key: cord-268470-dgxn32ls
authors: Sharma, Abhishek; Garg, Akash; Rout, Amit; Lavie, Carl J.
title: Obesity is Associated with More Critical Illness in COVID-19
date: 2020-07-02
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.06.046
sha: 
doc_id: 268470
cord_uid: dgxn32ls

nan

To the Editor: In follow-up to recent major state-of-the-art review on Obesity and Outcomes in SARS-CoV-2 (COVID-19), 1 we have additional data regarding the relationship of obesity with outcomes in patients with COVID-19. Clearly, obesity and metabolic syndrome have been shown to affect both innate and adaptive immunity, leading to increased infection severity. 1, 2 This is very important since current statistics indicate that three-fourths of the United States (US) population are either overweight or obese by body mass index (BMI) criteria, and currently over 42% meet criteria for obesity by BMI ≥30 kg/m 2 . More alarmingly, currently over 9% of the US population meet criteria for severe or morbid obesity (Class III obesity) by BMI ≥40 kg/m 2 . 1,2 Certainly, many other countries across the globe are experiencing marked increases in the prevalence and severity of obesity, 1,2 which may be particularly problematic in COVID-19 and other such pandemics. We performed a rapid review and meta-analysis to evaluate whether obesity is associated with worse outcomes in patients with COVID-19.

The present study was conducted in accordance with the PRISMA guidelines. We performed a comprehensive search in the MEDLINE and medrvix.org databases for studies published between January 01, 2019 and May 31, 2020. The following key words were used for search in different combinations: "Coronavirus 2019", "Covid-19", "SARS-CoV2", "Obesity", "Body mass index", and "Outcomes". Studies reporting the relationship between BMI (non-obese vs. obese) and outcomes among hospitalized patients with Covid-19 were included for analysis. Three reviewers (AS, A.G. and A.R.) screened the study titles and abstracts for relevance followed by full manuscript evaluation. The following data was collected from included studies: baseline characteristics, proportion of subjects classified by BMI categories (< 30 kg/m 2 vs. >30 kg/m 2 ), and percentage of hospitalized patients. The primary outcome was critical illness In this rapid review and meta-analysis, obesity was associated with a 39% increased risk of critical illness, defined by individual study protocol as ICU admission, need for IMV, or hospice admission or death. Considering the very high prevalence of obesity among adults in the US and worldwide, and even severe obesity approaching nearly a tenth of US adults, this increased critical illness is a worrisome sign. 2 Patients with obesity also have more endothelial dysfunction, as well as respiratory and renal diseases that could worsen COVID-19 outcomes. However, probably most importantly, COVID-19 coronavirus attaches to the angiotensin converting enzyme 2 (ACE2) receptors in the lungs and organs. 1 Obese patients have insulin resistance and activation of the renin angiotensin aldosterone system. 1 The presence of ACE2 may enable the entry of SARS-CoV-2 into adipocytes, which makes adipose tissue an important viral reservoir. 1 Therefore, adipose tissue, which is more abundant in obesity, might also be infected by SARS-CoV-2 and allow spread to other organs, thus explaining the more severe COVID-19 disease in obesity. 1 The prevention of obesity in the first place and, especially, its progression to more severe forms, is desperately needed for future pandemics, as well as for the primary and secondary prevention of diabetes mellitus and cardiovascular disease. 2 In this COVID-19 pandemic, clinicians should recognize the marked increased risks associated with obesity, and these patients need more aggressive triage and treatment.

Our study has several limitations. Due to lack of patient level data, the results in our study were not adjusted to baseline patient characteristics. Several studies analyzing the relationship between obesity and clinical outcomes have reported results after adjusting for different confounders. Due to differences in the variables used to adjust results in these studies, we have not performed the pooled analysis of those adjusted confidence interval and odds ratio. Further, studies did not have long term follow up data and most patients were still hospitalized without a definite outcome i.e. mortality, thus caution should be exercised before extrapolation of our results to long term outcomes.

Despite these study limitations, however, our data of a 39% increase in worse outcomes associated with obesity strongly supports the recent paper in Mayo Clinic Proceedings. 1 

Obesity and Outcomes in COVID-19: When an Epidemic and Pandemic Collide

Healthy Weight and Obesity Prevention: JACC Health Promotion Series

Association of obesity with disease severity among patients with COVID-19

Obesity and COVID-19 Severity in a Designated Hospital in Shenzhen, China (3/13/2020)

Lille Intensive Care 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 in patients younger than 60 years is a risk factor for Covid-19 hospital admission

Covid-19 in Critically Ill Patients in the Seattle Region -Case Series

Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City

Clinical Characteristics of Covid-19 in New York City

Risk Factors Associated with Clinical Outcomes in 323

COVID-19 Hospitalized Patients in Wuhan, China

Characterization and Clinical Course of 1000

Patients With Coronavirus Disease 2019 in New York: Retrospective Case Series

Obesity Is Associated With Worse Outcomes in COVID-19: Analysis of Early Data From

Obesity and COVID-19: An Italian Snapshot. Obesity (Silver Spring)

Prevalence of Obesity Among Adult Inpatients With COVID-19 in France

Severe Obesity, Increasing Age and Male Sex Are Independently Associated With Worse In-Hospital Outcomes, and Higher In-Hospital Mortality, in a Cohort of Patients With COVID-19 in the Bronx