Response by Hendren et al to Letter 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: Nicholas S. Hendren, James A. de Lemos, Justin L. Grodin
Journal: Circulation (2021)

HomeCirculationVol. 144, No. 1Response by Hendren et al to Letter 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/EPUBResponse by Hendren et al to Letter 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" Nicholas S. Hendren, James A. de Lemos and Justin L. Grodin Nicholas S. HendrenNicholas S. Hendren https://orcid.org/0000-0002-0551-7864 Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas. Parkland Health and Hospital System, Dallas, TX. , James A. de LemosJames A. de Lemos https://orcid.org/0000-0003-2211-7261 Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas. Parkland Health and Hospital System, Dallas, TX. and Justin L. GrodinJustin L. Grodin https://orcid.org/0000-0003-2400-3196 Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas. Parkland Health and Hospital System, Dallas, TX. Originally published6 Jul 2021https://doi.org/10.1161/CIRCULATIONAHA.121.054556Circulation. 2021;144:e8–e9In Response:We read with interest the letter by Yuping Li and Guangyu Lu in which they query whether an obesity paradox may exist for coronavirus disease 2019 (COVID-19). As the letter writers note, the obesity paradox has been described for several acute and chronic cardiovascular and pulmonary conditions, whereas overweight or mildly obese individuals may paradoxically have fewer adverse outcomes compared with individuals of normal weight.1 To date, however, an obesity paradox for hospitalization, risk for mechanical ventilation, and all-cause death has not been observed in COVID-19.2–4 The 2 largest studies have observed a greater dose-dependent risk for mechanical ventilation with increasing body mass index despite adjustment for patient risk factors.3,4 Likewise, a recent Centers for Disease Control study observed a greater dose-dependent risk of all-cause death in class I, II, or III obese individuals compared with either normal or overweight World Health Organization obesity classes.4 Accordingly, the relationship of body weight to risk for severe COVID-19 may be distinct from previously described populations for which the obesity paradox has been described. The relatively low rate of cardiovascular complications likely reflects the overall short follow-up period (index hospitalization), the high competing risk of death, and the practical challenges of diagnosing an acute stroke, heart failure, or myocardial infarction in the setting of an acute lung injury or critical illness.Because of the rapid acute lung injury in COVID-19, the direct association of body weight with adverse respiratory mechanics and cytokine production may increase the risk for mechanical ventilation, irrespective of baseline body fitness.5 Although it is plausible that high cardiorespiratory fitness may mitigate some of the hazards of obesity in patients with COVID-19, we cannot address this question because fitness was not captured in our dataset. Additionally, "obese but fit" likely represent a small proportion of the world's obese population. In our cohort, overweight and obese individuals hospitalized with COVID-19 had a high comorbid disease burden of diabetes, hypertension, and previous cardiovascular disease representative of an obese and unfit population.3 We believe the most prudent approach is to recognize that all obese individuals are at high risk for severe COVID-19 regardless of fitness and to encourage physical activity, weight loss, and COVID-19 vaccination.Disclosures Dr Grodin has received consulting fees from Pfizer, Eidos Therapeutics, Sarepta Therapeutics, and Alnylam Pharmaceuticals and research funding from Eidos Therapeutics and the Texas Health Resources Clinical Scholars fund. Dr de Lemos has received grant support from Roche Diagnostics and Abbott Diagnostics and consulting income from Siemens Health Care Diagnostics, Ortho Clinical Diagnostics, Quidel, and Regeneron. Dr Hendren reports no conflicts.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Hendren NS, Neeland IJ, Vongpatanasin W, Kumbhani DJ, Drazner MH, Tang WHW, Grodin JL. Intensive blood pressure control and body size.J Am Coll Cardiol. 2018; 72:1317–1318. doi: 10.1016/j.jacc.2018.06.058CrossrefMedlineGoogle Scholar2. Tartof SY, Qian L, Hong V, Wei R, Nadjafi RF, Fischer H, Li Z, Shaw SF, Caparosa SL, Nau CL, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization.Ann Intern Med. 2020; 173:773–781. doi: 10.7326/M20-3742CrossrefMedlineGoogle Scholar3. 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 Scholar4. Kompaniyets L, Goodman AB, Belay B, Freedman DS, Sucosky MS, Lange SJ, Gundlapalli AV, Boehmer TK, Blanck HM. Body mass index and risk for COVID-19-related hospitalization, intensive care unit admission, invasive mechanical ventilation, and death - United States, March-December 2020.MMWR Morb Mortal Wkly Rep. 2021; 70:355–361. doi: 10.15585/mmwr.mm7010e4CrossrefMedlineGoogle Scholar5. Dixon AE, Peters U. The effect of obesity on lung function.Expert Rev Respir Med. 2018; 12:755–767. doi: 10.1080/17476348.2018.1506331CrossrefMedlineGoogle 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 FiguresReferencesRelatedDetailsCited By Lukyanov M, Andreenko E, Martsevich S, Kutishenko N, Voronina V, Dindikova V, Dmitrieva N, Kudryavtseva M, Lerman O, Makoveeva A, Okshina E, Pulin A, Smirnov А, Klyashtorny V, Karpov O and Drapkina O (2023) Two-year outcomes in patients after hospitalization for COVID-19: data from the TARGET-VIP registry, Cardiovascular Therapy and Prevention, 10.15829/1728-8800-2023-3757, 22:10, (3757) Arutyunov A, Tarlovskaya E, Galstyan G, Batluk T, Bashkinov R, Arutyunov G, Belenkov Y, Konradi A, Lopatin Y, Rebrov A, Tereshchenko S, Chesnikova A, Hayrapetyan H, Babin A, Bakulin I, Bakulina N, Balykova L, Blagonravova A, Boldina M, Butomo M, Vaisberg A, Galyavich A, Gomonova V, Grigoryeva N, Gubareva I, Demko I, Evzerikhina A, Zharkov A, Zateishchikova A, Kamilova U, Kim Z, Kuznetsova T, Kulikov A, Lareva N, Makarova E, Malchikova S, Nedogoda S, Petrova M, Pochinka I, Protasov K, Protsenko D, Ruzanov D, Saiganov S, Sarybaev A, Selezneva N, Sugraliev A, Fomin I, Khlynova O, Chizhova O, Shaposhnik I, Schukarev D, Abdrakhmanova A, Avetisyan S, Avoyan H, Azaryan K, Aimakhanova G, Ayypova D, Akunov A, Alieva M, Almukhambedova A, Aparkina A, Aruslanova O, Ashina E, Badina O, Barysheva O, Batchaeva A, Bitieva A, Bikhteev I, Borodulina N, Bragin M, Brazhnik V, Budu A, Bykova G, Vagapova K, Varlamova D, Vezikova N, Verbitskaya E, Vilkova O, Vinnikova E, Vustina V, Galova E, Genkel V, Giller D, Gorshenina E, Grigoryeva E, Gubareva E, Dabylova G, Demchenko A, Dolgikh O, Duishobaev M, Evdokimov D, Egorova K, Ermilova A, Zheldybaeva A, Zarechnova N, Zimina Y, Ivanova S, Ivanchenko E, Ilina M, Kazakovtseva M, Kazymova E, Kalinina Y, Kamardina N, Karachenova A, Karetnikov I, Karoli N, Karsiev M, Kaskaeva D, Kasymova K, Kerimbekova Z, Kim E, Kiseleva N, Klimenko D, Klimova A, Kovalishena O, Kozlov S, Kolmakova E, Kolchinskaya T, Kolyadich M, Kondryakova O, Konoval M, Konstantinov D, Konstantinova E, Kordyukova V, Koroleva E, Kraposhina A, Kryukova T, Kuznetsova A, Kuzmina T, Kuzmichev K, Kulchoroeva C, Kuprina T, Kuranova I, Kurenkova L, Kurchugina N, Kushubakova N, Levankova V, Ledyaeva A, Lisun T, Lisyanskaya V, Lyubavina N, Magdeeva N, Mazalov K, Mayseenko V, Makarova A, Maripov A, Markov N, Marusina A, Melnikov E, Metlinskaya A, Moiseenko N, Muradova F, Muradyan R, Musaelyan S, Nekaeva E, Nikitina N, Nifontov S, Obolentseva E, Obukhova A, Ogurlieva B, Odegova A, Omarova Y, Omurzakova N, Ospanova S, Pavlova V, Pakhomova E, Petrov L, Plastinina S, Platonov D, Pogrebetskaya V, Polyakov D, Polyakov D, Ponomarenko E, Popova L, Potanin A, Prokofieva N, Rabik Y, Rakov N, Rakhimov A, Rozanova N, Samus I, Serikbolkyzy S, Sidorkina Y, Simonov A, Skachkova V, Skvortsova R, Skuridin D, Solovieva D, Solovieva I, Sukhomlinova I, Sushilova A, Tagaeva D, Titoykina Y, Tikhonova E, Tokmin D, Tolmacheva A, Torgunakova M, Trenogina K, Trostyanetskaya N, Trofimov D, Trubnikova M, Tulichev A, Tursunova A, Ulanova N, Fatenkov O, Fedorishina O, Fil T, Fomina I, Fominova I, Frolova I, Tsvinger S, Tsoma V, Cholponbaeva M, Chudinovskikh T, Shavrin I, Shevchenko O, Shikhaliev D, Shishkina E, Shishkov K, Shcherbakov S, Shcherbakova G and Yausheva E (2023) The impact of BMI on the course of the acute SARS-COV-2 infection and the risks that emerge during the first year after the hospital discharge. Subanalysis evidence of the AKTIV and AKTIV 2 registries, Problems of Endocrinology, 10.14341/probl13165, 68:6, (89-109) Slukhanchuk E, Bitsadze V, Khizroeva J, Tretyakova M, Shkoda A, Blinov D, Tsibizova V, Jinbo Z, Sheena S, Sсhulman S, Gris J, Elalamy I and Makatsariya A (2023) Antithrombotic therapy in COVID-19 patients, Obstetrics, Gynecology and Reproduction, 10.17749/2313-7347/ob.gyn.rep.2022.370, 16:6, (718-731) Zhao L, Dong X, Gao Y, Jia Z, Han S, Zhang J and Gao Y (2022) Effects of exercise combined with diet intervention on body composition and serum biochemical markers in adolescents with obesity: a systematic review and meta-analysis, Journal of Pediatric Endocrinology and Metabolism, 10.1515/jpem-2022-0193, 35:11, (1319-1336), Online publication date: 25-Nov-2022., Online publication date: 1-Nov-2022. Vassilopoulou E, Bumbacea R, Pappa A, Papadopoulos A and Bumbacea D (2022) Obesity and Infection: What Have We Learned From the COVID-19 Pandemic, Frontiers in Nutrition, 10.3389/fnut.2022.931313, 9 van Son J, Oussaada S, Şekercan A, Beudel M, Dongelmans D, van Assen S, Eland I, Moeniralam H, Dormans T, van Kalkeren C, Douma R, Rusch D, Simsek S, Liu L, Kootte R, Wyers C, IJzerman R, van den Bergh J, Stehouwer C, Nieuwdorp M, ter Horst K and Serlie M (2021) Overweight and Obesity Are Associated With Acute Kidney Injury and Acute Respiratory Distress Syndrome, but Not With Increased Mortality in Hospitalized COVID-19 Patients: A Retrospective Cohort Study, Frontiers in Endocrinology, 10.3389/fendo.2021.747732, 12 Kurakh A, Hechko M and Chopey I (2021) COVID-19 AND PRIMARY CARE: POSSIBILITIES FOR INCREASING POSITIVE OUTCOMES, Wiadomości Lekarskie, 10.36740/WLek202110225, 74:10, (2659-2662), Online publication date: 1-Oct-2021. July 6, 2021Vol 144, Issue 1 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.054556PMID: 34228477 Originally publishedJuly 6, 2021 PDF download Advertisement SubjectsCADASILQuality and Outcomes