Our study shows that PA level significantly decreased during the COVID-19 lockdown, which was related to increased weight gain by most of the trained population. Most prone to the pandemic quarantine were the elderly adults that were less likely to initiate home-based activities.
The current study demonstrates the negative effect of lockdown and social distancing policy on peoples' PA level and exercising habits as well as on health status among physically active adults during COVID-19. The study suggests that pandemics such as the current COVID-19,(1) pose unique health issues, possibly on account of the requirement to stay at home that causes the reduction in PA, among all people and especially among physically active individuals who habitually practicing in sports [28]. Although lockdown may be essential as a strategy to mitigate the pandemic, it also generates new challenges to health. Staying at home for a prolonged time may increase sedentary habit [2, 3] and decrease PA level [12, 29] which may lead to disturbing consequences such as an increased risk of worsening health conditions (including chronic ones) [2, 3], weight gain [12, 29], insufficient sunlight exposure, social isolation [2], and can effect metabolic health [30]. Altogether, sedentary behavior and low levels of PA can have negative effects on well-being and quality of life.
The Israeli Ministry of Health closed all organized activities in mid-March including gyms and fitness centers [31]. The government enforced restrictions on outdoor and recreational activities and limited outdoor and social activities to a maximal radius of 100 meters' distance from home. Whereas health policy has been directed to prevent the spread of COVID-19, there was no reference or guidance on how to maintain PA during times of social distancing and isolation, regardless of the health implications that could result from physical inactivity. Thus, our survey exhibited the difficulty of maintaining a healthy and active lifestyle during the lockdown. Seventy percent of the participants, who were physically active in their daily life before the pandemic broke, indicated a significant decrease in the PA level that was related to increased weight gain. A correlation was found between age, health status, and the decrease in the PA level. Most prone to the pandemic quarantine was the old adult population that was less likely to initiate home-based activities. The health toll in this population might be higher as a result of physical inactivity and can lead to deterioration of their health condition. Cardiovascular deconditioning might increase the risk for cardiovascular disease while deconditioning of the musculoskeletal system might increase frailty osteoporosis and risk of falling among the elderly [32, 33].
Physical inactivity and sedentary lifestyle are both risk factors for coronary vascular disease, diabetes, and many more non-communicable diseases (NCDs). Although the general activity of the old adult group has limited a priory, nevertheless, this population is the most vulnerable to high morbidity caused by COVID-19.(34–36) WHO data indicates that up to 40 million individuals die each year from NCDs and 20–30% of these cases are related to a deficiency in PA [37]. For individuals, the failure to perform adequate levels of PA increases the risk for cancer, heart disease, stroke, and diabetes by 20–30% and shortens their lifespan by 3–5 years [37]. The total volume of accumulated sedentary time in prolonged, uninterrupted bouts is also associated with all-causes of mortality. Therefore, any PA guidelines should aim to reduce the sedentary time to avoid the risk of death [38, 39].
Lifestyles and PA have been changed globally during the coronavirus pandemic lockdown [2, 28, 40]. Data collected by Fitbit wristwatches from over 30 million active users around the globe, showed a decrease in PA of 38% in Spain, a 14% decrease in North America and 24% decrease in Israel [41]. Garmin user's reported a massive decline in the overall number of steps taken during the second two weeks of March [42]. Therefore, it is important to grant access to activity substitutes, especially for old adults, to keep them fit and healthy at their own homes. However, this option is limited by the ability of people with specific physical habits to change to a new, unaccustomed regime that uses digital technology and social media. It is necessary to make digital technology effective and accessible for all people, particularly for those with special needs. Furthermore, there is a need to implement and improve people's digital orientation and attitude toward digital technology. Such technologies can help in introducing a wider range of PA and media solutions, focusing on different populations, communities, languages, and cultures. Using digital technology, it is possible to deliver content that is designed for remote PA exercise at home when regular training options are unavailable.
The current survey found that 55% of the participants gained weight during the March-April pandemic quarantine. Weight gain was significantly negatively correlated with age, PA level, and use of home digital PA modalities. However, a multiple regression analysis showed that only reduction in PA level significantly predicted weight gain. Weight gain and metabolic syndrome has emerged as a major public health problem around the world and raises more concern concerning sedentary behavior during the COVID-19 pandemic [43, 44]. The syndrome is related to increased weight gain, abdominal obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol, high blood pressure, and hyperglycemia [43, 45]. People having metabolic syndrome are at increased risk of developing diabetes and cardiovascular disease [45]. According to the Israeli Central Bureau of Statistics 48% of adults are overweight [46]. Although our survey was conducted on overall active individuals (57% of study participants were performing PA at list 3 times a week), the average increase in weight was considerable (1.25 kg). However, participants who conducted PA > 4 times/week did not gain weight. The weighted mean weight regained with or without exercise training was only 0.28 and 0.33 kg/month, respectively. Based on observational studies, an actual increase in energy expenditure of PA of approximately 6300–8400 kJ/week (1500–2000 kcal/week) is associated with improved weight maintenance [47]. he increased weight gain outcome in active individuals could be explained by the decrease in non-exercise activity thermogenesis (NEAT) which is the energy expenditure of all physical activities other than volitional sporting-like exercise. Since activity levels were decreased, it is not surprising that the whole NEAT decreased substantially, reflecting the increased indoor inactivity time. To reverse this, there is a need to develop strategies by re-engineering our home environments [48]. Exercise is also associated with long-term weight loss through the relationship of its associated psychological changes together with improved nutrition, then through direct effects of energy expenditures, which are typically minimal in deconditioned individuals. There is a mutual relationship between exercise and diet [49–51]. Exercise induces changes in mood, body image, self-efficacy, self-esteem, and improves eating habits and weight loss [49, 51]. Likewise, diet and dietary practices affect mental well-being.(50) Engaging in healthy behaviors leads to increased motivation for the enhancement of well-being and improvement of mental health. That mutual effect has a better impact than the direct effects of energy expenditures that are typically minimal in deconditioned individuals [13, 52, 53]. Weight gain is associated not only with PA level but also with nutrition. COVID-19 has influenced people's eating habits. Preliminary data from the Brookdale Institute survey in Israel showed changes in nutritional habits, during the home lockdown, wherein people were reporting consuming more food, more sweets and snacks [30].
The current survey showed PA behavioral changes among the trainee population. Even though participants have had more spare time to exercise, they had numerous difficulties maintaining their PA routine. This effect of the pandemic health crisis on a well-trained person's behavior is paradoxical. Hypothetically, a person who routinely exercises in normal times has acquired a "toolbox" filled with skills and training habits. Naturally, we would expect him/her to be able to use his/her skills while in urgent need. But paradoxically the study shows that most participants reduced their PA level and only 15% of the respondents increased their PA. One explanation for this aforementioned paradoxical effect might be related to stress. More specifically, the stressful situation caused by the pandemic might have brought difficulties in maintaining an active lifestyle. Another possible explanation for the observed reduction in the PA level might be related to differences in adherence to individualized and group exercise. At times of closure, it is not possible to use the existing infrastructure for PA found in residential areas such as parks and fitness clubs as Israel had closed all recreation and sports facilities. Therefore, the ability to exercise with others was limited. Exercising with others was associated with superior adherence behavior [54]. Adults exposed to a team-building activity intervention reported greater adherence than those who participated in a standard-care program [55]. Thus adherence was associated with team-building more than the actual exercise program [56]. An alternative to the group activity might be engaging in PA with digital technology. In our study, we found a correlation between physical activity frequency and the level of one's efficacy to adopt digital PA technology, such as training online, digital application, exercise video clips, and more. Appropriate adaptation to the changed situation allowed most of the participants to maintain their active routine even during the lockdown. However, that adjustment was age-dependent and older adults found it difficult to adopt digital technology as an alternative to organized PA [57, 58].
For an active adult population, the consequences of inactivity and improper diet will be reflected, long after the crisis is over. It may result in an increased burden of NCDs, increased risk for morbidity due to metabolic, cardiovascular disease, and muscular deconditioning. Thus, the various governmental institutions and health agencies need to consider how to prevent it. Within a health promotion policy, an emergency plan should be established to include specific policies and guidelines for home-based physical training. We hence encourage the various governmental institutions and health organizations to include clear exceptions for PA in nationwide lockdowns. These should also allow for the safe performance of outdoor PAs (e.g. walking, running, or other individual sports, where an adequate interpersonal distance can be maintained), and thus prevent any future pandemic from generating unfavorable consequences that should arise due to acute cessation of physical activity. Furthermore, it might be advisable to engage in community-wide campaigns that deliver messages regarding upholding the PA level during lockdown by using the media such as television, radio, and newspaper columns.
This study was subject to several methodological limitations. The majority of the participants who responded to the survey were women, the generalizability of this study may be limited mainly to overall active females. Besides, this cross-sectional study refers to reports on PA level and weight. Future studies should incorporate objective measures (e.g., accelerometry and weight measurements). Finally, the data presented in this study represents a snapshot of the current situation which is relevant to the early stages of the pandemic in Israel. As the pandemic evolves and subsequent national and institutional new policies and practices are developed and implemented, future follow-up investigations will be necessary to understand the effects of COVID-19 over time.