A Cloth Facemask Causes No Major Respiratory or Cardiovascular Perturbations during Moderate to Heavy Exercise

ObjectivesTo investigate whether wearing a cloth facemask could affect physiological and perceptual responses to exercise at distinct exercise intensities in non-trained men and women. MethodsIn a crossover design, participants (17 men and 18 women) underwent a progressive square-wave test at four intensities (i. at 80% of the ventilatory anerobic threshold [80%VAT]; ii. at VAT; iii. at the respiratory compensation point [RCP]; iv. at exercise peak [Peak] to exhaustion), with or without a triple-layered cloth mask (Mask or No-Mask). Several physiological, metabolic and perceptual measures were analyzed. ResultsMask reduced inspiratory capacity at all exercise intensities vs. No-Mask (p<0.0001), irrespective of sex. Mask reduced respiratory frequency vs. No-Mask (p=0.001) at Peak (-8.3 breaths{middle dot}min-1; CI: -5.8, -10.8), RCP (-6.9 breaths{middle dot}min-1; CI: -4.6, -9.2) and VAT (-6.5 breaths{middle dot}min-1; CI: -4.1, -8.8), but not at Baseline or at 80%VAT. Mask also reduced tidal volume (p<0.0001) at both RCP (-0.5L; CI: -0.3, -0.6) and Peak (-0.8L; CI: -0.6, -0.9), but not at Baseline, 80%VAT or VAT. Shallow breathing index was increased with Mask at Peak compared to No-Mask (11.3; CI: 7.5, 15.1), but not at any other intensities. Mask did not change heart rate, lactate, ratings of perceived exertion, blood pressure or oxygen saturation. ConclusionsWearing a cloth facemask during exercise at moderate to heavy intensities is unlikely to incur significant respiratory or cardiovascular changes, irrespective of sex. These data can inform new exercise recommendations for health during the COVID-19 pandemic and debunk unfounded allegations of harmful effects of masks during exercise. ClinicalTrials.gov: NCT04887714 What are the new findings?{checkmark} Using a progressive square-wave test, we showed that wearing a cloth facemask during exercise increased breathing difficulty, but this was dependent upon the exercise intensity. {checkmark}Respiratory variables (e.g., inspiratory capacity, respiratory frequency, shallow breathing index) were affected at higher rather than lower intensities. {checkmark}Mask wearing did not change heart rate, lactate, ratings of perceived exertion, blood pressure or oxygen saturation at any exercise intensity. {checkmark}There were no substantial sex differences on the effects of mask wearing during exercise. How might it impact on clinical practice in the future?{checkmark} These data can debunk unfounded allegations on harmful effects of masks during exercise, and help inform new exercise recommendations for health during the COVID-19 pandemic, particularly where facemasks remain necessary.

Changes in eating habits and sedentary behavior during the COVID-19 pandemic in adolescents with chronic conditions

PurposeTo report on the impact of the COVID-19 outbreak on eating habits and sedentary behavior among adolescents with multiple chronic conditions (n=347) from a tertiary, referral hospital vs. healthy peers. MethodsThis observational study was conducted in Sao Paulo (Brazil) between July and October 2020, period in which a set of social distancing measures to contain the pandemic. ResultsThe main findings of this study were that adolescents with chronic conditions showed important changes in eating habits (e.g., less often consumption of convenience foods and more often eating in front of television than before quarantine). Also, 86.8% of adolescents with chronic conditions reported increasing screen time during pandemic. No major differences were observed between patients and controls. ConclusionsAdolescents with chronic conditions exposed to pandemic showed substantial changes in lifestyle, stressing the need for specific care to mitigate poor eating habits and excessive sedentary behavior in this group.

Muscle Strength and Muscle Mass as Predictors of Hospital Length of Stay in Patients with Moderate to Severe COVID-19: A Prospective Observational Study

ImportanceStrength and muscle mass are predictors of relevant clinical outcomes in critically ill patients, but in hospitalized patients with COVID-19 remains to be determined. ObjectiveTo investigate whether muscle strength or muscle mass are predictive of hospital length of stay (LOS) in patients with moderate to severe COVID-19. DesignProspective observational study. SettingClinical Hospital of the School of Medicine of the University of Sao Paulo. ParticipantsOne hundred ninety-six patients were evaluated. Ten patients did not test positive for SARS-CoV-2 during hospitalization and were excluded from the analyses. The sample comprised patients of both sexes (50% male) with a mean age (SD) of 59 ({+/-}15) years, body mass index of 29.5 ({+/-}6.9) kg/m2. The prevalence of current smoking patients was 24.7%, and more prevalent coexisting conditions were hypertension (67.7%), obesity (40.9%), and type 2 diabetes (36.0%). Mean (SD) LOS was 8.6 days (7.7); 17.0% of the patients required intensive care; 3.8% used invasive mechanical ventilation; and 6.6% died during the hospitalization period. Main outcomeThe outcome was LOS, defined as time from hospital admission to medical discharge. ResultsThe crude Hazard Ratio (HR) for LOS was greatest for handgrip strength comparing the strongest vs. other patients (1.54 [95%CI: 1.12 - 2.12; p = 0.008]). Evidence of an association between increased handgrip strength and shorter hospital stay was also identified when handgrip strength was standardized according to the sex-specific mean and standard deviation (1.23 [95%CI: 1.06 - 1.19; p = 0.008]). The magnitude of these associations remained consistent and statistically significant after adjusting for other covariates. Mean LOS was shorter for the strongest patients (7.5 {+/-} 6.1 days) vs. others (9.2 {+/-} 8.4 days). Evidence of associations were also present for vastus lateralis cross-sectional area. The crude HR identified shorter hospital stay for patients with greater sex-specific standardized values (1.17 [95%CI: 1.01 - 1.36; p = 0.037]); however, we found increased uncertainty in the estimate with the addition of other covariates (1.18 [95%CI: 0.97 - 1.43; p = 0.092]). Evidence was also obtained associating longer hospital stays for patients with the lowest values for vastus lateralis cross-sectional area (0.69 [95%CI: 0.50 - 0.95; p = 0.025). Mean LOS for the patients with the lowest muscle cross-sectional area was longer (10.8 {+/-} 8.8 days) vs. others (7.7 {+/-} 7.2 days). Conclusions and RelevanceMuscle strength and mass assessed upon hospital admission are predictors of LOS in patients with moderate to severe COVID-19, which stresses the value of muscle health in prognosis of this disease. FundingThe authors acknowledge the support by the Brazilian National Council for Scientific and Technological Development (CNPq - grant 301571/2017-1). H.R. and B.G. are supported by grants from the Conselho Nacional de Pesquisa e Desenvolvimento (CNPq 428242/2018-9; 301571/2017-1; 301914/2017-6). B.G. is also supported by a grant from the Sao Paulo Research Foundation (FAPESP 2017/13552-2). Key pointsO_ST_ABSQuestionC_ST_ABSDo muscle strength and muscle mass predict hospital length of stay (LOS) in patients with moderate to severe COVID-19 patients? FindingsIn this prospective observational study that included 186 hospitalized patients with moderate to severe COVID-19, we observed that LOS was shorter among patients in the highest tertile of strength (assessed by handgrip) vs. those in the mid/lowest tertiles (crude Hazard Ratio [HR]: 1.54, 95%CI: 1.12-2.12). In addition, LOS was longer among patients in the lowest tertile of muscle cross-sectional area (assessed by ultrasound imaging) vs. those in the mid/highest tertiles (HR: 0.69, 95%CI: 0.50 - 0.95). MeaningMuscle strength and mass assessed on hospital admission are predictors of LOS in patients with moderate to severe COVID-19, suggesting that muscle health may be protective in this disease.

No associations between physical activity and clinical outcomes among hospitalized patients with severe COVID-19

PurposeThis small-scale, prospective cohort study nested within a randomized controlled trial aimed to investigate the possible associations between physical activity levels and clinical outcomes among hospitalized patients with severe COVID-19. MethodsHospitalized patients with severe COVID-19 were recruited from Clinical Hospital of the School of Medicine of the University of Sao Paulo (a quaternary referral teaching hospital), and from Ibirapuera Field Hospital, both located in Sao Paulo, Brazil. Physical activity levels were assessed by Baecke Questionnaire of Habitual Physical Activity. The primary outcome was hospital length of stay. The secondary outcomes were: mortality, admission to the intensive care unit (ICU), and mechanical ventilation requirement. ResultsMean hospital length of stay was 8.5 {+/-} 7.1 days; 3.3% of patients died, 13.8% were admitted to ICU, and 8.6% required mechanical ventilation. Linear regression models showed that physical activity indexes were not associated with hospital length of stay (work index: {beta}=-0.57 [95%CI: -1.80 to 0.65], p=0.355; sport index: {beta}=0.43 [95%CI: -0.94 to 1.80], p=0.536; leisure-time index: {beta}=1.18 [95%CI: -0.22 to 2.59], p=0.099; total activity index: {beta}=0.20 [95%CI: -0.48 to 0.87], p=0.563. Physical activity indexes were not associated with mortality, admission to ICU and mechanical ventilation requirement (all p>0.05). ConclusionsAmong hospitalized patients with COVID-19, physical activity did not associate with hospital length of stay or any other clinically-relevant outcomes. These findings suggest that previous physical activity levels may not change the prognosis of severe COVID-19.

Effect of Vitamin D3 Supplementation vs Placebo on Hospital Length of Stay in Patients with Severe COVID-19: A Multicenter, Double-blind, Randomized Controlled Trial.

ImportancePatients with COVID-19 may exhibit 25-hydroxyvitamin D deficiency, but the beneficial effects of vitamin D3 supplementation in this disease remain to be proven by randomized controlled trials. ObjectiveTo investigate the efficacy and safety of vitamin D3 supplementation in patients with severe COVID-19. Design, Setting, and ParticipantsThis is a multicenter, double-blind, randomized, placebo-controlled trial conducted in two centers (a quaternary hospital and a field hospital) in Sao Paulo, Brazil. The trial included 240 hospitalized patients with severe COVID-19. The study was conducted from June 2, 2020 to October 7, 2020. InterventionsPatients were randomly allocated (1:1 ratio) to receive either a single oral dose of 200,000 IU of vitamin D3 or placebo. Main Outcomes and MeasuresThe primary outcome was hospital length of stay, defined as hospital discharge from the date of randomization or death. Secondary outcomes were mortality, admission to ICU, mechanical ventilation requirement, and serum levels of 25-hydroxyvitamin D, creatinine, calcium, C-reactive protein, and D-dimer. ResultsOf 240 randomized patients (mean age, 56 years; 56% men), 232 (96.7%) were included in the primary analysis. Log-rank test showed that hospital length of stay was comparable between the vitamin D3 supplementation and placebo groups (7.0 days [95% CI, 6.1 to 7.9] and 7.0 days [95% CI, 6.2 to 7.8 days]; hazard ratio, 1.12 [95% CI, 0.9 to 1.5]; P = .379; respectively). The rate of mortality (7.0% vs 5.1%; P = .590), admission to ICU (15.8% vs 21.2%; P = .314), and mechanical ventilation requirement (7.0% vs 14.4%; P = .090) did not significantly differ between groups. Vitamin D3 supplementation significantly increased serum 25-hydroxyvitamin D levels compared to placebo (difference, 24.0 ng/mL [95% CI, 21.0% to 26.9%]; P = .001). No adverse events were observed. Conclusions and RelevanceAmong hospitalized patients with severe COVID-19, vitamin D3 supplementation was safe and increased 25-hydroxyvitamin D levels, but did not reduce hospital length of stay or any other relevant outcomes vs placebo. This trial does not support the use of vitamin D3 supplementation as an adjuvant treatment of patients with COVID-19. Key pointsO_ST_ABSQuestionC_ST_ABSCan vitamin D3 supplementation reduce hospital length of stay in hospitalized patients with severe COVID-19? FindingsIn this double-blind, randomized, placebo-controlled trial involving 240 hospitalized patients with severe COVID-19, a single dose of 200,000 IU of vitamin D3 supplementation was safe and effective in increasing 25-hydroxyvitamin D levels, but did not significantly reduce hospital length of stay (hazard ratio, 1.12) or any other clinically-relevant outcomes compared with placebo. MeaningVitamin D3 supplementation does not confer therapeutic benefits among hospitalized patients with severe COVID-19.

Influence of nutritional status on eating habits and food choice determinants among Brazilian women during the COVID-19 pandemic

We aimed to evaluate the influence of nutritional status on eating habits and food choice determinants among Brazilian women during the COVID-19 outbreak. This cross-sectional survey was conducted between June and September, 2020, period in which social distancing measures were in place. Participants (n=1,183) were classified as normal weight (60.4%), overweight (26.2%) and obese (13.4%). Eating habits changed during quarantine irrespective of nutritional status. The number of women participating in grocery shopping was reduced by 34% during quarantine (p<0.001, OR=0.55, 0.79), whereas participation in cooking and ordering delivery service increased by 28% (p=0.004, OR=1.08, 1.51) and 146% (p<0.001, OR=2.06, 2.95), respectively. The number of participants reporting the habit of snacking (p=0.005, OR=1.07, 1.43) and eating at the table increased by 24% and 40% (p<0.001, OR=1.20, 1.64). Interestingly, the number of participants reporting the habit of dieting decreased by 41% (p<0.001, OR=0.59 [0.50, 0.70]). During the quarantine, "liking", "need and hunger", and "habits" were the most commonly reported determinants of food choice overall. "Health", "natural concerns" and "need and hunger" were less important determinants for participants with overweight/obesity compared to those with normal weight. Regression models showed that (i) "health", "natural concerns" and "affect regulation"; (ii) "health", "pleasure", "convenience", and "natural concerns"; and (iii) "visual appeal" and "pleasure" were the food choice determinants more associated with eating habits among women with normal weight, overweight and obesity, respectively. In conclusion, eating habits were influenced during the pandemic despite nutritional status, whereas food choice determinants differed between overweight/obesity and normal weight women.

Increased prolonged sitting in rheumatoid arthritis patients during the COVID-19 pandemic: a within-subjects, accelerometer-based study

BackgroundSocial distancing measures designed to contain the COVID-19 pandemic can explicitly and implicitly restrict physical activity, a particular concern for high-risk patient groups. Using a within-subjects design with objective measurement (via validated accelerometers), we assessed rheumatoid arthritis patients physical activity and sedentary behavior levels prior to and during the social distancing measures implemented in Sao Paulo, Brazil. MethodsPost-menopausal women diagnosed with rheumatoid arthritis were assessed before (from March 2018 to March 2020) and during (from 24th May to 7th July 2020) social distancing measures to contain COVID-19 pandemic, using a within-subjects, repeated-measure design. Physical activity and sedentary behavior were assessed using postural-based accelerometry (ActivPAL micro). FindingsMean age was 60.9 years (95%CI: 58.0, 63.7) and BMI was 29.5 Kg/m2 (95%CI: 27.2, 31.9). Disease activity ranged from remission to moderate activity. Most of the patients were using disease-modifying anti-rheumatic drugs and prednisone. Hypertension and dyslipidemia were the most frequent comorbidities During social distancing, there were reductions in total stepping time (15.7% [-0.3 h/day, 95%CI: -0.4, -0.1; p = 0.004]), in light-intensity activity (13.0% [-0.2 h/day, 95%CI: -0.4, -0.04; p = 0.016]) and in moderate-to-vigorous physical activity (38.8% [-4.5 min/day, 95%CI: -8.1, -0.9; p = 0.015]), but no changes in total standing time or total sedentary time. However, time spent in prolonged bouts of sitting [≥] 30 min increased by 34% 1.0 h/day, 95%CI: 0.3, 1.7; p=0.006) and sitting bouts [≥]60 min increased by 85% (1.0 h/day, 95%CI: 0.5, 1.6) Sit-stand transitions were reduced by 10% (-5.1/day, 95%CI: -10.3, 0.0; p = 0.051) ConclusionImposed social distancing measures to contain the COVID-19 outbreak were associated with decreased physical activity and increased prolonged sitting among rheumatoid arthritis patients. Since this has the potential to increase the burden of cardiovascular disease in such high-risk patients, attention to maintaining physical activity is an urgent consideration during the pandemic.

Influence of adherence to social distancing due to the COVID-19 pandemic on physical activity level in post-bariatric patients

ObjectivesTo assess physical activity levels in post-bariatric patients who adhered or not to social distancing measures due to the Covid-19 pandemic. Our secondary aim was to compare physical activity estimates between objectively measured and self-reported physical activity level. MethodsIn this descriptive, cross-sectional study, we assessed physical activity level using accelerometers and a validated questionnaire in 33 post-bariatric patients who reported to be adherent (n=15) or not (n=18) to social distancing measures. ResultsPatients adherent to social distancing measures spent more time in sedentary behavior (1.1 hours/day [95%CI: 0.1, 2.2]; p=0.045) and less time in moderate-to-vigorous physical activity (-12.2 min/day [95%CI: -23.8, -0.6]; p=0.040) compared to non-adherent ones. No difference was observed for light-intensity physical activity. Bland-Altman analysis comparing objective and subjective physical activity estimates showed a bias for time spent in sedentary behavior and moderate-to-vigorous physical activity of 2.8 hours/day and 8.5 min/day, respectively. ConclusionPost-bariatric patients who were adherent to social distancing measures due to the Covid-19 outbreak were more inactive and sedentary than non-adherent ones. Additionally, questionnaire data widely underestimated sedentary behavior. Strategies to increase or at least sustain physical activity levels in post-bariatric patients exposed to social distancing measures are necessary during the Covid-19 pandemic. O_LSTWhat is already known about this subject?C_LSTO_LIReduced physical activity is associated with poor health-related outcomes in patient undergoing bariatric surgery. C_LIO_LIThe impact of the social distancing measures due to Covid-19 pandemic on objectively-measured physical activity in this condition remains unknown. C_LI O_LSTWhat are the new findings in your manuscript?C_LSTO_LIAdherence to social distancing due to Covid-19 pandemic was associated with decreased objectively measured physical activity and increased sedentary behavior in patients who had undergone bariatric surgery. C_LIO_LIQuestionnaire data widely underestimated sedentary behavior when compared to accelerometry data. C_LI O_LSTHow might your results change the direction of research or the focus of clinical practice?C_LSTO_LIGiven the increased burden of cardiovascular diseases related to inactivity and sedentary behavior, strategies to increase physical activity in post-bariatric patients are clinically relevant during the Covid-19 pandemic. C_LIO_LIThe use of validated accelerometers is recommended to screen and track physical activity during the pandemic. C_LI

Outpatient screening of health status and lifestyle among post-bariatric patients during the Covid-19 pandemic in Sao Paulo, Brazil.

Background/ObjectivesThis was an out-of-hospital screening of health status and lifestyle during the Covid-19 pandemic in post-operative bariatric patients from Sao Paulo, Brazil, prevented from face-to-face health care. Subjects/MethodsIn this cross-sectional study, 66 patients were remotely (via phone call) and in-person (by home visit) assessed for health status and lifestyle habits. Results: Mean age was 47.4 years. Patients were obese grade I (30.0%), II (22.0%), and III (30.0%), and 94.2% had above reference waist circumference values. Sixty-four percent displayed high blood pressure, whereas 24% showed CRP levels above normal range. Nineteen percent of patients reported irregular use of nutritional supplementation and 6.0% reported binge eating habits. Thirty-three exhibited symptoms of depression. Mild-to-moderate and moderate-to-severe anxiety symptoms were reported by 27.4% and 11.3% of the patients; 4.5% exhibited suicidal ideation and were referred to a specialist for healthcare. Of relevance, inactive patients (59.6%) had poorer global mental and physical health scores as compared to active peers (both p<0.05). Conclusion: This out-of-hospital screening revealed that the absence of face-to-face health care due to the Covid-19 pandemic is associated with suboptimal status of physical and mental health as well as lifestyle inadequacies among patients who have recently undergone bariatric surgery. Key pointsO_LIWe performed an out-of-hospital screening in post-operative bariatric patients prevented from face-to-face health care during the Covid-19 pandemic. C_LIO_LISixty-five percent displayed high blood pressure, whereas 24% showed C-reactive protein levels above normal range. C_LIO_LIAbout one third showed mild to severe symptoms of depression, whereas [~]40% showed mild to severe anxiety symptoms. C_LIO_LIInactive patients (59.6%) had poorer global mental and physical health scores as compared to active peers. C_LIO_LIThree patients exhibited suicidal ideation and were referred to a specialist for healthcare. C_LIO_LIDuring the Covid-19 pandemic, there are a considerable number of post-bariatric patients in need of direct health care. C_LI