Overweight and Obesity as Predictors of Post-acute Sequelae of SARS-Cov-2 Infection: Findings from the RECOVER Initiative

IMPORTANCEObesity increases the severe COVID-19 risk. Whether obesity is associated with an increased risk of post-acute sequelae of SARS-Cov-2 infection (PASC) among pediatrics, independent of its impacts on acute infection severity, is unclear. OBJECTIVETo quantify the association between body mass index (BMI) status before SARS-CoV-2 infection and pediatric PASC risk, controlling for acute infection severity. DESIGNRetrospective cohort study occurred from March 2020 to May 2023, with a minimal follow-up of 179 days. SETTINGTwenty-six US childrens hospitals. PARTICIPANTSIndividuals aged 5-20 years with SARS-CoV-2 infection. EXPOSURESElevated BMI status assessed before infection. MAIN OUTCOMES AND MEASURESTo identify PASC, we first used the ICD-10-CM code specific for post-COVID-19 conditions, and a second approach used clusters of symptoms and conditions that constitute the PASC phenotype. BMI was assessed within 18 months before infection; the measure closest to the index date was selected. Relative risk (RR) for BMI-PASC association was quantified by Poisson regression models, adjusting for sociodemographic, acute COVID severity, and other clinical factors. RESULTSAmong the 172136 participants included, the median age of BMI assessment and cohort entry were 12.8 and 13.2 years, 1402 (0.8%) were identified as having PASC with the ICD-10-CM code, and 74317 (43.2%) had [≥]1 incident occurrence of PASC symptoms and conditions. Compared with participants with a healthy weight, those who had overweight, obesity, and severe obesity had 4.7% (RR, 1.047; 95% CI, 0.868-1.263), 25.4% (RR, 1.254; 95% CI, 1.064-1.478) and 42.1% (RR, 1.421; 95% CI, 1.253-1.611) higher risk of PASC when identified using the diagnosis code, respectively. The risk for any occurrences of PASC symptoms and conditions also increased in overweight (RR, 1.030; 95% CI, 0.982-1.080), obesity (RR, 1.108; 95% CI, 1.064-1.154), and severe obesity (RR, 1.174; 95% CI, 1.138-1.213), and that for total incident occurrences increased, too, in overweight (RR, 1.053; 95% CI, 1.000-1.109), obesity (RR, 1.137; 95% CI, 1.088-1.188), and severe obesity (RR, 1.182; 95% CI, 1.142-1.223). CONCLUSIONS AND RELEVANCEElevated BMI was associated with a significantly increased PASC risk in a dose-dependent manner. The biological mechanisms for this association should be investigated in future research. Key PointsO_ST_ABSQuestionC_ST_ABSDo children, adolescents, and young adults with overweight and obesity have increased risk of developing post-acute sequelae of SARS-Cov-2 infection (PASC)? FindingsOverweight, obesity, and severe obesity were associated with significantly increased risk of pediatric PASC. Compared with pediatrics with body mass index in the healthy range, those who were overweight, obesity, or severely obesity had an increased incidence of 4.7%, 25.4%, and 42.1% of PASC, respectively. MeaningOverweight and obesity are important risk factors for pediatric PASC. The biological mechanisms for this association should be investigated in the future research.