key: cord-0907865-r149iu4f authors: López-Sánchez, Guillermo F; López-Bueno, Rubén; Gil-Salmerón, Alejandro; Zauder, Roksana; Skalska, Maria; Jastrzębska, Joanna; Jastrzębski, Zbigniew; Schuch, Felipe B; Grabovac, Igor; Tully, Mark A; Smith, Lee title: Comparison of physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine date: 2020-08-06 journal: Eur J Public Health DOI: 10.1093/eurpub/ckaa159 sha: 3e61424f1d021e8b34f380f39f041dac78b4fe20 doc_id: 907865 cord_uid: r149iu4f BACKGROUND: This is the first study analysing levels of physical activity in a sample of quarantined adults with chronic conditions. The aim of this study was to compare moderate-intensity and vigorous-intensity physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine. METHODS: A cross-sectional online survey was administered during the COVID-19 quarantine in Spain. A total of 163 participants with chronic conditions (113 females and 47 males; age range 18-64 years) completed the survey. A total of 26 chronic conditions were included. Participants self-reported average minutes/day of moderate and vigorous physical activity before and during quarantine. Differences in moderate-intensity physical activity and vigorous-intensity physical activity levels before and during COVID-19 quarantine (overall, by gender, by age, by number of chronic conditions and by each chronic condition) were assessed by Wilcoxon signed-rank test. RESULTS: During COVID-19 quarantine, there was a significant decrease of moderate-intensity physical activity in Spanish people with chronic conditions (in both males and females, in those aged 18-24, 25-34, 35-44 and 55-64 years, in those with multimorbidity, in those with one/two chronic condition/s, and in those diagnosed with asthma/hypercholesterolemia/chronic skin disease/hemorrhoids). Also, there was a significant decrease of vigorous-intensity physical activity in Spanish males with chronic conditions and in those with multimorbidity. CONCLUSIONS: These results should be considered to develop effective strategies of physical activity promotion targeting these specific groups when new quarantine or restriction measures are implemented, in order to avoid new significant decreases of physical activity in these vulnerable populations. (WHO) on the 11 th March of 2020. 1 At the time of writing (20 July 2020), 14 043 176 cases have been diagnosed globally, resulting in 597 583 fatalities thus far. 2 Spain is among the countries with the highest number of cases, with a total of 260 255 cases diagnosed that have resulted in 28 420 fatalities thus far. 3 Due to the proven effectiveness of traditional public health measures interrupting human-to-human transmission of viruses 4 , on 15 th March of 2020 the Spanish Government approved a period of quarantine due to COVID-19, in order to fight the spread of the virus. 5, 6 During the quarantine period, the Spanish population were instructed to stay in their homes and, by consequence, interrupt their usual activities. 5, 6 As prolonged home stays can increase behaviors that lead to inactivity, maintaining regular physical activity and routinely exercising in a safe home environment is an important strategy for healthy living during the coronavirus crisis. 7 In this context, special attention should be paid to people with chronic conditions because they are a vulnerable group in the COVID-19 pandemic, as they have higher risk of severe disease and mortality owing to COVID-19. [8] [9] [10] Participating in regular physical activity during COVID-19 quarantine is important for people with chronic conditions because greater levels of physical activity in this population are associated with both positive affect and physical functioning. 11,12 Indeed, physical activity is a potential health promotion modality for people with chronic conditions, 13 as it may ameliorate associated depression, mobility difficulties and pain. 14 Furthermore, as physical activity has shown to be an effective therapy for most chronic diseases with direct effects on both mental and physical health, physical activity has now been recommended as therapy to address the mental and physical consequences of COVID-19 quarantine. 15,16 Therefore, it is very important that, during quarantine periods, people with chronic conditions maintain adequate levels of physical activity by meeting the global recommendations on physical activity for health: at least 150 minutes/week of moderate-intensity physical activity, or 75 minutes/week of vigorous-intensity physical activity, or an equivalent combination of moderate-and vigorous-intensity physical activity. 17, 18 However, to the best of our knowledge no studies have been published yet analyzing the levels of physical activity in adults with chronic conditions before and during COVID-19 quarantine. Given this background, this study aimed to compare moderate-intensity and vigorous-intensity physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine (overall, by gender, by age, by number of chronic conditions and by each chronic condition), in order to identify specific groups that may require target physical activity interventions. It is hypothesised that in those with any chronic condition moderate intensity physical activity and vigorous intensity physical activity would had decreased from before to during COVID-19 quarantine. A cross-sectional online survey was administered during the COVID-19 quarantine in Spain. The Spanish quarantine started on the 15 March 2020. 18 This study followed the principles of the World Medical Association Declaration of Helsinki and was approved by the Ethics Committee of Research in Humans of the University of Valencia (1 April 2020; register code 1278789). The study lasted one month (from 1 April 2020 to 1 May 2020). On the 2 nd May 2020 the gradual opening in Spain commenced and physical activity outdoors was allowed again, albeit with time restrictions. 19 Spanish adults aged 18 years and over (age range of those who completed the survey 18-64 years) that were quarantined due to COVID-19 were eligible to participate. A convenience sample of participants were recruited through social media (e.g. Facebook, Twitter, Whatsapp). They were directed to a data encrypted website, where they indicated their consent to participate after reading an information sheet and they confirmed that they were in a quarantine situation. The data provided were anonymous and treated accordingly to Spanish law regarding general data protection. This manuscript was written in accordance with the STROBE Statement (Strengthening the Reporting of Observational studies in Epidemiology). 20 Participants were asked: 'Have you ever been diagnosed by a health professional with any of the following chronic conditions? (tick all that apply)'. Chronic conditions included were: depression, anxiety, other psychiatric disorders, obesity, hypertension, varicose veins of lower extremities, osteoarthritis, chronic neck pain, chronic low back pain, chronic allergy excluding allergic asthma, asthma including allergic asthma, chronic bronchitis, diabetes type 2, cataracts, peptic ulcer disease, urinary incontinence or urine control problems, hypercholesterolemia, chronic skin disease, chronic constipation, chronic migraine and other frequent chronic headaches, hemorrhoids, cancer, osteoporosis, thyroid disease, renal disease and injury. This list of chronic conditions was based on the list of chronic diseases of the Spanish National Health Survey. 21 Multimorbidity was defined as the cooccurrence of two or more chronic conditions. First, vigorous and moderate physical activity were described to participants: "Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal." Then, participants were asked: 1) How much time on an average day did you usually spend in moderate activity before quarantine? 2) How much time on an average day do you spend in moderate activity during quarantine? 3) How much time on an average day did you usually spend in vigorous activity before quarantine? 4) How much time on an average day do you spend in vigorous activity during quarantine? Responses were reported in minutes/day. The statistical analysis was performed with SPSS 23.0 (IBM, NY, USA). The Kołmogorov-Smirnov test was applied to check normality. Differences in moderate-intensity physical activity and vigorousintensity physical activity levels before and during COVID-19 quarantine (overall, by gender, by age, by number of chronic conditions and by each chronic condition) were assessed by Wilcoxon signedrank test, providing the mean and standard deviation of each group, the mean difference, the Z-value and the p-value. In addition, the effect size was calculated using Rosenthal's formula (r = Z/√N), 22 and it was classified as small (0.10), medium (0.30) and large (0.50). 23 There were missing data only on the following variables: gender (n=3: 1.84%) and age (n=3: 1.84%). Complete-case analysis was carried out (only participants for which we had no missing data on the variables of interest were included in the analyses, while participants with any missing data were excluded). The level of statistical significance was set at p < 0.05. A total of 163 participants with chronic conditions completed the survey. The gender distribution was: males (n=47) and females (n=113). The age distribution was: 18-24 years (n=59), 25-34 years (n=52), (Table 1a) . Vigorous-intensity physical activity significantly decreased in Spanish males with chronic conditions during COVID-19 quarantine (mean difference: 15.5 min/day; p=0.025). (Table 1b) . According to number of chronic conditions, moderate-intensity physical activity significantly decreased during COVID-19 quarantine in those with multimorbidity (mean difference: 30.1 min/day; p<0.001), in those with one chronic condition (mean difference: 29.9 min/day; p=0.001) and in those with two chronic conditions (mean difference: 34.8 min/day; p=0.002). (Table 2a) . Vigorous-intensity physical activity significantly decreased during COVID-19 quarantine in those with multimorbidity (mean difference: 11.4 min/day; p=0.045). (Table 2b) . Regarding each chronic condition, moderate-intensity physical activity significantly decreased during COVID-19 quarantine in those diagnosed with asthma (mean difference: 26.2 min/day; p=0.026), hypercholesterolemia (mean difference: 39.0 min/day; p=0.011), chronic skin disease (mean difference: 44.3 min/day; p=0.004) and hemorrhoids (mean difference: 50.1 min/day; p=0.009). (Table 3 ). There were no significant differences in vigorous-intensity physical activity by each chronic condition before and during COVID-19 quarantine. (Table 4 ). To our knowledge, this is the first study analysing levels of physical activity in a sample of quarantined adults with chronic conditions. The results of this study showed significant decreases of both moderate and vigorous physical activity during COVID-19 quarantine in Spanish people with chronic conditions. These results differ from a recent study that analysed physical activity levels during quarantine in Spanish adult general population (n=2741), which found an increase of physical activity. 24 There are several plausible reasons to explain the physical activity reductions in Spanish people with chronic conditions that were observed in the present study and the difference with the results obtained in the general adult population. 24 First, people with chronic conditions are a vulnerable group and they experience a greater number of barriers to physical activity participation than the general adult population, [25] [26] [27] [28] and it is likely that it is more difficult to overcome these barriers during a quarantine situation. Second, quarantine due to COVID-19 could produce, in those with chronic conditions, feelings of loneliness, lack of social support and isolation, which are also associated with reductions of physical activity and chronic conditions. 29-33 Third, natural light and natural environment exposure deprivation during quarantine might lead to a negative mood state, which consequently, may predispose for less physical activity. 34 Fourth, the prohibition of doing physical activity outdoors (very frequent in Spain due to the good weather of the country), could highly contribute to this reduction in physical activity levels in people with chronic conditions, as Spanish people are more used to outdoor than indoor physical activity. Also, the negative consequences that this significant reduction in physical activity can cause in people with chronic conditions should be considered in order to prevent other health problems. For example, several studies have reported that short-term physical inactivity (i.e.14 days) causes reversible metabolic derangements and changes in body composition. 35 Moreover, other negative short-term effects of physical inactivity are impaired endothelial function, arterial stiffness, increased arterial tone, insulin resistance, increased blood pressure and dyslipidemia. 36,37 Therefore, it is urgent and necessary to develop effective strategies of physical activity promotion in people with chronic conditions in order to avoid potential subsequent complications in their conditions. The main strength of this study is that it is the first study reporting levels of physical activity in a sample of quarantined adults with chronic conditions. Another strength of the present study is the high number of chronic conditions included (a total of 26 chronic conditions). However, the present findings must be interpreted in light of the study limitations. First, physical activity and chronic conditions were self-reported, potentially introducing self-reporting bias into the findings. Second, analyses were crosssectional and thus it was not possible to determine trajectories of physical activity during the whole period of quarantine. Third, due to the method of sampling (convenience sampling), there is the possibility of a selection bias. During COVID-19 quarantine, there was a significant decrease of moderate-intensity physical activity in Spanish people with chronic conditions (in both males and females, in those aged 18-44 years and 55-64 years, in those with multimorbidity, in those with one/two chronic condition/s, and in those diagnosed with asthma/hypercholesterolemia/chronic skin disease/hemorrhoids). Also, there was a significant decrease of vigorous-intensity physical activity in Spanish males with chronic conditions and in those with multimorbidity. These results should be considered to develop effective strategies of physical activity promotion targeting these specific groups when new quarantine or restriction measures are implemented, in order to avoid new significant decreases of physical activity in these vulnerable populations. Owing to the restrictions imposed during quarantine the promotion of appropriate home-based exercises are required for those with chronic conditions, it may be best to promote exercise programs during quarantine online either utilising existing, or developing new, exercise programs. Moreover, simple brief exercise advice could also be provided. 10. Nieman DC. COVID-19: A tocsin to our aging, unfit, corpulent, and immunodeficient society. World Health Organization. Coronavirus disease 2019 (COVID-19) situation report -51 World Health Organization. Coronavirus disease 2019 (COVID-19) situation report -138 Enfermedad por nuevo coronavirus, COVID-19: Situación actual. 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