key: cord-0786999-wps0f3dd
authors: Arena, Ross; Lavie, Carl J; Faghy, Mark A
title: What Comes First, the Behavior or the Condition? In the COVID-19 Era, It May Go Both Ways
date: 2021-08-12
journal: Curr Probl Cardiol
DOI: 10.1016/j.cpcardiol.2021.100963
sha: 05ac903bf65b0cfcfcbc2ea81cf09c653d56ed1e
doc_id: 786999
cord_uid: wps0f3dd

Which came first, the chicken or the egg? This causality dilemma was first proposed by the Greek biographer Plutarch in the 1st century CE. While the cause-effect relationship between lifestyle behaviors and chronic disease is not always a certainty, and genetic predisposition can independently lead to premature chronic disease, the likelihood of developing one or more chronic conditions is significantly higher in those who: 1) lead sedentary lifestyles; 2) consume unhealthy diets; 3) smoke; or 4) have excess body mass. Recently, the Royal College of General Practitioners issued an apology for the title of an online event that suggested the coronavirus disease 2019 (COVID-19) is a lifestyle disease. We feel that this was the correct course of action as leading an unhealthy lifestyle is certainly not the cause for an individual contracting COVID-19 (i.e., effect). However, a body of evidence has demonstrated that unhealthy lifestyle behaviors and characteristics as well as being diagnosed with one or more chronic diseases does significantly increase the risk for a complicated medical course in individuals infected with COVID-19. Moreover, the cause - effect relationship between lifestyle behaviors and characteristics and COVID-19 may eventually prove to go both ways, as the pandemic may lead to a higher prevalence of unhealthy lifestyle behaviors and characteristics over the long term that eventually leads to a higher prevalence of chronic disease. As such, health living medicine must be widely practiced and prescribed to all individuals globally.

Which came first, the chicken or the egg? This causality dilemma was first proposed by the Greek biographer Plutarch in the 1st century CE. While the cause-effect relationship between lifestyle behaviors and chronic disease is not always a certainty, and genetic predisposition can independently lead to premature chronic disease, the likelihood of developing one or more chronic conditions is significantly higher in those who: 1) lead sedentary lifestyles; 2) consume unhealthy diets; 3) smoke; or 4) have excess body mass. Recently, the Royal College of General Practitioners issued an apology for the title of an online event that suggested the coronavirus disease 2019 (COVID-19) is a lifestyle disease. We feel that this was the correct course of action as leading an unhealthy lifestyle is certainly not the cause for an individual contracting COVID-19 (i.e., effect). However, a body of evidence has demonstrated that unhealthy lifestyle behaviors and characteristics as well as being diagnosed with one or more chronic diseases does significantly increase the risk for a complicated medical course in individuals infected with COVID-19. Moreover, the cause -effect relationship between lifestyle behaviors and characteristics and COVID-19 may eventually prove to go both ways, as the pandemic may lead to a higher prevalence of unhealthy lifestyle behaviors and characteristics over the long term that eventually leads to a higher prevalence of chronic disease. As such, health living medicine must be widely practiced and prescribed to all individuals globally.

Key words: Physical activity, healthy diet, obesity, viral infection, chronic disease, Which came first, the chicken or the egg? This causality dilemma was first proposed by the Greek biographer Plutarch in the 1 st century CE. 1 This question has been used in numerous causality dilemmas over the centuries and holds relevance to the cause-effect relationship between lifestyle behaviors and the risk for the premature onset of one or more chronic diseases, including cardiovascular disease (CVD), diabetes, and certain forms of cancer. [2] [3] [4] The phrase "Exercise is Medicine" 5 is well known in medical and physical activity domains but while the cause-effect relationship between lifestyle behaviors and chronic disease is not always a certainty, and genetic predisposition can independently lead to premature chronic disease, the likelihood of developing one or more chronic conditions is significantly higher in those who: 1) lead sedentary lifestyles; 2) consume unhealthy diets; 3) smoke; or 4) have excess body mass. 6 Put another way, unhealthy lifestyle behaviors (i.e., sedentary lifestyle, poor nutrition and smoking) and characteristics (i.e., excess body mass) is a common, leading cause for premature chronic disease (i.e., effect). In a cohort of more than 110,000 individuals, Nyberg et al. 7 recently found males with the healthiest lifestyle behaviors and characteristics lived 9.9 (95% CI 6.7-13.1) more years free of chronic diseases, while women with the same characteristics lived 9.4 (95% CI 5.4-13.3) more years free of chronic diseases compared to those individuals with the unhealthiest lifestyle behaviors and characteristics. Given these and other findings, several chronic diseases have also been characterized as lifestyle-related diseases. [8] [9] [10] It is important to note that, even in individuals who are genetically predisposed to developing premature chronic disease, leading a healthy lifestyle significantly mitigates against this risk 11, 12 , further supporting the oftentimes cause-effect relationship between lifestyle and chronic disease. Lastly, while not a lifestyle behavior per-say, maintaining a high cardiorespiratory fitness (CRF), which is often the result of leading a healthy lifestyle (i.e., being physically active), is a proven independent prognostic marker and now designated as a vital sign. [13] [14] [15] [16] Recently, the Royal College of General Practitioners issued an apology for the title of an online event that suggested the coronavirus disease 2019 (COVID-19) is a lifestyle disease. 17 We feel that this was the correct course of action as leading an unhealthy lifestyle is certainly not the cause for an individual contracting COVID-19 (i.e., effect). To date, there have been more than 190 million cases of COVID-19 18 , certainly, millions of healthy individuals who lead a healthy lifestyle (i.e., exercise, consume a healthy diet, maintain a normal body weight and not smoking) and have no chronic disease diagnoses have contracted COVID-19. In fact, Rodriguez et al. 19 recently reported lifestyle habits and chronic disease diagnoses were not predictive of contracting COVID-19, rather, the rate of transmission is exacerbated by increased exposure to other individuals in public settings, not following disinfection recommendations, and living with someone with COVID-19 were all significant predictors on becoming infected. In this context, there is no cause and effect between unhealthy lifestyle behaviors and characteristics and contracting COVID-19 and, as such, issuing an apology was appropriate. However, a body of evidence has demonstrated that unhealthy lifestyle behaviors and characteristics as well as being diagnosed with one or more chronic diseases does significantly increase the risk for a complicated medical course in individuals infected with COVID-19. In 22 found individuals who reported adhering to "plant-based diets" had a 73% (OR 0.27, 95% CI 0.10 to 0.81) lower odds of moderate-severe COVID-19 symptoms while individuals who reported adhering to "plant-based diets or pescatarian diets" had a 59% (OR 0.41, 95% CI 0.17 to 0.99) lower odds of moderate-severe COVID-19 symptoms, when compared to individuals who did not report adhering to these diets. In a search of literature assessing risks for poor outcomes with COVID-19 infection, Harrison et al. 23 performed a comprehensive review of medical databases and preprint servers, identifying 31 reviews of moderate quality and one of high-quality. Obesity, smoking, hypertension, diabetes, and CVD were all associated with poorer outcomes following COVID-19 infection. Other analyses have also reported unhealthy lifestyle behaviors and characteristics and chronic disease diagnoses are clearly and significantly linked to an increased risk for increased symptom severity and poor outcomes with COVID-19 infection. 21, [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] In fact, the evidence demonstrating the increased risk for severe outcomes with COVID-19 infection in those with unhealthy lifestyle behaviors and characteristics and/or one or more chronic disease diagnoses may already be to a point where the link is irrefutable. In addition, evidence has emerged demonstrating a higher CRF, now considered a vital sign, provides protection against increased COVID-19 severity and may be a more important indicator of risk than obesity. [35] [36] [37] [38] [39] To reiterate, COVID-19 is not a lifestyle disease and the apology issued by the Royal College of General Practitioners for suggesting the converse was appropriate. However, it is readily apparent that lifestyle behaviors and characteristics play a significant role in determining health status, resiliency in the event of an untoward health event (e.g., COVID-19 infection), and the risk for premature chronic disease. 40 Moreover, it is also readily apparent that, in individuals who are infected with COVID-19, lifestyle behaviors and characteristics and the presence or absence of pre-existing chronic conditions significantly influence the severity of the viral infection. In this context, Table 1 Table   1 . In this sense, there is truly no causality dilemma; what comes first and what comes next is clear and beyond dispute. The outcomes of three of the four scenarios, in the context of COVID-19 severity, is, however, influenced by lifestyle behaviors and characteristics, both independently (e.g., unhealthy lifestyle and no chronic disease diagnoses) and secondary to their link to chronic disease risk (e.g., unhealthy lifestyle significantly increases risk for chronic disease). There is a fourth scenario in Table 1 that has not extensively investigated to this point and does warrant further investigation. This involves individuals with healthy lifestyle behaviors and characteristics who are genetically predisposed and have developed a chronic disease as well as individuals who, once diagnosed with a chronic disease, made a significant, long-term shift toward healthy lifestyle behaviors and characteristics. As previously mentioned, individuals who are genetically predisposed to developing premature chronic disease but who lead a healthy lifestyle have a significantly reduced risk for developing a chronic disease. 11 There is another troubling future causeeffectoutcome scenario to consider as we emerge from the COVID-19 pandemic. Evidence continues to demonstrate measures taken to mitigate viral spread (i.e., social distancing and lockdowns) have led to individuals, irrespective of viral infection status, leading unhealthier lifestyles (e.g., less physically active, poorer nutrition, etc.). [42] [43] [44] [45] [46] Over the long-term, there is justifiable concern that the international response to the COVID-19 pandemic in an attempt to curtail transmission, commonly referred to as the "new norm", will cause a larger percentage of the global population to lead an unhealthy lifestyle permanently, leading to a higher incidence of chronic disease and exacerbating pressures on healthcare systems globally. In this scenario, the COVID-19 pandemic came first, an increased prevalence of unhealthy lifestyle behaviors and characteristics came next, and the outcome over the long term may be an even higher risk for chronic disease on a population level.

This be truly troubling given physical inactivity and chronic diseases were already being characterized as pandemics prior to COVID-19. 47 In conclusion, as indicated in the title, the cause -effect relationship between lifestyle behaviors and characteristics and COVID-19 may eventually prove to go both ways. We recently proposed that the combination of unhealthy lifestyle behaviors and characteristicschronic disease -COVID-19 should be considered a syndemic, as it is clear these three conditions "adversely interact with and negatively affect the outcomes of one another". 48 Perhaps it would be best to view these conditions from the syndemic perspective as opposed to cause-and-effect. However, irrespective of the perspective adopted, these conditions are inextricably linked now and potentially for many years to come. Moreover, adopting healthy lifestyle behaviors and characteristics is vital to uncoupling this syndemic. As such, health living medicine must be widely practiced and prescribed to all individuals globally. 49, 50 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. One or more chronic disease diagnoses.

Increased likelihood for more severe course with viral infection and hospitalization

Healthy lifestyle behaviors and characteristics.

One or more chronic disease diagnoses.

More research is needed to determine the protection from a more severe course with viral infection and hospitalization healthy lifestyle behaviors and characteristics afford in those genetically predisposed to chronic disease or adopt healthy lifestyle behaviors and characteristics following a chronic disease diagnosis.

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