COVID-19 and obesity: ‘Think ahead, be more aggressive’
Obesity is a “common feature” among many adults who contract COVID-19 and develop more severe disease or are admitted to intensive care, and clinicians must work to better prepare patients and build trust, according to two speakers.
Despite approved vaccines and therapeutics, COVID-19 remains part of everyday life worldwide, and data show excess weight is associated with worse COVID-19 outcomes, Michael Osterholm, PhD, MPH, regents professor, McKnight Presidential Endowed Chair in Public Health, and director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, said during a key lecture during the virtual ObesityWeek annual meeting.
“What was notable was if you looked at the younger age [groups], those aged 20, 30 and 40 years, we were seeing a large preponderance of serious illness and death in the group that would be classified as obese,” Osterholm said. “That was striking, clinically, early on. As epidemiologic studies were conducted, looking more at the overall patient mix, that was confirmed. The challenge was how can we try to accommodate for that? What are the reasons we are seeing the increased occurrence? We are still trying to understand that, as well as vaccine response among those who are obese.”
Obesity, stigma as risk factors
Obesity is an independent risk factor for developing more severe disease after COVID-19 infection, even in the absence of other comorbidities, Rekha B. Kumar, MD, MS, associate professor of clinical medicine and attending endocrinologist at Weill Cornell Medical College, said during the presentation. Studies suggest the underlying pathophysiology related to obesity alone is likely the underlying inflammation and the endocrine disruption of abnormal lung mechanics, she said.
“There is a lot of pathophysiology in obesity that is unrelated to diabetes, hypertension or coronary disease that can put a person at higher risk for becoming ill,” Kumar said.
In addition to unknown biologic or genetic factors influencing disease severity, adults with excess weight often have had negative interactions with the health care system, increasing their risk for marginalization and stigmatization, Kumar said.
“They tend to not have the best relationship with the health care system; they may show up later and sicker at presentation,” Kumar said. “[Disease severity] is likely a combination of factors, obesity pathophysiology and societal factors.”
Care for people with obesity with other underlying health challenges — even when not infected with COVID-19 — has also been compromised during the pandemic, Osterholm said.
“We have seen so many health care systems around the country during these large surges go from the bending state to the breaking state,” Osterholm said. “When we look at people with comorbidities, we also have to look at how many excess deaths occurred, how much hospitalization occurred because these people did not have access to the care they would have had had there not been a COVID-19 pandemic.”
Long COVID risk higher
A study published in June in Diabetes, Obesity and Metabolism showed that, among COVID-19 survivors, risk for hospital admission after the acute phase of the disease was 30% higher among people with obesity compared with people without excess weight. The study also showed that the need for diagnostic tests to assess cardiac, pulmonary, vascular, renal, gastrointestinal and mental health problems was significantly higher among patients with a BMI of 35 kg/m2 or greater, compared with a person of normal BMI.
“You would expect to see an increase among people with obesity to potentially have long COVID because there is an increased incidence of moderate to severe disease in this population, which has been associated with long COVID,” Osterholm said. “Is [obesity] a confounder, or is this cause and effect? We are not quite sure yet. We are trying to understand long COVID, how it happens, if it is a single pathway, what you do about it, and the prognoses one might consider for helping the person.”
Kumar said she has seen symptoms of long COVID in her patients, including pericarditis, unexplained elevated heart rate, neurologic complications, mental fog and fatigue, and even dermatologic complaints, such as strange sensations on the skin.
Research is ongoing on whether weight loss, the use of weight-loss agents or metformin could reduce risk for developing severe COVID-19 disease, Kumar said.
Building trust with patients
Before the arrival of FDA-approved COVID-19 vaccines and monoclonal antibodies, Kumar said, she advised people with obesity to take additional precautions such as avoiding crowds and social distancing. Now, there are treatment options, but changing information has sometimes made building trust between clinicians and patients difficult, she said.
“When we still have questions about a more vulnerable population, such as waning immunity despite vaccination, we must encourage our patients to still take on the other precautions,” Kumar said. “For patients with obesity, something I have found on the clinical side that is frustrating for patients is they are vaccinated, but we are still asking them to wear a mask and perhaps not travel. People question what is the point of getting vaccinated? When we speak about this, we have to be careful.”
Osterholm said researchers and clinicians must take the lessons from COVID-19 and use them to prepare for future pandemics that are certain to follow in an increasingly connected society.
“A virus somewhere in the world today can be anywhere tomorrow,” Osterholm said. “It is very different than it was 100 years ago. We have had 11 flu pandemics in the last 150 years. The challenge now, today, is realizing how quickly this can be [transmitted] around the world.”
Kumar said the biggest pandemic lesson is to plan.
“We always felt that we were behind from a clinical care perspective, and I continue to feel that way today,” Kumar said. “Now, we are talking about breakthrough cases and patients who are vaccinated getting sick ... we tend to be behind, but perhaps we can use the information we have now on COVID-19 and obesity to think ahead, maybe be more aggressive in treating these people.”
Reference:
Aminian A, et al. Diabetes Obes Metab. 2021;doi:10.1111/dom.14454.
Collapse
Osterholm MT. In it for the long haul — considerations for long-term impacts of COVID-19 on people with obesity. Presented at: ObesityWeek; Nov. 1-5, 2021 (virtual meeting).
Read more about