The missing mandate: Promoting physical activity to reduce disparities during COVID-19 and beyond
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The missing mandate: Promoting physical activity to reduce disparities during COVID-19 and beyond

Rebecca Hasson, Ph.D., FACSM; Jim Sallis, Ph.D., FACSM; Nailah Coleman, M.D., FACSM; Navin Kaushal, Ph.D.; Vincenzo Nocera, M.S.; NiCole Keith, Ph.D., FACSM | Jun 03, 2020
diverse seniors exercising in park for health

In light of the current COVID-19 pandemic, government leaders have encouraged individuals and families to shelter in place and only venture out of their homes for essential activities including traveling to work and obtaining food and medicine. Frequent hand washing and maintaining an appropriate physical distance of at least six feet has also been endorsed as behaviors that will reduce the spread of the virus. These recommendations are essential to the protection of our communities; however, there is a lack of attention to one other action that is critical to survival. Physical activity is one of the most efficacious pathways to promoting mental and physical health, preventing disease and, most important to our current context, bolstering a stronger immune system. In addition to strengthening immunity, physical activity reduces inflammation, and both are involved in determining the severity of infections. While outdoor physical activity is permitted under stay-at-home guidelines, this is a passive acceptance of being active. It is imperative that a more proactive approach is adopted to publicly encourage individuals and families to maintain certain levels of physical fitness to protect themselves against COVID-19.

Approximately 95% of COVID-19 deaths are among people with pre-existing chronic diseases, including obesity, type 2 diabetes, hypertension and cardiovascular disease. Not only are these diseases more common among communities of color and older adults, but physical activity reduces the risk of all of these diseases. Communities of color and lower-income populations also tend to experience higher levels of stress and are likely to be disproportionately affected by multiple stressors during the pandemic. During periods of high stress, the hormone cortisol can over time decrease the effectiveness of the immune system to fight off diseases. Thus, promoting physical activity among communities of color and lower-income populations can have specific physical and mental health benefits related to COVID-19. Very important for the future, physical activity has also been shown to enhance the efficacy of vaccine responses. This is particularly important for older adults whose immune systems are generally less effective. Thus, physical activity can play a special role in reducing disparities in the health impact of COVID-19.

Efforts to flatten the curve of COVID-19 diagnosis have resulted in the temporary closure of exercise facilities and gyms, the suspension of sport activities and the recommendation that individuals and families avoid public recreational spaces (e.g., playgrounds, basketball courts, soccer fields, baseball/softball diamonds and some parks). All of these changes have made traditional opportunities to be physically active difficult to access. More specifically, existing disparities in access to social and environmental supports for physical activity have been exacerbated by these closures, potentially contributing to a widening gap in physical activity participation among those at greatest risk for COVID-19. For disadvantaged youth, school closures eliminate opportunities to engage in structured exercise as many of these youth lack safe spaces to exercise or play sports in their neighborhoods. For children with disabilities, school closures eliminate access to inclusive physical activity, which can negatively impact their social, physical, emotional and cognitive development. Stay-at-home mandates have also curtailed occupational and transportational physical activity opportunities for many adults and are especially harmful to people in low-wage jobs. For those who may still have to go into the workplace, limited time in their homes for home-based activities may further reduce their ability to be physically active. For aging adults, gym closures have reduced safe spaces to engage in supervised physical activity and stay socially engaged with others. While many exercise, dance and yoga classes have moved from in-person to online delivery, barriers remain, such as the need to pay, limited space and internet access at home. Internet and computer access is especially problematic for persons with lower incomes and many individuals living in rural areas. Greater attention needs to be given to promoting physical activity in vulnerable populations at the highest risk of being hospitalized for COVID-19.

In 2017, the American College of Sports Medicine (ACSM) developed a national roadmap that supports achieving health equity through a physically active lifestyle. Key pillars of this roadmap included: 1) raising awareness; 2) developing educational resources and community-based programs; 3) building partnerships; and 4) ensuring measurable progress in reducing physical activity disparities to promote health equity. Over the past three years, ACSM has made considerable progress in raising awareness of the issue and magnitude of health inequities and conveying the power of physical activity in promoting health equity. Now more than ever, attention to education and collaboration is needed to close the gap in physical activity disparities amidst the COVID-19 pandemic.

Call to action for individuals to remain physical active during COVID-19

Despite these pre-existing inequities that are magnified during this pandemic, there are realistic and safe options for providing more equitable opportunities for physical activity in disadvantaged communities. Walking, for instance, is the most common activity across every age group. It is healthy, free and current mandates allow walking outdoors. If you have a safe trail or route to walk, consider doing so while staying at least six feet away from others. When considering indoor activities, find resources to get yourself active and take steps towards turning your at-home activity routine into a habit. Make a list of everything that you could use to help get yourself moving (safely) at home - from technology (workout apps and videos) to any exercise equipment (jump ropes and elastic bands) to furniture (using a sofa edge for dips and the bottom space to support sit-ups).  If you are an older adult, use furniture to support yourself, such as resting an arm on a kitchen counter for assisted squats or chair exercises. If you live in an apartment building, put on your headphones and climb some stairs or set up a balcony dance party with your neighbors. In summary, select activities that are challenging and fun. But also remember that sweeping, mopping, vacuuming, dusting, gardening, mowing the lawn and all tasks that involve the use of large muscle groups count toward your physical activity minutes necessary for health protection. In the same manner as other traditional exercise sessions, performing these types of household chores are an effective way to defend against disease and infection, while improving your mental and physical health.

Now it is time to turn your activities into a habit. A habit is a behavior that has become automatic (e.g., your morning routine). To achieve this, keep a consistent time, so the workout becomes predictable, and pair it with a reminder cue. For example, place a jump rope on your bed in the morning as a cue. It remains on your bed until it is time for you to complete your workout. Afterward hide the rope to turn off the cue. Keep track of your goals and gradually add more to your program - maybe another round of stair climbing or another song for dancing.

Call to action for the development of physical activity resources during COVID-19.

It is imperative that educators, health care providers and public health professionals communicate the importance of physical activity and provide direction on methods to safely be physically active in the same way that information regarding other health advisories are being communicated. Here is an occasion in history that provides an opportunity to improve public health and protect against both disease and infection through a behavior that is available to everyone who chooses to engage. Physical activity participation must be encouraged as a matter of life or death. Science has repeatedly shown that persons most vulnerable to COVID-19, such as seniors and those with pre-existing conditions, benefit greatly from frequent, moderate intensity physical activity. At this extraordinary time health officials, policy makers and other government leaders have an opportunity to underscore the critical importance of daily physical activity, encouraging people to decrease their sedentary behavior and move more to improve health outcomes and to save lives. Most health benefits from physical activity come through frequency, not intensity, so whether one chooses to exercise for only a few minutes at a time, or for longer, every minute counts to lower risk of disease and infection.

Call to action to equitably increase access to outdoor physical activity spaces.

As states and communities across the country begin to reopen and lift shelter-in-place mandates, an equitable approach to increasing access to physical activity spaces includes park departments opening parks as quickly as it is safe to do so in lower-income communities and providing staff to ensure safe use of these spaces. Because schools are in almost every neighborhood, school facilities in lower-income communities can be reopened with park personnel assigned to supervise activities and provide education for safe distancing. Many communities across the country are also using the light traffic during shutdown periods to close some streets to traffic so residents have more safe space for walking, rolling and bicycling. “Open streets” require full closure to cars, whereas “slow streets” only close streets to through traffic so residents of each block can drive home, but pedestrians and non-motorized users are prioritized. Slow streets can be retained for weeks, months or even permanently. This is particularly useful in low-income communities where poor-quality sidewalks make walking for exercise a daily challenge. If open or slow streets are provided in every neighborhood, or provided first in lower-income neighborhoods, then there would be equitable access to physical activity opportunities for all age groups. Everyone can recommend these actions to your local leaders.

The message to move more to improve health is more important today than ever before as physical activity is essential to human health. There are feasible strategies to provide more equitable access to physical activity programs and spaces in every city and town. With a renewed investment in physical activity participation, this behavior can play a crucial role in improving population health and reducing disparities during the current COVID-19 pandemic and beyond.

Authors of this blog are a part of ACSM's Strategic Health Initiative on Health Equity.
Rebecca Hasson, Ph.D., FACSM; Jim Sallis, Ph.D., FACSM; Nailah Coleman, M.D., FACSM; Navin Kaushal, Ph.D.; Vincenzo Nocera, M.S.; NiCole Keith, Ph.D., FACSM