By Ellen Feldman, MD

Altru Health System, Grand Forks, ND

SYNOPSIS: A Canadian survey capturing one week in the early stages of the COVID- 19 pandemic found that respondents reporting exercising outdoors and decreasing or maintaining screen time were more likely to self-report higher levels of mental and physical health. This association was stronger in women when compared to men.

SOURCE: Colley RC, Bushnik T, Langlois K. Exercise and screen time during the COVID-19 pandemic. Health Rep 2020;31:3-11.

In March 2020, the world embarked on a race to control and slow the spread of severe acute respiratory coronavirus 2. “Lockdown,” “social distancing,” and “flatten the curve” became household terms. Schools and businesses closed or adopted remote access, unnecessary trips were discouraged, and, for many, electronic communication became the norm.

With a goal of understanding changes in screen time use, exercise, and any association with self-perceived mental or physical health, Colley et al surveyed a population-weighted cross section of Canadian adults during the week of March 29-April 3, 2020. Using a subgroup of participants from ongoing, large-scale surveys of health and related behaviors, 7,242 Canadians aged > 15 years were invited to participate in the Canadian Perspective Survey Series — Impacts of COVID-19 (CPSSI).¹ The 4,627 individuals who responded represent a population of 31 million. Of these, 4,524 responses from adults aged > 20 years contributed to the study.

The survey design is straightforward. Participants self-rated mental health and physical health by choosing one out of five possible responses from poor to excellent. Colley et al then combined the top two categories (very good and excellent) and bottom three (good, fair, and poor) to dichotomize results, facilitate analysis, and provide meaningful interpretation.

In addition, the survey asked if respondents were “doing any of the following activities for your health.” Choices included: exercising indoors for mental health, exercising indoors for physical health, exercising indoors for mental and physical health, exercising outdoors for mental health, exercising outdoors for physical health, exercising outdoors for mental and physical health, or none of these. Simplifying responses into exercising for any reason or not exercising aided with analysis.

The final survey category involved time spent with electronics, specifically television, internet, and video games. Respondents were asked if the weekly time spent on each of these pursuits had increased, decreased, or not changed at all. For analysis purposes, these responses were re-coded initially into increase vs. decrease/no change and then further simplified into increased two to three types of screens vs. increased 0 to one type of screen.

Results

Exercise and screen habits reported during the week of March 29-April 3, 2020, include:

1. Sixty percent to 70% of men and women reported exercising outdoors.
2. Sixty-three percent of women and 55% of men reported exercising indoors (P < 0.05).
3. More than 60% of men and women reported increasing TV time.
4. More than 60% of men and women reported increasing internet usage.
5. Sixteen percent of women and 24.1% of men reported increasing video game usage (P < 0.05).

A more detailed breakdown of results has been summarized in Tables 1 through 3.

Commentary

The results of this ambitious survey indicate that a cross section of Canadian adults who reported engaging in outdoor exercise while not increasing more than one type of screen usage over one week in March-April 2020 endorsed higher levels of mental health than those who did not report such a combination. This association was consistently higher in women than in men and held for general health in women as well.

Colley et al are clear about the limitations of this survey. There are no data available regarding pre-existing levels of exercise or screen usage, no clear definition of exercise, and no standard criteria for ranking levels of mental or general health. All data are self-reported, and thus subject to reporter bias. There is certainly no evidence of causation; in fact, it is conceivable that respondents who had high confidence in their own health (mental and general) were more likely to feel comfortable exercising outside — especially in the early stages of COVID-19 when transmission mode was uncertain.

In some respects, this study raises more questions than it generates answers. Areas for future investigations include understanding differences in health outcomes when comparing outdoor vs. indoor exercise, socioeconomic factors influencing exercise and screen habits, and if men and women have a baseline difference in self-reports of health status.

Yet, even with limitations, the results of this survey are translatable for clinical use. Previous studies have shown a link between exercise and improved mental and general health.^2,3 Exercise is an important adjunct treatment for depression, and there is evidence that exposure to full spectrum light aids in treatment of specific types of depression.⁴ Excessive screen use time often is associated with sedentary behavior, and linked to worsening symptoms of depression and development of metabolic syndrome.⁵ The results from this current study echo these findings from other studies.

Public health messaging during the COVID-19 pandemic has justifiably focused on managing disease spread, with social distancing a key factor.⁶ The results of this study imply that, during periods of social isolation, there is an association between limiting screen time, engaging in outdoor exercise, and higher self-perceptions of mental and general health, especially in women. With further investigations, public health messaging may incorporate these findings.

It is likely that many of the pandemic-related restrictions will continue for the near future. With “pandemic fatigue” settling in, a focus on wellness is critical. This survey can serve as a reminder to the primary care physician to alert patients to the myriad benefits of physical activity and some of the potential health hazards inherent in screen use. The results of this study suggest concrete steps, such as increasing outdoor exercise and decreasing screen time, to enhance the self-perception of health during a very stressful period.

REFERENCES

1. Canadian Research Data Centre Network. (CPSS-COVID) Canadian perspective survey series - COVID 19. Published in 2020. https://crdcn.org/datasets/cpss-covid19
2. Mikkelsen K, Stojanovska L, Polenakovic M, et al. Exercise and mental health. Maturitas 2017;10648-10656.
3. Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: The evidence. CMAJ 2006;174:801-809.
4. Chang C-H, Liu C-Y, Chen S-J, Tsai H-C. Efficacy of light therapy on nonseasonal depression among elderly adults: A systematic review and meta-analysis. Neuropsychiatr Dis Treat 2018;14:3091-3102.
5. Park JH, Moon JH, Kim HJ, et al. Sedentary lifestyle: Overview of updated evidence of potential health risks. Korean J Fam Med 2020;41:365-373.
6. Centers for Disease Control and Prevention. Public health guidance for community-related exposure. Updated Dec. 3, 2020. https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html