When Two Pandemics Meet

Being overweight during this sweeping COVID-19 era puts one at greater risk.

Posted Sep 28, 2020

Before there was COVID-19, there was another pandemic. It was identified several years ago and is not going away. Unlike COVID-19, it is not contagious, but when those suffering from this first pandemic encounter the viral pandemic, the effects can be deadly.

The first pandemic is obesity. According to many experts of infectious disease and obesity, when someone who is part of the obesity pandemic becomes infected with COVID-19, the outcome may be significantly worse than for someone of normal weight.

A recent article in Science reviewed what is known (and what is still speculation) about how obesity exacerbates the symptoms of COVID-19. Concern about this relationship began when young adults infected with COVID-19 began to die. The author cites a case of a man in his late 30s admitted to an intensive care unit with shortness of breath, who tested positive for COVID-19. He died two weeks later. He had been healthy with no underlying medical problem except one: obesity.

Concern about the relationship between obesity and the severity of the COVID-19 infection increased rapidly during the following months. By August, according to the article in Science, a report analyzing data from a number of international studies found that 74 percent of obese people with COVID-19 were more likely to be admitted to an ICU, and 47 percent more likely to die than those of normal weight. These sobering, and indeed scary, statistics motivated an acquaintance who is an obese gastroenterologist, to go on a strict diet and lose 30 pounds.

Why is obesity such a risk factor? The obvious answer is that obesity, often linked with diabetes, heart disease, lung disease, and impaired immune system, all of which can worsen the response to any infection, turned out to be only partially correct. Excess weight per se may worsen the outcome of the COVID-19 infection and is not limited to those who are obviously obese. Even being overweight, which is having a BMI of 25-30, increases the possibility of being hospitalized with COVID-19. (BMI is weight in kilograms divided by height in centimeters squared. Many Internet sites will calculate personal BMI in seconds by inputting weight in pounds and height in inches.)

Lung capacity can be impaired when abdominal fat pushes the diaphragm, a muscle below the chest, onto the lower part of the lungs (where more blood is oxygenated than in the upper areas of the lungs). If someone with this diminished lung capacity becomes ill with COVID-19, he or she may need a ventilator in an ICU.

Obesity is also associated with an increase in blood clots, which may infiltrate the lungs and can cause serious damage. COVID-19 has been shown to increase blood clots as well; the combination is considered deadly. Obesity also decreases immune function. This is well known and is thought to be related to a relationship between one’s fat cells and their triggering the production of substances like cytokines, which in turn may increase inflammation. Here, too, the interaction between obesity and COVID-19 is dangerous, as the virus may also increase cytokine formation.

The catch-22 in all of this is that obesity, during the best of times, is so hard to reverse. Many of the factors that increase weight gain, such as stress, isolation, lack of exercise, absence of support, and virtual rather than actual physician-patient interactions, are concomitants of our lifestyle with COVID-19. Those who are trying to lose weight can no longer rely on positive reinforcement from group support meetings or private in-person consultations. Talking to a “talking head” on one’s computer screen about stress eating and fear of going outside to exercise because people are not wearing masks is helpful…but is it enough? Moreover, social isolation easily reinforces the status quo of an obese or overweight individual: loose-fitting clothes, the appearance only of the head and neck on a Zoom call, the increased availability of delivered meals, and the absence of distractions from eating out of boredom and loneliness. 

It is important that family members, friends, employers, and people with whom one may come in contact (Amazon delivery personnel, retail store employees) are aware of the vulnerability of overweight and obese individuals to COVID-19. A distant relative who recovered a few years ago from a heart attack sends his wife to do the food shopping, yet she is obese, verging on morbidly obese. When confronted with the risk to his wife of getting very sick if she was exposed to the virus, he said that his heart attack made him the vulnerable party. They both should avoid contact with others as much as possible.

But the attitude of this relative (quite distant) brings up another difficulty in preventing overweight and obese individuals from becoming sick with what could be a deadly infection. It is easy to tell others that you are not going to stores or dining outside with friends because asserting that the underlying condition putting you at high risk of contracting COVID-19 is socially acceptable. An auto-immune disorder such as asthma, or a neurological condition such as Parkinson’s disease, undergoing treatment for cancer, or even old age, are all socially acceptable reasons for extra precautions. But obesity? It is still seen as something the individual caused to occur because of his or her eating behavior, so why should the obese individuals be eligible for any special services (such as someone doing the food shopping for them)?

But we should not overlook the fact that more than 40 percent of the adult population in the United States is obese or severely obese. According to the Centers for Disease Control, almost 40 percent of adults over the age of 20 in the United States are overweight. Thus, when recommendations to “be careful” to avoid exposure to COVID-19 are given to those who may become very sick, i.e. the overweight and obese; these recommendations are ultimately relevant for the majority of the country.

It is not easy to lose weight, but if there were a time when doing so may be critically important…it is now.