COVID-19 and Severe Obesity: A Big Problem?
Authors: David A. Kass
Journal: Annals of Internal Medicine (2020)

Editorials12 August 2020COVID-19 and Severe Obesity: A Big Problem?FREEDavid A. Kass, MDDavid A. Kass, MDThe Johns Hopkins University School of Medicine, Baltimore, Maryland (D.A.K.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-5677 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail On 11 March 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic. The disease, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has now infected nearly 20 million persons worldwide, with a global mortality rate of 3.7%. It is unusual in that symptoms range from none to severe respiratory failure with diffuse lung damage and death. Given these diverse effects, understanding the risks for developing the most severe manifestations was particularly important from the start. Early reports from China and Italy, where the pandemic first took hold, identified a broad range of factors—old age, autoimmune disease, hypertension, and coronary artery disease—as risks for worse outcomes. However, as the pandemic reached the United States, another factor appeared that was particularly common in severely affected patients: obesity. The United States has a 20% rate of severe obesity (body mass index [BMI] >35 kg/m2) and a 10% rate of morbid obesity (BMI >40 kg/m2)—the highest rates in the industrialized world. More than 40% of Americans are considered obese (BMI >30 kg/m2). One possibility was that given this high prevalence, one would expect to find obesity more often in patients with COVID-19 as well. Yet, by early April, research was countering this hypothesis, showing that patients with COVID-19 in the intensive care unit were more likely to be obese than historical intensive care unit patients without COVID-19 (1), and that obese persons who had COVID-19 were more likely to require hospitalization and intensive care unit treatment (2). In contrast to other known risk factors, obesity was very common even in persons younger than 50 years, and this high prevalence predicted a shift in severe COVID-19 disease to younger populations (3).During the past few months, nearly 300 articles have reported an association between severe obesity and increased morbidity and mortality from COVID-19. Most of the focus is on hospitalized patients and ranges from small single-center studies to large retrospective analyses of thousands of patients (4). They generally cover the period from March 2020, when the pandemic first exploded in New York City, to May 2020, when it had spread to the rest of the United States. The findings are consistent: There is a dose-dependent association of obesity with worse COVID-19 morbidity requiring hospitalization and intensive care and with mortality. This particularly applies to patients younger than 50 to 60 years (5).In their article, Tartof and colleagues (6) provide an analysis for a large community population: patients in the Kaiser Permanente Southern California system. They retrospectively examined records from 5652 persons with SARS-CoV-2, with the primary outcome being death within 3 weeks of diagnosis. Two thirds of patients were hospitalized, and 43% were ventilated. Patients with BMIs greater than 40 kg/m2 had higher death rates overall, and those with BMIs greater than 45 kg/m2 had a risk ratio of 4.18. Most strikingly, however, those younger than 60 years had increased risk ratios of 12 to 17 versus 1 to 3 if they were older; high BMI increased risk in men more than in women. More important, the obesity risk was adjusted for common comorbidities, including diabetes, hypertension, heart failure, myocardial infarction, and chronic lung or renal disease. The study also took into account when SARS-CoV-2 was detected. Interestingly, with each ensuing week, mortality risk declined substantially. This may reflect the growing social awareness with evolving policies to reduce spread and improve medical practice.This study follows 2 recent reports in Annals examining a similar question but solely in hospitalized patients. Goyal and colleagues (7) reported on 1687 hospitalized patients in 2 New York City hospitals, finding that those with BMIs greater than 40 kg/m2 were at higher risk for respiratory failure but not death. However, 69% of their cohort had a BMI less than 30 kg/m2, and only 5% had a BMI greater than 40 kg/m2. In a second study, Anderson and colleagues (8) reported on 2466 patients with COVID-19 that had at least 47 days of hospital observation. They found that those younger than 65 years with a BMI greater than 40 kg/m2 had a 2-fold higher risk for intubation; however, BMI was no longer a significant risk factor in older patients.The consistency of this new study and prior research should put to rest the contention that obesity is common in severe COVID-19 because it is common in the population. Obesity is an important independent risk factor for serious COVID-19 disease. That the risks are higher in younger patients is probably not because obesity is particularly damaging in this age group; it is more likely that other serious comorbidities that evolve later in life take over as dominant risk factors. That males are particularly affected may reflect their greater visceral adiposity over females, given that this fat is notably proinflammatory and contributes to metabolic and vascular disease. As a cardiologist who studies heart failure, I am struck by how many of the mechanisms that are mentioned in reviews of obesity risk and heart disease (9, 10) are also mentioned in reviews of obesity and COVID-19 (9). The top mechanisms include restrictive pulmonary physiology and sleep apnea, diabetes and dyslipidemia, immune dysfunction with depressed anti-inflammatory signaling (for example, adiponectin) and increased proinflammatory signaling (for example, leptin, interleukin-6, and tumor necrosis factor-α), endothelial dysfunction, and renin–angiotensin stimulation that stimulates hypertension and worsens lung inflammation and alveolar damage. Fat deposited in skeletal muscle may be sought after by top-end steakhouses but, in vivo, it compromises muscle metabolic efficiency, nutrient uptake, and performance. Then, there is Newton's second law: force = mass × acceleration. It requires more muscle force to displace the diaphragm downward when a substantial fat mass lies below it. Abdominal obesity also makes it more difficult to breathe in a prone position that is favored to improve ventilation in patients with COVID-19. Among more specific mechanisms is expression of angiotensin-converting enzyme 2 protein in adipose tissue. This is the docking protein for SARS-CoV-2 to enter a cell, and fat has higher levels than the lungs and so may serve as a viral refuge and replication site, prolonging virus shedding.Arguably the hardest question to answer is: What is to be done? Severe and morbid obesity is sufficiently common in the United States to have become part of our social fabric. That makes messaging about its health risks difficult but does not change the fact that they are real. The data consistently show major risks at BMIs greater than 35 kg/m2, and at that level, weight reduction is difficult and certainly is not achieved rapidly. Therefore, social distancing; altering behaviors to reduce viral exposure and transmission, such as wearing masks; and instituting policies and health care approaches that recognize the potential effects of obesity should be implemented. These actions should help and are certainly doable.References1. Caussy C, Pattou F, Wallet F, et al; COVID Outcomes HCL Consortium and Lille COVID–Obesity Study Group. Prevalence of obesity among adult inpatients with COVID-19 in France [Letter]. Lancet Diabetes Endocrinol. 2020;8:562-564. [PMID: 32437642] doi:10.1016/S2213-8587(20)30160-1 CrossrefMedlineGoogle Scholar2. Lighter J, Phillips M, Hochman S, et al. Obesity in patients younger than 60 years is a risk factor for COVID-19 hospital admission [Letter]. Clin Infect Dis. 2020;71:896-897. [PMID: 32271368] doi:10.1093/cid/ciaa415 CrossrefMedlineGoogle Scholar3. Kass DA, Duggal P, Cingolani O. Obesity could shift severe COVID-19 disease to younger ages [Letter]. Lancet. 2020;395:1544-1545. [PMID: 32380044] doi:10.1016/S0140-6736(20)31024-2 CrossrefMedlineGoogle Scholar4. Sattar N, Ho FK, Gill JM, et al. BMI and future risk for COVID-19 infection and death across sex, age and ethnicity: preliminary findings from UK Biobank. Diabetes Metab Syndr. 2020;14:1149-1151. [PMID: 32668401] doi:10.1016/j.dsx.2020.06.060 CrossrefMedlineGoogle Scholar5. Klang E, Kassim G, Soffer S, et al. Severe obesity as an independent risk factor for COVID-19 mortality in hospitalized patients younger than 50. Obesity (Silver Spring). 2020. [PMID: 32445512] doi:10.1002/oby.22913 CrossrefMedlineGoogle Scholar6. Tartof SY, Qian L, Hong V, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization. Ann Intern Med. 2020;173:773-81. doi:10.7326/M20-3742 LinkGoogle Scholar7. Goyal P, Ringel JB, Rajan M, et al. Obesity and COVID-19 in New York City. A retrospective cohort study [Letter]. Ann Intern Med. 2020;173:855-8. doi:10.7326/M20-2730 LinkGoogle Scholar8. Anderson MR, Geleris J, Anderson DR, et al. Body mass index and risk for intubation or death in SARS-CoV-2 infection. A retrospective cohort study. Ann Intern Med. 2020;173:782-90. doi:10.7326/M20-3214 LinkGoogle Scholar9. Koliaki C, Liatis S, Kokkinos A. Obesity and cardiovascular disease: revisiting an old relationship. Metabolism. 2019;92:98-107. [PMID: 30399375] doi:10.1016/j.metabol.2018.10.011 CrossrefMedlineGoogle Scholar10. Piché ME, Tchernof A, Després JP. Obesity phenotypes, diabetes, and cardiovascular diseases. Circ Res. 2020;126:1477-1500. [PMID: 32437302] doi:10.1161/CIRCRESAHA.120.316101 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Charles C. Meurehg, FAACPCentro Medico ABC13 August 2020 COVID-19 and Severe Obesity, A Big Problem? There are a number of articles that confuse more than spread confirmed data. This article is clear, substantiated and explicit. It should be read by general practitioners and by cardiology doctors or from other specialties who treat patients with COVID-19. Thank you very much for sharing important data. Disclosures: The author has nothing to disclose. John G. Spangler, MD, MPHWake Forest School of Medicine18 August 2020 On Describing People and Their Conditions. The title of Dr. David Kass' August 12, 2020 Annals editorial "COVID-19 and Severe Obesity: A Big Problem?"1 immediately troubled me. The title is a clever play on words of "big" describing both severe obesity and the scope of the "problem." But using the word "big" to label both the problem and the group of people who suffer from the problem unnecessarily stigmatizes individual people who make up the group with severe obesity. I am sure Dr. Kass was not intentionally trying to stigmatized people who are severely obese. Indeed, the ultimate point of his editorial is: "What is to be done?" Because morbid obesity is common in the United States, it has become intertwined with our culture and norms. "[M]essaging about its health risks [is] difficult," Kass argues, "but [this] does not change the fact that [the risks] are real."1 Certainly all of us can agree with that statement. Talking to patients about health risks related to obesity can be difficult. Moreover, we cannot avoid these difficult discussions because these risks are real—as the COVID-19 pandemic has dramatically shown. The difficulty lies in how we discuss these problems with colleagues and with patients. Linking the "bigness" of people with severe obesity with the "bigness" of the problem might not be the best approach to convey our message. First, "big" is not necessarily the way people with severe obesity want to be portrayed. Trainer et al.2 interviewed university-age participants about language they use to talk about obesity. Notably, this included phrases participants who were obese used to describe themselves. Out of the 21 most common words, "big" was thirteenth. "Unhealthy weight", "overweight", and "heavy" were the first, through third most preferred terms. Along with "big-boned" and "plus-sized", "big" was stigmatizing.2 Second, the play on words linking people who are "big" with a "big" problem, while based on facts, is not a neutral statement. As mentioned, people who are obese often find this word stigmatizing. To make a pun out of a person's size thus evinces at a minimum slight disrespect. Living with severe obesity can be overwhelming and demoralizing; a pun about people's size does not promote a collaborative patient-provider relationship.3 Third, all of us must become aware of our implicit anti-obesity biases which are present among health care providers of all types. Why? Because one-half of medical trainees have implicit weight biases, yet two-thirds of them are unaware of their anti-obesity bias. 4 * Fourth, why even mention size in the title? Innumerable other phrases are available. Meadows and Daníelsdóttir5 argue that the words we choose to describe obesity "reflect certain culturally constructed values." We need to examine the labels we use to see if they affirm the group's human dignity, elevate them on par with other social groups and promote the group's welfare and empowerment. If the labels we use accomplish opposite effects, "we will only perpetuate the stigma."5 Does this title accomplish opposite effects? I wonder what people with severe obesity might think. *This comment was corrected on 8/20/20. The author originally wrote "Because one-half of medical trainees have implicit weight biases, yet only two-thirds of them are aware of their anti-obesity bias." References: 1.Kass DA. COVID-19 and Severe Obesity: A Big Problem?. Annals of Internal Medicine. 2020 Aug 12. 2.Trainer S, Brewis A, Williams D, Chavez JR. Obese, fat, or "just big"? Young adult deployment of and reactions to weight terms. Human Organization. 2015;74(3):266-75. 3.Dickinson JK, Guzman SJ, Maryniuk MD, O'Brian CA, Kadohiro JK, Jackson RA, D'Hondt N, Montgomery B, Close KL, Funnell MM. The use of language in diabetes care and education. The Diabetes Educator. 2017 Dec;43(6):551-64. 4.Miller Jr DP, Spangler JG, Vitolins MZ, Davis MS, Ip EH, Marion GS, Crandall SJ. Are medical students aware of their anti-obesity bias?. Academic medicine: journal of the Association of American Medical Colleges. 2013 Jul;88(7):978. 5.Meadows A, Daníelsdóttir S. What's in a word? On weight stigma and terminology. Frontiers in psychology. 2016 Oct 5;7:1527. Disclosures: None David A. Kass, M.D.Johns Hopkins University19 August 2020 Response to the comment from Dr. Spangler Dr. Spangler raises something to which I am both sensitive and very sympathetic. The editorial's title was a play on words as titles of editorials and perspectives often are. I meant nothing more by it, and specifically in no way intended to demean or cast aspersions towards individuals who may be very overweight. In our daily speech, we often use adjectives related to the size of something when describing the extent of a particular problem; e.g. tiny, small, large, big, huge, gigantic, enormous. COVID-19 for example is an enormous problem. There are alternatives, as problems can also be trivial, major, minor, serious, worrisome, difficult, or intractable. Perhaps the better subtitle would not have referred to this as a problem at all, but as a serious challenge. That is more accurately how I view it. I am a cardiovascular researcher who primarily studies heart failure mechanisms including the impact of obesity and metabolic syndrome, and I fully appreciate how having a very high BMI adversely impacts the course of heart disease and its prognosis. I also know that severe obesity, unlike blood sugar or blood pressure elevation, is hard to reverse. My laboratory is currently trying to better understand the mechanisms by which obesity impacts heart disease and to uncover new therapies that might help enhance fat metabolism and in turn weight loss. So I do take this very seriously. However, rather than being remembered for a perceived pun in my title, I would like readers to appreciate my sensitivity to the challenges severe obesity presents, and also understand that this is a real medical risk, and there are actions impacted individuals can take to better protect themselves – in particular from COVID-19. Disclosures: None Author, Article, and Disclosure InformationAuthors: David A. Kass, MDAffiliations: The Johns Hopkins University School of Medicine, Baltimore, Maryland (D.A.K.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-5677.Corresponding Author: David A. Kass, MD, Ross Building 858, Johns Hopkins Medical Institutions, 720 Rutland Avenue, Baltimore, MD 21205; e-mail, dkass@jhmi.edu.This article was published at Annals.org on 12 August 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoBody Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection Michaela R. Anderson , Joshua Geleris , David R. Anderson , Jason Zucker , Yael R. Nobel , Daniel Freedberg , Jennifer Small-Saunders , Kartik N. Rajagopalan , Richard Greendyk , Sae-Rom Chae , Karthik Natarajan , David Roh , Ethan Edwin , Dympna Gallagher , Anna Podolanczuk , R. Graham Barr , Anthony W. Ferrante , and Matthew R. Baldwin Obesity and COVID-19 in New York City: A Retrospective Cohort Study Parag Goyal , Joanna Bryan Ringel , Mangala Rajan , Justin J. Choi , Laura C. Pinheiro , Han A. Li , Graham T. Wehmeyer , Mark N. Alshak , Assem Jabri , Edward J. Schenck , Ruijun Chen , Michael J. Satlin , Thomas R. Campion Jr. , Musarrat Nahid , Maria Plataki , Katherine L. Hoffman , Evgeniya Reshetnyak , Nathaniel Hupert , Evelyn M. Horn , Fernando J. Martinez , Roy M. Gulick , and Monika M. 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