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BackgroundSleep disturbance is common following hospitalisation both for COVID-19 and other causes. The clinical associations are poorly understood, despite it altering pathophysiology in other scenarios. We, therefore, investigated whether sleep disturbance is associated with dyspnoea along with relevant mediation pathways. MethodsSleep parameters were assessed in a prospective cohort of patients (n=2,468) hospitalised for COVID-19 in the United Kingdom in 39 centres using both subjective and device-based measures. Results were compared to a matched UK biobank cohort and associations were evaluated using multivariable linear regression. Findings64% (456/714) of participants reported poor sleep quality; 56% felt their sleep quality had deteriorated for at least 1-year following hospitalisation. Compared to the matched cohort, both sleep regularity (44.5 vs 59.2, p<0.001) and sleep efficiency (85.4% vs 88.5%, p<0.001) were lower whilst sleep period duration was longer (8.25h vs 7.32h, p<0.001). Overall sleep quality (effect estimate 4.2 (3.0-5.5)), deterioration in sleep quality following hospitalisation (effect estimate 3.2 (2.0-4.5)), and sleep regularity (effect estimate 5.9 (3.7-8.1)) were associated with both dyspnoea and impaired lung function (FEV1 and FVC). Depending on the sleep metric, anxiety mediated 13-42% of the effect of sleep disturbance on dyspnoea and muscle weakness mediated 29-43% of this effect. InterpretationSleep disturbance is associated with dyspnoea, anxiety and muscle weakness following COVID-19 hospitalisation. It could have similar effects for other causes of hospitalisation where sleep disturbance is prevalent. FundingUK Research and Innovation, National Institute for Health Research, and Engineering and Physical Sciences Research Council.
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ObjectiveTo estimate the risk of Long COVID by socioeconomic deprivation and to further examine the socioeconomic inequalities in Long COVID by sex and occupational groups. DesignWe analysed data from the COVID-19 Infection Survey conducted by the Office for National Statistics between 26/04/2020 and 31/01/2022. This is the largest and nationally representative survey of COVID-19 in the UK and provides uniquely rich, contemporaneous, and longitudinal data on occupation, health status, COVID-19 exposure, and Long COVID symptoms. SettingCommunity-based longitudinal survey of COVID-19 in the UK. ParticipantsWe included 201,799 participants in our analysis who were aged between 16 and 64 years and had a confirmed SARS-CoV-2 infection. Main outcome measuresWe used multivariable logistic regression models to estimate the risk of Long COVID at least 4 weeks after acute SARS-CoV-2 infection by deciles of index of multiple deprivation (IMD) and adjusted for a range of demographic and spatiotemporal factors. We further examined the modifying effects of socioeconomic deprivation by sex and occupational groups. ResultsA total of 19,315 (9.6%) participants reported having Long COVID symptoms. Compared to the least deprived IMD decile, participants in the most deprived decile had a higher adjusted risk of Long COVID (11.4% vs 8.2%; adjusted OR: 1.45; 95% confidence interval [CI]: 1.33, 1.57). There were particularly significantly higher inequalities (most vs least deprived decile) of Long COVID in healthcare and patient facing roles (aOR: 1.76; 1.27, 2.44), and in the education sector (aOR: 1.62; 1.26, 2.08). The inequality of Long COVID was higher in females (aOR: 1.54; 1.38, 1.71) than males (OR: 1.32; 1.15, 1.51). ConclusionsParticipants living in the most socioeconomically deprived areas had a higher risk of Long COVID. The inequality gap was wider in females and certain public facing occupations (e.g., healthcare and education). These findings will help inform public health policies and interventions in adopting a social justice and health inequality lens.
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ObjectiveTo assess the risk of death involving COVID-19 following infection from Omicron (B.1.1.539/BA.1) relative to Delta (B.1.617.2). DesignRetrospective cohort study. SettingEngland, UK, 1 December 2021 to 25 January 2022. Participants1,035,163 people aged 18-100 years who tested positive for SARS-CoV-2 in the national surveillance programme, and had an infection identified as either Omicron- or Delta compatible. Main outcome measuresDeath involving COVID-19 as identified from death certification records. The exposure of interest was the SARS-CoV-2 variant identified from NHS Test and Trace PCR positive tests taken in the community (pillar 2) and analysed by Lighthouse laboratories. Cause-specific Cox proportional hazard regression models were adjusted for sex, age, vaccination status, previous infection, calendar time, ethnicity, Index of Multiple Deprivation rank, household deprivation, university degree, keyworker status, country of birth, main language, region, disability, and comorbidities. Additionally, we tested for interactions between variant and sex, age, vaccination status and comorbidities. ResultsThe risk of death involving COVID-19 was 67% lower for Omicron compared to Delta and the reduction in the risk of death involving COVID-19 for Omicron compared to Delta was more pronounced in males than in females and in people under 70 years old than in people aged 70 years or over. Regardless of age, reduction of the risk of death from Omicron relative to Delta more was more pronounced in people who had received a booster than in those having received only two doses. ConclusionsOur results support early work showing the relative reduction in severity of Omicron compared to Delta in terms of hospitalisation and extends this research to assess COVID-19 mortality. Our work also highlights the importance of the vaccination booster campaign, where the reduction in risk of death involving COVID-19 is most pronounced in individuals who had received a booster. What is already known on this topicThe Omicron variant, which refers to the whole lineage (BA.1, BA.2, BA.3) had already been shown to be more transmissible than the Delta variant, but there is emerging evidence suggests that the risk of hospitalisation and risk of death within 28 days after a SARS-COV-2 test is lower. However, with a highly transmissible infection and high levels of population testing, definition of death within 28 days is more likely to be susceptible to misclassification bias due to asymptomatic or co-incidental infection. There is no study so far comparing the risk of COVID-19 death as identified from death certification records, with the cause of death assessed by the physician who attended the patient in the last illness. What this study addsUsing data from a large cohort of COVID-19 infections that occurred in December 2021, we examined the difference in the risk COVID-19 death, as identified from death certification records, between the Delta and Omicron BA.1 variant. Our study shows that risk of death involving COVID-19 was reduced by 67% following infection with the Omicron BA.1 variant relative to the Delta variant after adjusting for a wide range of potential confounders, including vaccination status and comorbidities. Importantly, we found that the relative risk of COVID-19 mortality following Omicron versus Delta infection varied by age and sex, with lower relative risk in younger individuals and for males than females. The reduction in risk of death involving COVID-19 was also most pronounced in individuals who had received a booster.
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BackgroundThe UK began an ambitious COVID-19 vaccination programme on 8th December 2020. This study describes variation in vaccination coverage by sociodemographic characteristics between December 2020 and August 2021. MethodsUsing population-level administrative records linked to the 2011 Census, we estimated monthly first dose vaccination rates by age group and sociodemographic characteristics amongst adults aged 18 years or over in England. We also present a tool to display the results interactively. FindingsOur study population included 35,223,466 adults. A lower percentage of males than females were vaccinated in the young and middle age groups (18-59 years) but not in the older age groups. Vaccination rates were highest among individuals of White British and Indian ethnic backgrounds and lowest among Black Africans (aged [≥]80 years) and Black Caribbeans (18-79 years). Differences by ethnic group emerged as soon as vaccination roll-out commenced and widened over time. Vaccination rates were also lower among individuals who identified as Muslim, lived in more deprived areas, reported having a disability, did not speak English as their main language, lived in rented housing, belonged to a lower socio-economic group, and had fewer qualifications. InterpretationWe found inequalities in COVID-19 vaccination rates by sex, ethnicity, religion, area deprivation, disability status, English language proficiency, socio-economic position, and educational attainment, but some of these differences varied by age group. Research is urgently needed to understand why these inequalities exist and how they can be addressed. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed for publications on sociodemographic inequalities in COVID-19 vaccination coverage. Several studies have reported differences in coverage by characteristics such as ethnicity and religion, however these have focused on older adults and the clinically vulnerable who were initially prioritized for vaccination. There is little evidence on sociodemographic inequalities in vaccination coverage among younger adults and evidence is also lacking on coverage by a wider range of characteristics such as sex, disability status, English language proficiency, socio-economic position, and educational attainment. Added value of this studyThis study provides the first evidence for sociodemographic inequalities in COVID-19 vaccination coverage among the entire adult population in England, using population-level administrative records linked to the 2011 Census. By disaggregating the data by age group, we were able to show that disparities in coverage by some sociodemographic characteristics differed by age group. For example, a lower proportion of males than females were vaccinated in the young and middle age groups (18-59 years) but not in the older age groups, and vaccination rates were lowest among Black Africans in those aged [≥]80 years but lowest among Black Caribbeans for all other age groups. Vaccination rates were also lower among individuals who identified as Muslim, lived in more deprived areas, reported having a disability, did not speak English as their main language, lived in rented housing, belonged to a lower socio-economic group, and had fewer qualifications. Implications of all the available evidenceMany of the groups with the lowest rates of COVID-19 vaccination are also the groups that have been disproportionately affected by the pandemic, including severe illness and mortality. Research is urgently needed to understand why these disparities exist and how they can be addressed, for example through public health or community engagement programmes. Since the relationships between sociodemographic characteristics and vaccination coverage may differ by age group, it is important for future research to disaggregate by age group when examining these inequalities.
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O_LIIn individuals with chronic kidney disease (CKD), Black and South Asian ethnic groups are twice as likely to have severe COVID-19 compared to White participants, whilst the most socially deprived groups are at a 50-60% increased risk of severe COVID-19. C_LIO_LIThis study is the first to highlight the association between ethnicity and socioeconomic deprivation and the risk of severe COVID-19 among those with CKD in the UK. C_LIO_LIInterventions to reduce morbidity and mortality amongst these groups and policy and practice improvements are needed to address the broad disparity among CKD patients. C_LI
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ImportanceObesity and ethnicity are well characterised risk factors for severe COVID-19 outcomes, but the differential effects of obesity on COVID-19 outcomes by race/ethnicity has not been examined robustly in the general population. ObjectiveTo investigate the association between body mass index (BMI) and COVID-19 mortality across different ethnic groups. Design, Setting, and ParticipantsThis is a retrospective cohort study using linked national Census, electronic health records and mortality data for English adults aged 40 years or older who were alive at the start of pandemic (24th January 2020). ExposuresBMI obtained from electronic health records. Self-reported ethnicity (white, black, South Asian, other) was the effect-modifying variable. Main Outcomes and MeasuresCOVID-19 related death identified by ICD-10 codes U07.1 or U07.2 mentioned on the death certificate from 24th January 2020 until December 28th 2020. ResultsThe analysis included white (n = 11,074,708; mean age 61.9 [{+/-}13.4] years; 54% women), black (n = 416,542; 56.4 [{+/-}11.7] years; 57% women), South Asian (621,691; 55.7 [{+/-}12.4] years; 51% women) and other (n = 478,196; 55.3 [{+/-}11.6] years; 55% women) ethnicities with linked BMI data. The association between BMI and COVID-19 mortality was stronger in ethnic minority groups. Compared to a BMI of 22.5 kg/m2 in white ethnicities, the adjusted HR for COVID-19 mortality at a BMI of 30 kg/m2 in white, black, South Asian and other ethnicities was 0.95 (95% CI: 0.87-1.03), 1.72 (1.52-1.94), 2.00 (1.78-2.25) and 1.39 (1.21-1.61), respectively. The estimated risk of COVID-19 mortality at a BMI of 40 kg/m2 in white ethnicities (HR = 1.73) was equivalent to the risk observed at a BMI of 30.1 kg/m2, 27.0 kg/m2, and 32.2 kg/m2 in black, South Asian and other ethnic groups, respectively. ConclusionsThis population-based study using linked Census and electronic health care records demonstrates that the risk of COVID-19 mortality associated with obesity is greater in ethnic minority groups compared to white populations. QuestionDoes the association between BMI and COVID-19 mortality vary by ethnicity? FindingsIn this study of 12.6 million adults, BMI was associated with COVID-19 in all ethnicities, but with stronger associations in ethnic minority populations such that the risk of COVID-19 mortality for a BMI of 40 kg/m2 in white ethnicities was observed at a BMI of 30.1 kg/m2, 27.0 kg/m2, and 32.2 kg/m2 in black, South Asian and other ethnicities, respectively. MeaningBMI is a stronger risk factor for COVID-19 mortality in ethnic minorities. Obesity management is therefore a priority in these populations.
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ObjectiveTo examine inequalities in COVID-19 vaccination rates amongst elderly adults in England DesignCohort study SettingPeople living in private households and communal establishments in England Participants6,829,643 adults aged [≥] 70 years (mean 78.7 years, 55.2% female) who were alive on 15 March 2021. Main outcome measuresHaving received the first dose of a vaccine against COVID-19 by 15 March 2021. We calculated vaccination rates and estimated unadjusted and adjusted odds ratios using logistic regression models. ResultsBy 15 March 2021, 93.2% of people living in England aged 70 years and over had received at least one dose of a COVID-19 vaccine. While vaccination rates differed across all factors considered apart from sex, the greatest disparities were seen between ethnic and religious groups. The lowest rates were in people of Black African and Black Caribbean ethnic backgrounds, where only 67.2% and 73.9% had received a vaccine, with adjusted odds of not being vaccinated at 5.01 (95% CI 4.86 - 5.16) and 4.85 (4.75 - 4.96) times greater than the White British group. The proportion of individuals self-identifying as Muslim and Buddhist who had received a vaccine was 79.1% and 84.1%, respectively. Older age, greater area deprivation, less advantaged socio-economic position (proxied by living in a rented home), being disabled and living either alone or in a multi-generational household were also associated with higher odds of not having received the vaccine. ConclusionPeople disproportionately affected seem most hesitant to COVID-19 vaccinations. Policy Interventions to improve these disparities are urgently needed. Summary BoxO_ST_ABSWhat is already known on this subject?C_ST_ABSThe UK began an ambitious vaccination programme to combat the COVID-19 pandemic on 8th December 2020. Existing evidence suggests that COVID-19 vaccination rates differ by level of area deprivation, ethnicity and certain underlying health conditions, such as learning disability and mental health problems. What does this study add?Our study shows that first dose vaccination rates in adults aged 70 or over differed markedly by ethnic group and self-reported religious affiliation, even after adjusting for geography, socio-demographic factors and underlying health conditions. Our study also highlights differences in vaccination rates by deprivation, household composition, and disability status, factors disproportionately associated with SARS-CoV-2 infection. Public health policy and community engagement aimed at promoting vaccination uptake is these groups are urgently needed. Strengths and limitations of this studyO_LIUsing nationwide linked population-level data from clinical records and the 2011 Census, we examined a wide range of socio-demographic characteristics not available n electronic health records C_LIO_LIMost demographic and socio-economic characteristics are derived from the 2011 Census and therefore are 10 years old. However, we focus primarily on characteristics that are unlikely to change over time, such as ethnicity or religion, or likely to be stable for our population C_LIO_LIBecause the data are based on the 2011 Census, it excluded people living in England in 2011 but not taking part in the 2011 Census; respondents who could not be linked to the 2011-2013 NHS patients register; recent migrants. Consequently, we excluded 5.4% of vaccinated people who could not be linked C_LI
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BackgroundCoronavirus disease{square}2019 (COVID{square}19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS{square}CoV{square}2 virus). The role of skeletal muscle mass in modulating immune response is well documented. Whilst obesity is well-established as a key factor in COVID-19 infection and outcome, no study has examined the influence of both sarcopenia (low muscle mass) and obesity, termed sarcopenic obesity on COVID-19 risk. MethodsThis study uses data from UK Biobank. Probable sarcopenia was defined as low handgrip strength. Sarcopenic obesity was mutually exclusively defined as the presence of obesity and low muscle mass (based on two established criteria: appendicular lean mass (ALM) adjusted for either: 1) height and 2) body mass index (BMI)). Severe COVID-19 was defined by a positive test result in a hospital setting or death with a primary cause reported as COVID-19. Fully adjusted logistic regression models were used to analyse the associations between sarcopenic status and severe COVID-19. This work was conducted under UK Biobank application number 52553. ResultsWe analysed data from 490,301 UK Biobank participants. 2203 (0.4%) had severe COVID-19 infection. Individuals with probable sarcopenia were 64% more likely to have had severe COVID-19 infection (odds ratio (OR) 1.638; P<.001). Obesity increased the likelihood of severe COVID-19 infection by 76% (P<.001). Using either ALM index and ALM/BMI index to define low muscle mass, those with sarcopenic obesity were 2.6 times more likely to have severe COVID-19 (OR: 2.619; P<.001). Sarcopenia alone did not increase the risk of COVID-19. ConclusionsSarcopenic obesity may increase the risk of severe COVID-19 infection, over that of obesity alone. The mechanisms for this are complex but could be a result of a reduction in respiratory functioning, immune response, and ability to respond to metabolic stress.
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BackgroundHealth and key workers are at an increased risk of developing severe COVID-19; it is not known, however, if this risk is exacerbated in those with irregular work patterns. We aimed to investigate the risk of severe COVID-19 in health and shift workers. MethodsWe included UK Biobank participants in employment or self-employed at baseline and with linked COVID-19 data to 31st August 2020. Participants were grouped as neither a health worker nor shift worker (reference category), health worker only, shift worker only, or both and associations with severe COVID-19 investigated in logistic regressions. FindingsOf 235,685 participants (81{middle dot}5% neither health nor shift worker, 1{middle dot}4% health worker only, 16{middle dot}9% shift worker only, and 0{middle dot}3% both), there were 580 (0{middle dot}25%) cases of severe COVID-19. The risk of severe COVID-19 was higher in health workers (adjusted odds ratio: 2.32 [95% CI: 1{middle dot}33, 4{middle dot}05]; shift workers (2{middle dot}06 [1{middle dot}72, 2{middle dot}47]); and in health workers who worked shifts (7{middle dot}56 [3{middle dot}86, 14{middle dot}79]). Being both a health worker and a shift worker had a possible greater impact on the risk severe COVID-19 in South Asian and Black and African Caribbean ethnicities compared to White individuals. InterpretationBoth health and shift work were independently associated with over twice the risk of severe COVID-19; the risk was over seven times higher in health workers who work shifts. Vaccinations, therapeutic and preventative options should take into consideration not only health and key worker status but also shift worker status. FundingNational Institute for Health Research, UK Research and Innovation. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThe risk of developing severe COVID-19 is greater in occupational groups with higher levels of viral exposure, e.g. health and key workers. We searched PubMed and medRxiv up to December 8, 2020 for papers on shift work patterns, health work and incidence of COVID-19 using the keywords "COVID-19", "SARS-CoV-2", "shift work" "health worker". Recent evidence suggests shift workers are also at increased risk of severe COVID-19 but it is not clear if the risk is exacerbated in those who work shifts in healthcare. Added value of this studyThis study uses data from UK Biobank, a prospective cohort of >500,000 adults aged 40-69 years with baseline assessments between March 2006 and July 2010. Participants occupation was categorised according to whether or not they were health workers and/or shift workers at baseline. Results showed that being a health worker, or working shifts, were similarly and independently associated with over twice the population level risk of severe COVID-19 independent of age, sex, ethnicity, deprivation and co-morbidities. The risk was seven times higher in health workers with shift working patterns. The impact of health and shift work tended to be higher in males and in minority ethnic groups, who are already at an increased risk of severe COVID-19. In people over the age of retirement, the risk of developing severe COVID-19 associated with baseline health worker status was no longer apparent, suggesting the risk is likely explained by exposure to the virus. However, the elevated risk associated with baseline shift worker status persisted, albeit attenuated. Implications of all the available evidenceShift workers are at elevated risk of developing severe COVID-19. The persistence of an elevated risk in people who are now over retirement age, but had a shift worker status at baseline, suggests the risk may not be fully explained by increased exposure to the virus. Vaccination, therapeutic and prevention programmes are being prioritised for health care workers. Our data suggests that shift workers should also be prioritised for these preventive measures.
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BackgroundPre-existing comorbidities have been linked to SARS-CoV-2 infection but evidence is sparse on the importance and pattern of multimorbidity (2 or more conditions) and severity of infection indicated by hospitalisation or mortality. We aimed to use a multimorbidity index developed specifically for COVID-19 to investigate the association between multimorbidity and risk of severe SARS-CoV-2 infection. MethodsWe used data from the UK Biobank linked to laboratory confirmed test results for SARS-CoV-2 infection and mortality data from Public Health England between March 16 and July 26, 2020. By reviewing the current literature on COVID-19 we derived a multimorbidity index including: 1) angina; 2) asthma; 3) atrial fibrillation; 4) cancer; 5) chronic kidney disease; 6) chronic obstructive pulmonary disease; 7) diabetes mellitus; 8) heart failure; 9) hypertension; 10) myocardial infarction; 11) peripheral vascular disease; 12) stroke. Adjusted logistic regression models were used to assess the association between multimorbidity and risk of severe SARS-CoV-2 infection (hospitalisation or death). Potential effect modifiers of the association were assessed: age, sex, ethnicity, deprivation, smoking status, body mass index, air pollution, 25-hydroxyvitamin D, cardiorespiratory fitness, high sensitivity C-reactive protein. ResultsAmong 360,283 participants, the median age was 68 [range, 48-85] years, most were White (94.5%), and 1,706 had severe SARS-CoV-2 infection. The prevalence of multimorbidity was more than double in those with severe SARS-CoV-2 infection (25%) compared to those without (11%), and clusters of several multimorbidities were more common in those with severe SARS-CoV-2 infection. The most common clusters with severe SARS-CoV-2 infection were stroke with hypertension (79% of those with stroke had hypertension); diabetes and hypertension (72%); and chronic kidney disease and hypertension (68%). Multimorbidity was independently associated with a greater risk of severe SARS-CoV-2 infection (adjusted odds ratio 1.91 [95% confidence interval 1.70, 2.15] compared to no multimorbidity). The risk remained consistent across potential effect modifiers, except for greater risk among men. ConclusionThe risk of severe SARS-CoV-2 infection is higher in individuals with multimorbidity, indicating the need to target research and resources in people with SARS-CoV-2 infection and multimorbidity.
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Unstructured abstractObesity is an emerging risk factor for coronavirus disease-2019 (COVID-19). Simple measures of physical fitness, such as self-reported walking pace, could also be important risk factors, but have not been well documented. This analysis includes 414,201 UK Biobank participants with complete covariate and linked COVID-19 data. We analysed the risk of severe (in-hospital) COVID-19 across categories of obesity status and walking pace. As of June 20th 2020 there were 972 cases of severe COVID-19 that had occurred within the cohort. Compared to normal weight individuals, the adjusted odds ratio (OR) for severe COVID-9 in those with obesity was 1.49 (1.24, 1.78). Compared to those with a brisk walking pace, the OR in slow walkers was 1.84 (1.49, 2.27). Slow walkers had the highest risk of severe COVID-19 regardless of obesity status. For example, compared to normal weight brisk walkers, the odds of severe COVID-19 in obese brisk walkers was 1.39 (0.99, 1.98), whereas the odds in normal weight slow walkers was 2.48 (1.56, 3.93). Self-reported walking pace, a simple measure of functional fitness, appears to be a risk factor for severe COVID-19 that is independent of obesity. This may help inform simple pragmatic public health risk stratification and preventative strategies.
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Weight loss is an important goal in the management of several chronic conditions, including type 2 diabetes mellitus, and pharmacological therapies that aid weight loss are appealing. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) are novel glucose-lowering therapies that have been shown to induce clinically significant reductions in body weight. However, this weight loss may not be attributed solely to fat mass (FM). Given the importance of skeletal muscle and lean body mass (LBM) on cardio-metabolic health and physical function, we reviewed the available literature reporting the effects of GLP-1RAs and SGLT2is on body composition. Results demonstrate that, in most circumstances, the weight loss associated with both therapies predominantly comprises a reduction in FM, although significant heterogeneity exists between studies. In over half of the studies identified, the proportion of LBM reduction ranged between 20% and 50% of total weight lost, which is consistent with diet-induced weight loss and bariatric surgery. No clear differences existed between GLP-1RAs and SGLT2is. Consequently, the loss of LBM and skeletal muscle associated with weight loss induced by GLP-1RAs and SGLT2is warrants attention. Strategies to preserve skeletal muscle and improve physical function, for example through structured exercise, are of great importance.
