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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 5  |  Page : 14-17

Obesity and COVID-19


Department of Surgery, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission03-Jul-2020
Date of Acceptance29-Jul-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Arun Prasad
Department of Minimal Access, Bariatric and Robotic Surgery, Indraprastha Apollo Hospitals, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_78_20

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  Abstract 


The coronavirus disease 2019 (COVID-19) pandemic has affected the global population. More and more studies are emerging that are showing the increased susceptibility of the obese to this infection. The adipose tissue along with the low-grade inflammation sets the background for a severe infection in most of the infected obese people. They have a longer hospital stay, increased chances of requiring ventilatory support, and also a higher mortality rate. We do a short review of some of the recent articles studying obesity and COVID-19 infection. While extra care and precautions have to be taken with the obese getting infected with this virus, there is an increased need to highlight the disease of obesity and the ways to fight it. Diet, exercise, medications, and endoscopic and bariatric surgeries would need to be seen in a new light during and after this pandemic.

Keywords: Bariatric surgery, COVID-19, obesity


How to cite this article:
Prasad A, Tiwari A, Siddiqui D, Osman N. Obesity and COVID-19. Apollo Med 2020;17, Suppl S1:14-7

How to cite this URL:
Prasad A, Tiwari A, Siddiqui D, Osman N. Obesity and COVID-19. Apollo Med [serial online] 2020 [cited 2020 Sep 19];17, Suppl S1:14-7. Available from: http://www.apollomedicine.org/text.asp?2020/17/5/14/292703


  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic has had a huge impact on the health-care services worldwide. Worryingly, the severity of COVID-19 infection is worse in patients suffering from obesity.[1]

It is the immune system, an important player in the pathogenesis of COVID-19, which plays a key role in obesity-induced inflammation of adipose tissue. This results in metabolic dysfunction, potentially leading to dyslipidemia, insulin resistance, Type 2 diabetes mellitus, hypertension, and cardiovascular disease.[2]

A pro-inflammatory state coupled with malnutrition may lead to impaired immune response in patients suffering from obesity and increased susceptibility to all influenza viruses including COVID-19.

While the world battles with the COVID-19 pandemic, the obesity pandemic continues to have a huge impact on the general health and mortality. Weight loss is extremely important to reduce the health risks in obese individuals.


  Reviews Top


  1. In a case series by Richardson et al. that included 5700 patients hospitalized with COVID-19 in the New York City area, the most common comorbidities were hypertension (3026, 56.6%), obesity (1737, 41.7%), and diabetes (1808, 33.8%)[3]
  2. An analysis of data by Petrilli et al. from 4103 patients with COVID-19 in New York City found that obesity was a prominent risk factor for hospitalization and critical illness (defined as care in intensive care unit [ICU], mechanical ventilation, discharge to hospice, or death). The chronic condition with the strongest association with critical illness was obesity, with a substantially higher odds ratio than any cardiovascular or pulmonary disease[4]
  3. An analysis of general population data by Hamer et al. from 387,109 adults in the United Kingdom (UK Biobank Study) found that overweight and obesity were strongly associated with hospitalization with the novel coronavirus. Based on the UK risk factor prevalence estimates, unhealthy behaviors in combination accounted for up to 51% of the population-attributable fraction of severe COVID-19[5]
  4. A report from China by Cai et al. drawing on data from 383 patients hospitalized with COVID-19 found that obesity, especially in men, increased the odds of developing severe pneumonia[6]
  5. A study by Caussy et al. on 340 patients admitted to a hospital in Lyon, France, with severe COVID-19, found a higher rate of obesity than that in the general French population. There were also higher rates of obesity among patients requiring intensive care treatment for COVID-19, compared to the general French population. After standardization of age and sex, the prevalence of obesity was 1.35 times (95% confidence interval: 1.08–1.66) higher in patients with severe COVID-19 than that in the general French population (P = 0.0034). Similarly, in the ICU, the prevalence of obesity was 1.89 times (1.33–2.53) higher than that in the general French population (P = 0.0011)[7]
  6. In a study by Simonnet et al. on 124 patients admitted to the ICU in a French hospital, the need for invasive mechanical ventilation (IMV) was associated with severe obesity. Obesity (body mass index [BMI] >30) and severe obesity (BMI >35) were present in 47.6% and 28.2% of cases, respectively. Overall, 85 patients (68.6%) required IMV. The proportion of patients who required IMV increased with BMI categories (P < 0.01, Chi-square test for trend), and it was greatest in patients with BMI >35 (85.7%). On multivariate logistic regression, the need for IMV was statistically significantly associated with male sex (P < 0.05) and BMI (P < 0.05), independent of age, diabetes, and hypertension. The odds ratio for IMV in patients with BMI >35 versus patients with BMI <25 was 7.36 (1.63–33.14; P = 0.02)[1]
  7. A case series by Goyal et al. on 393 adults admitted to a hospital in New York City with COVID-19 found that patients who received mechanical ventilation were more likely to have obesity. Obesity was a risk factor for respiratory failure, leading to IMV[8]
  8. A large prospective study by Docherty, Harrison etal. on 20,133 patients admitted to a hospital in the UK with COVID-19 found that obesity was associated with increased risk of dying in the hospital[9]
  9. A study by Klang et al. on 3406 patients admitted to a hospital in New York City with COVID-19 found that patients younger than 50 years with morbid obesity are far more likely to die from the novel coronavirus than others hospitalized with the virus in this age group[10]
  10. Memtsoudis et al. reported an overprevalence of obesity among both critically ill COVID-19 patients with respiratory failure admitted to the ICU and severely ill patients not admitted to the ICU. The authors suggested that obstructive sleep apnea-associated baseline inflammation and generation of intrathoracic shear forces could explain the co-occurrence of obesity and severe-to-critical COVID-19 disease.[11]



  Discussion: Corona and Obese Top


Many reasons have been proposed for the increase in the risk of complications from viral infections in obesity and Type 2 diabetes:

  1. There is a low-grade chronic inflammation with an excess of pro-inflammatory cytokines, reduced natural killer cell number and activity, and poor antigen stimulation response
  2. The added problem is that COVID-19 virus enters host cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor. This disturbs the protective ACE2 functions, which reduces vasoconstriction, sodium retention, inflammation, and metabolic degeneration
  3. The high blood sugars also downregulate ACE2 expression, and further reduction of ACE2 during the COVID-19 infection contributes to hyperinflammation and respiratory failure in patients with Type 2 diabetes
  4. There is a disruption of the immune system in the obese, leading to a state of chronic inflammation. It is possible that this could lead to an exaggerated response in case of a corona infection, which can be harmful
  5. In addition, raised interleukin-6 levels are associated with obesity and/or metabolic syndrome. In medical terminology, “the abnormal secretion of adipokines and cytokines such as tumor necrosis factor-a and interferon characterizes a chronic low-grade inflammation in abdominal obesity and may induce an impaired immune response during the COVID-19 infection”
  6. People with obesity are also prone to hypoventilation syndrome, cardiovascular disease, heart failure, and other conditions that could increase the risk of COVID-19 mortality
  7. Obese persons are more likely to have weak respiratory muscles, increased resistance in their airways, and lower lung volumes, which are important defense mechanisms to fight COVID-19. Hence obese persons are more likely to develop pneumonia. This will also cause stress on the heart


  8. Obesity and metabolic syndrome are known to increase Type 2 inflammation, which has adverse effects on the lung.


There are other practical problems such as transport to the hospital in regular ambulances and special large beds for those requiring admission. Intubation and ICU care needs specially designed equipment. Hopefully, health-care facilities will gear up for these factors too.

How to prevent?

  1. Self-isolation
  2. Diet that improves immunity
  3. Exercise to increase fitness.


Self-isolation, wearing of masks and gloves, avoiding touching of commonly infection-transmitting surfaces (fomites), and frequent handwashing are few of the commonsense preventive measures.


  Diet during Corona Times Top


Vitamins A, E, and D – the three fat-soluble vitamins; C and B vitamins; minerals such as zinc, selenium, iron, and copper; phytonutrients; amino acids; and fatty acids are necessary for optimal immune function (to prevent the establishment of viral infection) and immune regulation (to check the uncontrolled proliferation of immune cells that may cause more harm than good to the body).

These nutrients are critical for the function of T-cells, B-cells, killer cells, macrophages, and neutrophils/granulocytes that are involved in the killing and elimination of infectious microbes:

  • They enhance both native and adaptive immune functions and prevent infection, regulate immune function, keep inflammation under control, and prevent tissue damage
  • They aid in immune memory formation that helps in preventing reinfection with the same pathogen
  • They help clear/scavenge oxidant species (toxins) that are produced in large quantities in the body during infection and immune response
  • They increase beneficial probiotic bacteria in the intestine, regulate gut microbiota, maintain intestinal integrity, and thereby reduce transmission of toxins from the intestine to the blood circulation.


In addition, there are many other immune-related functions that are carried out by these nutrients and phytonutrients, as follows:

  • Vitamin A maintains the structure and function of the mucosal epithelial cells of the respiratory tract and enhances mucosal immunity (critical for the prevention of respiratory infection)
  • Vitamin E, beta-carotene (precursor of Vitamin A), Vitamin B, zinc, and selenium act as potent antioxidants and reduce oxidative stress in the body
  • Vitamin C has been given to speed up recovery from viral infections due to its antioxidant activities
  • Vitamin D deficiency makes people more prone to viral infections and respiratory complications.


A Google search can help you find what is available in your part of the world and the seasonal availability [Figure 1].
Figure 1: Diet

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  Exercise Top


This is important to keep you fit. Exercise improves your respiratory reserves, which is very crucial in case of corona infections [Figure 2].
Figure 2: Exercise

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Deep breathing exercises are the simplest exercise anyone can do regardless of weight and availability of gym or an exercise area.

While at home, you could do some of the low-impact YouTube video exercises that do not cause bodily damage in the obese.


  Bariatric Surgery Top


Medically necessary bariatric surgery [Figure 3] is on hold at the time of writing this article, with one of the reasons being hospital beds and ICU need to be available for the corona victims. Secondly, there is a risk of post operative respiratory complications for those who may be in the incubation period of the virus. Some morbidly obese persons have raised a question about having bariatric surgery to reduce weight and hence reduce the chances of complications if and when they get the infection in future. There is no answer to this question.
Figure 3: Surgery

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Currently, with no end in sight for the COVID-19 pandemic and bariatric surgery services coming to a standstill, patients suffering from obesity will have to bear this additional burden of being labeled as high risk. To make matters worse, we leave them with no significant options to be able to reduce their risk status. While the world battles with the COVID-19 pandemic, the obesity pandemic continues to have a huge impact on the general health and mortality. Weight loss is extremely important to reduce the health risks, and surgery is currently the only way to achieve that. Bariatric surgery has a positive impact on the quality of life and survival that is at least comparable with cancer surgery.[12]

In the near future, however, hospitals are going to gear up and ensure the following:

  1. Corona testing for patients and hospital staff
  2. Protective environment to prevent patient–staff, patient–patient, and staff–patient risk of transmission
  3. Upgrading of the operation room technology to provide things such as smoke evacuators, better energy devices, personal protective equipment, and viral filters for all surgeries.



  Conclusion Top


We do not have enough data on COVID-19 and BMI, but most publications are showing an important role of obesity in the COVID-19 pandemic that must not be ignored. It has been shown that obesity plays a key role in the pathogenesis of COVID-19 infection. It is important to take extra attention and precautions for patients with obesity. Meanwhile, the battle to fight the fat should continue with contributions from diet, exercise, medications, and bariatric surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Simonnet A, Chetboun M, Poissy J, Raverdy V, Noulette J, Duhamel A, et al. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation. Obesity (Silver Spring). 2020;28:1195-9.  Back to cited text no. 1
    
2.
Kassir R. Risk of COVID-19 for patients with obesity. Obes Rev 2020;21:e13034.  Back to cited text no. 2
    
3.
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323:2052-59.  Back to cited text no. 3
    
4.
Petrilli CM, Jones SA, Yang J, Rajagopalan H, O'Donnell L, Chernyak Y, et al. 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.  Back to cited text no. 4
    
5.
Hamer M, Kivimäki M, Gale CR, Batty GD. Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain Behav Immun 2020;87:184-7.  Back to cited text no. 5
    
6.
Cai Q, Chen F, Wang T, Luo F, Liu X, Wu Q, et al. Obesity and COVID-19 Severity in a Designated Hospital in Shenzhen, China. Diabetes Care 2020;43:1392-8.  Back to cited text no. 6
    
7.
Caussy C, Pattou F, Wallet F, Simon C, Chalopin S, Telliam C, et al. Prevalence of obesity among adult inpatients with COVID-19 in France. Lancet Diabetes Endocrinol 2020;8:562-4.  Back to cited text no. 7
    
8.
Goyal P, Choi JJ, Pinheiro LC, Schenck EJ, Chen R, Jabri A, et al. Clinical Characteristics of Covid-19 in New York City. N Engl J Med 2020;382:2372-4.  Back to cited text no. 8
    
9.
Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L. Features of 20133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ, m1985. 2020. https://doi.org/10.1136/bmj.m1985.  Back to cited text no. 9
    
10.
Klang E, Kassim G, Soffer S, Freeman R, Levin MA, Reich DL. Severe Obesity as an Independent Risk Factor for COVID-19 Mortality in Hospitalized Patients Younger than 50. Obesity 2020. https://doi.org/10.1002/oby.22913.  Back to cited text no. 10
    
11.
Memtsoudis SG, Ivascu NS, Pryor KO, Goldstein PA. Obesity as a risk factor for poor outcome in COVID-19-induced lung injury: The potential role of undiagnosed obstructive sleep apnoea. Br J Anaesth 2020;125:e262-3.  Back to cited text no. 11
    
12.
Bhasker AG, Greve JW. Are Patients Suffering from Severe Obesity Getting a Raw Deal During COVID-19 Pandemic? [published online ahead of print, 2020 May 12]. Obes Surg. 2020;1-2. doi:10.1007/s11695-020-04677-z.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Reviews
Discussion: Coro...
Diet during Coro...
Exercise
Bariatric Surgery
Conclusion
References
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