Obesity & COVID 19
In a recently held webinar, Dr. Chen Po-Lin from Taiwan made a significant observation: Over 35% of patients admitted to hospitals in the UK, were either overweight, obese or morbidly obese! This is a significant statement that underlines the risk that obesity poses in this pandemic.
Let’s try to understand why obesity makes us more susceptible
We already know that patients with obesity-related conditions such as cardiovascular disease are at higher risk of diabetes, which can mean a higher risk of developing complications if you catch COVID-19. But can obesity itself be a risk factor for developing complications and, if so, why?
People are overweight for different reasons
Writing about obesity is always difficult. People are overweight for different reasons, and often these are far-reaching and complex in nature. It is also unfair to group all overweight people into the same category, but for the purpose of this article, I will be looking at obesity as an individual risk factor for complications of COVID-19 from a strictly medical point of view.
Last week, Diederik Gommers, chairman of the Dutch Intensive Care Association, told TV reporters in the Netherlands that 66 percent to 80 percent of COVID-19 patients in intensive care wards that he had seen were overweight.
On the same TV news programme, Peter van der Voort, of Groningen University’s teaching hospital, said of the higher numbers of overweight COVID-19 patients in ICU beds: “We don’t know why, but it is very noticeable.”
Is obesity a risk factor for disease?
Obesity impacts millions of people around the world. According to the World Health Organization (WHO), in 2016, more than 1.9 billion adults were overweight, of whom 650 million were classed as obese. A greater understanding of obesity’s associated physiological disturbances is needed to address this key public health concern.
During the influenza A (H1N1) – or swine flu – viral pandemic of 2009, studies showed that obesity was an independent risk factor for increased morbidity and mortality following infection.
Those studies found that people with a Body Mass Index (BMI) – a calculation taking into account height and weight – of 30 or above fared much worse after being infected by the flu virus than those with a “normal” BMI of 24.9 or below, with more cases of pneumonia reported in this cohort.
But is the same true for coronavirus?
A Chinese study published last month looked at 112 COVID-19 patients and their outcomes. Sadly, 17 of these patients died. Fifteen of the deceased (88 percent) were classed as being overweight or more on the BMI scale. By comparison, only 18 of the 95 survivors (19 percent) were classed as overweight or above on the BMI scale. This study prompted experts to question what it was about obesity that might make it a risk factor when it comes to coronavirus.
What problems can obesity cause?
Obesity is defined as a disruption of energy balance that leads to weight gain and metabolic disturbances that cause tissue stress and dysfunction. This means that obesity is not just being overweight but also the adverse effect that being overweight has on your body’s health.
One of these adverse effects is a disruption in a function of the immune system called the lymphoid and neutrophil line. These are cells that can tell infection from normal tissue and that need to be kept in careful balance in order to maintain a healthy immune system.
Obesity can disrupt this balance and lead to a low level of chronic inflammation of normal tissue, caused by these cells. This places the body under a constant low level of physical stress on a microscopic scale.
This imbalance in the immune system and chronic inflammation of normal tissue has put people with obesity at increased risk of complications of infections and higher rates of chronic diseases generally.
This is true of common infections such as skin or wound infections. Their immune systems are already working hard, even at rest. It comes as no surprise, then, that if people who are obese are struck down with the COVID-19 virus, they will also be at increased risk of its complications, including breathing difficulties and pneumonia.
People with obesity are harder to transport. Specialist beds and equipment are often needed for larger patients, equipment that is not widely available.
Obesity & Covid-19: Significant Challenges
There are significant challenges when it comes to managing patients with obesity in ICUs. They are physically more difficult to intubate – a procedure where an airway tube is fed down the throat to allow air to pass into the lungs – due to the fact that their neck tends to be thicker, putting pressure on the airways, especially when the patient is flat on his or her back.
It is fair to say that most healthcare systems are not well set up to manage patients with obesity, and this pandemic may well highlight that fact and expose its limitations further.
Obesity-related conditions seem to worsen the effect of COVID-19; indeed, the Centers for Disease Control and Prevention (CDC) reported that people with heart disease and diabetes are at higher risk of COVID-19 complications.
Given the extremely high rates of obesity around the globe we expect that a high percentage of the population who will contract coronavirus will also have a BMI over 25. Furthermore, persons with obesity who become ill and require intensive care present challenges in patient management as it is more difficult to intubate patients with obesity, it can be more challenging to obtain diagnostic imaging (as there are weight limits on imaging machines), patients are more difficult to position and transport by nursing staff and, like pregnant patients in ICUs, they may not do well when in a prone position.
Special beds and positioning/transport equipment are available in specialized surgery units but may not be widely available elsewhere in hospitals and certainly not in all countries. In general, health systems are already not well set up to manage patients with obesity (as reported by our MAPPS study published in Clinical Obesity) and the current crisis will expose their limitations even more.
This global pandemic is also quickly becoming a global economic crisis, which will disproportionately affect the world’s most vulnerable population. In many countries this same segment of the population is also the one at higher risk of obesity, which might worsen the obesity crisis in the future.
In addition to that, the current pandemic might contribute to an increase in obesity rates as weight loss programmes (which are often delivered in groups) and interventions such as surgery are being severely curtailed at present – and this is likely to go on for a long period of time. The measures introduced in some countries (e.g. not leaving the home for several weeks even for those who are not sick) will have an impact on mobility and enforced physical inactivity even for short periods of time increases the risk of metabolic disease.
Finally, the current crisis and the need for self-isolation is prompting many to rely on processed food with longer shelf life (instead of fresh produce) and canned food (with higher quantities of sodium) and we might see an increase in weight if this persists for a longer period of time.
Coronavirus disease (COVID-19) outbreak for people living with obesity
The World Health Organization (WHO) has declared the COVID-19 outbreak to be an international public health emergency. Coronaviruses can cause more severe symptoms and complications in people with obesity-related conditions. There are simple, effective behaviours we can adopt to reduce our risk of catching coronavirus or transmitting the virus to other people.
How to prepare for the Coronavirus with obesity
Obesity can increase severity of COVID-19 symptoms. According to Dr. Karl Nadolsky, the chairman of the American Association of Clinical Endocrinologists’ (AACE) Obesity and Nutrition Diseases State Network and an assistant professor of medicine at the University of Michigan: “There is a concern even for metabolically healthy patients with obesity, just from the excess adiposity based upon angiotensin-converting enzyme 2 (ACE2).” To break this down, that ACE2 enzyme binds well to viruses, like severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nadolsky says that this suggests an increased risk of illness severity due to the amount of actual fat in the body.
Unfortunately, the risk of serious illness increases even more if you have comorbidities, or illnesses or conditions that occur together. These might include diabetes, sleep apnea, coronary artery disease, or heart failure, says Dr. Nadolsky. “Based on data from China,” he says, “fatality was higher for those with preexisting adiposity-based chronic disease.”
If you are currently managing any of those conditions, you may experience a severe form of the illness if you were to contract the virus. If you are older, the risk is further increased.
Understanding that the risks are increased if you’re clinically overweight or obese, it may be frightening to scour social media every day — especially when it is full of misinformation and rumors.
You should know, however, that some overweight and obese people might not be treated with ventilators. Cheryl Allen, ARNP, an internal medicine nurse practitioner, says that people who are seriously overweight or obese may have excess tissue that makes ventilator use dangerous.
The World Obesity Foundation says it can also be more challenging to “obtain diagnostic imaging (as there are weight limits on imaging machines),” and that some obese patients may be more difficult to transport or position in a time of crisis. Sadly, there’s a general lack of focus on obese patients in the healthcare system, as shown by a study published in Clinical Obesity.
While the pandemic is certainly frightening and complex, try not to worry about what might happen, as that can get in the way of living, Nadolsky says. Focus on what you can do right now to mitigate your risk. Working on getting healthier is a great way to feel in control in these very uncertain times. Focus on you, your own protection, and your health going forward.
The best thing to do to stay safe from coronavirus if you are obese
- Take self-isolation and Government precautions very seriously, Nadolsky says.
- You’ll want to clean your hands well and often (for at least 20 seconds), especially after being in public.
- Avoid touching your eyes, nose, mouth, or anything else with unwashed hands,
- Don’t go within six feet of others or attend gatherings of any type.
- If you have family members or housemates going in and out of the house, you may want to isolate yourself from them, as they may carry the virus even if they do not have symptoms.
This may seem difficult to pull off, but the spread is rapid and highly contagious. The CDC believes that respiratory droplets produced by coughs or sneezes easily pass from person to person.
Nadolsky says that younger patients with obesity who are otherwise metabolically healthy and practice good physical fitness may be on the much lower-risk end. If this is you, you’ll still need to practice social distancing along with the other precautions.
At this time, it may also be worth it to explore or revisit lifestyle changes to help you stay healthy in general and during the COVID-19 pandemic, he says. You might start a daily workout routine or begin eating healthier while in quarantine, for example — changes that will benefit you well after quarantine is over.
There are many free, low-impact YouTube workout videos made for people in quarantine or in small apartments, for example. It might also be wise to start stocking up on plant-based foods, like fruits, veggies, and grains, in addition to lean proteins — or to look into a healthy meal delivery service if you don’t want to leave your home for groceries.
Nadolsky also stresses continuing all of your current medications — including ACE inhibitors (for BP control) — which may carry some increased risk.
Recalibrate your diet
“Think about muscles as little factories you need to keep churning and burning.”
If you’re already passionate about diet and exercise, now is a good time to deepen your relationship with healthy foods and movement. Easy adjustments? “Since you can’t go to the gym, make sure you spend more time up and walking than sitting. Go do 15 minutes on your stairs. If you watch TV, do some pushups while you do it,” Nadolsky offers.
And finally, stay safe. Stay home!