Letter by Li and Lu Regarding Article, “Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry”
Authors: Yuping Li, Guangyu Lu
Journal: Circulation (2021)

HomeCirculationVol. 144, No. 1Letter by Li and Lu Regarding Article, "Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Li and Lu Regarding Article, "Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry" Yuping Li and Guangyu Lu Yuping LiYuping Li https://orcid.org/0000-0002-4527-2582 Department of Neurosurgery, The Clinical Medical College of Yangzhou University (Y.L.), Yangzhou University, China. and Guangyu LuGuangyu Lu https://orcid.org/0000-0003-2568-7091 Department of Public Health and Center of Clinical Epidemiology, Medical School of Yangzhou University (G.L.), Yangzhou University, China. Originally published6 Jul 2021https://doi.org/10.1161/CIRCULATIONAHA.121.054075Circulation. 2021;144:e6–e7To the Editor:We read with interest the article by Hendren et al1 in the recent issue of Circulation, in which they provide further evidence that obese patients are more likely to be hospitalized with coronavirus disease 2019 (COVID-19) and are at greater risk of in-hospital death or mechanical ventilation, even in young adults. Previously, Cai et al2 reported that obesity increased the risk for developing severe pneumonia in patients with COVID-19. Later, Simonnet et al3 described that patients with COVID-19 with a body mass index >35 kg/m2 had more than a 7-fold greater risk of invasive mechanical ventilation than patients with a body mass index <25 kg/m2. Further, more research demonstrated that any degree of obesity (body mass index ≥30 kg/m2) has been associated with poor prognosis in patients with COVID-19.4 However, we wonder whether the "obesity paradox," which has already been demonstrated in patients with chronic obstructive pulmonary disease, many forms of cardiovascular disease, and advanced renal disease, exists in the case of COVID-19. The "obesity paradox" refers to the phenomenon that patients with high physical activity and fitness generally had a good prognosis regardless of weight ("fat but fit" phenomenon), whereas leaner patients with low physical fitness have a particularly poor prognosis.5 As part of the authors' findings, obese individuals with COVID-19 did not show a high rate of major adverse cardiovascular events, including in-hospital stroke, heart failure, myocardial infarction, or all-cause death,1 which might be explained by the obesity paradox (some patients with COVID-19 are "obese but fit"). It is known that the obesity paradox is influenced by the physical activity; however, these studies do not include data for physical activity and fitness. Based on this doubt, we suggest that further investigation of the combined effect of cardiorespiratory fitness and adiposity on mortality in patients with COVID-19 is needed. This evidence is important in delivering clear public health messages: for example, remaining fit by increased physical activity and cardiorespiratory fitness may be a more effective health promotion strategy, rather than weight loss alone. Again, describing the obesity paradox is not a promotion of being overweight or a suggestion that weight gain is beneficial.5 Another aspect for reporting the obesity paradox is to emphasize that besides COVID-19 patients with overweight or obese body mass indexes, unfit patients with COVID-19 who may be lean or underweight may also need to be closely monitored and actively treated to help improve prognosis for possible future pandemics.Sources of FundingThe authors acknowledge the financial support from the National Natural Science Foundation of China (grant no. 71904165), and the Jiangsu Province Post-doctoral Research Funding (grant no. 2020Z003 and 2020Z276).Disclosures None.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Hendren NS, de Lemos JA, Ayers C, Das SR, Rao A, Carter S, Rosenblatt A, Walchok J, Omar W, Khera R, et al. Association of body mass index and age with morbidity and mortality in patients hospitalized with COVID-19: results from the American Heart Association COVID-19 Cardiovascular Disease Registry.Circulation. 2021; 143:135–144. doi: 10.1161/CIRCULATIONAHA.120.051936LinkGoogle Scholar2. Cai Q, Chen F, Wang T, Luo F, Liu X, Wu Q, He Q, Wang Z, Liu Y, Liu L, et al. Obesity and COVID-19 severity in a designated hospital in Shenzhen, China.Diabetes Care. 2020; 43:1392–1398. doi: 10.2337/dc20-0576CrossrefMedlineGoogle Scholar3. Simonnet A, Chetboun M, Poissy J, Raverdy V, Noulette J, Duhamel A, Labreuche J, Mathieu D, Pattou F, Jourdain M; LICORN and the Lille COVID-19 and Obesity Study Group. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation.Obesity (Silver Spring). 2020; 28:1195–1199. doi: 10.1002/oby.22831CrossrefMedlineGoogle Scholar4. Petrilli CM, Jones SA, Yang J, Rajagopalan H, O'Donnell L, Chernyak Y, Tobin KA, Cerfolio RJ, Francois F, Horwitz LI. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study.BMJ. 2020; 369:m1966. doi: 10.1136/bmj.m1966CrossrefMedlineGoogle Scholar5. Elagizi A, Kachur S, Lavie CJ, Carbone S, Pandey A, Ortega FB, Milani RV. An overview and update on obesity and the obesity paradox in cardiovascular diseases.Prog Cardiovasc Dis. 2018; 61:142–150. doi: 10.1016/j.pcad.2018.07.003CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails July 6, 2021Vol 144, Issue 1 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.054075PMID: 34228482 Originally publishedJuly 6, 2021 PDF download Advertisement SubjectsCADASILQuality and Outcomes