At the end of 2019, a new coronavirus (Covid-19) outbreak occurred in Wuhan, China, and spread throughout the world despite efforts to contain the virus. At the end of January 2020, the General Director of the World Health Organization (WHO) declared a Public Health Emergency of International Concern, and by mid-May 2020, the worldwide number of known Covid-19 cases had surpassed 4.4 million including more than 300,000 deaths..

Bachl, N.

Badtieva, V.

Bigard, X.

Bilzon, J.L.J.

Börjesson, M.

Casasco, M.

Debruyne, A.

Di Luigi, L.

Dohi, M.

Geistlinger, M.

Ionescu, A.

Löllgen, H.

Miller, M.

Muniz-Pardos, B.

Papadopoulou, T.

Pigozzi, F.

Pitsiladis, Y.P.

Shurlock, J.

Singleton, P.

Steinacker, J.M.

Swart, J.

Tsofliou, Fotini

Webborn, N.

Wolfarth, B.

Zelenkova, I.

Zupet, P.

English

Muñiz-Pardos, B.

Tsofliou, F.

Repositorio Universidad de Zaragoza

Muniz-Pardos et al. Sports Medicine - Open            (2020) 6:35 https://doi.org/10.1186/s40798-020-00267-6COMMENTARY Open AccessCollateral Health Issues Derived from theCovid-19 PandemicBorja Muniz-Pardos1, Jonathan Shurlock2, Andre Debruyne3,4, Juergen M. Steinacker3,4,5, Mats Börjesson3,4,6,Bernd Wolfarth4,7, James L. J. Bilzon4,8, Herbert Löllgen3, Anca Ionescu3, Petra Zupet3, Michiko Dohi4,9,Jeroen Swart4,10, Victoriya Badtieva4,11,12, Irina Zelenkova1,11, Maurizio Casasco3,4,13, Michael Geistlinger4,14,Norbert Bachl3,4,15,16, Fotini Tsofliou17, Luigi Di Luigi4,18, Xavier Bigard3,19, Theodora Papadopoulou3,4,20,21,Nick Webborn22, Patrick Singleton23, Mike Miller23, Fabio Pigozzi4,24,25 and Yannis P. Pitsiladis3,4,26*Collateral Health IssuesAt the end of 2019, a new coronavirus (Covid-19) out-break occurred in Wuhan, China, and spread throughoutthe world despite efforts to contain the virus. At the endof January 2020, the General Director of the WorldHealth Organization (WHO) declared a Public HealthEmergency of International Concern, and by mid-May2020, the worldwide number of known Covid-19 caseshad surpassed 4.4 million including more than 300,000deaths [1].Currently, elderly individuals (i.e. > 65 years) andothers suffering from respiratory diseases, diabetes, can-cer, obesity, hypertension and cardiovascular diseaseshave been classified as populations at higher risk for dis-ease severity and death due to Covid-19 infection [2].Paradoxically, such individuals are also especially vulner-able to physical inactivity and lack of physical exercise.The enforced confinement renders it difficult for manyindividuals to adhere to the WHO recommendations onthe minimal amount of physical activity (PA) (i.e. 150min of moderate-intensity or 75 min of vigorous-intensity PA per week, or any equivalent combination ofthe two) [3]. A recent report by Fitbit Inc. demonstratesthe severity of the Covid-19-related decline in PA inEurope as determined by the “number of steps” in over30 million people, with a reduction in this proxy of PAranging between 7 and 38% (Fig. 1) [4].The impact of the Covid-19-related reduction in PA isworrying considering the already insufficient PA levels© The Author(s). 2020 Open Access This articlewhich permits use, sharing, adaptation, distribuappropriate credit to the original author(s) andchanges were made. The images or other thirdlicence, unless indicated otherwise in a credit llicence and your intended use is not permittedpermission directly from the copyright holder.* Correspondence: y.pitsiladis@brighton.ac.uk3European Federation of Sports Medicine Associations (EFSMA), Lausanne,Switzerland4International Federation of Sports Medicine (FIMS), Lausanne, SwitzerlandFull list of author information is available at the end of the articleobserved prior to the Covid-19 pandemic, with approxi-mately 27.5% of adults not meeting the WHO recom-mendations for PA in 2016 [5]. This figure is howeverdetermined through self-reporting surveys and not moreobjective measurements (e.g. accelerometry), which islikely to bias and underestimate this prevalence. Thesenumbers would be assuming that current WHO recom-mendations on the minimum weekly PA are sufficientfor healthy adults and older adults, with some authorsfavouring more challenging minimum levels of 300 minper week as often as possible, or even more [6]. Notably,older individuals or medical patients unable to reach300 min or even 150 min per week will aim to performas much as their abilities and condition allow, inaddition to balance and strength exercises [7]. Specificrecommendations focused on decreasing sedentary be-haviour (e.g. minimal amount of sedentary behaviourchange required to produce meaningful health benefits[8]) are of crucial importance, especially during a lock-down period where the performance of moderate-vigorous PA can be challenging. A recent study has fo-cused on the negative consequences of the lockdown onthe health of the oldest age group (i.e. > 85 years andabove) [9], which could further exacerbate sarcopenia,frailty, age-related functional decline and therefore anincreased risk of chronic disease and associated all-causemortality. This investigation highlighted the importanceof increasing PA levels during lockdown through simplehome-based exercises to reduce sedentary behaviour, toattenuate the decline in physical fitness and to optimizequality of life. The promotion of home-based activitiesthat increase mobility such as gardening, mild house-work and preparation of flavoursome meals can be usedto break sedentary behaviour, increase levels of PA andis licensed under a Creative Commons Attribution 4.0 International License,tion and reproduction in any medium or format, as long as you givethe source, provide a link to the Creative Commons licence, and indicate ifparty material in this article are included in the article's Creative Commonsine to the material. If material is not included in the article's Creative Commonsby statutory regulation or exceeds the permitted use, you will need to obtainTo view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.Fig. 1 Reduction in physical activity levels in European countries dated the 22nd of March 2020. Data extracted from a report published byFitbit Inc [4]Muniz-Pardos et al. Sports Medicine - Open            (2020) 6:35 Page 2 of 4muscular strength and enhance mood in older people[10], thus promoting health and wellbeing.In addition to the negative impact of low PA levels orincreased sedentary behaviour on individual health andfitness status, the fear of succumbing to Covid-19 seemsto deter patients suffering from traditional medical is-sues (e.g. heart attacks, strokes and other medical emer-gencies) from seeking the treatment they may require,and this delay can compound further their health status,resulting in more heart attacks, strokes, and deaths [11].A delay of only a few hours in a patient with an acutecoronary syndrome seeking medical care can signifi-cantly impact patient survival [12], with a 30-min delayreducing average life expectancy by 1 year [13]. Thiscompromised treatment strategy; whether due to a fearof infection or hospital saturation may threaten the lifeof many patients with no access to adequate treatment,intervention or rehabilitation, considerably increasingthe number of deaths in the future.The current need for social distancing compounds fur-ther the aforementioned issues. However, new policiesthat could include developing greater telemedicine cap-acity to rectify the lack of in-person treatment areurgently required. Such examples include hospital-at-home programmes that provide individuals requiringhospitalisation for reasons other than Covid-19 constanthealth care through a combination of virtual and in-person visits [14]. Such approaches could also be used toimplement individualised exercise prescription or re-habilitation remotely in order to maintain physical fit-ness and improve health during the lockdown; physicalexercise is the most economical remedy for a healthy so-ciety. This home-based exercise prescription supportedby suitable technology could also target weight loss/pre-vention of weight gain as well as prevention of muscleloss in order to strengthen immune functions and re-duce the severity of a potential infection, particularlyconsidering recent evidence that obesity is an additionalrisk factor for Covid-19 [15].Lockdown and social isolation have also been shownto have a profound impact on mental health [16]. In-creases in alcohol consumption, drug abuse (especiallyanxiolytics and antidepressants), domestic and childabuse and online gambling during the lockdown reflecta high prevalence of mental health disruptions duringthis period. Additionally, the economic downturn andMuniz-Pardos et al. Sports Medicine - Open            (2020) 6:35 Page 3 of 4the associated increase in unemployment derived fromthe lockdown measures are likely to produce profoundmental disorders and increases in suicide rates [16]. Insport, the inability of thousands of recreational and pro-fessional athletes to follow their physical training rou-tines due to the enforced lockdown is triggeringadditional collateral health issues [17, 18]. The reductionin PA and exercise training during the lockdown limitsthe beneficial effects of exercise on depression, anxietyand mood, further compounding these adverse effectson mental health [19]. Mental health disorders are likelyto occur or worsen especially in those elite athletes en-gaged in meticulous preparation for international events(e.g. Tokyo Olympics) as the postponement orcancellation of these events could ruin their last oppor-tunity to compete at the top level.While professional sport has been placed on hold, newtechnologies have played an important substitute roleand several e-sports applications are being used world-wide to allow elite athletes and users at all levels to at-tenuate their fitness loss and also to socialise during thelockdown. For example, sports clubs have been very cre-ative in offering virtual competitions via online platforms(e.g. Zwift, Strava or Bkool), which allow some athletesto train in simulated scenarios and maintain their fitness.As the lockdown restrictions are loosened in those coun-tries which seem to be retarding the spread of the virus,professional sport under certain conditions is being reac-tivated, with boxing, football or basketball competitionsamong the first to be resumed in May–June 2020. Ath-letes from these contact and team sports are particularlyvulnerable to the virus transmission due to the contactnature of the activity. The lockdown period has forcedsome international sports federations (e.g. FIFA) aimingto maintain the finishing dates of their leagues to con-centrate a high number of competitions before the sum-mer break, which translates into a saturated calendar ofcompetitions implemented after several weeks of insuffi-cient training. FIFA recently increased the maximumnumber of substitutions in a match from three to fivehoping to prevent excessive injuries, although this miti-gation may not be enough to safeguard the health of theathletes, especially after a long interruption of training.Despite all these collateral issues derived from theCovid-19 lockdown, there are concurrently a number ofpositive factors impacting public health. A reduction inair pollution has been reported across 27 countries after2 weeks of lockdown, and this improvement in air qual-ity is estimated to have prevented 7400 prematuredeaths (all-cause) and 6600 cases of paediatric asthma[20]. Outdoor exercise, despite being recommended bydifferent health organisations, has a number of adverseeffects when performed in a polluted environment. Highlevels of pollutants can negatively impact oncardiorespiratory function, especially in those individualssuffering from cardiovascular or respiratory illnesses[21]. While current containing measures are unsustain-able, such findings illustrate the great health benefits ofreducing traffic-related air pollutant emissions, suggest-ing that periodic home-based activities/work (when/ifpossible) might be accompanied with rapid improve-ments of both air pollution and respiratory health, allow-ing for a safer opportunity to perform outdoor exercise.The direct impact of the Covid-19 pandemic has beenthe main focus for health organisations in order to con-tain the spread of the virus, to set the most effectivelockdown measures and to identify the best treatmentsor engineer a safe and effective vaccine. However, afocus on the collateral health- and sports-related issuesis crucial as the health and economic consequences ofnot doing this may be even more catastrophic. There aremany vital lessons to be learned beyond the rightly nar-row focus to contain and manage the virus. There is anequally urgent need to manage all the collateral damageto public health caused by a worldwide pandemic inorder to prevent the “cure” being worse than the disease.AbbreviationsPA: Physical activity; WHO: World Health OrganizationAcknowledgementsNonePatient Consent for PublicationNot applicable.Authors’ ContributionsBorja Muniz-Pardos, Jonathan Shurlock, Andre Debruyne, Juergen M.Steinacker, Mats Börjesson, Bernd Wolfarth, James L. J. Bilzon, Herbert Löllgen,Anca Ionescu, Petra Zupet, Michiko Dohi, Jeroen Swart, Victoriya Badtieva,Irina Zelenkova, Maurizio Casasco, Michael Geistlinger, Norbert Bachl, FotiniTsofliou, Luigi Di Luigi, Xavier Bigard, Theodora Papadopoulou, NickWebborn, Patrick Singleton, Mike Miller, Fabio Pigozzi and Yannis Pitsiladishave drafted the work or substantively revised it and have approved thesubmitted version of the present manuscript.Authors’ InformationNoneFundingThe authors have not declared a specific grant for this research from anyfunding agency in the public, commercial or not-for-profit sectors.Availability of Data and MaterialsNot applicable.Ethics Approval and Consent to ParticipateNot Applicable.Consent for PublicationNot applicable.Competing InterestsBorja Muniz-Pardos, Jonathan Shurlock, Andre Debruyne, Juergen M. Stei-nacker, Mats Börjesson, Bernd Wolfarth, James L. J. Bilzon, Herbert Löllgen,Anca Ionescu, Petra Zupet, Michiko Dohi, Jeroen Swart, Victoriya Badtieva,Irina Zelenkova, Maurizio Casasco, Michael Geistlinger, Norbert Bachl, FotiniTsofliou, Luigi Di Luigi, Xavier Bigard, Theodora Papadopoulou, NickMuniz-Pardos et al. Sports Medicine - Open            (2020) 6:35 Page 4 of 4Webborn, Patrick Singleton, Mike Miller, Fabio Pigozzi and Yannis Pitsiladisdeclare that they have no conflicts of interest relevant to the content of thisarticle.Author details1GENUD (Growth, Exercise, Nutrition and Development) research group,University of Zaragoza, Zaragoza, Spain. 2Brighton and Sussex UniversityHospitals, Brighton, UK. 3European Federation of Sports MedicineAssociations (EFSMA), Lausanne, Switzerland. 4International Federation ofSports Medicine (FIMS), Lausanne, Switzerland. 5Division of Sports andRehabilitation Medicine, Ulm University Hospital, Ulm, Germany. 6Departmentof Molecular and Clinical Medicine, Sahlgrenska Academy and Center forHealth and Performance, Gothenburg University and Sahlgrenska UniversityHospital/Ostra, Gothenburg, Sweden. 7Department of Sports Medicine,Humboldt University and Charité University School of Medicine, Berlin,Germany. 8Department for Health, University of Bath, Bath, UK. 9SportMedical Center, Japan Institute of Sports Sciences, Tokyo, Japan. 10UCTResearch Unit for Exercise Science and Sports Medicine, Cape Town, SouthAfrica. 11I.M. Sechenov First Moscow State Medical University (SechenovUniversity), Ministry of Health of Russia, Moscow, Russian Federation.12Moscow Research and Practical Centre for Medical Rehabilitation,Restorative and Sports Medicine, Moscow Healthcare Department, Moscow,Russian Federation. 13Italian Federation of Sports Medicine (FMSI), Rome,Italy. 14Unit International Law, Department of Constitutional, Internationaland European Law, University of Salzburg, Salzburg, Austria. 15Institute ofSports Science, University of Vienna, Vienna, Austria. 16Austrian Institute ofSports Medicine, Vienna, Austria. 17Department of Rehabilitation, Nutritionand Sport Sciences, Bournemouth University, Bournemouth, UK. 18Unit ofEndocrinology, Department of Movement, Human and Health Sciences,University of Rome “Foro Italico”, Rome, Italy. 19Union Cycliste Internationale(UCI), Aigle, Switzerland. 20British Association Sport and Exercise Medicine,Doncaster, UK. 21Defense Medical Rehabilitation Centre (DMRC),Loughborough, UK. 22School of Sport and Service Management, University ofBrighton, Eastbourne, UK. 23World Olympians Association, Lausanne,Switzerland. 24University of Rome “Foro Italico”, Rome, Italy. 25Villa StuartSport Clinic, FIFA Medical Center of Excellence, Rome, Italy. 26CollaboratingCentre of Sports Medicine, University of Brighton, Eastbourne, UK.Received: 3 July 2020 Accepted: 29 July 2020References1. 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Collateral Health Issues Derived from the Covid-19 Pandemic

Bournemouth University Research Online

Collateral Health Issues Derived from the Covid-19 Pandemic.

Muniz-Pardos, Borja

Shurlock, Jonathan

Pitsiladis, Yannis

University of Brighton Research Portal

http://eprints.bournemouth.ac.uk/34447/1/collateral%20health%20issues%20covid19%20.pdf

Collateral Health Issues Derived from the Covid-19 Pandemic.

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