Chapter 4 110 resulting in a heterogenous patient group requiring different management strategies. A universally accepted and evidence-based definition of post-COVID syndrome is key to comparing findings across studies and settings, and to develop syndrome-specific interventions. Our study, for example, shows recovery beyond approximately 6 months after illness onset is uncommon, suggesting that individuals who remain symptomatic beyond this point may require more intensive support and care. Moreover, our findings suggest that women and obese individuals, regardless of age and the number of comorbidities at illness onset, may benefit from early intervention. In addition to the direct effect of obesity on recovery, high BMI is associated with having a lower socioeconomic status and reduced access to health and care services[25], both of which may further amplify a slower recovery from symptoms. Reducing the prevalence of obesity may therefore help to reduce both acute complications[4, 26] and long-term sequelae of COVID-19. Fatigue was the most commonly reported symptom both during the acute phase and at 12 weeks from illness onset, including among individuals with mild or moderate disease. Previous analyses have estimated that the societal impact of fatigue can be significant, due to both direct healthcare costs and indirect financial losses resulting from reduced economic productivity[27]. As those with mild COVID-19 represent the majority of COVID-19 cases worldwide in terms of absolute numbers, developing strategies to prevent, diagnose and manage post-COVID fatigue should be given priority. Among participants with moderate and severe/critical disease, dyspnoea and myalgia additionally persisted beyond 12 weeks in a large proportion of participants. Similar results have been reported in other settings: previously-hospitalised COVID-19 patients in Wuhan, China still had abnormal chest imaging findings and pulmonary diffusing capacity at 6 months after illness onset [5], whilst a cross-sectional study of hospitalised COVID-19 patients in the UK reported that the majority of participants reported myalgia at a median follow-up of 16 weeks after discharge from hospital[28]. In our multivariable analysis, older age was the most important determinant of slower time to recovery from both of these symptoms. Exploring the underlying mechanism as to why these symptoms persist in older patients may help identify interventions that could be beneficial in the recovery process. This study has several strengths. Frequent symptom questionnaires collected longitudinally since illness onset allowed the natural progression of COVID-19 symptoms to be described to a level of detail not previously reported. We were able to enrol patients with mild symptoms (underrepresented in other studies) as well as those who were critically ill, so that the full spectrum of COVID-19 disease could be represented. Several limitations must
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