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Requests for reprints should be addressed to Ross Arena, PhD, PT, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, 1919 W. Taylor Street (MC 898), Chicago, IL 60612.
Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IllHealthPartners Institute, Minneapolis, MinnDepartment of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IllHerbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La JollaMary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Vic, Australia
Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IllDepartment of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-University of Queensland School of Medicine, New Orleans, La
Tragically, the United States (US) surpassed one million documented deaths due to the coronavirus disease 2019 (COVID-19) pandemic. A convincing association between unhealthy lifestyle behaviors and poorer outcomes associated with COVID-19 infection has already been demonstrated and communicated by the Centers for Disease Control and Prevention in public health messaging. The US is experiencing not a pandemic, but a syndemic, specifically an unhealthy lifestyle behaviors–chronic diseases–COVID-19 syndemic. This syndemic has almost certainly significantly contributed to the more than one million deaths the United States has experienced during the pandemic. Decades of a high prevalence of unhealthy lifestyle behaviors laid the foundation for our current unfortunate situation by increasing vulnerability to a novel virus, especially among subgroups who have been historically marginalized. As such, a major pathway to defeating this syndemic is through the promotion of healthy living behaviors for all. Now is the time for action appropriate to meet the demands of a syndemic and a new path forward to a healthier and more equitable future.
The United States surpassed one million documented deaths due to the coronavirus disease 2019 (COVID-19) pandemic.
A convincing association between unhealthy lifestyle behaviors and poorer outcomes associated with COVID-19 infection has been demonstrated and communicated by the Centers for Disease Control and Prevention in public health messaging.
Clinicians play a central role in this pathway by embracing and commonly practicing healthy living medicine.
Tragically, the United States surpassed one million documented deaths due to the coronavirus disease 2019 (COVID-19) pandemic. Figure 1 from the Centers for Disease Control and Prevention (CDC) illustrates the state-by-state death rate per 100,000 individuals.
Clearly, the COVID-19 mortality rates across the states differed substantially, with the Southeast region bearing a heavier burden from this pandemic. The United States and many other parts of the world have begun to emerge from the COVID-19 health crisis, although challenges remain with variants of the virus and controlling outbreaks. At this time, it is important not only to look ahead but also to reflect on challenges faced and patterns that have emerged during the pandemic. Perhaps, as we reflect on the now more than one million lives lost in the United States and apparent differences in mortality rates across states, lessons can be learned from comparing similar mapping patterns for other major health issues we face.
A convincing association between unhealthy lifestyle behaviors and poorer outcomes associated with COVID-19 infection (eg, hospitalization and mortality risk) has already been demonstrated and communicated by the CDC in public health messaging.
assessed the relationship between physical activity and both COVID-19 cases and deaths across US counties, demonstrating that low physical activity levels were associated with higher death rates (ie, those with COVID-19 cases had a higher mortality rate if physical activity levels were low). In fact, based on the study by Sallis et al
These observations are consistent with previous research demonstrating a similar trend between higher physical activity levels and lower severity of infection during the 2009 H1N1 influenza epidemic; physical activity clearly improves immune function and is therefore a vital medicine to combat viral infections.
assessed food environment and diet trends in the United States, providing several nationwide maps illustrated in Figure 5. Moreover, sleep-related hypoxia has been associated with a worsening of COVID-19-related outcomes,
Long-term effects of sleep on COVID-19 outcomes and the pandemic-related impact on population sleep patterns still need to be assessed longitudinally. Figure 6 provides the CDC map related to the prevalence of short sleep duration.
Collectively, a clear pattern emerges among the maps illustrated in Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6. Specifically, COVID-19 mortality rates are generally highest in the Southeast region, where unhealthy lifestyle behaviors (ie, physical inactivity, poor nutrition, smoking, low sleep quality) and excess body mass likewise have the highest prevalence.
A similar example, using US maps to illustrate the link between poor outcomes and unhealthy lifestyle behaviors, is possible when comparing COVID-19 mortality rates with maps for chronic disease mortality rates. As a leading chronic disease example, illustrated in Figure 7,
cardiovascular disease death rates are again highest in the Southeast region. The link between unhealthy lifestyle behaviors and an increased risk of prematurely being diagnosed with one or more chronic diseases has been known for decades and is beyond dispute.
Furthermore, evidence has emerged during the COVID-19 pandemic convincingly indicating a significantly higher risk for hospitalization and mortality in individuals diagnosed with one or more chronic condition when infected with COVID-19.
These lines of evidence combine to support a conclusion that the United States is experiencing not a pandemic, but a syndemic, defined as “two or more health conditions or diseases that negatively interact with and affect the outcomes of one another,”
has almost certainly significantly contributed to the more than one million deaths the United States has experienced during the pandemic.
Given that the threshold for a syndemic is 2 highly prevalent health conditions or diseases, we will remain in an unhealthy lifestyle–chronic disease syndemic for the foreseeable future. If something drastic does not change, we will remain poorly prepared for the next viral pandemic and suffer similar, if not worse, outcomes than those experienced during the COVID-19 pandemic. Researchers are already acknowledging that future pandemic preparedness must focus on addressing the chronic disease and unhealthy lifestyle crises.
Unfortunately, early evidence indicates the COVID-19 pandemic has resulted in a further deterioration of healthy living behaviors around the world (ie, further declines in physical activity and poorer nutritional habits), which now seems to be resulting in an acceleration in weight gain trends on a population level.
If this observation signals the new unhealthy lifestyle baseline, chronic disease incidence and prevalence will increase further in the coming decades, with catastrophic consequences.
How did we get to this point? It can be convincingly argued that the deleterious health outcomes we are currently experiencing have been decades in the making, and the ever-increasing prevalence of unhealthy living phenotypes creates widespread vulnerabilities across the population for both chronic and infectious diseases. This is not to say that a universal adoption of healthy living behaviors would eliminate all chronic disease and poor outcomes with viral pandemics. Certainly, contributory factors to an unfavorable health trajectory (eg, cardiovascular disease, cancer, hospitalization/death due to a viral infection) are multifactorial. However, the link between healthy living behaviors and a significantly higher likelihood for a favorable health trajectory across the lifespan is undeniable.
Imagine a world where physical activity, good nutrition, not using tobacco products, sleep hygiene, and a healthy body weight were normative across the population. Chronic disease incidence and prevalence would have been far lower in the United States leading up to the COVID-19 pandemic. For example, population-level adoption of a more physically active lifestyle, increasing moderate-vigorous intensity physical activity by 10 minutes per day, was recently projected to prevent 111,174 deaths per year in the United States.
found that men and women with an ideal lifestyle score—based on smoking status, body weight, physical activity, and alcohol consumption—lived approximately 9 years longer without a chronic disease diagnosis, compared with those with the poorest lifestyle score. Although broad, population-level adoption of healthy living behaviors would not have prevented the current viral pandemic, far fewer than one million COVID-19-related deaths in the United States would likely have occurred. We are unaware of any current analysis that has estimated the number of COVID-19 deaths that would have been prevented with increased adoption of a healthy lifestyle. We are confident that, when such analyses are performed, the number of deaths that could have been prevented will be shown to be substantial. There is evidence emerging during the COVID-19 pandemic which indicates that healthy living behaviors may have altered the projected impact of the COVID-19 pandemic in certain parts of the world. For example, hospitalization and mortality rates due to COVID-19 are far lower in Sub-Saharan Africa than projected during the initial phases of this global health crisis. One postulated reason for these better-than-expected outcomes is the higher prevalence of a physically active lifestyle in this part of the world.
The message provided in this commentary is not new, but it is nonetheless extremely important and worthy of repeating in the context of the COVID-19 crisis until the reality of the current syndemic is understood and stimulates meaningful change in public health actions. The similarities among the US maps of COVID-19, chronic diseases, and healthy lifestyle behaviors illustrated herein provide yet more supporting evidence justifying a call to action. An appropriate response to the syndemic requires systematic and coordinated policy, systems, and educational and programmatic actions that promote and support the adoption of healthy living behaviors on a population level.
A first step in this call to action is to examine and understand the complex relationships among the adoption of lifestyle behaviors, both healthy and unhealthy, and key health outcomes, such as chronic diseases and the viral pandemics. Recently, Pronk and Faghy
proposed a causal systems mapping approach to promote healthy living behaviors for pandemic preparedness. The authors recognize that “promoting healthy living factors remains challenged by a lack of scalability and sustainability due, in part, to a mismatch between intervention focus on individual behavior change as opposed to recognizing complex and multifactorial causes that prevent people from living healthy lifestyles and maintaining them long term (such as political will, economic benefits, and urban planning).”
The authors further propose that a causal systems map approach would aid key stakeholders across multiple sectors and enhance preparedness for future pandemics on a population level. A similar causal systems map approach would be beneficial in exploring the complex relationship between lifestyle behaviors and chronic diseases. Causal systems mapping could be used to better understand the complex relationships among COVID-19, chronic disease, and unhealthy lifestyle behaviors. Understanding these complex relationships will increase the likelihood of implementing effective healthy living messaging and programming across multiple sectors (eg, community, education, health care). Ma and Sallis
also rightly recognize that the COVID-19 response and preparedness must account for the chronic disease health crisis we have been living with well before the current viral pandemic. As mentioned previously, COVID-19, chronic disease, and unhealthy lifestyle behaviors have become a new syndemic that must be addressed comprehensively if we hope to improve outcomes in the remainder of the COVID-19 crisis and be better prepared for future syndemics.
There is a critical race and social justice component to the present syndemic such that individuals in underserved communities are being disproportionately impacted by poor COVID-19 outcomes, chronic disease incidence and prevalence, and unhealthy living behaviors.
In fact, the health inequities associated with the COVID-19–chronic disease–unhealthy lifestyle triad are an integral part of this syndemic that must be simultaneously addressed in the renewed spirit of race and social justice.
Meaningfully moving toward an increased adoption of healthy living behaviors on a population level, for all individuals regardless of race, sex, or social strata, is central to addressing the present syndemic, which can be argued to be one of the biggest health crises of our generation.
In conclusion, surpassing one million deaths related to COVID-19 was a tragic milestone for the United States. Visualization of the US COVID-19 mortality map, in comparison with US maps of several lifestyle behaviors, obesity, and chronic disease, show a clear pattern that convincingly demonstrates the syndemic we currently face. Decades of a high prevalence of unhealthy lifestyle behaviors laid the foundation for our current unfortunate situation by increasing vulnerability to a novel virus, especially among subgroups who have been historically marginalized. Other authors have referred to the COVID-19 pandemic as a “a wake-up call for lifestyle-related preventable conditions,”
and we could not agree more. As such, a major pathway to defeating this syndemic is through the promotion of healthy living behaviors for all. Now is the time for action appropriate to meet the demands of a syndemic and a new path forward to a healthier and more equitable future.
Authorship: All authors had access to the data. RA: Drafting and editing the manuscript; NP: Drafting sections and editing the manuscript; DL: Critical review and editing the manuscript; LW: Critical review and editing the manuscript; JS: Critical review and editing the manuscript; CL: Critical review and editing the manuscript.