Body composition and cardiorespiratory fitness of overweight COVID … – Nature.com

The present study aimed to analyze the self-reported sequelae after COVID-19 and possible changes in body composition and cardiorespiratory fitness after 1 year. The main outcomes observed were (i) the most recurrent persistent symptoms were related to memory deficit, fatigue, difficulty concentrating, dyspnea, and capillary loss, although there were no differences between the severity of disease; and (ii) increasing LM, SMM, and FFM in the severe/critical group after 1-year; (iii) a group effect with lower values of BF in the FM mild group when compared to the severe/critical group; (iv) increase in the distance walked in the Bruce test just for the severe/critical group after 1 year; (vi) a group effect for DBP post-Bruce test with lower values for mild group when compared to moderate and severe/critical groups. No significant differences were observed for the anthropometric and other ergospirometric and hemodynamic variables.

The persistent symptoms of COVID-19 require early intervention to minimize possible sequelae in different severity symptoms, i.e., mild, moderate, and severe/critical patients with follow-up. Asymptomatic patients also require follow-up, especially those with some vulnerable condition or associated comorbidities, combined with multidisciplinary actions to promote better outcomes given the reported sequelae22,23.

Patients with greater loss of LM 6 months after contracting COVID-19 could not recover muscle health24, and unplanned hospitalizations tend to promote a reduction in upper limb muscle strength, LM, limb muscle strength, maximum isometric handgrip strength, and of one-repetition maximum in the extensor chair25,26. Long COVID-19 patients also have a decreased LM compared to a control group (without a diagnosis of COVID-19)23. However, the present study showed increased LM, SMM, and FFM for severe/critical patients after 1 year. Discrepancies in the measurement time between the present study and the others may justify this finding. In this regard, there was a need for medical clearance of the present study participants to perform submaximal exercise tests, and the recovery time will depend on each patient and possible limitations sequels.

The convalescent period after infection is susceptible to different complications, especially with distinct immunological signatures that open an "immunological window," allowing the development of complications such as acute myocardial infarction and myocarditis, among other clinical manifestations27,28. Therefore, the morphophysiological parameters were collected after recovery from the acute sequelae recorded within the subdivision of symptoms (mild, moderate, and severe/critical). Another study indicates that long COVID-19 patients showed significant improvement in muscle strength, mobility, and cardiorespiratory fitness after 12 months of in-person physical therapy rehabilitation29.

Previous studies found that BF was higher in long COVID patients compared to a control group (i.e., without a diagnosis of COVID-19), and outpatients had a lower FM compared to patients hospitalized for COVID-19 with the same BMI9,26. Considering the difference in FM between groups persisted after 1 year (mild with lower FM vs severe/critical cases), actions to provide improvement in body composition, with reduction of FM, BF, and increase in LM, remain substantial for improving the body composition of COVID-19 survivors. Concurrent training may be a relevant strategy for improving health-related physical fitness by increasing muscle strength, cardiorespiratory fitness, and LM, in addition to reducing FM30. Rehabilitation sessions via aerobic and resistance exercise should control volume, intensity, density, frequency, and progression based on each clinical case, as well as on the physical fitness indicators that were most affected by the disease20,30.

VO2 peak, HR peak, and RPE did not differ between groups, and there was no difference between the times (at baseline vs after 1 year), suggesting that the intensity was similar. Significant differences between outpatients and severe/critical patients were found previously9. The absence of differences between the groups in the present study may be related to a reduction in endothelial damage during convalescence and a subsequent return to activities of daily living for severe/critical patients9,31. However, the self-reported level of physical activity of patients with different symptoms did not differ.

The distance walked in the Bruce test increased the severe/critical group after 1 year, indicating an improvement in physical fitness and a possible reduction in sequels provoked by COVID-19 survivors. Similar responses were identified in another study, with a significant increase in the distance walked in the 6-min walk test 12 months after hospital discharge30. In the present study, less than 50% of the patients (mild, moderate, and severe/critical) reported being physically active, i.e.,>150 min of physical activity/week. However, the improvement in patients' cardiorespiratory fitness is also associated with the physical reconditioning of individuals who returned to their respective activities of daily living, in addition to a possible reduction in residual inflammation and organic damage (this condition was not analyzed in the present study)9,31.

Considering the increased distance walked during the Bruce test, an interaction was also observed with higher values for the RQ of severe/critical patients after 1 year, suggesting an improvement in high exercise tolerance in long duration, justified by the increased intolerance of exercise intensity29. Final SpO2 post-Bruce test showed a group effect, with significantly lower values for severe/critical patients that may be related to chronic hypoxemia after physical effort or even to vascular and pulmonary changes and a decrease in pulmonary function10,31,32.

The main signals that affect respiratory control are derived from the response of peripheral chemoreceptors and mechanoreceptors, in addition to an abnormal muscular effort of thoracic muscles and a reduction in lung compliance, accentuating dyspnea that affects performance in the effort33. Cardiorespiratory rehabilitation of these patients requires monitoring of SpO2, blood pressure, and cardiac function in addition to the application of the principles of interdependence between volume and intensity, increasing loads, biological individuality, and periodic assessments for evaluation of outcomes and mitigation of possible sequelae of COVID-1934.

Post-Bruce test DBP test also differed among long COVID-19 patients, with higher values for the moderate and severe/critical group than for the mild group. DBP response during physical exertion is related to comorbidities (prevalence of obesity, systemic arterial hypertension, diabetes mellitus, and tobacco use) but is not independently associated with a higher risk of death from cardiovascular diseases35. A systematic review with meta-analysis identified that SBP210 mmHg for males and190 mmHg for females in moderate effort intensity can be considered an independent risk factor for cardiovascular events and increased mortality36. The physiology and pathophysiology of DBP after physical effort have not yet been fully elucidated, and the increase in DBP may be concatenated to greater peripheral arteriolar resistance, increased afterload, and even arterial stiffness or dysfunction, and early signs of atherosclerotic vascular disease35.

A high DBP response to physical effort is a predictive factor for increased systemic arterial hypertension. Because systemic arterial hypertension can often be asymptomatic, patients can progress to structural and/or functional changes in target organs and endothelial dysfunction, with an imbalance between vasodilating and vasoconstrictor substances affecting vascular function, with reduced blood pressure compliance capacity of the great arteries, impairing pressure homeostasis37,38. A study observed a significant increase in SBP and DBP in males and females during the pandemic period (between 2019 and 2020)39, probably associated with increased alcohol consumption, weight gain, lower level of physical activity, emotional stress, and less continuous medical care (with reduced medication adherence), although the parameters above were not observed and/or measured in the present study, since the collections were performed strictly during the pandemic period. However, the increase in SBP during physical exercise is a normal response related to the intensity of effort40.

This study has some limitations. First, the lack of follow-up during the acute infection of the patients is justified by the intolerance to exercise. Second, there was no follow-up after the 1 year between the evaluations, and behavior changes (e.g., physical activity and nutrition habits) and other features not accessed in the study might be associated with improving body composition and cardiopulmonary fitness in the hospitalized groups. Third, the loss of follow-up in the second evaluation may have impacted the results; however, loss rates were similar in all groups. Unfortunately, these patients opted not to return for re-assessment, and this was related to (i) lack of time; (ii) not understanding the necessity to perform a re-assessment; (iii) patients believe they are completely recovered from COVID; and (iv) lack of financial resources to travel to university and not work part-time. Considering the future perspectives for research, Patients may be evaluated over months and even years to understand pathophysiological responses. Furthermore, actions that seek to assess, intervene, and re-evaluate long COVID patients associated with a control group (without the disease) may guide more assertive rehabilitation actions.

Given clinical relevance, some points can be highlighted: (i) hospitalized patients need to be monitored periodically on body composition, cardiorespiratory fitness, and vital signs; (ii) all COVID-19 survivors independently of the disease severity can be monitored about fatigue, dyspnea, muscle pain, joint pain, dizziness, tinnitus, sensation of hearing loss, otalgia, ageusia, anosmia, memory deficit, difficulty concentrating and capillary loss and (iii) earlier interventions with health professionals can reduce the possible impacts (sequels) of COVID-19.

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