted eating group calories distribution was 40% at the first meal (“break the fast”), 25% at the second meal and 35% at the last meal.

After 12 months of daily fasting for 16 hours, the experimental group showed losses of 3.3% body mass and 11.8% body fat mass. The normal diet group showed gains of 3.4% and 2.9% of body mass and fat mass, respectively. The visceral adipose tissue measured via dual-energy x-ray absorptiometry decreased by 18.8% in the experimental group.

Interestingly, the long-term fasting period impacted the testosterone levels of participants, inducing a 16.8% reduction within the experimental group, while no change was observed in the normal diet group. Furthermore, the same trend was observed for insulin-like growth factor 1. The fasting protocol also had an impact on the cholesterol profile and insulin resistance, which improved significantly, and inflammatory markers, which decreased by more than 13% in 12 months.

These findings demonstrated that well-trained resistance exercisers who adhere to a fasting protocol for a long period of time can obtain beneficial effects on health biomarkers and inflammatory indices. Moreover, the long-term time-restricted eating approach spontaneously reduced the total caloric intake, driving a “healthy weight loss.” However, long-term, time-restricted eating negatively affected muscle mass due to the significant negative impact reported on anabolic hormones in this population.

Our study provides new insight into the management of meal frequency and meal timing for people expert in resistance training activities. The main take-home message is that there are pros and cons to prolonged time-restricted eating. Although time-restricted eating may produce some physiological advantages, it is not a miracle as often suggested in social media posts.


Antonio Paoli, M.D., FACSM, FECSS, is a professor and dean of Sport and Exercise Sciences at the University of Padua in Italy. He earned a B.S. in Physical Education (ISEF) from the University of Bologna (Italy) and his medical degree from the University of Padova. In 2008, he obtained a specialization in sport medicine from the University of Pavia. Dr. Paoli also serves as a professor and chair of Strength Training and Sport Nutrition at the University UCAM (Murcia, Spain) and as the president of the Italian Society of Sport and Exercise Science (SISMES) and the European Sport Nutrition Society (ESNS). His current major research directions include the interaction of exercise and diet, mainly ketogenic diet and time-restricted-eating, the molecular bases of exercise training adaptation and the effects of different methodology of resistance training on health parameters and body composition in young and adults.

^{Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent positions or policies of ACSM. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.}

How to Enjoy Holiday Meals with Less Stress

The holidays, while joyful, can often be a source of stress for many, especially around food and fitness. A non-diet approach can help clients to make progress towards health goals while also feeling calm, present and able to live in the moment with loved ones.

Intuitive eating is a self-care model of eating that honors not just physical health, but also mental and emotional health. It was developed in 1995 by dietitians Evelyn Tribole and Elyse Resch, with a validated assessment scale and over 140 evidence-based studies to date (1). These tips can help clients, friends, family (and you!) to make the most out of this holiday season.

1. Avoid the diet mentality.

Aim to eat regular meals and snacks to help balance blood sugars, energy levels and mood. Skipping meals to "save calories," over exercising to "earn your food" and other restrictive behaviors will only leave you feeling deprived and more likely to overeat later in the day. 

2. Remember it's okay to say no.

If you identify feelings of fullness, recognize that it is okay to honor these physical feelings, and deny pressure for seconds from others. Helpful responses might include, “No thanks, but can I have the recipe?” or, “I would love to take home leftovers to enjoy when I’m not so full!” 

3. Choose foods that satisfy. 

When you allow yourself to eat the foods you enjoy, you will be more likely to eat the amount you need. Consider different textures, flavors and dishes that hold sentimental value as well. All of these contribute to a more positive eating experience. 

4. Practice mindful eating.

Using the five senses while eating can also help you to pay attention, further enhancing the eating experience. The visual appeal, the aromas and the awareness can help contribute to feeling present and in the moment (2). 

5. Move in a way that feels good. 

The holiday season might bring changes in schedules and routines, making it hard to stick to any type of plan. Embrace this and aim to move in a way that feels good. That might look like taking more steps/walking laps at the airport or trying a new fitness class with a family member. Aim for increased physical activity and worry less about structured exercise. 

6. Treat yourself with kindness. 

Health and longevity in life require looking at the total picture of wellness including not just your physical health, but also your mental, emotional, spiritual health and more. Remember, all foods can be part of a healthy diet without guilt and shame! 

If you are looking for more support for yourself or clients throughout the holidays, consider working with a Registered Dietitian Nutritionist. Practicing intuitive eating and a non-diet approach will contribute to your health through the holidays and beyond!

More Resources: 

Five Fast FAQs on Nutrition | Blog Post
Creating a Healthy Eating Pattern | Handout

Katie Hake RDN, LD, ACSM-CPT, is a Registered Dietitian and Fitness Professional with a passion for helping women to stop dieting and start living. She works with women to eliminate the rigid, all-or-nothing mindset and replace it with one that celebrates life’s small wins to let them grow. Through both nutrition and fitness coaching, she empowers women to become the expert of their own bodies. She is a Certified Intuitive Eating Counselor and has a virtual practice based out of Indianapolis, Indiana. You can find out more about her at www.katiehake.com or by subscribing to the Fit Friends Happy Hour Podcast, which she hosts.

References:
1. 10 Principles of Intuitive Eating [cited 2021 Nov 16].
2. Mindful Eating: The Art of Presence While You Eat [cited 2021 Nov 16].

Regular physical activity provides several long-term benefits that can help prevent and treat mental health disorders. Fitness professionals can support the mental and physical well-being of their clients by implementing some basic strategies that address their health from a 360-degree perspective. 

1. What do they like to do?

Identify and encourage activities that best fit each client’s preferences and abilities. Aerobic, resistance and mind-body exercises and of light, moderate or vigorous intensity all benefit mental well-being. Greater enjoyment of the activity can be more mentally beneficial.

2. How confident are they?

Help identify activities that are in line with your client’s self-efficacy or confidence in their ability to take part. Then focus on incremental improvements toward mastering these activities. This can enhance adherence, enjoyment and overall mental wellness.

3. What are their barriers?

It can be challenging to engage in physical activity when having symptoms of stress, depression or anxiety. Discuss your client’s barriers to being active and provide strategies to help them continue to engage in activity.

4. What motivation do they need?

Increase the likelihood of adherence with regular follow up on progress to help motivate and encourage clients toward achieving goals.

5. Do they have social support?

Help your client identify avenues for social support. This can help with program adherence and provide mental health benefits through positive social interactions.

6. Can you take it outside?

Consider a training session outside or encourage outdoor activities. Time spent in nature and exercising outdoors can help relieve stress, increase energy and boost mood.

Learn more about physical activity for mental well-being and keep these six tactics handy by downloading this handout, developed exclusively for ACSM Certified Professionals, by ACSM's American Fitness Index^®.

Download the Handout

Additional Resources:

Could All Those Zoom Meetings be Bad for Your Health? | Blog Post

Muscling Up on Mental Illness | Online Course, worth 2 CECs

"Promoting Physical Activity for Mental Well-Being" | Article by Stephanie Cooper, Ph.D., ACSM-CEP, in ACSM's Health & Fitness Journal®

ACSM American Fitness Index^® Rankings | See how each of the 100 cities ranks in mental health of residents, as well as other indicators of health.

Amanda Paluch, Ph.D., is an assistant professor of kinesiology at the University of Massachusetts Amherst. She is a member of the ACSM American Fitness Index Advisory Board. Her long-term career goal is to reduce the burden of chronic diseases through technology-assisted physical activity interventions that can be disseminated through clinicians and/or population level efforts.

Over the past few weeks, Congress and the Biden Administration have been embroiled in many different controversies regarding infrastructure funding, social spending, overall fiscal spending and the debt limit. Unfortunately, the physical activity guidelines legislation ACSM supports was pulled into the debate.

Earlier this year, the Senate passed by unanimous consent S. 1301, the Promoting Physical Activity for Americans Act. The legislation would require the Secretary of Health and Human Services to publish physical activity guidelines based on the latest scientific research every 10 years. Once the bill was passed in the Senate, it was forwarded to the House for their consideration. However, to try and circumvent regular order in the Senate, House Democrat leadership decided to use S. 1301 as the vehicle to pass a debt limit suspension. They amended the bill by deleting the physical activity language and inserting the debt limit suspension language. Within 24 hours, the bill was amended, passed on the House floor and sent to the Senate for their consideration. The bill has since been amended and passed by the Senate, passed again by the House and is now on its way for signature by President Biden.

What this means in the short run is that we no longer have a Senate-passed version of the physical activity guidelines bill. We are left with the House version, which is H.R. 2094, the Promoting Physical Activity for Americans Act. Having the Senate bill used as the debt limit vehicle means that we will have an added hurdle to clear to get the physical activity guidelines bill passed and signed into law. Once the House passes the legislation, it will again be sent to the Senate for their consideration, and then, if there are no changes to the House-passed bill, it will be sent to President Biden for his signature.

We need your help to get this bill passed in the House.
TAKE ACTION: Contact your member of Congress to ask them to support the bill.

Stay up to date with ACSM's Advocacy efforts by following us on Twitter @ACSMAdvocacy.