Lifestyle Medicine During (and After) the COVID-19 Pandemic

Abstract

The COVID-19 pandemic has made it challenging for individuals and families to maintain a healthy lifestyle, quality of life, and well-being. Preliminary evidence have suggested that higher odds of both mortality and severity of the COVID-19 are closely associated to unhealthy lifestyle behaviors. Thus, in an effort to contribute to this challenging global situation, we joined a group of lifestyle medicine researchers and/or practitioners to provide scientifically sound information, recommendations, resources, and suggestions related to the main pillars of lifestyle medicine (healthy eating, physical activity, sleep, tobacco/alcohol, stress management, relationships, and planetary health) that may help health practitioners to support clients and patients maintain a healthy lifestyle during (and after) the COVID-19 crisis.

‘. . . initial evidence supports that unhealthy behaviors, in combination, accounted for up to 51% of the population-attributable fraction of COVID-19 hospitalizations.’

The coronavirus disease 2019 (COVID-19) has reached pandemic status, disturbing most of the population worldwide. Local health authorities have recommended and/or implemented a variety of containment and mitigation strategies, such as social distance, quarantine, widespread lockdown measures, among others.

Although crucial, such strategies may lead to several associated physical, mental, and/or psychological health distress.^1,2 The disruption of daily routine may cause important unintended consequences, such as making it challenging for individuals and families to maintain a healthy lifestyle, quality of life, and well-being.^3,4 In addition, preliminary evidence suggests that higher odds of both mortality and severity of the COVID-19 are associated with advanced age and/or underlying medical comorbidities such as cardiovascular disease, diabetes mellitus, chronic lung disease, hypertension, and cancer.^5-7 Of particular interest, initial evidence supports that unhealthy behaviors, in combination, accounted for up to 51% of the population-attributable fraction of COVID-19 hospitalizations.⁸ Hence, the importance of maintaining and/or improving one’s health through a healthy lifestyle becomes even more relevant.

In this context, lifestyle medicine (LM), the “evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life,”⁹ is considered a cornerstone in health promotion, once it involves the underlying, lifestyle-related causes of the leading risk factors for mortality and morbidity worldwide.^10-12 In an effort to contribute to this challenging global situation,¹³ we joined a group of LM researchers and/or practitioners to offer a brief overview on the impact of COVID-19 pandemic on several LM facets, such as healthy eating, physical activity, sleep, risky substances use (tobacco and alcohol), stress management, and relationships. In addition, we provide scientifically sound information, recommendations, resources, and suggestions that may help health practitioners to support clients and patients to maintain a healthy lifestyle during (and after) the COVID-19 crisis.

Healthy Eating

An important challenge during (and after) the COVID-19 pandemic is the management of health risk factors such as healthy eating. While the prevalence of unhealthy diets within the general population is already high, the routine disruptions caused by the COVID-19 crisis may exacerbate it even further. Although families may have the opportunity to cook at home more often, the lack of knowledge on what constitutes a healthy eating pattern and the lack of cooking skills can lead to individuals and families increase their use of fast food delivery options and having poor eating choices. Such behavior, in addition to the increased physical inactivity, sedentary time, and screen time, may exacerbate the epidemic of adult and childhood obesity.¹⁴

Today, unhealthy diets cause more deaths globally than any other risk factor.¹⁵ Nutrition has a key role in health, preventing, managing, and treating a series of chronic conditions such as cardiovascular diseases, obesity, diabetes, and cancer, conditions likely associated with COVID-19 mortality and severity.^5-7 For instance, chronic hyperglycemia negatively affects immune function and increases the risk of morbidity and mortality due to any infection,¹⁶ while obesity alters innate and adaptive immune response characterized by a state of chronic and low-grade inflammation.¹⁷ Eating behaviors are closely related to immune function regulation, as immune cells depend on adequate function of cofactors, intrinsically related to vitamins and minerals. Thus, it is essential that individuals and families receive scientifically sound and actionable information on healthy eating.

Whole-foods, plant-based (WFPB) diets represent eating patterns consisting predominantly of fruits, vegetables, whole grains, legumes and nuts, and minimally processed foods naturally rich in fibers and antioxidants, and poor in cholesterol, saturated, and trans fat. WFPB diets are traditionally associated with decreased incidence and/or mortality of cardiovascular diseases and cancer¹⁸ and have been recommended by several medical scientific and professionals organizations. Regarding chronic diseases prevention, its positive effects are mainly by reducing the obesity-related inflammation and oxidative stress.¹⁹ It also promotes gut microbiota diversity and stability due to the higher presence of fibers and polyphenols, protecting against pathogens, inflammation, and regulating the immune system.^20,21 Due to its low caloric density and increased satiety, it also helps weight management/reduction. It is noteworthy that consuming a WFPB does not mean one will not be infected and develop COVID-19, but it may strengthens the immune system and potentially reduces complications, especially among those with previous comorbidities. Of notice, there are no robust evidence, to date, of a nutritional supplement for infection prevention.

It is important to highlight that a WFPB diet should be culturally and socially tasteful and relevant, as well as environmentally sustainable. Below we present 6 steps for the adoption of a WFPB diet and improvement of the quality of eating behaviors daily*:

1. Increase the consumption of fruits—200 to 300 g (2-3 portions). Always have washed and ready fruits available.

2. Eat more vegetables—300 to 400 g. Prepare it in a variety of ways (roasted, grilled, sauté, etc).

3. Whole grains and cereals—100 to 150 g. Add vegetables to add and improve flavor, color, and nutrients.

4. Beans and legumes—can be eaten as snacks and/or paste-like snacks.

5. Seeds and nuts—20 to 30 g. Can be consumed as snacks, paste, milks, with vegetables and salads, yogurts, and so on.

6. Hydration with water.

• *We highlight the key importance of self and food hygiene, as the virus which causes COVID-19 can be picked up by touching contaminated objects and surfaces.

In addition, we also provide 6 nutritional recommendations to improve individuals’ eating behavior²²:

1. Organize, develop, exercise, and share culinary skills.

2. Avoid snacking and skipping meals.

3. Eat slowly and in smaller portions: a sensation of satiety will appear after about 20 minutes after the beginning of the meal.

4. Eat mindfully: take a moment to relax, listen to your favorite music, and try to anticipate the meal to come.

5. Sit down at a table (no standing or walking) to eat without doing anything else (television, smartphone, tablet, radio, reading, etc).

6. Be aware of how the intensity of your hunger sensation decreases progressively throughout the meal.

In conclusion, therapeutic patient education is a relevant tool for health professionals, which has clearly showed to improve health outcomes, including quality of life. It is time to put the health back into health care.

Physical Activity

Several of the containment and mitigation strategies used during the COVID-19 pandemic are likely leading to 2 unintended consequences related to LM: excessive physical inactivity and sedentary behavior. At the same time that the activity restrictions may disrupt exercise and daily physical activity habits of individuals and families in different contexts (occupational, transportation, and leisure), sedentary behaviors (sitting/reclining time, screen time, etc) are probably increasing.³ In fact, preliminary reports have showed that individuals have presented a reduction in average step count ranging from 7% to 38% across countries,²³ a reduction in physical activity of ~30% among previously active participants,²⁴ and a drastic reduction in physical activity among children.²⁵ In addition, concerns have already been issued that the COVID-19 crisis has the potential to further impact and accelerate the physical inactivity and sedentary behavior pandemics.²⁶

Insufficient physical activity is one of the leading risk factors for death worldwide, as well as a key risk factor for, at least, 35 conditions,²⁷ including cardiovascular diseases, cancer, and diabetes.^28,29 Particularly during this moment, it is important to highlight that there is only preliminary evidence on the influence of physical activity on COVID-19.⁸ However, it is noteworthy the positive effects of light and moderate intensity physical activity on the immune system,³⁰ as well as in reducing anxiety, depression risk, improving sleep, and quality of life.²⁸

Taking into account the specific recommendations of local health authorities concerning the COVID-19, as well as safety precautions of exercise during this period,³¹ we provide evidence-based resources for practitioners to support individuals and families, so they can continue benefiting from the positive effects of movement for health:

1. “Staying Physically Active During the COVID-19 Pandemic”—American College of Sports Medicine (https://www.acsm.org/read-research/newsroom/news-releases/news-detail/2020/03/16/staying-physically-active-during-covid-19-pandemic). Useful and reliable resources to help individuals and families to avoid excessive physical inactivity and sedentary behavior, and to safely maintain their physical activity.

2. “Stay Physically Active During Self-Quarantine”—World Health Organization European Region (http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/stay-physically-active-during-self-quarantine). Tips on how to stay active and reduce sedentary behavior while at home in self-quarantine, as well as examples of easy home-based exercises.

3. “Moving Medicine”—UK Faculty of Sport and Exercise Medicine (FSEM) in partnership with Public Health England and Sport England (https://movingmedicine.ac.uk/). Resources to support health care professionals to integrate physical activity counseling (“prescribing movement”) into routine clinical care with an evidence-based, versatile, tailored, and pragmatic step-by-step guided process.

4. “Fitness”—American Heart Association (https://www.heart.org/en/healthy-living/fitness). Several resources with information, tips, infographics, and so on. We highlight a specific content for kids, as millions of children are currently at home (https://www.heart.org/kidsactivities).

All our bodily systems need frequent amounts of movement to function properly. We encourage health professionals, individuals, and families to, responsibly, be active and reduce sedentary time. In times of distress, we shall use LM in our favor.

Sleep

In this difficult moment for everyone, with so many changes, expectations, and unpredictability, human characteristics are requested: adaptation or learning. We need to learn to deal with a new routine, new triggers for behaviors, changes of previous rewards, a new way of dealing with people around us and with our society, and even with the planet itself. For this challenging task we are able to count on a fascinating organ, the brain, which allow us to learn and even grow with changes.

Learning takes 4 steps: attention, motivation, feedback, and consolidation of information. The latter requires a crucial feature—sleep. Sleep is an essential component of neuroplasticity, that is, the brain’s ability to physically change its connections to functionally adapt its internal model to changes in the external world. It is by sleeping with quality and quantity that the brain consolidates or erases the memories acquired during the day. Not only memories of events in time and space, but also affective and motor memories. That is why during this moment which requires so much learning, adaptation, and updating, that we need to pay attention to sleep. Here are some tips so that we can go through this moment of crisis with more well-being and, why not, aiming for personal and social growth.

Apply sleep hygiene to maximize sleep quantity and quality. These are behavioral measures that increases sleep competence and satisfaction.

• Use your bedroom only for sleep and sex: turn your bedroom into a sleep trigger.

• Keep the bedroom dark, quiet, and cool.

• Avoid screens at least 1 hour before bedtime (TV, mobile phones or tablets).

• Plan your sleep and wake-up time, avoiding naps outside the routine.

• Get out of bed if you do not sleep.

• Avoid heavy meals in the evening, alcohol consumption and caffeine after 4 pm.

• Finally, use relaxation and mindfulness techniques.

The privilege of this dynamic brain forces us to embrace the responsibility of building a routine so that it flourishes. Surround yourself with good routines and you will naturally reap the best of your brain, turning the epidemic into a springboard for growth and learning. For that, count on your sleep.

Tobacco

Smoking is a leading cause of disease, disability, and premature death worldwide.³² Many individuals begin smoking during adolescence, and end up keeping this habit since it becomes an easy, attractive, and rather effective way of coping with stress.

Social distancing measures implemented during the current coronavirus pandemic may pose a significant stress burden on the population. Staying at home for long periods, disruption of the daily routine, maintaining work by home office, or keeping up with household duties while caring for children, can be quite challenging. Additionally, the overwhelming amount of information on the internet generate confusion and panic and may lead smokers to rely even more on cigarettes to relieve stress.

Smokers are likely at greater risk for developing respiratory infections in general and present poorer prognosis. For instance, previous studies have suggested that smokers and chronic obstructive pulmonary disease patients are more susceptible to Middle East respiratory syndrome coronavirus (MERS-CoV).³³ Smokers are also at a greater risk for cardiovascular disease, and as seen with influenza, a respiratory infection is, in many cases, related to sudden cardiovascular events such as ischemic heart attack or cerebrovascular disease.³⁴

However, we want to bring a brighter side to the situation, providing recommendations and suggestions to transform what could be a stressful confinement into an opportunity to quit smoking and develop a healthier lifestyle. Not all smokers would find this unsettling period an attractive opportunity for a quitting attempt. Thus, assessing readiness to quit is crucial to deliver appropriate counseling tailored for each individual.

• Inform about the benefits of cutting down or quitting smoking, such as better overall health, breathing, and immune function.

• Propose establishing physical limits to smoking. For example, smoking would be allowed only outdoors or at the balcony. This would also spare other members of the family, especially nonsmokers, from the known harms of secondhand smoking.

• Make a brief pause and reflect on the real need for each cigarette. This may help avoid some cigarettes that are tied to specific behaviors, such as smoking while drinking coffee, after meals, or after a stressful event at work.

• Focus on a healthy diet. Many smokers who attempt to quit gain weight. By focusing on a healthy diet with plenty of fruits, vegetables, whole grains, legumes, nuts and seeds, one can increase satiety, gain the health benefits of a more plant-based diet, and minimize the tendency to gain weight.

• Try not to replace tobacco with sugar or alcohol as a way of dealing with stress.

• Maintain a regular schedule of activities and consistent sleeping habits.

• Encourage regular physical activity, either outdoors (when appropriate) or indoors, as part of a healthy daily routine.

• Propose the development of a new daily activity that does not include cigarettes, with the purpose of coping with stress. Some examples are guided meditation, yoga, reading books, or simply talking with family and friends.

• Over-the-counter nicotine replacement therapy can help attenuate the symptoms of nicotine withdrawal.³⁵

• Many health professionals offer counseling or treatment by phone or the internet, and evidence suggests this is an effective way of helping smokers to quit.³⁵

There is no amount of tobacco that benefits health. While smoking can be a way of relieving stress, the associated health risks far outweigh the benefits, especially during a pandemic of a potentially severe respiratory infection. Focusing on a healthy lifestyle can transform a stressful situation into an opportunity for boosting health and well-being.

Alcohol

Alcohol, a toxic and psychoactive substance present in alcoholic beverages, with dependence producing properties, contributes to 3 million deaths annually. It represents the leading risk factor for premature mortality and disability among those aged 15 to 49 years. Alcohol has negative effects on almost every single organ of our bodies, both in short- and long-term, with no “safe limit” for its consumption.³⁶

Harmful alcohol consumption may weaken the immune system, reducing our bodies’ ability to cope with infectious diseases, as well as alter our thoughts, judgment, decision-making, and behavior. Alcohol consumption can exacerbate health risks and vulnerability, risk-taking behaviors, mental health issues, and violence. During the COVID-19 pandemic, alcohol misuse can be an additional public health issue.³⁷

Below we provide recommendations, information, and tips³⁸ that may help health practitioners, individuals and families:

• Avoid alcohol altogether—so that you do not undermine your own immune system and health and do not put the health of others at risk.

• Do not use alcohol as a way of dealing with your emotions and stress—alcohol is not a good coping mechanism, as it is known to increase the symptoms of panic and anxiety disorders, depression, and other mental disorders, as well as the risk of family and domestic violence.

• Never mix alcohol with medications—even herbal or over-the-counter remedies, as this could make them less effective, or it might increase their potency to a level where they become toxic and dangerous. Particular attention should be given if taking any medication acting on the central nervous system (eg, pain killers, sleeping tablets, antidepressants, etc), as alcohol might interfere with your liver function and cause liver failure or other serious problems.

• Avoid alcohol as a social cue for smoking, and vice versa—people tend to smoke, or smoke more, if they drink alcohol, and smoking is associated with more complicated and dangerous progression of COVID-19.

• Discuss the effect of alcohol on risk-taking behaviors, such as potential violations of quarantine and physical distancing measures, which can make the COVID-19 pandemic worse.

• Alcohol is not a necessary part of your diet and should not be a priority on your shopping list. Avoid stockpiling alcohol at home, as this will potentially increase your alcohol consumption and the consumption of others in your household. Your time, money and other resources are better invested in healthy and purposeful ways.

• The present situation is a unique opportunity to quit drinking, or at least to cut down considerably. Be a role model for children, young people, your families, friends, and community.

• Reach out for help—if you think your drinking or the drinking of someone close to you is out of control.

Finally, given the misinformation spread through social media and other communication channels about alcohol and COVID-19, it is important to highlight that under no circumstances should you drink any type of product containing alcohol as a means of preventing or treating COVID-19 infection.

Stress Management

Stress is a physiological phenomenon that involves acute brain and body functioning modifications whenever we need to adapt to new situations.³⁹ During threatening situations, the cerebral amygdala activates the sympathetic nervous system, releasing the hormones cortisol and adrenaline, which generate a series of biological adaptations to promptly prepare our bodies to the circumstances. When these stress responses prolong over time or are triggered recurrently, the physiological reactions shift from adaptive to detrimental to our health.

Challenges of the current COVID-19 pandemic, such as fear of infection, the need for social isolation, and financial uncertainties,¹ potentially exacerbate the physiological stress response. This can not only increase the manifestation of physical symptoms such as insomnia, muscle tension, and bruxism but also lead to immune system dysfunction, raising the susceptibility of nonspecific infections.⁴⁰ In addition, anxiety disorders and triggering/exacerbation of panic episodes can occur either in the short-term or in the long-term, in case the isolation strategies continue for several weeks/months,⁴¹ especially in individuals with a history of psychiatric disorders. Mentally, common manifestations are memory dysfunction, impaired concentration, attention and logical reasoning capacity. Prolonged periods of stress can also affect behavior, increasing the tendency for risky substance abuse, such as alcohol and tobacco, dysfunctional social isolation, compulsive eating behavior (particularly foods rich in sugar and fat), and physical inactivity and sedentary behavior.⁴²

Thus, periods of stress can be detrimental to our health directly and indirectly, once its effects can also disrupt all the other interconnected LM domains covered here, representing a double burden on chronic diseases during and after the pandemic. Hence, it is essential to develop stress management strategies for patients, individuals, and families, as well as to health professionals during this cognitively demanding and physically and mentally taxing times.

Effective strategies include the stress management triad: (1) reduction of the stress response; (2) promotion of the relaxation response; and (3) development of adaptive strategies.⁴³ First, an important element of reducing reactivity to stress is through the recognition of its warning signs within the body and emotions, which can be trained by mindfulness practices, body scan techniques, or biofeedback devices. Second, the relaxation response can be obtained through mind-body practices such as meditation, yoga, tai-chi, guided imagery, breathing, and relaxation techniques.⁴⁴ Last, the third pillar of stress management is based on developing adaptive strategies related to a healthy lifestyle, use of cognitive behavioral therapy tools and positive psychology, and strengthening of social connections and reinforcement of the individual and collective network of support.

In times of intense stress responses, as the currently promoted by a global pandemic, raising awareness to this topic is timely. We stimulate health professionals to cultivate self-care routines, allowing a better professional work practice and avoiding debilitating physical and emotional overload. Finally, we stimulate the implementation of these stress management techniques for both COVID-19 patients, as well as individuals and families engaging in “social distancing,” in order to minimize the short- and long-term effects of distress caused by this epidemic.

Relationships

Healthy relationships is an important pillar of LM.^45,46 There is robust scientific evidence that authentic social interactions, even the brief ones, have positive effects on longevity and health in general.⁴⁷

According to a 75-year cohort study on adult development from Harvard University, healthy social connections are considered the single most important predictor of happiness and longevity. Connectivity can activate the parasympathetic nervous system, lowering stress and its hazardous consequences.^48,49

However, during the COVID-19 crisis, social distancing is a very important recommendation to control the infections and help saving lives. Virtual connections, once considered villains for depression,⁵⁰ are now recommended in every document of mental health during pandemic times, including the American College of Lifestyle Medicine. It is important to highlight the good use of social media and virtual interactions for positive connectivity, not to spread fear and intolerance. This pandemic has proved us that virtual interactions are effective to cultivate positive feelings and provide a sense of belonging, so important during quarantine. It is possible to engage online in interest groups and volunteering activities that increase health, happiness, and purpose. Employers and schools can create virtual opportunities for social connections. Pets are a valid way to feel connected as well. People should be encouraged to find new ways to connect, and nurture healthy relationships during quarantine in order to protect mental health during the COVID-19 pandemic. Social distancing is not necessarily a synonym of social isolation.

Helpful links are given below:

• Harvard T.H. Chan School of Public Health—Coping with coronavirus: Dealing with daily stress, anxiety, and a range of other emotions: https://www.health.harvard.edu/diseases-and-conditions/coping-with-coronavirus

• Centers for Disease Control and Prevention—Coronavirus disease 2019: Manage anxiety & stress: https://stacks.cdc.gov/view/cdc/86077

• World Health Organization—Mental health and psychosocial considerations during COVID-19 outbreak: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_2

• American Psychiatric Association—Coronavirus and mental health: Taking care of ourselves during outbreaks: https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2020/02/coronavirus-and-mental-health-taking-care-of-ourselves-during-infectious-disease-outbreaks

Planetary Health

The global response to COVID-19 is simultaneously a challenge and a demonstration that humanity can stop the frantic “businesses as usual.” If we try to understand all the complex causes of these difficult times, the best hope is the progress to a new and more harmonic human lifestyle with natural ecosystems. One of the essential concepts to promote integrative human and planetary health is the idea of co-benefits.⁵¹ This approach is key to global public health in the 21st century. Our sustainable, salutogenic, and systemic lifestyle is vital to promote co-benefits to a more equitable human society and the environment that encompass all ecosystems responsible for supporting all life on the Earth.

Conclusion

Despite our tendency to approach the different LM facets individually and uniquely, it is remarkable the interconnectedness and synergy which they possess. Improving one aspect of lifestyle will likely bring multiple benefits, creating a virtuous health cycle. This is of paramount and timely importance, as unpleasant experiences caused by quarantine, such as loss of freedom, uncertainty over disease status, unemployment, loss of loved ones, boredom, among others, may affect our quality of life and well-being, leading to stress- and anxiety-driven unhealthy behaviors.⁵² Consequently, an increase of cardiovascular risk—as well as psychological and mental disorders—during and after the quarantine is expected due to the unhealthy lifestyle during outbreak and its carry over long-term effects on health.⁵²

Lastly, acknowledging the need to broaden our view beyond the human body, encompassing a planetary health perspective, is key moving forward. We hope the information provided here, alongside additional healthy living initiatives emerging from this crisis,⁵³ help practitioners, individuals, and families during (and after) the COVID-19 pandemic.