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SARS-CoV-2 Does Not Affect Long-Term Performance of Top-level Elite Athletes

2021; Lippincott Williams & Wilkins; Volume: 20; Issue: 11 Linguagem: Inglês

10.1249/jsr.0000000000000900

1537-8918

George Siopis,

Sports injuries and prevention

The World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic on the 11th of March 2020. As part of the initial response to the pandemic, a hiatus was imposed on professional sporting activities throughout the world. A few months later, resumption of sporting activities ensued but to ensure a safe return-to-play for the athletes, the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections were carefully monitored. Clinical Symptoms of SARS-CoV-2 Infections in Athletes Some athletes reported persistent and residual symptoms, such as cough, tachycardia, and extreme fatigue, lasting several weeks to months after the initial infection (1). Major professional sporting leagues in the United States implemented mandatory cardiac screening for players testing positive for SARS-CoV-2, before clearing them for a safe return-to-play. Screening of 789 athletes identified five cases (0.6%) with inflammatory heart disease (2). The five athletes were advised to not participate in professional sporting activities. The rest were cleared to resume professional sport participation and did not exhibit any adverse effects following return-to-play (2). Screening of 1597 U.S. college athletes recovering from COVID-19 using cardiovascular magnetic resonance imaging revealed a 2.3% prevalence of clinical and subclinical myocarditis (3). The effects of myocarditis in athletes recovering from COVID-19 are not yet known; however, as vaccinations proceed apace its incidence seems to decrease, with currently one to two cases for every 100 athletes (4). In addition to U.S. college athletes, several professional athletes from around the world tested positive for SARS-CoV-2 after the resumption of professional sporting activities (5). Although some reported experiencing loss of smell or fatigue that persisted for a few months, the majority of the professional athletes were mostly asymptomatic, and their performance did not seem to be affected. Effects of SARS-CoV-2 Infection on Athletic Performance Notable examples of athletes contracting SARS-CoV-2 can be found across all sports. Tennis player Novak Djokovic managed to win the Australian open just a few months after testing positive for the novel coronavirus in 2020, and in 2021, he has already won three "Grand Slam" tournaments, the Australian open, the Roland Garros, and Wimbledon, indicating no short- or long-term adverse effects on his performance from the SARS-CoV-2 infection. British swimmer Tom Dean won the gold medal in the 200 m freestyle in the Tokyo 2020 Olympic Games (in July 2021), having battled SARS-CoV-2 twice and needing to have an extended time out of the pool each time (6). Katie Nageotte won a gold medal for the United States in the pole vault event in the same Olympics Games, despite having COVID-19 earlier this year and reportedly experiencing brain fog (7). Chistiano Ronaldo returned a positive SARS-CoV-2 test on multiple occasions, but this did not slow him down from writing history for his sport by becoming the top goal scorer in the history of soccer. Lewis Hamilton managed to win the Formula 1 championship in 2020, despite having to miss a race after contracting SARS-CoV-2. The National Basketball Association (NBA) was the first professional sporting league to pause its operations after two players tested positive for SARS-CoV-2 in March 2020. After resumption of the league, several players who contracted the virus recorded historic performances. Rudy Gobert, who was the first to test positive for the virus, won the "defensive player of the year" award in 2021, and Nikola Jokic won the award of the "most valuable player". Russell Westbrook broke the long-standing all-time NBA record for the most triple doubles. Donovan Mitchell and Kevin Durant recorded historic performances (8,9). Jason Tatum tied legendary player Larry Bird as the top scorer in the Boston Celtics history, a few months after having COVID-19 and despite reporting experiencing lingering shortness of breath (10). Chris Paul managed to lead his team to their first victory in the 2021 NBA finals, only two weeks after testing positive for the novel coronavirus (11). Physical Activity and Overall Fitness May Confer Protection Against Adverse COVID-19 Outcomes The list of elite athletes who were able to maintain peak performance after contracting the novel coronavirus is not restricted to the few examples listed above. Although athletes were not immune to clinical symptoms, most of these symptoms were mild and sports performance seemed unaffected. The plethora of examples from different sports suggests no decline in several athletic performance indices, such as acceleration, endurance, or reaction rate, despite previous reports of adverse effects of SARS-CoV-2 infections on maximal aerobic capacity and the nervous system, reported in nonelite athlete populations (12,13). Physical activity appears to confer protection against adverse outcomes from COVID-19, with a lower risk for severe morbidity seen in people who participate in physical activity (14). Interestingly, this protection can last for many years, even after the cessation of regular physical activity (15). However, the Centers for Disease and Control Prevention (CDC) have recognized obesity as the strongest risk factor for morbidity and mortality from COVID-19 (16). Thus, another reason for the milder effects of infections seen in elite athletes may be their healthier body composition. Several sports require athletes to maintain a low body fat percentage for peak performance. But even in the sports in which a surplus of adipose tissue confers an advantage, it can be argued that athletes will store this adiposity in a metabolic healthier manner than sedentary counterparts with the same body fat mass. Exercise promotes fat deposition intramuscularly and within the superficial compartment of the subcutaneous adipose tissue. Both these stores constitute healthier reserves than the visceral and the deep subcutaneous adipose tissue stores, where inactive people mostly store their fat (17). Although most reports from professional sports indicate mild outcomes of infections in athletes, there are reports of severe disease and death from COVID-19. To date, it appears that serious and severe outcomes were mostly seen in retired athletes. Exceptions are a young Spanish football coach, who died at the age of 21 years but who also was battling leukemia, and a 28-year-old Japanese sumo wrestler, for whom the presence of underlying health conditions is not known, but sumo is known as a sport that pushes the human body to the extremes of adiposity (18). It is not surprising that some retired athletes could not overcome COVID-19. After retirement from competitive sport, a great proportion of athletes put on weight, as they no longer perform the same volume and intensity of physical activity, yet it is not uncommon for them to continue to consume a high-calorie diet. Since they are not exercising as vigorously, the extra calories no longer contribute to muscle, glycogen, or the intramuscular fat reserves as would have been the case during their competitive days, but instead, they are mostly stored within the less healthy compartments of adipose tissue, such as the visceral and the superficial subcutaneous adipose tissue, which increase the risk for metabolic disease. Athletes who maintain an active lifestyle after retirement from competitive sport, and who balance their energy intake to their expenditure, exhibit a low risk for cardiometabolic disease. Strong Public Health Actions Are Needed to Promote Physical Activity on a Population Level The protective effects of physical activity against serious adverse outcomes from COVID-19 and the ability of elite athletes to sustain peak performance both in the short- and long-term postinfection with the novel coronavirus, further emphasize the importance of participating in regular and sufficient physical activity, maintaining a favorable body composition, and achieving overall fitness for general health and well-being (19,20). The COVID-19 pandemic provides a unique opportunity to reflect on the evolution of our species. From relying on movement to fend for ourselves in the early phases of our history, humans are more and more adopting a life with increasingly less demand for movement, with technology rendering the need for physical activity even more redundant with time. Yet, although not necessary to move to commute, or perform other tasks in our daily life, it appears that movement is key to metabolic health and to the health of the immune system (21). With overweight and obesity affecting more than two thirds of the American population, and the known associations between obesity and adverse outcomes from communicable and noncommunicable diseases, drastic public health actions are urgently required to promote a healthy lifestyle on a population level. The UK government is launching a scheme to offer incentives for leading a healthy lifestyle (22). Governments around the world must seize the COVID-19 prevention and control as an opportunity to increase commitment for and investment in "up-stream prevention" through population-level promotion of healthy lifestyles. SARS-CoV-2, with its variants, may likely become a chronic public health issue. Therefore, preventive medicine measures, such as advocacy and incentives to eat healthily and to participate in regular and adequate physical activity, are pressing and self-evident as another shield, along with vaccines, in the arsenal against COVID-19, and to also reduce the longstanding burden from noncommunicable diseases.