Updates from EIM

Inactivity Linked to Severe COVID-19

April 22, 2021 by James Sallis, Ph.D., FACSM and Robert Sallis, M.D., FACSM

Starting March 2020, near the beginning of the pandemic, exercise scientists and clinicians published blogs about the mechanisms by which physical activity could likely reduce harm from COVID-19. There was strong evidence that physical activity improves immune function, reduces inflammation, prevents and treats most common chronic diseases, decreases the psychological and physiological burden of stress, and improves immune responses to vaccinations among older adults.

Though these blogs gained attention in the exercise science community, they had no impact on the public response to the pandemic in the US. We did not see coverage in the mainstream press on how physical activity could benefit people during the pandemic. Instead, we saw many of the venues where people are physically active (gyms, parks, trails) closed during lockdowns. The CDC did not list physical inactivity as a risk factor for severe COVID-19, but the World Health Organization did. 

Perhaps US public health leaders were waiting for direct evidence about physical activity benefits specific to COVID-19? Now in April 2021, we have just such evidence. A study of 48,440 COVID-19 patients from Kaiser Permanente Southern California was published April 14, which we co-authored with colleagues. These patients were diagnosed with COVID-19 and had reported their physical activity at least 3 times during outpatient visits over the prior 2 years. The study showed a diverse sample of adults (65% Hispanic/Latino) who reported being physically inactive before diagnosis were 2.49 times more likely to die of COVID-19 than those who regularly met physical activity guidelines of 150 minutes per week. Similar benefits of physical activity were seen for hospital and ICU admissions. These results were adjusted for demographics, along with the CDC-identified risk factors for severe COVID-19.  Most notably, physical inactivity was a stronger risk factor for severe COVID-19 than heart disease, cancer, diabetes, hypertension, smoking, and obesity.  The study was also featured in a New York Times story by Gretchen Reynolds on April 14, 2021.  

These findings could never have been uncovered without the Exercise Vital Sign (EVS) embedded in Kaiser Permanente’s electronic health record.  The integration of the Physical Activity Vital Sign (PAVS or EVS) is a key tenet of the Exercise is Medicine® initiative.  This allows for health systems to collect data on health outcomes and the financial impact of physical activity behaviors among patient populations and identify opportunities for intervention. 

Our study provides compelling evidence that physical inactivity should be considered a major risk factor for severe COVID-19 cases and death, and other recent studies point to the same conclusion. We assert that cumulative recent evidence should lead to actions by public health and medical leaders to promote physical activity during the pandemic.

  •        Physical inactivity should be identified by the CDC as a risk factor for severe COVID-19 outcomes, including death.
  •        Public health authorities at local, state, and federal levels should educate people about the benefits of being physically active during the pandemic.
  •        Rapid funding should be provided for scaling up physical activity interventions shown to be effective or promising, such as those in the US National Physical Activity PlanCDC’s Active People Healthy Nation,  and the WHO’s Global Action Plan for Physical Activity.   
  •        Health care providers should routinely assess, advise, and assist patients to be physically active, as recommended by numerous groups, including Exercise Is Medicine®.

The documented benefits of physical activity have been neglected for the first year of the pandemic, missing an opportunity to reduce suffering and death. People are still getting sick and dying of COVID-19, so it is not too late to take action to help people be more active. As a health professional and physical activity expert, your voice can help convince public health leaders to act on this evidence. Please share this information widely and personally contact leaders who can put this evidence into practice in the US and around the world.


James Sallis, Ph.D., FACSM is with the Herbert Wertheim School of Public Health at UC San Diego and Mary MacKillop Institute for Health Research at Australian Catholic University. He studies physical activity and advocates using evidence to improve policy and practice. He is a past Vice-President of American College of Sports Medicine (ACSM).

Robert Sallis, M.D., FACSM is a family medicine physician practicing at Kaiser Permanente Medical Center in Fontana, California, where he serves as Director of the Sports Medicine Fellowship program.  He is a Clinical Professor of Family Medicine at the University of California, Riverside School of Medicine, a Past-President of ACSM and currently chairs the Advisory Board for the Exercise is Medicine Global Health Initiative.

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