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The association between healthy walking and COVID-19 symptom severity: A cross-sectional study on the first peak following China’s prevention policy change

BMC Public Health volume 25, Article number: 1497 (2025) Cite this article

Abstract

Background

Healthy walking is a moderate aerobic exercise with a step frequency of more than 100 steps per minute. This study aims to assess the impact of Healthy Walking, a novel form of physical activity, on the severity and course of COVID-19 among patients aged from 18 to 65 years old.

Methods

This cross-sectional study included 1,128 adult participants who completed the questionnaire after recovering from the first wave of COVID-19 infections following China`s modification of its prevention policy. The survey questions included their health status when suffering from COVID-19, basic sociodemographic data, and medical history concerning chronic conditions and lifestyle. A multiple logistic regression model and linear regression model were used to evaluate the dependent variable that reflects the severity of COVID-19 infection.

Results

Among the 1,128 adult participants, the mean age was 39.93 ± 10.18 (IQR: 31.75-48), and 407 (36.08%) were male. Participants who walked up to 300 min per week had a negative association with COVID-19 (OR: 0.562, 95% CI: 0.41–0.863). Receiving three vaccine doses was negatively associated with severe COVID-19 (OR: 0.289, 95% CI:0.092–0.742) compared with receiving only one dose. Females (OR: 1.935, 95% CI:1.475–2.540) had a positive association with severe COVID-19, also a high incidence of co-habitatants was also positively associated (OR: 2.741, 95% CI:1.284–5.881) In the linear model assessing risk factor affecting the course of COVID-19, habitual Healthy Walking (\(\:\beta\:\) =-0.433, \(\:p\)=0.004) was linked to a reduced disease duration after adjusting all significant risk factors.

Conclusions

Regular Healthy Walking may help alleviate symptoms and speed up recovery. Therefore, incorporating walking into other physical exercise may reduce COVID-19 symptom severity and speed up COVID-19 recovery.

Peer Review reports

Introduction

Healthy Walking, defined as a moderate aerobic exercise with a step frequency of 100 steps per minute, is convenient and feasible for most people, especially elder individuals [1]. Several studies have explored the health benefits of walking, including its occupational advantages [2]. For instance, research conducted by Sánchez-Domínguez et al. revealed that Healthy Walking has an immediate positive effect on the cardio-ankle vascular index, primarily among males [3]. Similarly, other studies have found a correlation between body weight-supported walking and muscle strength [4]. 10,000 Steps a dayProgram, launched by the Chronic Disease Center for Disease Control and Prevention in 2016, encourages worker to engage in brisk walking.

Moreover, supportive evidence shows the vital role of physical exercise in improving physical and psychological health. Previous research showed that physical activities could activate immune system, improve mental well-being, reduce inflammation, and stimulate the production of substances (such as endorphins) to prevent infectious diseases or relieve symptoms, including COVID-19 [5, 6]. It has previously been shown that regular physical activities and higher physical fitness levels might reduce susceptibility to COVID-19 infection and its severity [7,8,9]. A large population-based study in patients undergoing SARS-CoV-2 RT‒PCR testing showed that a higher frequency of PA is associated with a lower rate of positive test results [10].

Furthermore, Healthy Walking increases serum levels of anti-inflammatory and immunomodulatory cytokines (IL-1ra, IL-10) [11, 12], boosting immune system and reducing inflammation [13]. Exercise increases peripheral blood neutrophil numbers by activating various physiological mechanisms, increases metabolic rate, and releases heat shock proteins, catecholamines, cortisol, and insulin-like growth factors [14,15,16]. Regular moderate exercise training may products against common respiratory infections and systemic low-grade inflammation [14, 17]. Therefore, regular Healthy Walking may act as a protective factor against severe COVID-19.

On December 7, 2022, China relaxed its zero-COVID policy. Shortly after, a surge in COVID-19 cases was reported across the country. Although the exact number of cases remained uncertain, it was estimated that 60–80% of people in major cities were infected, including a large number of adults under the age of 65 [18, 19]. The impact of COVID-19 was severe and alarming, making it crucial to alleviate the symptoms to help patients battle the disease.

Most exercise methods typically require sports equipment. However, walking is a convenient and accessible form of physical activity for many individuals. Given this, we conducted a study to explore the potential of Healthy Walking effectively prevents individuals from experiencing severe COVID-19 symptoms. Additionally, we sought to discover new preventive methods to relieve these symptoms.

Methods

Study population and questionnaire

This cross-sectional study investigated the COVID-19 symptoms of native Chinese patients who participated in a healthy walking program. The investigation was based on a self-designed questionnaire that was sent to patients via the Wenjuanxing website. All the respondents had participated in the Healthy Walking program for over a year. The eligibility criteria were as follows: (1) aged between 18 and 65; (2) infected with COVID-19 between November 2022 and February 2023; (3) participation in the Healthy Walking program.

Questionnaire: All COVID-19 infection cases were confirmed by real-time PCR, antigen test, or symptoms of COVID-19 infection. Basic sociodemographic data, such as age, sex, body mass, and height, were collected along with information of self-reported COVID-19 infection. The potential confounders considered included the history of smoking, habitation, body mass index (BMI), vaccine doses, time of last vaccination, incidence of co-habitation, treatment method, sedentary time, change of comorbidities, emotional state, and communication with friends. Healthy Walking was categorized into four types: (1) none; (2) more than 75 min per week; (3) more than 150 min per week; and (4) more than 300 min per week. Healthy Walking was defined as having a step frequency of more than 100 steps per minute. When the speed met the criterion, Participants reported their walking time based on the data recorded by an electronic pedometer. The severity of COVID-19 symptoms was assessed based on three factors: fever, severity of other symptoms, and duration of COVID-19 infection. The mild, moderate and severe fevers were < 38℃, between 38℃ and 38℃ and above 39℃, respectively. The severity of each symptom - including cough, sore throat, headache, fatigue, muscle weakness, rhinobyon, falling chilly, loss of smell, loss of appetite, loss of taste, diarrhea, nausea, vomiting, and various rashes [20,21,22] - was evaluated on a scale of 0 to 5. The mild, moderate and severe symptoms were total symptom score less than 28, between 28 and 52 and above 52, respectively. The mild, moderate and severe course were duration of COVID-19 infection less than 7days, between 7 and 14, and longer than 14 days, respectively.

Considering that potential bias could affect the model’s accuracy, we included two variables (comorbidities and treatment method) to assess the quality of our model and identify the variables that affect symptom severity.

Statistical analysis

Statistical analysis was conducted with R4.1.3 software. Categorical variables were described using absolute and relative frequencies, expressed as percentages. To investigate the interplay between categorical variables, chi-square tests were employed. Quantitative variables with a normal distribution, as determined by the Shapiro‒Wilk test, were represented as means ± standard deviations, whereas those without a normal distribution are presented as the median and interquartile range. When a normal distribution was present, student’s t-test was utilized to compare quantitative variables between the groups. However, the nonparametric Mann‒Whitney U test was employed for independent categorical variables or nonnormally distributed quantitative variables. A multiple logistic regression model and linear regression model were built to evaluate the dependent variable that reflected the severity of COVID-19 infection. Both stepwise methods were used to screen the independent variable affecting the severity of COVID-19 symptoms. Missing data were excluded from all analyses. In each case, a p-value less than 0.05 was deemed statistically significant.

Results

Demographics

This study included 1,128 adult participants, the mean age was 39.93 ± 10.18 (IQR: 31.75-48). and 407 (36.08%) were male. All respondents were vaccinated, and 991 (87.85%) participants received three vaccine doses. Among all participants, only 93 (8.24%) were hospitalized. A total of 129 (11.44%) did not take any medicine. The majority (1092, 96.81%) of patients had been vaccinated more than once. A total of 738 (65.43%) participants did not have any comorbidities and 127 (11.26%) did not have any chronic disease. The mean BMI was 22.86 ± 4.01 (IQR: 20.93–25.10). Respondents with severe COVID-19 symptoms had a longer duration of Healthy Walking than those with mild or moderate symptoms (p < 0.018). Females had a higher proportion of severe symptoms (p < 0.001). The time since the latest Vaccination was not a significant factor in COVID-19 severity (p = 0.387). The proportion of severe symptoms was inversely correlated with the number of vaccine doses (p = 0.012). (Table 1)

Table 1 Baseline characteristics of the study population
Full size table

Potential risk factors

In the reduced logistic models with both stepwise methods, participants who walked up to 300 min per week showed a negative association with severe COVID-19 (OR: 0.562, 95% CI:0.410–0.863). Receiving three vaccine doses was negatively associated with severe COVID-19 (OR: 0.289, 95% CI:0.092–0.742) compared with a single dose. Females showed a positive association with severe COVID-19 (OR: 1.935, 95% CI:1.475–2.540), also the incidence of cohabitation also showed a positive association (OR: 2.741, 95% CI:1.284–5.881). Please refer to Table 2 for detailed results of the full and reduced models.

Table 2 Full and reduced both Stepwise logistic regression analysis model assessing the impact of risk factors on the severity of COVID-19
Full size table

We divide the course of COVID-19 into two parts: the first seven days and the period thereafter. Our study, utilizing reduced logistic models with both stepwise methods, revealed that elderly respondents(OR: 1.029, 95% CI:1.015–1.044) were positively associated with longer disease courses. Being female was positively associated with COVID-19 (OR: 1.935, 95% CI:1.436–2.615), while having comorbidities were positively associated with longer disease courses (OR: 1.195, 95% CI:1.054–1.359). Walking up to 300 min per week also showed a positive association with a longer course (OR: 0.518, 95% CI: 0.36–0.743). (Table 3) Furthermore, the multi-variable linear regression models, involving stepwise analyses with the course as the response variable, highlighted that being female ( \(\:\beta\:\) =1.805, \(\:p\) <0.001), older (value 0.067, p < 0.001), and having poor communication with others (\(\:\beta\:\) =0.906, \(\:p\) <0.001) were associated with a prolonged course. In contrast, engaging in Healthy Walking (\(\:\beta\:\) =-0.433, \(\:p\)=0.004) was linked to a shorter course (Table 4).

Table 3 Full and reduced both Stepwise logistic regression analysis model assessing the impact of risk factors on the course of COVID-19
Full size table
Table 4 Full and reduced both Stepwise linear regression analysis model assessing the course of COVID-19 infection
Full size table

Discussion

When COVID-19 infection was unavoidable, more and more people consider about exercise as a method of mitigating symptoms. While most studies exploring the association between lifestyle and COVID-19 focus on elderly individuals infected [19, 23], it is also important to consider other age groups that may experience severe symptoms. This research examines how Healthy Walking may potentially alleviate COVID-19 symptoms in middle-aged individuals. In summary, the study shows that factors such as sex, age, vaccination doses, cohabitation, amount of Healthy Walking (more than 300 min per week), social interaction, and emotional well-being significantly affect the severity of COVID-19 symptoms.

Our study revealed that Healthy Walking reduces the risk of severe COVID-19 by 1.82 times. Similar findings have been reported in other studies focusing on physical activities. Kapusta et al. discovered that physical activities reduced the risk of severe COVID-19 in senior citizens by over 3.4 times [24, 25]. Yuan et al.‘s study also demonstrated that preexisting physical inactivity was associated with an increased risk of experiencing severe COVID-19 for middle-aged and elderly individuals [26]. Similarly, another source suggests that a physically active lifestyle may reduce the incidence of acute respiratory infection and the severity of COVID-19 symptoms [27]. Hamer et al.‘s research identified a lack of physical activities as a contributing variable to the risk profile of hospitalized patients during the follow-up period [28]. Both home- and outdoor-based exercise, regardless of age and chronic conditions, could aid in mitigating infection progression [29]. The majority of previous studies had come to a similar conclusion; however, they demonstrated more efficacious results. This discrepancy may be attributable to the fact that the present study focused on a younger demographic. Viktor et al. have a similar age(18 ~ 65) group and obtained results comparable to ours [27]. Additionally, some researchers determined that high-intensity physical activity can suppress the immune system and increase the severity of clinical symptoms in COVID-19 [30, 31]. However, our analysis indicated that engaging in Healthy Walking for up to 300 min per week was associated with shorter disease courses compared with having no Healthy Walking. The result is influenced by the varying characteristics of different types of physical activity. Healthy Walking, being a low or moderate-intensity activity, is difficult to elevate to high-intensity levels. We assess the intensity of Healthy Walking based on the duration of the walk. Therefore, even a prolonged period of Healthy Walking still qualifies as moderate-intensity physical activity when compared with other forms of exercise.

Additionally, our study indicated that individuals who had experienced negative communication and emotional challenges were at a greater risk for severe COVID-19 symptoms. The development of depressive disorders might contribute to more severe symptoms. Studies have found that stress in the four weeks prior to contracting COVID-19 is a risk factor for increasing severity. A cohort study matched our result, showing that increasing psychological distress during the early stages of the pandemic can worsen symptoms. A study also shows that older individuals with psychiatric or physical illnesses or dysfunctions are also at risk [32].

Our research concluded that females have a higher risk of a severe disease course and a longer duration of symptoms, which is consistent with other research findings [25].

J. Kapusta et al. reported that, in contrast, some researchers have reached a different conclusion. C. Fernández-de-las-Peñas et al. presented that female sex is not a risk factor for COVID-19 symptoms, but it is associated with long-term COVID-19 symptoms [33]. Our study shows that aging also increases the risk of severe symptoms and a longer disease course. Similarly, a systematic review indicated that the age-specific fatality rate increased progressively with age, particularly among middle-aged and older adults [23]. Advanced age may be associated with changes in both innate and adaptive immune responses, which can lead to compromised immunity, disease, and an increased risk of most chronic diseases [34,35,36,37,38,39].

However, there are some limitations in this study. Firstly, we do not have data on individuals’ daily walking habits, step count, or walking speed, which prevents an exact measurement of symptom mitigation. All the respondents were vaccinated, which may cause potential bias. Furthermore, we did not consider other types of exercise that could influence the severity of symptoms. Although we measured the intensity of regular walking based on walking duration, it was actually influenced by both time and walking speed. Evaluating an activity as intense but easy for ordinary people to comprehend is inaccurate. To reduce bias, we divided the total duration of Healthy Walking into three groups and adjust the common confounders. Secondly, self-reported diagnoses could lead to confusion with other illnesses, such as the flu, while self-reported symptom and exercise scales may introduce inaccuracies. To address the limitation, we conducted the investigation one month later after China relaxed its zero-COVID policy, which was during the peak of SARS-CoV-2 infections. Additionally, the smoking variable yielded an unexpected outcome, with nonsmokers experiencing more severe symptoms and a longer course of illness. This is likely due to sex being a confounding factor, as most nonsmokers are women and most smokers are men. Finally, causal inference is impossible due to the cross-sectional nature of this study. This study suggests that regular walking may help mitigate the severity of COVID-19 symptoms, but further analytical epidemiology studies are needed to confirm our conclusion.

Conclusions

In conclusion, the study identified females as potential risk factors for severe COVID-19. It also found that age remains a risk factor for severe COVID-19 in adults under 65. Additionally, Regular Healthy Walking may help alleviate symptoms and speed up recovery. Therefore, incorporating walking into other physical exercises may reduce COVID-19 symptom severity and speed up COVID-19 recovery. Future studies should consider conducting prospective longitudinal studies to minimize potential confounders and further investigate the association between Healthy Walking and long-term COVID.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

PA:

Physical activity

IQR:

Interquartile range

COVID-19:

Corona Virus Disease 2019

SARS-COV-2:

Severe Acute Respiratory Syndrome Coronavirus 2

PCR:

Polymerase Chain Reaction

B:

Unstandardized regression coefficient

OR:

Odds ratio

CI:

Confidence Interval

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Acknowledgements

We acknowledge Dr. Lian Jian (Chongqing Center for Disease Control and Prevention) for his advice on the research. We would also like to acknowledge Xi (Mingwei) Li and Jiang Xiaodong (Chongqing Three Gorges Medical College) for editing and correcting the grammar to improve the readability of this article.

Funding

This research was supported by the General Program of Chongqing Three Gorges Medical College Natural Science in 2021 (XJ2021000201) and the General Program of Chongqing Three Gorges Medical College Natural Science in 2019 (2019XZYB21).

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Authors and Affiliations

  1. School of Public Health and Management, Chongqing Three Gorges Medical College, Chongqing, 404120, P. R. China

    Wanyuan Xia, Daikun Zheng, Liliang Yu, Xiujuan Jiang, Mingyue Fan, ChangFeng Li, Min Liu & Jiming Kang

  2. Chaling Center for Disease Prevention and Control, Zhuzhou City, 412400, Hunan Province, China

    Xiaomin chen

  3. Zhiping Central Hospital, Jiangjin District, Chongqing, 402260, China

    Haifang ZOU

  4. Ministry of Public Infrastructure, Chongqing Three Gorges Medical College, Chongqing, 404120, China

    Yan Zhao

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  1. Wanyuan Xia
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Contributions

Wanyuan Xia and Jiming Kang– development of assumptions and research methods, questionnaire design, collecting source materials and carrying out research, statistical analysis of research results, preparation of the text of the study, interpretation of obtained results, review and editing; Daikun Zheng, Xiaomin chen, Liliang Yu and Xiujuan Jian– preparation of the text of the study, data collection, review and editing; Mingyue Fan, Haifang ZOU, Changfeng Li and Min Liu– statistical analysis of research results, interpretation of the obtained results; Yan Zhao– interpretation of obtained results, review and editing; All authors reviewed the manuscript.

Corresponding author

Correspondence to Jiming Kang.

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This study protocol was approved by the Ethics Committee of Three Gorges Medical College (Approval number: SYYZ-H-2301-0001). All participants voluntarily participated, and informed consent was obtained from all subjects and/or their legal guardian(s) prior to questionnaire administration. All methods and procedures followed in this study were in accordance with relevant guidelines and regulations.

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Xia, W., Zheng, D., chen, X. et al. The association between healthy walking and COVID-19 symptom severity: A cross-sectional study on the first peak following China’s prevention policy change. BMC Public Health 25, 1497 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-025-22748-7

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-025-22748-7

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BMC Public Health

ISSN: 1471-2458

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