The Collision of Two Pandemics: Obesity and COVID19

The pandemic of COVID‐19 is bringing public health to the forefront of the society. Lacking herd immunity and in the absence of effective vaccines or antiviral therapies, countries around the world are witnessing an unprecedented strain on their health systems and disruption of economies.

While most people with COVID‐19 develop no symptoms or have only mild illness, a significant number of patients develop severe disease that requires hospitalization and oxygen support, or even admission to an intensive care unit (ICU) and mechanical ventilation.

Older age and comorbid diseases have been reported as risk factors for severe illness and death. However, a growing body of research suggests that obesity is also a key risk factor, particularly for younger patients.

People of any age with severe obesity (a Body mass index of 40 or more) are considered to be at high risk of serious illness from COVID-19, according to the Centers for Disease Control and Prevention.

Persons with obesity are already at high risk for severe complications of COVID‐19, by virtue of the increased risk of chronic diseases that obesity drives, such as diabetes, hypertension, heart failure, obstructive sleep apnea, some cancers, etc. Furthermore, people with obesity usually have multiple comorbidities at the same time.

Patients with obesity usually already have various degrees of pulmonary dysfunction and lower oxygen levels. They already are at increased pulmonary risk, and when they get COVID-19, a mainly respiratory illness, they are more likely to have serious lung complications. Research shows that the need for invasive mechanical ventilation is significantly greater in people with obesity, independent of age, sex, diabetes and hypertension.

Another concerning aspect is that obesity is associated with a state of chronic inflammation which weakens a person’s immune system, making it more difficult to combat infections. We have learned much from influenza in patients with obesity and there will almost certainly be parallels to COVID‐19. During the 2009 H1N1 pandemic, obesity was recognized as an independent risk factor for complications from influenza, and it is likely that obesity shall be an independent risk factor for severe complications with COVID‐19 as well.

In addition, prior research has shown that persons with obesity have diminished protection from influenza vaccines. They tend to get sicker from the respiratory disease even if they've been immunized. In fact, researchers have found that as people gain excess weight, their metabolism changes and this shift make the immune system less effective at fighting off viruses. The condition of obesity seems to therefore impair the critical immune response needed to both deal with the virus infection and  to mount a robust response to a vaccine.

Furthermore, persons with severe obesity who become ill and require intensive care, present unique challenges in patient management—more bariatric hospital beds, more challenging intubations, more difficult to obtain imaging diagnostic studies (there are weight limits on imaging machines), more difficulty in positioning and transportation by nursing staff. And like pregnant patients in ICUs, they may not do well when prone.  In general health systems are already not well set up to manage patients with obesity and the current crisis will expose their limitations even more.

There will likely also be a psychological toll of the viral pandemic. Persons with obesity who are avoiding social contact are already stigmatized and are experiencing higher rates of depression. The current COVID-19 pandemic will likely deepen the negative psychological effects of social isolation for people with obesity.

This pandemic brings into focus the vulnerability of the millions of people living with obesity and other lifestyle-related chronic diseases.

As we’re understanding more and more that the obesity pandemic can have a great influence on the current COVID-19 pandemic, and likely on future viral pandemics, we need to understand that taking obesity seriously should be part of future control of global viral pandemics.

What are the initial conclusions we can draw from these facts? First and foremost, all nations must develop and preserve efficient national health systems based on principles such as: “prevention is key”, “investing in the training of the health force is a continuous effort”, “medical services should be part of a care continuum”, “the patient should be at the center of the whole system”, etc. Research performed amongst various health systems over the last 30 years is telling us the same simple truth: health systems, no matter how weak or how strong, cannot be and should not be left alone.

In each European country the health of the population is the final result of the work performed by complex health systems, with their own peculiarities and idiosyncrasies, systems which may, or may not be properly funded. These health systems are serviced by multidisciplinary teams providing their services at various levels (primary, secondary, tertiary care), and relying on infrastructure which, even in the best endowed nation, can always be improved. But in the end, achieving positive health outcomes in the fight against COVID-19 might depend on very simple measures. Some of these simple measures may include lifestyle changes, improving nutrition-related habits and increasing individual physical activity.

In the end “health promotion across all settings” remains an approach which should be assumed by all medical staff, at all levels, and across all healthcare services. Therefore, Workplace Health Promotion could become a powerful tool in the hands of managers of companies that are striving to improve the health of their employees and their resilience in tackling pandemics, both as a workforce and at the level of the individual. This will improve the productivity of the workforce and will contribute to the overall effort of the society.

IOANA HARATAU, MD: Attending Physician at John H. Stroger, Jr. Hospital of Cook County, Chicago (Illinois)

THEODOR HARATAU, MD, MBA: ENWHP Board member and Project Officer at European Commission

GIUSEPPE MASANOTTI, MD: ENWHP Board member and professor at the Faculty of Medicine (University of Perugia)