Pre-COVID-19 body mass index and postacute cardiovascular, gastrointestinal, and neuropsychiatric outcomes among children and young adults with SARS-CoV-2 infection: An EHR-based cohort study from the RECOVER Initiative

• February 2026
• Journal of Infection

Publication Details

DOI: 10.1016/j.jinf.2026.106702

Abstract

Objectives: Postacute sequelae of SARS-CoV-2 infection (PASC) can affect multiple organ systems, but the role of preinfectional body mass index (BMI) in these outcomes among children and young adults remains unclear. We aimed to evaluate the association between pre-COVID-19 BMI status and postacute cardiovascular, gastrointestinal, and neuropsychiatric outcomes in children and young adults. 

Methods: We conducted a retrospective cohort study using data from 139,320 individuals aged 5 to 20 years with confirmed SARS-CoV-2 infection between March 2020 and September 2023 across 20 U.S. pediatric health systems participating in the RECOVER Initiative. Pre-infection BMI was defined using measurements obtained within 18 months before the index date and categorized as healthy weight, overweight, obesity, or severe obesity; when multiple values were available, the most recent measurement was selected. We assessed incident postacute cardiovascular, gastrointestinal, and neuropsychiatric symptoms and conditions occurring 28 to 179 days post-infection. Adjusted relative risks (RRs) were estimated using modified Poisson regression models, comparing elevated BMI categories to the healthy weight. 

Findings: Among 139,320 participants (mean [SD] age, 13.0 [4.3] years; 51.6% female), severe obesity was associated with a higher risk of cardiovascular disorders (adjusted RR 2.56; 95% CI 1.93-3.41), particularly hypertension (adjusted RR 3.68; 95% CI 2.65-5.11). Severe obesity was also linked with increased risks of diarrhea (adjusted RR 1.34; 95% CI 1.10-1.64) and gastroesophageal reflux disease (adjusted RR 1.29; 95% CI 1.06-1.58). Associations between BMI and neuropsychiatric outcomes were heterogeneous, with inverse associations observed for some conditions, including anxiety and major depression. 

Interpretation: In this cohort study, pre-COVID-19 BMI status was associated with the risk and pattern of postacute cardiovascular and gastrointestinal outcomes among children and young adults. Association between pre-infection BMI and neuropsychiatric outcomes was more variable and should be interpreted with caution. These findings suggest BMI-stratified post-COVID-19 monitoring strategies may help inform long-term care in youth.

Authors

Ting Zhou, Bingyu Zhang, Dazheng Zhang, Ravi Jhaveri, Jiajie Chen, Michael J Becich, Leah Castro, Yu Chen, Nymisha Chilukuri, Sharon Herring, Yuqing Lei, Lu Li, Yiwen Lu, Maxwell Hornig, Amrik Singh Khalsa, David Liebovitz, Abu Saleh Mohammad Mosa, Bradley W Taylor, Yacob Tedla, Drew Thodeson, Jiayi Tong, Qiong Wu, Christopher B Forrest, Yong Chen

Keywords

Body mass index; COVID-19; Cardiovascular outcomes; Children and young adults; Electronic health records; Gastrointestinal outcomes; Long COVID; Neuropsychiatric outcomes; Pediatric obesity; Postacute sequelae of SARS-CoV-2 infection